About the service: Four Rivers nursing home is a residential care home registered to accommodate up to 40 people. Accommodation is set out in four self-contained units. At the time of this inspection the service was providing personal and nursing care to 39 people some of whom were living with dementia.

People’s experience of using this service:

•People and their relatives were positive about the care and support provided. One person said, “I love all the staff. I am very happy here.” A relative told us, “The staff are incredible and they have transformed my [relative’s] life.”

•The provider had made improvements to the service since our last inspection.

•Governance of the service had improved. Effective checks and audits were carried out to determine the quality of the care. The provider had acted promptly to address areas identified for improvement.

•The provider had informed us of significant events and Deprivation of Liberty authorisations in accordance with their legal responsibilities.

•There were safe systems for the management and administration of people’s prescribed medicines. People received their medicines when they needed them from staff who were trained and competent.

•Risks to people were monitored and procedures were in place to help keep people safe.

•People were supported by adequate numbers of staff who were safe and competent to work with them.

•People were protected from the risks associated with the control and spread of infection.

•Staff understood the importance of ensuring people’s rights were understood and protected.

•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’s health care and nutritional needs were monitored and understood by staff.

•People told us staff understood their needs and were kind, caring and compassionate.

•People had opportunities for social stimulation and were able to maintain links with the local community.

Rating at last inspection: The service was rated Requires Improvement at the last inspection in April 2018 (Report published May 2018).

Why we inspected: This was a scheduled inspection based on the previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This was an unannounced comprehensive inspection carried out on the 5 April 2018, with a further announced visit on the 9 April 2018.

Four Rivers Nursing Home is a ‘care home’. People in care homes received 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. Four Rivers Nursing Home accommodates up to 40 people within one adapted building, and specialises in the care of people living with dementia and older people requiring general nursing care. There were 38 people living at the home at the time of our inspection.

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.

At our last comprehensive inspection of the service on 7 October 2015, the overall rating for the service was judged to be ‘good.’ At this inspection we have rated the service as ‘requires improvement’.

During this inspection we identified three breaches of regulation. These were in relation to the safe management and administration of medicines, effective quality assurance systems and failure to notify the CQC of a statutory notification injury and authorised Deprivation of Liberty Safeguards applications as required by law.

The administration and management of medicines was not always safe. Out of date medicines had been administered to two people. The provider could not demonstrate how people’s prescribed cream was applied in accordance with their prescriptions. When people were prescribed medicines to be taken ‘when required' (PRN), information was not always consistently available to help staff decide when the medicines were needed. This meant people were at risk of not being given medicines when they needed them, or too often. There were no systems in place to ensure regular audits of medicines administration and storage were undertaken by the provider.

The provider had failed to effectively assess, monitor and improve the quality and safety of service provided and ensure records were up to date and accurate. We found that management systems were not always effective, and the home lacked any clear strategy in relation to the effective monitoring of the quality of services provided by staff. Though the provider had some management systems in place to record and monitor the standards of care delivered within the home, these were not always completed or were effective. The auditing of care files were at random with no clear evidence available that issues had been addressed. Care plans did not always reflect people’s current care needs.

Registered providers are required by law to notify the CQC of incidents where people have suffered harm, injury, abuse or suspected abuse. The provider is also required to notify CQC when an application is made in relation to depriving a person of their liberty, once the outcome is known. In February 2018, the provider had failed to report to us an event regarding a person’s health condition as required by notification. The provider had failed to notify us of one serious injury notification that had occurred in February 2018. They had also failed to tell us of 20 approved Deprivation of Liberty Safeguard orders that had been approved by the authorising local authority, and related to people currently living at the home.

We were not assured the management team had an appropriate understanding of, and fully promoted, people’s rights under the Mental Capacity Act(MCA). When using bed rails, which can act as potential restraints, the management team had not always obtained the consent of the people involved. Where people lacked the m

The inspection was carried out on 7 October 2015 and was unannounced. At our previous inspection on 15 October 2013 we found that they were meeting the Regulations we assessed them against.

