This inspection took place on 18 and 20 July 2018, and was unannounced. At the last inspection on 15 March 2017, we rated the service as requires improvement. At this inspection we found the service had made the required improvements. However, further improvements were needed to ensure people’s needs were met.

The Conifers Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Conifers Nursing Home accommodates up to 40 people in one adapted building. At the time of the inspection there were 39 people living in the care home.

There was a registered manager in post at the time of the inspection. 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.

Medicines were not always stored safely. We found medicines had been stored at the wrong temperature and people were at risk of receiving medicines that may be unsuitable for use. Checks on the quality of the service provided to people were not always effective. This was a breach of regulations; you can see what action we told the provider to take at the back of the full version of the report.

People were protected from abuse. People had their risks assessed, identified and managed appropriately. The home and equipment were maintained to minimise the risk of cross infection. People were supported by sufficient staff that were safely recruited. People received their medicines as prescribed. The registered manager had systems in place to learn when things went wrong.

People had their needs assessed and care plans were in place to guide staff. People received consistent care and had access to health professionals as required. New staff were provided with an induction into their role and their competency was checked. The staff received updates to their training. People had a choice of meals and were supported by staff to eat and drink sufficient amounts. The environment was suitable to meet people’s 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.

People received support from caring staff. People were supported to make choices and retain their independence. People’s communication needs were assessed and systems were in place to support them. People were treated with dignity and respect.

People received support from staff that understood their needs and preferences. People’s life history and interests were understood and they had access to activities which were of interest to them. Staff understood how to provide end of their life. People understood how to complain and these were responded to.

People and their relatives had the opportunity to share their feedback. Staff felt supported by the management team.

We carried out an unannounced comprehensive inspection of this service on 15 March 2017 to see if the provider had met the requirements as set out in the warning notice. We found that the provider had made the necessary improvements in this area.

The service was registered to provide accommodation, personal care and nursing care for up to 40 people. At the time of the inspection 37 people were using the service.

There was a not registered manager in post. A new manager had recently been appointed and had started working in 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.

We found that quality checks were completed within the service. However, we did not see how this information was used to drive improvement within the service as we were unable to see previous audits that had been completed. The provider sought the opinions from people who used the service however we could not be assured this information was used to make changes.

We could not be assured people received personalised care as care was task focused and staff felt rushed to deliver this care. The provider had not fully considered how people living with dementia made choices.

When people lacked capacity to make certain decisions for themselves we saw capacity assessments were in place however these decisions were for key areas and not always specific for the decision that was being made. In some capacity assessments it was unclear how decisions had been made and details explaining this were not documented.

There were enough staff to support people. As the provider had increased staffing since the last inspection people, relatives and staff felt this had helped improve the time people had to wait for support. People felt safe and were supported by staff who knew them well. The provider had suitable recruitment processes in place to ensure staffs suitability to work within the home.

Staff understood how to recognise and report potential abuse. They felt listened to and were assured action would be taken if concerns were raised. Individual risks had been identified for people and staff had the information needed to keep people safe. Medicines were administered, stored and recorded to ensure people were protected from the risks associated to them

People were supported in a caring way and encouraged to remain independent. People’s privacy and dignity was maintained. When people needed support to access health professionals this was available for them. Visitors felt welcomed in the home.

A new manager had recently started working within the home that some people had the opportunity to meet. The provider understood their responsibilities around registration with us and notified us of significant events with in the home, they were also displaying their previous rating as required.

We carried out an unannounced comprehensive inspection of this service on 25 May 2016. Breaches of legal requirements were found including insufficient staffing and risks to people were not managed in a safe way. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection on 22 November 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Conifers Nursing Home on our website at www.cqc.org.

The service was registered to provide accommodation, personal care and nursing care for up to 40 people. At the time of the inspection 38 people were using the service.

There was 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.

There were insufficient staff to offer support to people and there were delays for people when they received personal care. The action the provider had told us they had taken had been ineffective in making improvements in this area.

Where previous risks with equipment had been identified the provider had completed a risk assessment, however the measures put in place had not reduced the risk. Creams were being administered by care staff and signed for by the registered nurse without observation and when needed guidance for staff was not in place when people were refusing their medicines. People did not always receive care in their preferred way and when requested.

