This unannounced inspection was carried on 21 August 2018.

Horton Cross Nursing home is a care home registered to provide care and accommodation for up to 47 people. The home specialises in the care of older people. At the time of the inspection there were 41 people living at the home.

At our last inspection, in March 2016, we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

.

At this inspection we found the service remained Good.

Why the service is rated Good.

People lived in a home where staff morale was good which created a happy and relaxed atmosphere. One person told us, “Staff are always happy and chatty.”

People received safe care and support from adequate numbers of staff who had the skills and experience to meet their needs.

Staff were kind and caring and treated people with respect and dignity. One person said, “If I had to sum up the staff I would say, very caring and loving.”

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 was monitored by trained nurses and they had access to other healthcare professionals to meet their individual needs. People received their medicines safely.

People’s nutritional needs were assessed and met. People received the support they required to eat their meals and were happy with the food provided. One person told us, “I’m a fussy eater but they are brilliant. If I don’t want what’s on the menu they make me something different.”

People were treated as individuals and staff supported people to make choices about their day to day lives. Staff knew people well and provided care that was personalised to their wishes and needs.

The home was well led by a stable management team. The management team kept up to date with good practice to make sure people’s care was provided in accordance with best practice guidelines and current legislation.

There were effective quality assurance systems which monitored standards of care and addressed any shortfalls in the service.

Further information is in the detailed findings below.

This inspection was carried out on 30 March 2016 and was unannounced.

The last inspection of the service was carried out on 2 April 2014. No concerns were identified with the care being provided to people at that inspection.

Horton Cross Nursing Home provides accommodation with nursing care for up to 47 people. The home provides a service for older people. Accommodation is arranged over two floors and all bedrooms are for single occupancy. The home is staffed 24 hours a day and a registered nurse is on duty at all times.

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.

From the management down; staff were committed to making sure people were safe, happy and received the care and support they needed and wanted. Staff were very kind, caring and patient when they interacted and assisted people. People spoke highly of the staff team. One person said “All the staff are so very kind. That’s from the top down.” Another person said “I cannot speak highly enough of the staff. Nothing is too much trouble and they are all so kind to me.” A visitor told us “I can’t praise them [the staff] enough. They are so kind and welcoming.”

People received care and support which was adjusted to meet their changing needs. People had access to appropriate healthcare professionals to make sure they received effective treatment when required. People received their medicines when they needed them and medicines were stored securely. Medicines were managed and administered by registered nurses whose skills and knowledge were regularly monitored.

People were supported to have enough to eat and drink. People were positive about the quality, quantity and choice of food available. One person told us “The food here is very good and there is plenty of it.” Another person said “The food is excellent and they know what you like.”

Risks to people were minimised because there were effective procedures in place to identify and manage risks. These included reducing the risk of falls, assisting people to mobilise and reducing risks to people who were at high risk of malnutrition and pressure damage to their skin. A plan of care had been developed to minimise risks and these were understood and followed by staff. Staff recruitment procedures minimised risks to people because potential staff were thoroughly checked to make sure they were suitable to work with vulnerable people. Staff had received training and knew how to recognise and report abuse. All were confident that any concerns reported would be fully investigated and action would be taken to make sure people were safe.

The registered manager made sure staff skills and knowledge were up to date and that they were competent to care for the people who lived at the home. This was achieved through regular supervisions, observation of their practice and on-going training. People were very complementary about the staff who supported them and felt they had the skills required to effectively care for them. One person said “All the staff are really good. They know what they are doing and I have great confidence in all of them.”

People told us they were never made to do something they did not want to do. One person said “I get up when I want and go to bed when I want. It’s very relaxed here.” During the afternoon we heard staff asking one person if they would like to go to their room as they appeared sleepy. The person indicated they would and they were assisted to do so.

People were provided with opportunities for social stimulation and they were supported to maintain contact with their friends and family. People told us they could see their visitors whenever they wished and that they were

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service safe?

We found the service to be safe because they had a range of policies and procedures in place to protect the people who lived in the home.

There were risk assessments in place regarding mobility, nutrition and skin care. Where someone had been assessed as being at high risk of pressure damage appropriate equipment such as pressure relieving mattresses and cushions were in place. The manager told us there were never any problems obtaining specialised equipment to meet people’s assessed needs.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that staff knew how to ensure people's rights were respected.

We saw that staff had received training about safeguarding adults from abuse and those spoken with demonstrated a good understanding about what constituted abuse and how to report any concerns. Staff confirmed they would not hesitate in reporting concerns if they had any. They also told us they felt confident that any concerns would be responded to and appropriately investigated.

