We undertook this unannounced inspection on 13 and 15 November 2018. The last comprehensive inspection of the service was carried out in August 2017, and a focussed inspection was carried out in February 2018.

At the last comprehensive inspection, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Shortfalls related to safeguarding people and obtaining their consent, staff training and insufficient staff to support people. Audits did not always identify shortfalls found during the inspection. Following the last comprehensive inspection, we asked the provider to make improvements to the service. At this inspection, we found that improvements had been made.

Cranhill is a 'nursing home'. People in nursing homes receive accommodation and nursing care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Cranhill Nursing Home provides care for up to 31 people. At the time of our inspection there were 19 people living there. The communal areas of the service were all on the ground floor. Bedrooms were available on all floors and an elevator and stair lifts enabled people to access each floor. Some bedrooms were en-suite, and some were large enough to enable couples to share a room.

A registered manager was in post at the time of our 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.

People were supported by adequate numbers of staff to meet their needs, however agency staff supported shortfalls in staffing numbers. At the time of the inspection, the provider was trying to recruit to fill vacant posts. The provider followed effective procedures to ensure prospective staff were suitable to work in the service, and checks were also carried out on staff who had worked at the service for many years.

Staff were trained in a range of relevant subjects, although some training records required reviewing and updating. Staff usually received regular supervision and appraisals, and the staff we spoke with were positive about the service.

Care records were clear, although some needed more detailed information about people’s needs and preferences. Individual risk assessments were in place, although some of these also needed checking for consistency. Care plans were reviewed regularly to ensure they continued to meet people’s needs. Relatives told us that they were consulted with and informed about people’s care.

Systems and processes were in place to protect people from the risk of harm. Staff had received training and told us about their responsibilities in making sure the service was safe. The principles of the Mental Capacity Act 2005 were being followed and the provider had made safeguarding referrals to the local authority appropriately.

People's medicines were administered as prescribed and managed safely by suitably trained staff.

Policies, procedures and checks were in place to manage health and safety. This included the management of incidents and accidents.

A wide range of audits and monitoring tools were in place. This included regular checks of pressure mattress settings, call bell responses, health and safety, medicines and falls. Shortfalls and themes had been identified and action plans put in place to continually monitor and improve the quality of the service.

Cranhill Nursing Home provides accommodation and personal care for up to 31 people. At the time of the inspection there were 22 people living at the home.

We undertook this unannounced focused inspection of Cranhill Nursing Home on 23 February 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on the 3, 7, 9 August 2017 had been made.

Two breaches of legal requirements were found following the comprehensive inspection. We used our enforcement powers and served a Warning Notice on the provider on 4 December 2017. This was a formal notice which confirmed the provider had to meet the legal requirement by the 29 December 2017 for good governance and the 5 December 2017 for protecting service users from abuse and improper treatment.

We undertook this unannounced focused inspection to check two of the five questions we ask about services: is the service safe and well led? This is because the service was not meeting some legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cranhill Nursing Home on our website at www.cqc.org.uk

No risks or concerns were identified in the remaining Key Questions through our on going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

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.

We found action had been taken to improve the governance of the service. However there was a lack of accurate monitoring of the suitability of air pressure cushions. We found one person had no clear guidance on what their individual cushion pressure should be set to.

New systems had been implemented for auditing the service, which identifies risks and concerns. There were associated action plans in place to address any shortfalls.

The new system was proactive in spotting risks and concerns early so action could be taken to prevent incidents from occurring.

At our last comprehensive inspection of this service on 5 July 2016 we found four breaches of legal requirements were found. This included risk assessments were not always in place, incidents and accidents forms were incomplete, medicines were unsafe, water temperatures were unsafe, checks were not recorded, personal evacuation plans had not been completed. We also found people were not involved in their care plan reviews, staff were not receiving sufficient training and induction and there was a lack of accurate records and no quality assurance systems in place.

Following this inspection the provider confirmed how they were going to meet legal requirements in relation to these breaches.

At the last inspection, the service was rated requires improvement.

We undertook this unannounced comprehensive inspection on the 3, 7 & 9 August 2017. This was to follow up the previous breaches of legal requirements. At this inspection whilst there were improvements there were still concerns relating to previous breaches including shortfalls in staff training and inadequate staffing. Systems were not always identifying shortfalls found during this inspection.

The service had a registered manager. 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.