People felt safe and staff knew how to recognise and report potential abuse. The provider ensured staffs suitability to work within the home. Risks to people had been considered and when people had behaviours that may challenge guidance for staff had been introduced. People had the opportunity to participate in activities they enjoyed and were involved with reviewing their care.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We inspected this service on 25 May 2016 and it was an unannounced inspection. Our last inspection took place in March 2015 and we found that some improvements were needed.

We found people were experiencing delays and not receiving support when they needed it. People were at risk of harm as they didn’t not receive care as planned. We also found people’s care was not provided in a manner that promoted people’s welfare and safety. The provider sent us an action plan in June 2015 stating what action they were taking to address the concerns identified. At this inspection we found some improvements had been made, however further improvements were needed.

The service was registered to provide accommodation, personal care and nursing care for up to 40 people. At the time of the inspection 37 people were using the service.

There was 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.

People continued to experience delays and had to wait for the care and support they required because there were not enough staff available. We received an action plan the following day identifying how this was being addressed. When people had behaviours that may challenge they were not supported consistently. People were not always receiving care and support as planned or in a way they preferred. Risks to people were not always managed in a safe way.

People were supported in a safe way and when people needed specialist equipment it was provided for them. Staff had an induction and training that helped them to support people and checks were completed by the provider to confirm their suitability to work within the home.

The principles of the Mental Capacity Act 2005 were followed and when needed capacity assessment and best interest decisions were in place. The provider had considered when people were being restricted unlawfully and DoLS applications to the local authority had been made.

People enjoyed the food and were offered choices, people were supported to remain hydrated and systems were in place to support people with this. People and relatives told us they were happy with the staff and they were caring. We found people’s privacy was upheld and people were able to make decisions about how to spend their day. Activities were offered and people had the opportunity to participate in pastimes they enjoyed.

Quality monitoring was completed to bring about changes and the provider sought the opinions of relatives and people who used the service. There was a new registered manager in post and staff felt listened to and supported, they told us they had the opportunity to raise concerns. People and relatives knew how to complain and there were systems in place to manage complaints.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 10 March 2015 and was unannounced. We did not have any concerns with the service at our previous inspection in April 2014.

The service provided accommodation, nursing and personal care for up to 40 people. At the time of the inspection there were 35 people who used the service.

The home currently did not have a registered manager, but a person had been recruited for this position and was due to start shortly. 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.

People who used the service experienced delays and had to wait for the care and support they required because there were insufficient numbers of staff.

People were not always kept safe because their health and wellbeing were not consistently identified and managed. People did not always receive their care as planned.

Medication was managed by the nursing staff. People did not always receive their medications as they had been prescribed by their doctor.

Some people who used the service were unable to make certain decisions about their care. The legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) were being followed. The MCA and the DoLS set out the requirements that ensure where applicable, decisions are made in people’s best interests when they are unable to do this for themselves. Arrangements were in place for best interest meetings and decisions to be made when required.

Health care professionals were contacted when additional support and help was required to ensure people’s health care needs were met however actions were not always taken following advice and recommendations made by professionals.

People told us they liked the food and had enough to eat. Some people required their daily intake to be monitored in order for them to remain well.

Sometimes people were not treated with the care, compassion and respect they should have received. Peoples’ continence needs were not well managed. People experienced institutional regimes and were at risk of skin damage.

Some limited hobbies and recreational activities were available within the home. Some people were at risk of isolation because they stayed in bed and received interaction with staff only when physical interventions were provided.

The home had not had a registered manager in place for a period of time. People told us this has had a negative impact on the provision of care.

We visited Conifers Nursing home on a planned unannounced inspection which meant that the service did not know we were coming.

We are changing how we inspect services in the future and also making changes in how we report our findings. Below is a summary of our finding based on our observations, speaking to people who used the service, their relatives, the staff supporting them and from looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Systems were in place to ensure that the premises were safe and secure. The required health and safety checks and servicing were completed.

Sufficient staff were provided to deliver people's care needs and they received the training they needed to provide the necessary care and support.

