Greetwell House Nursing Home is registered to provide accommodation for up to 25 people requiring nursing or personal care, including older people and people with physical disabilities.

We inspected the home on 27 and 28 September 2017. The inspection was unannounced. There were 12 people living in the home. This was because, following our last inspection in November 2016, we imposed an additional condition of registration preventing the registered provider admitting anyone to the home without our written permission. This was to give the provider an opportunity to focus fully on the needs of the people already living in the home and ensure they were receiving the service they were entitled to expect.

The home had a registered manager in post. A registered manager is a person who has registered with CQC to manage the service. Like registered providers (‘the provider’) 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.

In November 2016 we conducted a first comprehensive inspection of the home. We found the provider was in breach of legal requirements in seven areas. We rated the home as Inadequate. We also placed the home in Special Measures and, as described above, took action to restrict further admissions.

On this inspection we were pleased to find significant improvement had been made. All seven breaches of regulations had been addressed and the home is longer in Special Measures. The overall rating is now Requires Improvement, reflecting the need for further action in two specific areas. Our additional condition of registration remains in place but we have advised the provider that we are now prepared to permit new admissions to the home, as long as this is done in a measured way which does not jeopardise the progress made since our last inspection.

Improvement was required to ensure staff were consistently person-centred care in their approach and to strengthen the management and administrative resources in the home. In all other areas, the provider was meeting people’s needs safely and effectively.

Although she had only been in post for eight months, the registered manager had won the loyalty and admiration of everyone connected to the home.

There were sufficient staff to keep people safe and meet their care and support needs. Staff worked well together in a mutually supportive way. Training and supervision systems were in place to provide staff with the knowledge and skills they required to meet people’s needs effectively.

There was a friendly, relaxed atmosphere and staff were kind and attentive in their approach. People were provided with food and drink of good quality that met their individual needs and preferences.

People’s medicines were managed safely and staff worked closely with local healthcare services to ensure people had access to any specialist support they required. Systems were in place to ensure effective infection prevention and control and to address other environmental hazards.

A comprehensive range of audits was in place to monitor the quality and safety of service provision. People’s individual risk assessments were reviewed and updated to take account of changes in their needs. Staff knew how to recognise and report any concerns to keep people safe from harm.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection the provider had been granted DoLS authorisations for 4 people living in the home. Staff understood the principles of the MCA and demonstrated their awareness of the need to obtain consent before

Greetwell House Nursing Home is registered to provide accommodation for up to 25 people requiring nursing or personal care, including older people and people with physical disabilities. There were 19 people living in the home on the day of our inspection.

We inspected the home on 8 November 2016. The inspection was unannounced.

The home had no registered manager. The last registered manager left in May 2016 and the home had been without a permanent manager since that time. At the time of our inspection visit, two of the nurses were providing some management support to the home, in addition to their nursing duties. A registered manager is a person who has registered with CQC to manage the service. Like registered providers (‘the provider’) 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.

During our inspection we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had failed to properly assess and mitigate risks to people’s safety; staffing levels were insufficient; staff did not always respect people’s privacy and dignity; people did not receive person-centred care that met their needs and personal preferences; the ratings of previous CQC inspections were not on display in the home and the provider had failed to establish systems and processes to mitigate risks relating to people’s health, safety and welfare and to assess, monitor and improve the quality of the service.

We also found one breach of the Care Quality Commission (Registration) Regulations 2009.This was because the provider had failed to notify us of issues relating to the safety and welfare of people living in the home.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special Measures'.

We have taken action against the registered provider to ensure that they make the necessary improvements to become compliant with legal requirements. You can see what action we have taken at the end of the full version of this report.

We found other areas in which improvement was required to ensure people received the safe, effective, caring and responsive service they were entitled to expect.

Although people’s healthcare needs were monitored and supported through the involvement of a range of professionals, some people said they did not always receive prompt medical attention when they were unwell.

The systems for the induction and training of staff were not consistently effective. Additionally, staff were not provided with sufficient supervision and support.

At times, staff supported the people who lived in the home in a task-centred way and failed to establish warm, friendly relationships with them.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection, DoLS authorisations had been granted for three people living in the home and two further applications were in the process of being assessed by the local authority. Although staff had an understanding of the MCA, their use of best interests decision making processes did not always ensure people’s legal rights were fully protected.

In a small number of areas, we found the provider was meeting people’s needs effectively.

The recruitment of new staff was managed safely. People were provided with food and drink of good quality that met their needs and preferences. Staff encouraged people to maintain their independence.

