This inspection took place on 24 September 2018 and was unannounced. A second and third day of inspection took place on 26 and 27 September 2018, which was announced.

Falstone Manor is a care home with nursing. People in care homes receive accommodation and nursing or personal 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. Falstone Manor can accommodate 51 people in one adapted building across three floors. It is situated in a residential area of Roker, Sunderland near the coast. At the time of the inspection 46 people were resident, some of whom were living with a dementia.

At our last inspection in September 2017 we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to Good Governance and Staffing. Following this inspection, the provider sent us an action plan which included detailed actions and dates by which actions would be achieved. As part of this inspection we were able to evidence some improvements been made as a result of those actions taken.

The service did have a registered manager who had been in post since January 2018. 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 a robust recruitment process in place to ensure that only suitable people were employed to care for vulnerable people.

Staff had received training in safeguarding practices and were able to describe how they would keep people safe from harm and abuse.

Regular risk assessments and care plan reviews were carried out to ensure that people’s care was appropriate for their needs.

The provider had a good system in place for recording any incidents and accidents which allowed for analysis of any emerging trends. Any issues highlighted were addressed and where applicable involvement from other Health Care Professionals was sought.

Medication records showed that medication was handled safely, including the receipt, storage, and disposal of medication. People we spoke with told us they received their medication on time. However, we identified an ongoing issue with how some people’s medication was documented in terms of administration.

The home was clean, bright and free from malodours. We saw evidence of regular environmental checks to ensure the home was clean and tidy. Records showed that regular health and safety premises checks were carried out.

Staff training records showed that staff had received regular training which provided them with the skills they required to look after people safely. Staff also received regular supervision sessions with their manager.

People were supported to maintain a good level of nutrition and hydration. People we spoke with were complimentary regarding the food served. People had access to a range of healthcare services such as dieticians, GPs and hospital appointments.

People and their relatives we spoke with praised staff for the care they received. They told us that staff were thoughtful, respectful and maintained people’s dignity at all times.

Prior to any admission to the service, the provider carried out a detailed assessment to ensure that the service was able to meet people’s needs in terms of their care and well-being

The provider provides a range of social activities both within and outside of the home with a dedicated activity co-ordinator employed to oversee this.

Regular meetings took place for people, relatives and staff.

The provider has a range of quality assurance systems in place which included a variety of in-house monthly audits. In addition to these, the service is also inspected by the provider’s own quality a

The inspection took place on 4 and 12 September 2017 and was unannounced. We previously inspected the service on 17 and 23 March 2016 and found the service met the regulations we inspected against at that time. The service was rated as ‘good’ overall with each domain being rated as ‘good’. During this inspection we found the provider had breached the regulations in relation to staffing and good governance.

Falstone Manor is a three storey home that provides personal care, nursing care and support for up to 51 people, some of whom are living with dementia. At the time of the inspection there were 45 people using the service.

The home did not have a registered manager. The manager registered with CQC had left in August 2016. Since this date there had been at least three temporary managers in post. In order to stabilise management arrangements at the home the provider had been proactive in arranging for an experienced registered manager from an adjoining home to provide leadership to Falstone Manor. At the time of this inspection this situation was under review and due to be evaluated to assess the potential outcome on the home and people using the service. 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.

This inspection was triggered due to a number of concerns we received about inadequate staffing levels. These included people having to wait considerable periods of time for assistance; people being left unsupervised in communal areas; people left in bed or put to bed early due to a lack of staff and no personalisation or choice. Although we did not find evidence that people were put to bed early, we observed some examples of the other concerns raised with us. For example, we saw

people were often left unsupervised in communal areas, sometimes for significant periods of time. People and relatives gave us positive feedback about the caring nature of the staff providing their care, however they told us due to staff shortages they did not always receive the personalised care they required. We also saw examples of people having to wait a considerable amount of time for assistance.

Without exception people, relatives and staff told us staffing levels at the home were insufficient to meet people’s needs appropriately. People described to us how they often had to wait for assistance. Staff members confirmed they were unable to help people in a timely manner. People, relatives and staff had consistently raised concerns about staffing levels since January 2017. Following out inspection the provider confirmed that people’s dependency levels and staffing levels were regularly reviewed. The provider us with a copy of the most recent review and details of a plan to trial a change to how staff were deployed in the home.

People and staff told us there had been numerous temporary managers and a lack of leadership to make improvements to the care provided at the home.

Staff members were not receiving regular supervisions and appraisals. Some staff said they did not always feel supported, particularly in relation to staffing levels. Moving and assisting training was overdue for some staff.

Some care records were inaccurate. Although people’s care plans were in the process of being updated, progress to date had been limited. Periodic reviews of people’s care were also overdue for most people.

You can see what action we told the provider to take at the back of the full version of the report.

Safeguarding concerns were dealt with effectively with appropriate referrals made to the local authority safeguarding team. Staff had been trained in safeguarding and had a good understanding of safeguarding and the provider’s whistle blowing procedure.

Medicine

The inspection took place on 26 May and 1 June 2016 and was unannounced. Falstone Manor shares catering and laundry services with an adjoining service, Falstone Court. These areas were inspected on 26 May whilst inspectors were inspecting Falstone Court.

Falstone Manor is a three storey home that provides personal care, nursing care and support for up to 51 people. Some of whom are living with learning or physical disabilities. At the time of the inspection there were 49 people living in 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.

Staff had a good understanding of safeguarding and whistleblowing, and were confident in their role of safeguarding people. Safeguarding concerns were investigated with outcomes fed back to staff. Where necessary, practices were changed in order to prevent reoccurrences.

