About the service: Holmwood Nursing Home is a care home that provides personal and nursing care to 25 older people living with dementia at the time of the inspection.

People’s experience of using this service:

There had been improvements to the safety of the service made since the last inspection however, some people were sometimes still at risk of unsafe care and treatment. There was an inconsistent approach to risk management for people who may develop pressure sores or require support with their nutritional needs. Staff competency and responsiveness had improved but some staff did not always know people’s needs well.

There was a new manager in post who had taken steps to improve staff training and had made changes to the environment to help people living with dementia. Whilst this was positive there were further improvements needed to help give people with dementia a better experience of living at the service. Activities had also improved but care planning remained a concern. The provider had introduced a new care planning system which had not been fully used at the time of the inspection. Quality assurance audits had identified and addressed some issues in certain areas but not all those that had been found at the inspection. Further improvements need to be made before we can be satisfied that these will be sustained and embedded into practice.

Rating at last inspection: The rating at the last inspection was Inadequate (3 September 2018). At this inspection the rating had improved. Despite an improvement in the overall rating the service will remain in special measures as the key question of Well-led was rated Inadequate.

Why we inspected: This was a scheduled comprehensive inspection based on the previous rating applied. We were following up to make sure that improvements had been made to the safety and quality of care being provided.

Follow up: We will be monitoring the service and will be re-inspecting to ensure improvements continue and are sustained.

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

Holmwood Nursing Home provides nursing and care for up to 48 people most of whom are living with dementia. Care and support are provided over two floors. Each bedroom has en-suite toilet and washing facilities. 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. There were 38 people living at the service at the time of our inspection.

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. The registered manager was present during the inspection.

This unannounced inspection took place on 3 September 2018. At the last inspection we identified breaches of regulations as risks to people were not always managed and some areas of the service smelled. There were not always enough staff deployed to meet people’s needs and the quality assurance processes had not been effective at ensuring people received good quality care. At this inspection we found that the safety and quality of the service had deteriorated.

There were not enough staff to safely meet people’s needs which affected all areas of care delivery. Relatives told us that weekends were affected the most however we saw, and staff told us, there were not enough staff working. Safe staffing levels based on the provider’s dependency tool had not been maintained for 27 out of 28 days over a four-week period. Infection control practices were poor which placed people at risk. People’s rooms were dirty and the smell of urine was noticeable throughout the service. Equipment such as hoists were also dirty, the lift had not been working for a month and the premises required improvement.

Risks to people were not always acted upon or reduced to keep them safe. People who were nursed in bed had their pressure mattresses on the wrong setting and were not always re-positioned when they should be. Lessons were not always learned when things went wrong as accidents and incidents were not analysed for patterns or trends. People were not protected from the risk of abuse as safeguarding incidents were not reported appropriately to the local authority. Medicines management required improvement in some areas however medicines were stored and disposed of appropriately.

Staff did not always follow safe moving and handling procedures and training in mandatory areas was not always completed. This affected the quality of care people received. Mealtimes for people were a poor experience as there were limited food choices available. People’s specific dietary requirements were not always followed.

The principles of the Mental Capacity Act 2005 (MCA) was not always followed. Decisions were not always being made lawfully or in people’s best interests. The design and adaptation of the premises did not meet people’s needs. People living with dementia would not be able to orientate themselves as there was inadequate signage to guide them. There were duplicate numbers or no numbers on people’s bedrooms, which made it confusing for people to find their bedrooms. Outcomes for people were not always positive although people had access to healthcare professionals to help maintain good health.

People were not living in a dignified manner. The lack of staff and problems with the environment contributed to a service that was not caring. Staff did not always treat people well or with kindness and respect. People’s privacy and dignity was not maintained and they were not able to express their views about the care they received. There were instances when people were treated well by staff who were able to take time to reassu

Holmwood Nursing Home provides nursing and care for up to 48 people most of whom have dementia. Care and support are provided on two floors. Each bedroom has en-suite toilet and washing facilities. There were 37 people living here at the time of our inspection.

Communal areas include two large rooms, one of which leads out to the secured gardens.

Holmwood Nursing Home 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.

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. The registered manager was present during the inspection.

People and their relatives gave positive feedback about the home, and its staff. However we noticed that aspects of care and support had dropped in quality since our last inspection.

People were not always safe at Holmwood Nursing Home. Risks of harm to people had not always been identified so clear plans and guidelines were not always in place to minimise these risks.

Staff deployment around the home needed to improve. At times people at risk of harm, or in need of support, such as to access the toilet, were left in areas unsupervised by staff.

The effectiveness of the systems to monitor the quality of care and support that people received had declined since our last inspection. Quality assurance records were not all up to date to show that the provider had checked on important aspects of the management of the home. The registered manager had not ensured that accurate records relating to the care and treatment of people and the overall management of the service were maintained.

People had access to some activities; however these were not always focused on supporting people living with dementia. Access to outside trips and visits to the local community were limited for some people who live here.

People had enough to eat and drink, and received support from staff where a need had been identified. People’s individual dietary requirements where met. Overall people were happy with the quality of the food; however they felt the choices dropped when the chef was not there. The registered manager and staff team were working with an outside agency to improve people’s diets.

The staff were kind and caring and treated people with dignity and respect, but peoples experiences were inconsistent. Staff took time to sit and talk with some people and encouraged them to take part in activities. However others were left on their own for periods of time and did not receive as much positive interaction from staff. Caring interactions were seen throughout the inspection, such as staff holding people’s hands. The staff knew the people they cared for as individuals.