We carried out this unannounced focused inspection on 30 September 2015.

The service provides accommodation for up to 25 older people, who have social and nursing care needs. At the time of our inspection there were 20 people living at the home.

The last inspection took place on 3 February 2015. At this inspection a breach of legal requirements was found. This was because there were not enough staff on duty to ensure that people’s needs would be met. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

During our inspection we found that the appropriate actions and improvements had been completed by the provider and they now met the legal requirements.

This report only covers our findings in relations to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Greetwell House on our website at www.cqc.org.uk

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.

On the day of our inspection we found staff interacted well with people and people were cared for safely. People told us their needs were being met. Staff told us they had sufficient time to meet people’s needs and to help them take part in social activities. The provider had systems in place to ensure they knew the needs of people living at the home and could adjust the staffing levels when required.

The service provides care and support for up to 25 people, some of whom may experience memory loss associated with conditions such as dementia. When we undertook our inspection there were 19 people living at the service.

We inspected Greetwell House on 3 February 2015. This was an unannounced inspection. Our last inspection took place on 17 July 2014 during which we found the service was not meeting all the standards we assessed. At our July 2014 inspection we found there were no systems in place to assess and monitor the quality of the services provided; storage of medicines was poor, some records were kept insecurely and staff had not been supervised. At this inspection we found the provider had completed everything on their action plans and were now compliant.

At the time of our inspection there was not 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. The manager had sent an application and was due to be registered shortly.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection there were was one person who was subject to a DoLS authorisation and a second person who was now subject to a Court of Protection order. People’s rights were protected by the manager and staff who understood the Mental Capacity Act 2005 code of practice and Deprivation o Liberty Safeguards. They followed the correct procedures when these were applied.

We found that most people’s health care needs were assessed, and care planned and delivered in a consistent way through the use of a care plan. People told us they were involved in the planning of their care and had agreed to the care provided.The information and guidance provided to staff in the care plans was clear. Risks associated with people’s care needs were assessed and plans put in place to minimise risk in order to keep people safe.

Although people felt safe within the home, we found there were times when there were not enough staff to meet people’s needs. This impacted on the support that people were provided with at certain times of the day.

The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives. However there was no evidence to support that people had been asked about their social interests and few stimulating activities arranged.

People were treated with kindness, compassion and respect. The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home.

People had a choice of meals, snacks and drinks. Meals could be taken in a dining room, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

The provider used safe systems when new staff were recruited. All new staff completed thorough training before working in the home. The staff were aware of their responsibilities to protect people from harm or abuse. They knew the action to take if they were concerned about the welfare of an individual.

Our inspection team on this occasion was made up of one inspector. We considered our evidence to help us answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who use the service, their relatives, the staff supporting them, talking with health and social care professionals and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

Regular checks were undertaken to ensure the environment was safe. However when actions had to be set no times were put and no records kept of when actions had been completed. This could mean actions could be on going for sometime which could put peoples health and welfare at risk.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly. However when audits had been completed there were no records of when equipment failures had been rectified, which could put people at risk of using unsafe equipment.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in discussions about their care needs and they reflected their current needs.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely.

The effectiveness of the care people were receiving was not being monitored or recorded by staff. People told us they were asked their opinions about their care but not about the running of the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People commented, "The nurses are lovely to me" and "Staff speak nicely to me."

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

People received their prescribed medicines. However checks by staff were not picking up that some entries had not been correctly recorded in the controlled medicines register.

Is the service responsive?

People told us they could speak with staff each day and share their concerns. They told us staff acted quickly when they called for assistance. Relatives told us they could speak with staff about their family member's needs, when that person could not make decisions for themselves.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

However staff did not receive adequate supervision and did not know if they needed to improve the standard of care they gave to people who used the service.

The service did not have a quality assurance system in place which ensured any failures when checks took place had been corrected.

Not all records on people who used the service and staff were stored in a secure place and there was no system in place to ensure they were retained and disposed of correctly.

The location is currently without a registered manager and the there was no evidence to support how the provider was monitoring the quality of the service on their visits.

During our previous visit in May 2013 we said the provider needed to take action to improve the ways in which people’s safety was maintained when they were being supported to move, and the way in which they were offered opportunities to enrich their daily lives. We also said the provider must take action to improve the way in which people were given information to help them make a choice about their service provision.

