Clare Hall is a nursing home that provides personal and nursing care for up to 57 older people. Most people at the home have complex needs including dementia. On the day of inspection there were 27 people living at the home. Most people lived on the ground floor of the home in single bedrooms. There were communal lounges, a dining room and there were spacious grounds.

This inspection was unannounced and took place on 10 August 2017. The home has a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection in April 2016 we found people were not safe as there were not enough staff to meet their needs and the provider did not follow safe staff recruitment procedures. We also found people were at risk of having their human rights breeched because the principles of the Mental Capacity Act 2005 (MCA) were not always being followed.

At this inspection we found there was sufficient staff to meet people’s needs, keep people safe and respond to their requests for assistance. We found the risks of abuse to people were minimised because the provider had a robust recruitment procedure. We also found staff had received training on the principles of the MCA. People’s rights were protected because staff worked in accordance with the MCA.

People felt safe at the home and with the staff who supported them. One person said, “Always feel very safe.” Training for all staff made sure they were able to recognise and report any suspicions of abuse. Staff said they felt confident they could report abuse and it would be managed appropriately.

There was a full programme of activities including a strong relationship with the local community village church and local school. People had access to extensive grounds which were used for events which involved the local community. People and their relatives told us they enjoyed the gardens and during the inspection we saw people sitting and chatting in the sunshine.

People received effective care and support from staff who were well trained and competent in their roles. Staff monitored people’s health and made referrals to healthcare professionals according to their individual needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The organisation’s philosophy was, “Our home aims to provide its service users with a secure relaxed and homely environment in which their care, well-being, and comfort is of prime importance.” These principles could be seen throughout the home and during the inspection. One relative said, “It has become home from home for me. We love to sit in the gardens and there is a very peaceful ‘arbour’ of trees we like to sit in.”

People were cared for by kind and patient staff who respected their privacy and dignity and helped them to maintain their independence.

People benefitted from a management team who were open and approachable and had systems in place to seek people’s views. People were always asked for their consent before staff assisted them with any tasks and staff knew the procedures to follow to make sure peoples legal and human rights were protected.

There were systems in place to monitor the care provided and people’s views and opinions were sought regularly. Suggestions for change were listened to and actions taken to improve the service provided. All incidents and accidents were monitored, trends identified and learning shared with staff to put into practice.

Further information is in the detailed findings below

Clare Hall is a nursing home that provides personal and nursing care for up to 57 older people. Most people at the home have complex needs including dementia and as a result many of them had limited communication skills. On the day of inspection there were 32 people living at the home. Most people lived on the ground floor of the home in single bedrooms. There were communal lounges, a dining room and there were spacious grounds.

This inspection was unannounced and took place on 28 April and 4 May 2016.

The home has a registered manager who began working after the last inspection on 4 March 2015. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the previous inspection we found concerns because people were not always being listened to and they had a lack of activities. Both these areas had improved at this inspection.

People and relatives told us they felt safe but we found there were risks to their safety. We found problems with staff levels and recruitment. There were times people were not kept safe or had their needs met because there were not enough staff or they had not been deployed in the best way. People were at risk because the provider was not always keeping the appropriate records for staff members or completing the correct checks. Staff were supervised and did receive enough training to meet people’s needs.

Staff were aware of their responsibility to protect people from avoidable harm or abuse and had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home or the provider and they knew whom to contact externally. The registered manager understood when they were responsible for informing the local authority and CQC about safeguarding.

Most of the medication procedures in the home were safe but sometimes additional checks were not completed and there were missing signatures in the records. People who needed medicines as required and hidden had the correct procedures followed. Storage of medicines was done safely and in line with regulations.

Staff and the registered manager had some understanding about people who lacked capacity to make decisions for themselves. However, people were at risk of having their human rights breached when they lacked capacity because the Mental Capacity Act Code of Practice was not followed. Staff understood about Deprivation of Liberty Safeguards (DoLS) and the process to follow. One person had an authorised DoLS with no conditions and others had applications submitted correctly.

