About the service: Henford House Nursing Home is a care home that is registered to provide personal and nursing care to up to 58 people. At the time of the inspection, 32 people were living at the home.

People’s experience of using this service:

Following the last inspection, we issued a requirement to ensure appropriate procedures were followed regarding capacity and decision making. This remained outstanding as the assessments were not always decision specific. In addition, the information did not always show how decisions had been made or whether the least restrictive option had been considered. The registered manager agreed this was “work in progress” and said more staff training in this area would be arranged.

Other requirements made at the last inspection had been addressed. For example, improvements had been made to records detailing the monitoring of people’s food and fluid intake and repositioning regimes, to minimise the risk of pressure ulceration. The safety of medicines had also been enhanced yet information about “as required” medicines lacked detail and was not person centred.

There were variable views about staffing levels and at times, there was a limited staff presence. The home however was calm, and staff were not rushed. Call bells were answered quickly, and any requests were made without delay. The registered manager told us the number of staff required and ways to allocate staff more efficiently, was being reviewed.

People were complimentary about their care and spoke highly of the staff team. They could follow their preferred routines and join in with a range of activities if they wanted too. People were encouraged to give their views about the service they received and knew how to make a complaint. People were encouraged to have visitors at any time and be a part of the local community. Their rights to privacy, dignity and independence were maintained.

People could administer their own medicines if deemed safe to do so and saw various health and social care professionals, to help maintain good health.

People said they enjoyed the food and had enough to eat and drink. A varied menu based on people’s preferences and good nutrition, was in place.

People were happy with the standard of cleanliness maintained and could personalise their room to make it as homely as possible. There was a well-maintained garden and people could enjoy views across open countryside.

Risks to people safety had been identified and measures taken to minimise these. Staff were knowledgeable about keeping people safe and were aware of their responsibilities to report an allegation or suspicion of abuse. Staff had received up to date safeguarding training.

Staff felt well supported and received a range of training to help them do their job more effectively. New staff were safely recruited although records did not show the rationale for appointing one member of staff. New staff completed a nationally recognised induction programme and worked with more experienced staff, before supporting people on their own. Staff had one to one meetings with their line manager to discuss their work.

People, their relatives and staff were complimentary about the registered manager and felt the service had improved since they had been in post. The registered manager had a person-centred focus and was passionate about ensuring high standards of care. They had clear plans in place to develop the service and were working with staff to implement these.

Rating at last inspection: At the last inspection on 9 and 10 January 2018, the service was rated as Requires Improvement. The report of this inspection was published on 23 March 2018.

Why we inspected: This was a planned, comprehensive inspection, based on the rating at the last inspection.

Action we told provider to take: We repeated the requirement to ensure the breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, was met. This wa

This inspection took place on 9 and 10 January 2018 and was unannounced.

Henford House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Henford House accommodates up to 58 people in a two storey building set in its own grounds on the outskirts of Warminster. At time of our inspection, 41 people were living at the home, three of whom were on respite care.

The service had 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 administering of medicines were not always managed safely. Although, we found that medicines were stored and disposed of safely.

There was sufficient staff to meet people’s basic care needs. However, we found that staff were not always visible and people who were unable to use their call bells, were unable to alert staff, unless staff were in the vicinity or another person rang their bell.

Staff showed a good understanding of the principles of the MCA (2005). However, some people who lacked capacity to consent to living at Henford House still had no capacity assessment in place. The service had not taken the necessary action following a recommendation from our previous inspection.

Where people had specific health conditions, we found not all care plans had the necessary detail and guidance for staff on how to manage these conditions. We also found staff had access to a variety of training, but had not always received relevant training for specific health conditions, such as Parkinson’s disease.

People’s health care needs were monitored and any changes in their health or well-being prompted a referral to their GP or other health care professionals. However, we received mixed feedback from people and their relatives about the promptness of these referrals.

People told us they felt safe living at Henford House and were happy with the care they received. Relatives told us the home was friendly and welcoming and they could visit at any time.

