Hartcliffe Nursing Home is a care home. 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. Hartcliffe provides accommodation with nursing and personal care for up to 66 people. At the time of our inspection 50 people were living in the home.

At the last inspection on 28 and 29 March 2017 the service was rated Requires Improvement. We found a repeated breach of the regulation relating to Consent to Care and we issued a Warning Notice. We also found breaches of the regulation relating to safe care and treatment. Following the inspection, the provider sent us an action plan telling us how they would make the required improvements.

We carried out a comprehensive inspection on 30 and 31 May 2018. At this inspection, we found improvements had been made and the legal requirements had been met. We found further improvements were needed to make sure that care was always delivered and recorded in line with people’s assessed and changing needs.

Overall, the service has improved to Good.

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.

Sufficient numbers of staff were deployed at the time of our visit. Staff performance was monitored. Staff received supervision and training to ensure they could meet people’s needs.

Medicines management shortfalls were promptly acted upon and actions taken to make improvements.

Staff demonstrated a good understanding of safeguarding and whistle-blowing and knew how to report concerns.

People were helped to exercise support and control over their lives. People were supported to consent to care and make decisions. The principles of the Mental Capacity Act (MCA) 2005 had been followed.

Risk assessments and risk management plans were in place. Improvements were needed to make sure care was consistently delivered in line with assessed needs and that accurate monitoring records were maintained.

Incidents and accidents were recorded and showed that actions were taken to minimise the risk of reoccurrence.

People’s dietary requirements and preferences were recorded and people were provided with choices at mealtimes.

Staff were kind and caring. People were being treated with dignity and respect and people’s privacy was maintained.

A range of activities were offered and provided people with entertainment both in and out of the home.

Systems were in place for monitoring quality and safety. Where improvements were needed the provider took action to address identified shortfalls.

We carried out a comprehensive inspection on 28 & 29 March 2017. At our last inspection in November 2014, we found one breach of the regulations with regard to consent to care. Overall the service was rated as good. At this inspection we found insufficient actions had been taken to address the breach. We found a further breach of the regulations and have rated the service as requires improvement. You will see the actions we told the provider to take at the back of the full version of this report.

The inspection was unannounced. Hartcliffe Nursing Home provides nursing and personal care for up to 66 people. At the time of our inspection there were 62 people living in the home.

There was a registered manager in place 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. However, the registered manager was leaving the care home during the week of our inspection. The provider had arranged for a registered manager from one of their other care homes to provide interim management cover, until a new manager was appointed.

People told us they felt safe in the home. They were cared for by staff that had been trained and understood their responsibilities with regard to keeping people safe from avoidable harm and abuse. Risk assessments were completed and risk management plans were in place. Overall, peoples’ medicines were safely managed.

Consent to care was not always sought in line with legal requirements and there was insufficient recording of best interest decisions made on behalf of people.

People‘s healthcare needs were not always met. When changes to care, such as frequency of positional changes had been identified and recorded, these were not always implemented. Staff had access to, and obtained support and guidance from, external health care professionals. People received the support they needed with eating and drinking.

Staff received training relevant to their roles. Staff confirmed they received supervision and were able to develop themselves through additional training.

Staff demonstrated a kind and caring approach and they treated people with dignity and respect. Staff knew people well and were able to tell us about people’s likes, dislikes and preferred routines which were reflected in their care records.

There was a wide range of activities that people could participate in and people were enjoying group activities on the days of our inspection. A team of volunteers provided additional support.

People, staff and relatives told us the home was well-managed. People and relatives told us the registered manager was readily accessible and available to them. Staff told us they were well-supported and described the home as a good place to work.

This inspection took place on 25 November 2014 and was unannounced. The service was last inspected in November 2013 and no breaches of regulation were found at this time.

The service provides care and nursing care for up to 66 older people. There is a registered manager in place. 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 in the home were safe. Staff received training in safeguarding adults, and demonstrated

knowledge about recognising the signs of potential abuse. Everyone that we spoke with was positive about the care they received.

There were sufficient numbers of suitably skilled staff to meet people’s needs and to ensure that people were cared for in a safe way. Staff were supported to care for people safely because there were risk assessments in place describing various aspects of people’s care.

The risks associated with medicines were minimised because they were stored appropriately and administered safely.