Medicines were managed safely, effectively and in a way which reflected people’s individual needs. All records were up to date and fully completed, with medicine audits being carried out regularly. Staff competency to administer medicines was regularly checked.

Records were kept for all accidents and incidents including details of investigations, outcomes and action taken. The registered manager analysed accidents and incidents to identify any trends and put additional measures in place to reduce the likelihood of any reoccurrences.

People had risk assessments in place and associated care plans were clearly linked and updated in line with risk assessment reviews. There were also general risk assessments regarding the premises and environment.

Staff were recruited in a safe and consistent manner with all necessary checks carried out. Staffing requirements were assessed in line with peoples’ needs. The registered manager also considered the skill mix and gender of staff. From staffing rotas we saw staffing levels were consistent. At the time of the inspection the home had two vacancies for night time nurses. Those roles were being covered by two agency nurses who had both worked in the service for at least 12 months to ensure consistency for people.

Staff received regular training on mandatory subjects such as safeguarding adults, management of medicines and moving and handling. They also received training on specific subjects relating to people's needs. The registered manager was pro-active in encouraging staff to complete training as and when it was due. They had introduced an internal competition whereby staff were split into three teams and by the end of the eight week period, the team who had completed the most training assigned to them won the competition and a prize.

Staff felt supported in their roles. They received regular supervisions as well as direct observations and annual appraisals. Staff felt these were useful in discussing training and development wishes.

We observed people and staff during mealtimes. People were enjoying their meals, some independently and others with support from staff. Menu choices were available for people and support provided by staff was caring, compassionate and at an appropriate pace for each person

We saw and people told us staff were "lovely" and "nice" and that they were friendly and chatty. Staff spoke to people in a gentle and friendly manner, referring to them by name. People responded positively. Throughout the inspection there was laughter and smiling from people in the service.

Care plans were personalised, detailed and contained people’s personal preferences, likes and dislikes. Care plans were up to date and reflective of each person’s individual needs.

There was a wide range of activities available both within the home and in th

Records and discussions during the follow up inspection showed that the provider had implemented the actions it determined were needed to be compliant in relation to staffing. This inspection found that people using the service and their relatives were happier about the staffing situation and records showed new systems identifying what staff were to be on duty were in place.

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 safe?

The home had systems in place to keep people safe. When people were admitted attention to their needs was demonstrated, and suitable risk assessments were generated. The environment was clean and hygienic, and equipment was in good repair. Night time staffing was more of a concern as not all agency staff used had the right capability to deliver essential care.

Is the service effective?

The staff we spoke with understood the needs of each person. One person said, “The staff work hard and are wonderful, their attention saved my life as I was very ill when I came in.” Observations of staff showed that they knew what people wanted and made sure they received the care necessary to keep them well.

Is the service caring?

Observations and feedback showed that the staff within the home were caring and attentive. Systems within the home identified people’s needs and how to meet them. One person said, “My relative has been in other places, but its better here. The staff are very patient and considerate”. Another person said “I couldn’t fault the staff they are so caring.”

Is the service responsive?

Systems within the home showed it was responsive to changing needs. Staff were observed offering choice in a variety of ways giving people the chance to make decisions for themselves. Records showed that care plans were changed when people’s needs changed. The dietician commented, “The home is careful to adhere to our guidance.”

Is the service well-led ?

There was a new manager in place who was experienced. She was in the process of improving the home. One person said, “The new manager is making a difference to the home there is a better atmosphere now.” Another person said the home was “very well run”. The manager was reducing the use of agency staff and there were four nurses and four care staff waiting for their final checks before commencing work at the 2 homes.

We carried out an unannounced visit following anonymous concerns made known to the Care Quality Commission (CQC) about shortage of staff during the day and at night. We spoke with a number of people throughout the day both in small groups of people who were sitting in the lounge. They told us they were happy with the service provided by the staff. One person said "Things are fine, I like living here" and the staff are lovely and were described as being really pleasant and supportive". Staff members were seen to interact well with people and knew them by their first name People had been individually assessed to see if they could make their own decisions. Care records had enough information so staff would be able to know how to support each person in the right way. People who used the service were protected from the risk of abuse and the provider had an effective system to regularly assess and monitor the quality of service that people received.

We saw on the day of our visit, there were sufficient qualified, skilled and experienced staff to meet people’s needs. The provider had a system for checking the quality and safety of the service and records were maintained and held securely.

We spoke with two people on the young physically disabled unit and two people on the frail elderly units. People told us they were “happy” and “staff do a good job”.

We spoke with two relatives who were positive about the care their relatives received. Both relatives we spoke to felt their relative was safe but expressed a wish for more staff at the home.

We found people’s privacy, dignity and independence was respected and people experienced care, treatment and support that met their needs and protected their rights. People who used the service were protected from the risk of abuse and the provider had an effective system to regularly assess and monitor the quality of service that people received.

The provider could not demonstrate there were enough qualified, skilled and experienced staff to respond to people’s needs.

We spoke with people on the young physically disabled unit and the two frail elderly units. They told us about their experiences at Falstone Manor Nursing Home. People told us they were happy and had been consulted by the staff regarding their care.

The relatives that we spoke with told us they were happy with the care that their relatives were receiving. Relatives told us that the staff involved them in the decisions relating to the relatives’ care.

We observed staff interacting with people who used services. They were respectful of the people and treated them with dignity. Relatives told us they felt the people received good care and were “Well” looked after. One relative said, “I visit regularly and I think these people receive good care. The home is always striving for “excellence”.