There were sufficient numbers of suitably qualified, skilled and experienced staff on duty to meet the needs of the people who lived at the home.

Is the service effective?

We found the service to be effective because people's care treatment and support achieved good outcomes. We also found that people's rights and choices were respected by staff.

The majority of people required staff assistance to mobilise. Throughout our visit we heard staff checking people were happy with where they were sitting. We observed staff assisting people to their bedrooms where requested. The people we spoke with told us that staff respected their wishes. Comments included “They don’t do anything without checking with me first. They are very good” and “the staff keep me informed and make sure I can have my say.”

Is the service caring?

People told us the service was caring. The people we spoke with were positive about the care and support provided by the home. Comments included “I am very satisfied with everything. They do a good job” and “It’s nice to be able to have a laugh and joke with the staff.”

People told us they felt safe and well cared for and all commented on the kindness of the staff. Throughout our visit we observed staff interactions with people to be kind and respectful and people appeared very comfortable in the presence of staff.

Is the service responsive?

The service was responsive to people's needs. We saw that people’s health care needs were monitored and responded to appropriately. Information about people’s health needs and contact with health and social care professionals had been recorded. We were informed that the service received good support from health and social care professionals and there were no problems obtaining their input for people when required. The people we spoke with made the following comments “I am diabetic and the nurses make sure I get regular visits from the chiropodist” and “I haven’t needed the doctor yet but I am confident they would sort something if I was poorly.”

Staff were able to respond appropriately to people's needs because they had up to date guidance on how to support each individual. We read the care plans of four people who lived at the home. These contained assessments of need and outlined how needs would be met. The assessments were regularly reviewed to ensure they reflected people's up to date needs and preferences.

Is the service well led?

The service was well led because there were systems in place which monitored the quality of the service provided. The service was proactive in seeking the views of the people who lived at the home and their representatives. We saw that the service responded to any comments or suggestions made.

The service was managed by a person who had been registered by the Commission. The registered manager, who is a registered nurse, regularly provided 'hands-on' care. This meant they remained up to date with the needs and preferences of the people who lived at the home. The people we spoke with were positive about the manager. They told us the manager was "approachable" and was "always ready to listen." The staff we spoke with told us they received the training and support they needed. They told us the manager responded to training requests and that they found her "very approachable."

We found procedures were in place to minimise any risks to the people who lived at the home. Regular internal audits had been carried out which monitored the on-going health and safety of people. Internal audits included checks on the home's fire systems, environment, care planning and the management of people's medicines.

When we visited 41 people were using the service. We spoke with 21 people, four visitors and three members of staff. We also spent time observing how staff interacted with the people who lived at the home. Staff interactions were kind and respectful.

Some people were able to tell us that staff sought their consent about the care and treatment they received. One person told us that they had recently had a flu jab. They told us that this had been explained to them and they had been given the option not to have one.

People's human rights were not always protected because the home did not follow the principles of the Mental Capacity Act 2005 or Deprivation of Liberty safeguards.

The people we spoke with, including four visitors, were positive about the care and support provided by the home. Comments included “they really saved my life. I moved here after eight months in hospital. I have improved so much since being here. I feel better than ever” and “I cannot fault the care here. They are all so kind and caring.”

The home’s health and safety procedures minimised risks to the people who lived at the home. We saw that people had been provided with equipment in line with their assessed needs.

People using the service were provided with opportunities to express a view on the quality of the service they received. Quality assurance procedures helped to reduce risks to people who lived at the home.

People appeared very comfortable in the presence of staff and it was evident staff knew people well. Staff were observed being kind, caring and patient when they supported people.

We spoke with two visitors who told us that the home kept them “well informed” about the well being of their relative. One visitor told us that they had been involved in the development and review of their relative’s care plan. People spoken with were also aware that they had a plan of care and we saw that people had been involved in the review of their care.

We asked people if they were able to make choices about how and where they spent their day. They told us “I can come to my room when ever I want to. There are no strict rules” and “They know that I like to go to bed early and get up early. That’s always been my routine.”

The home had policies and procedures for recognising and reporting abuse and whistle blowing for staff. All staff spoken with were aware of issues of abuse and knew how to report any worries or concerns. All said they felt confident that any reports would be fully investigated to ensure that people were protected.

People using the service told us that they were able to make decisions about their lives and that the staff team treated them with respect. People said “I can choose where I spend my day and can spend time in my bedroom whenever I want to”; “I have my electric wheelchair and can go anywhere I like in the home”.

We spoke with a number of people during our visit and they were positive about the care and choices they received.