Staff had the knowledge and confidence to identify safeguarding concerns and act on them to protect people. They told us they would not hesitate to raise their concerns and felt confident it would be dealt with appropriately.

Risks to people’s personal safety had been assessed and plans were in place to minimise these risks. However, we found charts to monitor risks such as pressure sores and dehydration, were not always fully completed.

Most people said that they enjoyed the food and the variety of choices. People’s nutritional needs were met and where people were losing weight, appropriate action was taken, for example the use of a fortified diet.

The home was spacious, which allowed people to spend time on their own if they wished to do so. People had access to the gardens, and we observed some people going out with relatives. We found though the home had not been developed to support people living with dementia.

People told us that staff always respected their privacy, knocked on the door before entering and asked permission before supporting them. People said that they were offered everyday choices about their care.

People had a range of activities they could be involved in. People were able to choose what activities they took part in and suggest other activities they would like to complete. However, this was not always the case for people staying in their bedrooms or for people living with dementia.

The registered manager had made various community links and was working with different agencies to involve the community more within the home.

Qualit

Henford House is registered to provide nursing care to 58 people. The home is a detached, two storey building set in its own grounds on the outskirts of Warminster. At time of our inspection, 44 people were living at the home.

The inspection was unannounced and took place on the 13 and 14 December 2016.

The service had a registered manager who was responsible for the day to day running of the home. 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 told us they felt safe living at Henford House and were happy with the care they received. Relatives told us the home was friendly and welcoming.

Systems were in place for the storage, administration and disposal of medicines; however the ordering and delivering of prescriptions were not completed in a timely way. This meant some people’s prescribed medicines were not available.

Where people did not have the capacity to make the decisions themselves, mental capacity assessments were in place and records showed that decisions had been made in line with best interests, however we found mental capacity assessments were not always decision specific.

We have made a recommendation that the service seek advice on the implementation of the MCA 2005.

There were sufficient staff to meet people’s basic care needs; however people who remained in bed or their rooms did not receive much interaction from staff, other than care provision. This increased the risk to their emotional well-being and social isolation.

Staff had the knowledge and confidence to identify safeguarding concerns and act on them to protect people.

Care records showed that people's individual needs were assessed before admission into the home and where risks were identified appropriate guidance was in place to minimise potential risks.

People’s health care needs were monitored and any changes in their health or well-being prompted a referral to their GP or other health care professionals.

The provider had quality monitoring systems in place. Accidents and incidents were investigated and discussed with staff and at team meetings to minimise the risks of reoccurrence.

Arrangements were in place for keeping the home clean and hygienic and to ensure people were protected from the risk of infections. During our visit we observed that bedrooms, bathrooms and communal areas were clean and tidy and free from odours.

There is no registered manager at the home. A newly appointed manager was in place who was applying to be the registered manager of the home.

We considered all the evidence we had gathered under the outcomes we inspected. During the inspection, we spoke with four people using the service and a relative, and observed care for people in the communal areas of the home. We spoke with four members of staff, the deputy manager and a regional operations manager.

We used the information to answer the five questions we always ask

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• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found -

Is the service safe?

People were treated with respect and dignity by staff. People told us that staff treated them well. People were cared for by staff who were aware of the risks to their safety and health and staff knew how to support them in a safe way.

People's safety was protected and promoted because the service obtained advice and support from other health and social care services that people required to meet their needs effectively. If important decisions had to be made about people's health, appropriate processes were followed to ensure significant health care decisions were made in people's best interests.

Staff had attended safeguarding training and knew how to recognise and report abuse. They demonstrated good awareness of safeguarding issues and their responsibilities in reporting concerns. They confirmed that they would feel comfortable raising and reporting any concerns with the manager.

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

The Care Quality Commission (CQC) is the independent regulator of all health and social care in England. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Although no applications had needed to be submitted relevant staff had been trained to understand when an application should be made and in how to submit one. This meant that people were kept safe from harm.