People received the clinical care and support as detailed in their care plans, however the care plans were not always person centred, and there were gaps in information. This gave a risk that staff became task focused, with little work being done around people living their lives to the fullest. People and relatives were involved in reviews of care to ensure it was of a good standard and meeting the person’s clinical needs.

Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

People received their medicines when they needed them. Staff managed medicines in a safe way and were trained in the safe administration of medicines.

People would be protected in the event of an emergency. Each person had a plan which det

Holmwood Nursing Home provides nursing and care for up to 48 people most of whom have dementia. At the time of our inspection 35 people lived here.

Care and support are provided on two floors. Each bedroom has an en-suite toilet and washing facilities. Communal areas include two large rooms, one of which leads out to the secured gardens.

At our previous inspection in September 2015 we had identified seven breaches in the regulations. The provider had taken appropriate action and addressed all of these concerns.

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.

People told us they were happy living here. One person said, “‘I am well looked after.” Another person said, “It’s a great place.” Staff were happy in their work and proud of the job they do.

People were safe at Holmwood Nursing Home. There were sufficient numbers of staff who were appropriately trained to meet the needs of the people who live here. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. In the event of an emergency people were protected because there were clear procedures in place to evacuate the building. Each person had a plan which detailed the support they needed to get safely out of the building in an emergency.

Staff recruitment procedures were safe to ensure staff were suitable to support people in the home. The provider had carried out appropriate recruitment checks before staff commenced employment. They had also checked to ensure staff were eligible to work in the UK.

Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported. Staff received regular support in the form of annual appraisals and formal supervision to ensure they gave a good standard of safe care and support.

Staff managed the medicines in a safe way and were trained in the safe administration of medicines. People received their medicines when they needed them.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had enough to eat and drink, and received support from staff where a need had been identified. People’s individual dietary requirements where met. The registered manager was investigating the use of ready meals. They assured us that people would be involved in this process to ensure meals offered choice, and a good quality of fresh food.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. People’s health was seen to improve due to the care and support staff gave.

The staff were kind and caring and treated people with dignity and respect. Good interactions were seen throughout the day of our inspection, such as staff talking with people and showing interest in what they were doing. The staff knew the people they cared for as individuals.

People received the care and support as detailed in their care plans. Care plans were based around the individual preferences of people as well as their medical needs. People and relatives were involved in reviews of care to ensure it w

Holmwood Nursing Home provides nursing and care for up to 48 people most of whom have dementia. At the time of our visit 38 people lived here.

Care and support are provided on two floors. Each bedroom has en-suite toilet and washing facilities. Communal areas, include two large rooms, one of which leads out to the secured gardens.

The inspection took place on 30 September 2015 and was unannounced. At our previous inspection in November 2014 we had not identified any concerns at the home

Overall there was positive feedback about the home and caring nature of staff from people and their relatives. One person said, “The carers are very friendly here.” A relative said, “I can’t fault the care here. They look after my family member so well. The manager is wonderful.” Another said, “Nothing is too much bother for them (referring to the staff). I never felt a care home could be like this.” However we identified a number of concerns around the home.

The leadership and management of the home had an impact across all five of the key questions that we looked at. It impacted on the safety of people as risks to people had not been identified; It limited the effectiveness of the service to be able to provide person centred care, such as supporting people to keep healthy; It affected the caring nature of the staff as staff had little time to spend with people to talk or get to know them; It reduced the responsiveness of the service so people did not receive care that met their needs.

People were not always safe at Holmwood Nursing Home. People’s medicines were not always managed in a safe way. Risks to people’s health and safety had not always been identified. Plans were therefore not in place to manage these risks.

The home was not responsive to the needs of the people that live here. Visibly obvious signs that people needed care were not seen by staff. Support needs identified in assessments carried out with people before they came to the home had not been carried across to care records. Staff were unaware of the need and people did not have the support they needed. People did not have activities that met their needs. Staff did not always know the people they cared for as individuals.

People did not always receive support to remain healthy. Although some people did have referrals to external health care professionals we could not be assured that the recommendations made had been followed by staff. Other people had not been referred to healthcare professionals where they should have been, so were not receiving effective care that met their needs.

Where people did not have the capacity to understand or consent to a decision the provider had not always followed the requirements of the Mental Capacity Act (2005). Decisions had been made for people without an appropriate assessment and review being completed. People told us that staff did ask their permission before they provided care.

Where people’s liberty may be restricted to keep them safe, the provider had not always followed the requirements of the Deprivation of Liberty Safeguards to ensure the person’s rights were protected. People were not free to access all areas of the home. The front door and some interior doors were operated by keypad entry. Many bedrooms had gates on the doors to stop people wondering into to others rooms.

Some people had behaviour that may challenge themselves of others. These people were at risk of harm. Staff had not been given the guidance or training to respond in a safe manner and not injure the person. Staff had not received training to support the individual needs of people in a safe way in other areas, such as choking.

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.

Modifications have been made to the home to meet the needs of people that live here. Extensive redecoration of the home was in progress at the time of our inspection. The registered manager assured us that part of the redecoration would be to make the home more suited to the needs of people that live with the experience of dementia.

People told us that they enjoyed the food and had enough to eat and drink. They were given a choice if they did not like what was on offer. People’s specific dietary needs were met.

Staff had a good knowledge of their responsibilities for keeping people safe from abuse. The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home.

People told us that staff were kind and caring and treated them with dignity and respect. People knew how to make a complaint. Feedback from people was that the registered manager and staff would do their best to put things right if they ever needed to complain.

We identified seven breaches of the regulations. You can see what action we told the provider to take at the back of the full version of this report.