Staff had knowledge of the Mental Capacity Act 2005 (MCA), however the principles of this legislation were not yet fully embedded in to practice to protect people who lacked mental capacity. We saw that relatives were asked to sign their consent for bed rails to be used by people. Under the MCA, a next of kin does not have an automatic right to consent on behalf of their relative. Mental capacity assessments were not always carried out and the registered manager could not demonstrate whether less restrictive options had been considered or a best interests decision had been taken.

Staff received good support in their roles, including regular supervision and training to ensure that they were able to carry out their roles effectively. Staff were positive about the support they received.

People in the home were able to see other healthcare professionals when necessary, for example GPs and the tissue viability nurse. This ensured that people received effective care and specialist support when it was required.

People were protected against the risks associated with malnutrition because their weight was monitored and action taken to seek specialist advice if any concerns were identified. People were positive about the meals provided and we observed a meal time where people received the support they required.

We made observations of caring interactions between staff and people in the home. People and their relatives all reported that they were happy with the care, and some gave specific examples of how staff had made a positive difference to the health and wellbeing of their relative.

People were able to take part in a programme of activities if they wished to do so. and we made observations of this during our inspection. This included 1-1 support to make craft items if a person said that they wished to.

Staff understood the individual needs and preferences of people in the home and took action to ensure that these were met. Support plans were in place that supported staff in knowing the individual ways in which people preferred to be cared for.

People felt confident in being able to raise issues or concerns. There were systems in place to respond to formal complaints.

The home was well led. People were positive about the registered manager and we saw there was an open and transparent culture in the home. We heard about examples of where concerns had been raised and the registered manager had responded positively to resolve them. There were systems in place to monitor the quality and safety of the service and this included gathering feedback from people in the home.

People that we spoke with during our inspection provided positive feedback about the care that they or their relative received. One relative commented that "they try their hardest to be perfect". Another person said "my relative gets lovely care here and is always clean and tidy. I have nothing to worry about and feel comfortable knowing that everything is the same when I am not here".

People's care was planned and delivered in a person centred manner. Any risks with people's support were identified and measures put in place to help ensure that people were cared for safely. Where possible, people's consent was sought in relation to the care they received, for example through signing consent forms. If necessary, relatives were asked to sign paperwork on people's behalf.

Staff in the home went through a recruitment process that ensured they had the skills to carry out their roles. Checks were in place to ensure that they were suitable to work in the home, this included gathering references from previous employers. A system was in place to monitor the quality and safety of the home and this included gathering the views of people and their relatives.

We used a number of different methods to help us understand the experiences of people using the service including talking with people who live there and their relatives. Talking with staff and managers, looking at records, care files and observations of practice.

We spoke with eight people who use the service and they told us “It’s a lovely home it’s the best in the area”, “the staff are very good and helpful”, “I am very happy here the people are nice”.

Six relatives were also present in the home comments included;” excellent care provided by the staff”,” Its friendly and homely and I can visit when I like", "I can’t praise them enough", "they are very kind to me". Another person said “They are considerate and welcoming here, the manager is always around if needed, and it’s the best home in the district I think!”

Staff told us “We serve a community here and the home has a real community feel”. “I couldn’t imagine working anywhere else

People told us during the visit that they were consulted about their care and could make decisions about how they want to spend their time including when personal care was given.

Care plans detailed how a person wanted to be supported including their preferences, likes and dislikes.

People spoken with during the visit confirmed that staff ask them how they wanted to be supported and decisions made by them were respected.

People have a varied and nutritional diet which meets their cultural and health care needs. Comments we received about the food were positive.

We spoke to five people, and four relatives and all commented positively about the cleanliness of the home. One person said “it is home from home, my bedroom is cleaned regularly and I can find no fault”. One relative said that when they first visited and every time since they have found the home to always be clean and free from odour.

People spoken with during the visit said that the staff supported them with their medication and that if they were in pain, pain relief was offered appropriately.

We were told people were encouraged to personalise their rooms with their own furniture, furnishings and decor as far as is practicable. Great attention had been paid to make communal areas homely and a comfortable place to sit and relax.

We spoke to a number of people receiving a service and their relatives; generally the feedback about the staff was positive. Comments included “the majority of the staff are professional, kind and caring” , “All the staff are caring”, “the staff know me and quite often can tell how I am feeling without me saying anything especially if I am in pain”, “the staff are excellent I would recommend this home”. “It is like home from home the staff are kind and caring and go the extra mile”.

We spoke to a number of people during the visit and it was evident that they were aware of how to complain and had confidence in the staff and the manager to deal responsively to the concerns raised.

Good systems were in place to review the quality of the service which included seeking the views of the people they support and their relatives.