Four Rivers Nursing Home provides accommodation and personal care with nursing for up to 40 older people, some of who are living with dementia. There is 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 told us they had attended training on safeguarding people. They talked of their awareness about identifying abuse and how to report it. Recruitment procedures were thorough. Risk

management plans were in place to support people to have as much independence as possible while keeping them safe.

Medicines were safely stored, administered and recorded in line with current guidance to ensure people received their prescribed medicines in a safe way. People had regular access to healthcare professionals. A wide choice of food and drink was available to people that met their nutritional needs and took into account their personal preferences. People enjoyed the food and drinks provided.

People were supported by skilled staff who knew them well and were available in sufficient numbers to meet people's needs effectively. People’s dignity and privacy was respected. Staff were kind and caring. Visitors were welcomed and people were supported to maintain relationships and participate in social activities.

Staff were well trained and used their training well to support people. Staff protected people’s rights by making sure they obtained their consent correctly. Staff were able to demonstrate a good understanding and knowledge of people’s specific support needs, so as to ensure people’s safety.

Care plans were regularly reviewed and showed that the person, or where appropriate their relatives, had been involved as best practice. They included people’s preferences and individual needs so that staff had clear information on how to give people the care that they required. People told us that they received the care they needed.

People were able to express their views and were confident that their complaints or concerns were listened to, taken seriously and acted upon.

The service was well led as people knew who the registered manager was and found them to be approachable and available in the home. People who lived and staff that worked in the service had an opportunity to say how they felt about the provider and the service provided. Their views were listened to and actions were taken in response. The provider and registered manager had systems in place to check on the quality and safety of the service provided, to put action plans in place where needed, and to check that these were completed.

We talked with some of the people who lived in this home and they said that they were well looked after. They said the staff always asked them how they would like things to be done. They said staff were always mindful of their privacy and treated them with respect.

People told us that they felt able to raise any issues with the manager or staff should they have any concerns. Staff spoke of their awareness of how to keep people safe from harm. Staff told us about the training that the home had arranged for them to attend so that they would recognise abuse and how to report it.

People told us that staff were available when they needed help. They said that the staff were friendly and always acted professionally. One person said, “All the staff are very good, I can visit when I like, the staff are very good to me as well. They are keeping my Mum very comfortable”.

The provider had developed a system whereby they can monitor how well the home was meeting the needs of the people who live there.

We spoke with five people in private and three relatives. This enabled us to gather people’s views and experiences of the service provided. When we were unable to speak with people we spent time observing their care and support. We also spoke with six staff members.

People told us that they were happy living at Four Rivers. One person told us, “It’s really nice here. I don’t need much help but when I do need anything they always help me”. Staff told us that they aimed to promote people’s independence as far as possible and we saw people being encouraged to do things for themselves.

People told us that they were involved in making decisions about their care and support and relatives said that they had also been consulted in the care planning process.

Staff met people’s care and support needs in ways that they preferred. People were treated with dignity and respect, however we saw that staff, on occasion, supported people without interaction or discussion. Everyone said that staff were kind and helpful.

We found that improvements were needed to ensure that activities met people’s individual needs. The management team had recognised this and were looking at implementing changes.

People were protected because staff were confident to recognise and report abuse.

People were supported by a well trained and well supported staff team.

The home ensured that people's views were considered and listened to and they had systems in place to monitor care provided.

People told us that they are content living at Four Rivers Nursing Home. They told us that they are consulted about their care, that their views are taken into account in the way the service is provided and delivered.

People said their privacy and dignity is very much respected and their independence promoted.

People told us that the home is very well run by the manager and her deputy. They said that they wouldn’t hesitate to ask questions or request help with any aspect of their care. “The staff are very caring and I couldn’t choose a better place to be now I need help”.

People told us they are happy with their bedrooms and that they can either remain in the privacy of their own room or join other people in the range of communal areas available. They said their rooms are kept clean and when they moved in they were encouraged to bring in some of their personal belongings if they wished.