Is the service effective?

People received appropriate care and support because there were effective systems in place to assess, plan, implement, monitor and evaluate people's needs. This ensured their needs were clearly identified and action taken to improve their care.

People told us that they were happy with the care they received and told us “the care staff are very nice” and “they (the care staff) come in and do everything for me”. We spoke with a relative about the care provided. They were very satisfied and confident that their relative was receiving good care. They said, "I can't fault them, everything is fine”. It was clear from observations and from speaking with staff that they had a good understanding of people's care and treatment.

People were supported in obtaining an advocate if needed which meant that when this was required people could access additional support.

People told us they were happy living at the home and helped to make decisions about their lifestyle. Through our observations we saw that staff had built good relationships with people and that people were comfortable in the company of staff.

People were provided with a range of activities in and outside of the home and were supported to maintain relationships with their families. We observed meaningful activities people were involved with that were chosen by them.

Is the service caring?

Staff had a good awareness of individuals' needs and treated people in a warm and respectful manner. This was confirmed by people and relatives we spoke with. Staff were knowledgeable about people's preferences and interests and encouraged people to be involved in meaningful activities.

Staff involved people in conversations. We observed staff paid attention to people who needed additional support ensuring they were understood. We saw people were receiving care in a sensitive way. We observed people being supported in making choices about their daily routines and the activities they would like to do.

Is the service responsive?

People's care had been reviewed regularly with those involved in their care. Referrals to appropriate healthcare specialists were made and they were consulted when there were changes to people's care. Positive comments were received from a healthcare professional about the way the home had improved in a care practice.

People had been involved in the care they received. Their needs, preferences and interests had been documented to help plan an individual service. Staff spoken with told us they had enough information about people's needs and demonstrated their knowledge about individual needs and preferences.

We were told by one person that there had been occasions when they had not got a timely response when they had needed assistance. We asked the provider to look in to this and respond to the person who has raised the concern.

Is the service well-led?

There is no registered manager at the home. A newly appointed manager is in place who will is applying to be the registered manager of the home.

Quality assurance processes helped to make improvements to the quality of the service where they were needed. Actions were recorded and followed up at regular intervals.

There was an appropriate staffing structure in place and staff had a good understanding about their roles and responsibilities.

When we inspected there were 41 people living in the home. We spoke with 12 people who used the service, one relative and 11 staff. We also made our own observations during the visit.

People who used the service told us they were satisfied with the service they received. People felt the staff supported them and met their needs. One person who used the service said "it’s a lovely home."

People told us that staff treated them with dignity and respect. One person said “I get on well with the staff.” We saw staff speaking and responding to people in a kind and respectful manner.

The care records showed us that people's health needs had been assessed before they came to live in the home. These records included information from health and social care professionals which helped ensure people got the care and treatment they needed.

The home trained their staff and had procedures which protected people from any form of abuse. Arrangements were in place for staff to be supervised. People told us they did not have any complaints but would speak to the manager or staff if they had any concerns. One person said “I would tell one of the staff.”

The service and the building were monitored and risk assessed to ensure they were suitable for the people who used them. One person told us "I have a nice room."

The evidence we collected showed us the service kept people safe and met their care needs.

People told us they were happy with the care and treatment provided.

People's care and support needs were regularly reviewed and care plans updated. People were involved in decisions about their care. Assessments were carried out if people were at risk of developing complex care and treatment needs.

Management made sure that members of staff knew that abuse was not tolerated.

People had the benefit of sufficient numbers of skilled and trained staff to meet their needs at different times of day and night. Members of staff had good access to a range of training relevant to the needs of people who used the service.

Staff engaged with people in a positive, friendly and professional manner. It was clear that people had good relationships with members of staff and management. Members of staff told us they felt well supported by each other and management.

Systems were in place to make sure the quality of the services provided was regularly reviewed. People who used the service and others involved were asked what they thought about the service and how things could be improved.