During this visit we saw arrangements had been put in place to provide a range of regular activities which were meaningful to people who lived in the home. The acting manager described how she had addressed the issues regarding people being supported to move in a safe way. Throughout this visit we saw staff using appropriate techniques to do this.

During this visit we also saw the provider had an up to date statement of purpose which was displayed for people who lived in the home, and visitors, to see.

Following our visit in May 2013 we received information of concern about the processes relating to the recruitment and selection of staff. We did not find any issues with these processes during our visit in May 2013. However we checked them again at this visit.

We found the recruitment and selection procedures generally continued to be effective. However, we highlighted to the provider there was no audit trail to show how decisions had been made to employ people where there had been issues disclosed at application or interview.

During the visit we spoke in detail with four people who lived at the home, two members of staff, the manager and the deputy manager. We also spoke with two relatives. We had general discussions with other people who lived at the home and staff members.

The manager had recently started work at the home but had not yet registered with us.

People told us they felt happy and safe living at the home. We saw their likes and dislikes were taken into account by staff and their decisions were respected. However we found there was no suitable arrangements in place to ensure people had access to regular activities. We also found there was no system in place to monitor how staff implemented appropriate moving and handling procedures.

People were protected from the risks of inadequate nutrition and dehydration and they were cared for in a clean and hygienic environment.

There were effective staff recruitment systems in place and systems to monitor the quality of the services provided in the home.

Although information was in place about the home and the services provided, the information was not accessible to people who use or may wish to use the service.

We reviewed all of the information we held about this provider before we visited. This included information from other agencies and the provider’s records.

We looked at four outcome areas which at previous visits, we had said needed improvements to be made.

We did not speak to people who lived in the home directly about most of these outcomes because most of the improvements we asked the provider to make were related to record keeping and staff support.

However people we spoke with and a visitor told us there were a lot more activities taking place in the home and we saw they had been involved in planning what they wanted.

During the visit we saw staff had made improvements to the way they set out and completed care records. We also saw support and training for staff was more organised and regularly carried out.

We also saw the provider now had an effective system in place to monitor the quality of the service they provided.

We followed up on one area of non-compliance identified in a previous inspection. We reviewed evidence that demonstrated the provider's compliance in this outcome area.

We spoke with people who lived there and the staff who supported them. There were 16 people living in the home when we visited, some of whom had complex needs.

We saw that people looked well groomed and comfortable. They made comments such as “I’m fine thank you” and “They come when I call.”

We looked at records, including personal care plans. We spoke with the manager and staff who were supporting people and we observed how they provided that support.

One person told us, “The staff are lovely here and food is very good.” Another person said, “The staff know what they are doing and they help me do what I need to do.” A third person commented, “They’re always busy but you don’t have to wait a long time for them to come.”

We saw people who lived in the home received individualised care and support, from staff that were knowledgeable about their needs, wishes and preferences. Staff clearly understood each person's way of communicating their needs and wishes. They supported them to make choices and decisions about their lifestyles wherever they could do so.

We could not see evidence of staff being supported effectively. There was a lack of information about staff supervisions and training. We were also unable to find any evidence that monitoring the quality of the service took place.

We visited the home on two consecutive days in August 2012, after receiving concerns about the numbers of staff that were on duty within the home.

Seventeen people were living in the home when we visited, some of whom had complex nursing care needs.

During the first day of our visit we saw that two members of staff were on duty between the hours of 8am and 8pm. This was below the minimum levels of staffing that the provider had said were needed to meet people’s needs, which was three staff on each shift.

We saw that some people had to wait, for sometimes lengthy periods to have their needs met. This was because the staff on duty were attending to other people. We saw that whilst staff were attending to a person's needs in private, there was no on-going monitoring and observation of the needs of the other people living within the home.

The people we spoke with told us the home was a nice place to live and they praised the staff, who they said were understanding and helpful. One person told us, “The carers are lovely, very friendly and good at their job.” Another person said, “The staff are very good, they only have one pair of hands but they always see to you.”

People said staff respected their privacy and dignity while encouraging them to be as independent as they were able to be. When we asked them if they ever felt their dignity was not maintained they could not think of any instances where this had happened.

People were complimentary about the meals provided. One person told us, “Every meal has been lovely and there have been lots of changes to the menu so you get a good variety of dishes.”

Although there was a list of activities on a board in the reception area people could not tell us what was planned for that day. They said they normally spent time watching television and chatting to people and that activities rarely took place.

The people we spoke with said they felt safe living at the home and raised no concerns about the way they were cared for. They told us they felt comfortable speaking to any of the staff about any concerns they might have.