Staff encouraged and supported people to make choices and decisions. When people did not have the capacity to make certain decisions, family and medical professionals were involved.

Is the service responsive?

People’s health, social and support needs were assessed and reviewed at regular intervals.

We saw staff were available in all areas of the home. We did not see or hear anyone had to wait for support when it was requested and needed.

The service had a complaints procedure for people to use where they were unsatisfied with the care provided.

Is the service caring?

People who used the service told us that the staff were very good and they were satisfied with the care and support provided. One person told us that they had no concerns with the staff, food or accommodation.

People who were unable to comment or did not wish to speak with us looked comfortable, snug and well cared for.

The home had regular resident/relatives meetings which offered people the opportunity to discuss life at the home. People who used the service were regularly asked their views in relation to food and care that was provided.

Is the service effective?

People who used the service told us they were able to do whatever they wished to do each day. Sometimes they liked to participate in group activities and at other times liked to spend time alone. We saw that staff respected these choices.

People's health and care needs were assessed. We saw that mostly the plans were up to date and corresponded with the discussions we held with staff. The daily support plans would benefit from more frequent review to ensure they include and document the very latest care and support needs of people.

Is the service well led?

There have been changes in the management of the home and a new manager has recently taken up the post. Staff we spoke with were clear about the management structure and felt supported by the managers.

We previously had concerns about the monitoring of the quality and safety of the service. We saw that some improvements had been made. The provider had a quality assurance system in place to ensure that the necessary checks were in place to provide and maintain a good service.

We carried out this inspection to check on the care and welfare of people using this service. The visit was unannounced which meant the provider and the staff did not know we were coming.

Thirty four people were in residence when we visited. There was a new general manager in post who had not yet submitted their registered manager application to CQC. We spoke with five people who used the service, two relatives, the general manager, the delivery and development manager and two staff.

Some of the people who used the service were unable to give us their views and we observed the interactions between them and staff. We looked at how people who used the service spent their time and whether they enjoyed living at the home.

We found people were supported to make their own decisions about their daily lives, however some improvements were needed to promote choices and independence for all people who used the service.

We found people who used services were protected against the risks of receiving unsafe or unsuitable care.

Staff told us they felt supported by their manager and received the training they needed. This meant staff were competent to meet the needs of the people who used the service.

There was on going development to the quality assurance process for the general manager and provider to monitor the quality of the service at the home.

We visited the service to check on the care and welfare of people who were living at the Conifers Nursing Home. The visit was unannounced.

During our visit we used different methods to help us understand the experiences of

people using the service. We spoke with people living at the home, staff members, the manager and the development manager, and we spent time observing the care provided in the home.

We spoke to eight people living at the home and two visiting relatives. People we spoke

with were positive about the care and support that they or their relative received. One person told us, "My relative was poorly, and now she’s much better" and another said, "The staff have been helping my mum to eat". People told us that staff were kind and caring. They told us that staff assisted them when they needed it. One relative said, "I have had cause to complain in the past, but things have been put right since then". People said that they got up and retired to bed when they choose.

We found that the home was comfortable and that people were able to personalise their bedrooms as they chose to, to reflect their own taste and interests. People were consulted about their care, and relatives were kept informed by staff if there were any changes in their relative’s condition.

People told us about the activities at the home, and said they joined in when they could. There was a planned programme of activities each week. We were told that the activities organiser provided 25 hours of activities weekly.

The environment was well maintained by the provider, people told us that they only needed to ask, and the job was done straight away.

We were told that the food in the home was good, and that there was a four week rotational menu which was changed according to the season.

We checked the administration of medication, and found that people had their medicines at the times they needed them, and in a safe way.

There were systems in place to gain and review consent from people who live in the home, and act upon them.

Individual care plans and risk assessments were comprehensively and clearly documented, and provided detailed information for care staff on actions that were needed to minimise risks to people.

We found that the home had a robust recruitment system in place, and staff told us they were supported and inducted into their role and responsibilities. Regular and documented staff supervision was taking place, and staff received updated and refresher training.

We saw that there had been regular audits of the service, undertaken by the development manager and the manager, and there had been recent surveys undertaken by the home to provide assurance that people received safe and appropriate care.