People said “I have a key worker who makes sure I have everything I need”, “The staff are so kind and always ask if I am alright”, “There is no pressure to do anything”

During our visit we were able to observe staff interactions with people living at the home. These were noted to be kind and respectful. People were referred to using their preferred form of address and we observed staff offering people choices about how and where to spend their day. Those who were able were observed moving freely around the home.

Each person living at the home has a plan of care which identifies their assessed needs and preferences. We were able to see that these were regularly reviewed with the involvement of the individual and or their representative. Staff spoken with told us that they referred to peoples’ care plans on a daily basis and that they “don’t experience any problems in meeting peoples’ assessed needs”.

During our visit we were able to see lunch being served. The meal looked wholesome and plentiful and we saw that people were served with their chosen option. We observed staff offering assistance to those who required it. Assistance was provided in a dignified and unhurried manner.

We asked people living at the home what they thought about the meals and choices available. They told us; “The food is very nice and I certainly never feel hungry”, “the food is good, choices are available and there is always salt and pepper which I like”. We examined some care plans and these contained information about peoples’ preferences and any special dietary needs. We spoke with one person living at the home who told us, “They make sure that I get my special food because of my diabetes”.

The home ensures that people have access to appropriate health care professionals. People living at the home told us “they are very good at getting the doctor to come if you are not feeling very well”. One person told us, “I have recently seen the doctor and he is going to come back if the antibiotics don’t work”.

The registered manager and staff working at the home told us that they have “very good” support and input from doctors and specialised health care professionals.

During our visit we were able to speak with a number of staff working at the home and they were able to demonstrate a good understanding of what constituted abuse and of how to report any abuse. Staff told us that they had received training in abuse and safeguarding adults and would feel “confident” in following these procedures.

People living at the home appeared relaxed and comfortable in the presence of staff and nobody spoken with raised any concerns regarding the way they were treated or of the care they received. People said, “The staff are very kind here”, “I have my favourites but they are all lovely and will always help you”.

During our visit we viewed all communal areas and a selection of bedrooms and we found the standard of cleanliness to be good with no malodours.

We were able to see that staff had access to a good supply of protective equipment such as gloves and aprons and that these were being used appropriately as ‘single use’.

Peoples’ medicines are managed and administered by the registered nurses on duty. We saw that systems were in place to ensure that people using the service always had sufficient supplies of their prescribed medicines. We were also able to see that regular reviews were taking place with peoples’ doctors to ensure that prescribed medicines remain appropriate and effective for the individual.

Records examined during our visit confirmed that people were receiving their prescribed medicines in accordance with the prescriber’s instructions.

The home has been suitably adapted to meet the needs of people using the service and to assist people to maintain a level of independence with mobility needs. Grab rails and ramps are appropriately sited throughout the home and a shaft lift provides access to first floor accommodation.

Bedrooms are situated over two floors with a number of comfortable communal areas situated on the ground floor. All bedrooms seen during our visit were comfortably furnished and had been personalised to reflect the tastes of the individual person. People are able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel.

People told us; “I am very happy with my room and can spend time here whenever I want to”, “It is so nice that I could bring my little bits of furniture from home”.

During our visit we saw that people have access to a good supply of specialised equipment such as reclining and upright chairs, profiling beds and pressure relieving equipment.

Mobile and fixed hoists are available to assist people with their mobility needs and people have access to appropriate numbers of assisted bathing and toilet facilities. We were able to see evidence that all equipment had been regularly serviced by outside contractors.

A call bell system is installed throughout the home so that people can call staff for assistance as required. People told us that staff responded promptly to call bells. “I sometimes have to use my call bell at night and the staff come quite quickly”, “I don’t need to use my bell much but the staff always come when I need them”.

During our visit we saw that people had easy access to their call bells.

We looked at the home’s procedures for the recruitment of staff and found that ‘robust’ procedures were being followed which reduce the risk of harm or abuse to people using the service.

We were able to see that staff do not commence employment at the home until all required checks and documentation have been received. Applicants are also required to complete a satisfactory interview and health check.

The home ensure that newly appointed staff complete a period of induction so that they have the skills and training needed to enable them to meet the needs of people living at the home.

Staff working at the home receive regular supervisions and appraisals and this helps to ensure that staff are appropriately supported and that any training needs can be identified.

We noted a good staff presence throughout our visit and people told us “there is always someone about to help you”.

The atmosphere in the home was noted to be relaxed and we observed staff spending quality time with people. The home also employs designated ‘activity’ staff to provide people with a range of activities both within the home and in the community. We looked at some albums which were in one of the lounges and these contained photographs of people enjoying trips out and events within the home.

People told us that they felt “well looked after”. Staff confirmed that they did not experience any concerns in meeting the needs of people living at the home. Read the full inspection report (PDF)