People were supported to see a wide range of health and social care professionals to help with their care needs. Staff supported and respected the choices made by people. People’s differences were respected. People had a choice of meals, snacks and drinks, which they told us they enjoyed. When a special diet was required by a person it was provided. People and their relatives thought the staff were kind and caring and we observed positive interactions. The privacy and dignity of people was respected.

Staff had good knowledge about people’s needs and their care plans were being revised to a new format. The needs of the people were reflected in their care plans.

There were quality assurance procedures in place to keep people safe. When shortfalls had been identified they rectified the issue. However, people were at risk of not being informed when changes occurred because they had not updated their statement of purpose or ensured their CQC ratings were available on their website; following the inspection these were rectified. There were good systems in pla

This inspection was unannounced and took place on 4 March 2015.

Clare Hall Nursing Home is registered to provide care and accommodation to up to 50 people. Part of the home is not currently in use due to difficulties with access. At the time of this inspection there were 29 people using the service.

The registered manager had recently left the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had advertised for a new manager and had suitable arrangements in place to manage the home in the absence of a registered manager.

Improvements were needed to make sure people were able to make choices about all aspects of their care regardless of their abilities. This includes ensuring people are given the opportunity to express their wishes about their daily routines.

Improvements were also needed to make sure people had access to activities and occupation in line with their interests and hobbies. At the time of inspection there were limited opportunities to make sure people received social stimulation and avoid isolation.

People told us they felt safe living at the home and were comfortable with the staff who supported them. One person said “I feel well looked after and safe.” Another person said “There’s a good atmosphere they treat you well.”

Staff had opportunities to take part in on-going training to make sure their skills and knowledge were kept up to date. This enabled people to receive care and treatment in line with up to date best practice. People received effective care to meet their physical needs and had confidence in the skills of the staff who supported them.

The risks of abuse to people were minimised because all staff were thoroughly checked before they began work. Staff knew how to recognise abuse and knew what to do if they had any concerns. All were confident action would be taken to make sure people were protected.

People told us they would be comfortable to make a complaint and were confident that complaints would be listed too. One person who had made a complaint in the past said they had been very satisfied with how the complaint had been handled.

Visitors were always made welcome which enabled people to maintain relationships with their friends and family.

People were able to choose were they spent their time and their privacy was respected. People were able to personalise their rooms in line with their tastes and preferences. All personal care was provided in private to promote people’s dignity.

There was a varied menu and specialist diets were catered for. People were complimentary about the food in the home. Comments included; “Food on the whole is pretty good,” “Food is very good and well cooked” and “Meals are lovely.” People who required a specialist diet said they received this. One person said “They make sure I still get a choice and I definitely have no complaints about how they’ve catered for my diet.”

People received their medicines at the right time from registered nurses who were trained to carry out this task safely. Registered nurses monitored people’s health and well-being to make sure they received appropriate treatment to meet their needs.

During our inspection we spoke with 15 people who used the service, four people’s relatives, six care staff, four ancillary workers. All of the people we spoke with gave mostly positive feedback but were concerned there were not enough staff available. One person told us “'I can't grumble about anything. They make me comfortable.” Care staff we spoke with told us they provided good care but there was a problem with staffing levels.

We saw the home assessed people's needs and care plans were developed to meet these needs. These plans had not always been completed with sufficient detail to ensure care delivery to meet needs. People told us they felt safe living at the home and confident staff would respond to any concerns they raised.

We found people were not protected from the risk of infection because appropriate guidance had not been followed. For example, we saw open used commodes and urinals in people’s rooms. We saw the housekeeper’s mops and buckets were dirty and did not follow national guidance for the prevention and spread of infection.

We found staffing levels were not always appropriate to meet the needs of people who lived in the home. We saw medication being administered later than prescribed and people told us they had to wait for their care needs to be met when they requested help.

We saw care records and other required records were incomplete and did not include appropriate information to protect people from unsafe treatment.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service caring?