Cranhill nursing home provides care and accommodation for up to 31 people. On the days of the inspection 23 people were living at the home. The home is on four floors, with a lift or stairs. Some bedrooms have en-suit facilities. There are shower facilities and toilets. Communal areas include one lounge, one dining area and a sitting room. There is also a front garden with a patio area.

People were not always supported by adequate staff to meet their individual needs and three people told us they had to wait 10 minutes for their bell to be answered. At the time of the inspection the home had a number of vacant hours. The home was actively recruiting to fill those shortfalls. Following the inspection we received confirmation that the home always sought the same agency staff for continuity. People were not always supported by staff who had received training or an update to ensure they had the skills and competencies relevant to their role.

Where concerns had been raised these were not always being raised following safeguarding procedures to ensure people were being protected from potential abuse. Three people who were at risk of developing pressure ulcers had incorrect mattress settings in relation to their care. There was no daily check in place to ensure these were accurately set in between the monthly audit.

Two people who were losing weight had no action taken to prevent them from losing more weight.

People ate in the dining room or in their room. People who required assistance from staff had to wait for meals to be delivered to their rooms.

Care plans confirmed if people lacked capacity, however where people lacked capacity there was no best interest decision in place relating to their care and support.

Medicines were not always stored safely as we found thickening agent left in two rooms. We also found records relating to creams administered required improving.

People were supported by staff who had suitable pre-employment checks although there was no system in place that checked staff who had worked for the service for years.

Incidents were not always being recorded where staff were being scratched and injured whilst supporting people.

People’s care plans contained important information relating to their likes, dislikes and routines however, one support plan looked at for when a person became upset or distressed could be improved upon.

People felt able to talk to the registered manager an

The inspection took place on 5 July 2016 and was unannounced. The care home was last inspected on 21 August 2013 and met the legal requirements at that time. Cranhill Nursing Home is registered to provide nursing and personal care for up to 31 people. There were 25 people living in the home on the day of our visit.

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 were assessed before they moved into the home to ensure their needs could be met. Initial care plans were devised with input from people and their relatives. Follow up reviews did not always include people and their relatives.

Most risks to people were assessed, however, actions were not always taken to reduce the risks and keep people safe.

People did not always receive personalised care that was responsive to their needs. Care plans did not always reflect that people’s individual needs, preferences and choices had been considered.

Governance systems were not in place to monitor and mitigate the risks relating to the health, safety and welfare of people.

People were supported to have their nutritional needs met.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. Where people were deprived of their liberty this was done lawfully.

People who were supported by the service felt safe. Staff understood how to safeguard people, and knew the actions they would take if they suspected abuse.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We carried out a follow up inspection to check compliance had been achieved with: Respecting and involving people who use services. The manager sent us an action plan following our previous visit to tell us how compliance was to be achieved.

The people we spoke with told us the staff respected their privacy and they were cared for in a dignified manner. One person whose choice was to stay in their bedroom said “I stay in my room all the time, the staff are in and out and they always knock before they enter.”

We observed the way staff interacted with people. At lunchtime people were given time to eat their meals at their own pace. We heard staff ask people if they needed help to take their medicines. We saw another member of staff spend time with one person who stayed in their bedroom. The conversation between staff and this person was friendly and showed the staff understood the best approach to use with people that lived at the home.

Overall people told us the meals were good and one person said the meals were “excellent”. Other people said “the potatoes are hard sometimes,” and “they always serve the same vegetables.”

People told us the management of their medicines was handled by staff and they were happy with this arrangement.

People told us they approached the manager with complaints. One relative of a person who lived at the home said “If I was worried I would see the manager. She does listen and so does the deputy.” We saw the complaints procedure was on display which told people how to complain and reassured them their concerns would be taken seriously.

We spoke with three people that lived at the home, three relatives and one social and health care professional.

The three people we asked said the staff were good and they were cared for in the way they wanted, but were not able to say if they were involved in the planning of their care. They also told us there were activities and in-house entertainment organised and they were able to join in.

The three relatives and social and healthcare professional we spoke with said the staff were good and they knew how to meet the needs of the people who lived at the home.

When we spoke with the staff, they referred to the people who lived at the home by the room number they occupied rather than their names. We read where staff had recorded inappropriate judgemental comments about people’s behaviour which showed a lack of understanding of people’s needs. During our observations we saw there was a lack of interaction between staff and people using the service. We found people at the home were not fully respected as individuals and as a result staff showed a lack of insight into the people’s needs.