We found from our observations and talking with people the service was caring. We observed staff treated each individual with dignity and respect. People told us how friendly staff were and how they felt staff listened to what they wanted. One person told us "staff always ask me what I want to do". We observed staff supporting people with care tasks such as assisting with meals. They did so in a dignified and caring manner. Interactions observed between people and care staff were supportive and respectful. Staff respected people's privacy and did not enter people's rooms without knocking and asking their permission to enter.

One person told us their relative was always made to feel welcome when they visited the home. A relative we spoke with told us "the staff are always friendly and I feel informed about the care my relative is receiving".

Is the service responsive?

We found the service responsive to people's wishes and choices and responded to the health and social care needs of individuals. People we spoke with told us their choices about how they spent their day were respected. People's preferences were actively sought and recorded as part of personal care planning. We were told currently people were being consulted about how breakfast was arranged as part of giving more choice to people. However we have noted how people were not able to have a bath if this was their preferred choice and the continued failure of the provider to resolve the lack of this facility.

Staff told us there was good communication and there were daily handovers so they felt informed about people's care needs. Staff told us if they had any concerns they would speak to the nurse in charge or the care manager.

The service was responsive to people's needs. Care plans we looked at contained assessments of need and outlined how needs would be met. The assessments were regularly reviewed to ensure they reflected people's up to date needs and preferences. We found where people had complex needs relating to their physical health, such as nutrition, professional advice and guidance was sought to ensure people's needs were met.

Is the service safe?

We found from what people told us and how the service responded to risks the service was safe. People who lived in the home told us they felt safe. One person told us "if I am unhappy about anything I will tell one of the carers they would do something about it". Another person told us "I know I can always make a compliant if I am really not happy about something. I am sure they would listen to me and do something about it".

The service identified, assessed and managed risks to the health, safety and welfare of people. People's care plans contained individual risk assessments to minimise these risks. Where people had moving and handling needs these were clearly specified so people were assisted in a safe manner.

We found there were improved arrangements to help ensure people were, as far as possible, safe from the risks to their health as a result of infections.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The manager said they had not needed to submit any Deprivation of Liberty Safeguards applications but they knew about the procedures to follow if an application was ever needed.

Is the service effective?

We found the service to be effective because people's care treatment and support achieved good outcomes. There was evidence of improved health for example where an individual had a pressure wound. The condition of the wound had significantly improved as a result of the care the person received. Another person's condition had improved to the extent they were now independent in having their meals and able to eat normally.

One person told us how coming to the home had been the best decisions she had made and how much their health had improved since living in the home. Another person went to their own home at night yet still retained their accommodation in the home and received care during the day.

We saw evidence of where people's health had improved in relation to treatment and care. In one instance this was the care of an individual who had a pressure wound. We saw where the service had referred individuals to specialists such as dietician and the mental health team. This enabled the service to support people with complex health and care needs so they could effectively meet those specific needs.

Is the service well led?

Currently this service has a manager who is not registered with the Care Quality Commission. There is also a care manager in place to support the manager in the provision of care. We found inconsistent practice in how the service was led in that there were failures to make the improvements we had previously identified. The provider and manager had clearly through its audits, improved guidance and communication with staff made real efforts to address failures in the quality of care. However shortfalls in record keeping continued from the previous inspection. The system put in place namely checking of food and fluid charts by nursing staff was not identified by managers as failing. Where people needed creams applied for skin conditions records of this care did not demonstrate this care was being consistently provided. This meant whilst managers reacted to the areas of non-compliance they had not ensured improvements had taken place and were sustained.

We found improvements had been made in the providing of individual supervision this ensured staff received this element of support. There were regular staff meetings and staff told us they found managers approachable and supportive.

There were comprehensive systems in place to monitor and audit the quality of the service. People views were sought about how they felt about the service they received. There were actions put in place and some improvements made as a result of external and internal audits. However there was a failure to identify through the audits undertaken shortfalls in practice around completion of records evidencing the consistency of care being provided. This showed these quality assurance systems were not effective or robust in identifying areas for improvement.