This inspection took place on 7 and 8 November 2017. It was an unannounced visit to the service.

Hulcott 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.

It is registered to provide support to older people, some of whom may have dementia. The building was originally built in 1862 and was formerly the village rectory. Over the years the home has been renovated and this work continues to ensure accommodation is suitable and fit for purpose. At the time of our inspection 35 people lived at the home, three of whom were in hospital.

At the last inspection, the service was rated Good. At this inspection we found the service remained Good.

At the last inspection on 10 and 11 October 2016 we asked the provider to take action to make improvements in relation to informing CQC of certain events and this action has been completed.

People were supported by staff who had a good understanding of their likes and dislikes. We were informed people had developed good working relationships with staff. One person told us “They’re [Staff] like my friends, a lot of the staff, because you can chat with them. They [Staff] make time as they like to make sure you’re happy at all times. If they see you looking a bit down they come and ask what’s the matter? and talk to you.”

We received positive comments from people about their experience of living in the home. People told us “They’re [Staff] very good to us. They look after us very well. This is a lovely nursing home. As soon as you press your buzzer they come and see what’s the matter.” “They look after us very well” and “They’re very kind. They do everything for you and look after you.”

We found mixed practice around the recruitment of staff. There were four staff who had been recruited and there was no information available to justify their appointment. We have made a recommendation about this in the report.

People were supported by staff who had access to on-going training to enable them to work with people and keep their skills up to date. Staff felt valued by people and the management.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

People were provided with a personalised service as staff were knowledgeable about them and showed an interest in getting to know them.

People were supported by staff to engage in activities of their choice. A range of opportunities existed for people to join group activities in the home or go out from the home.

The home had quality assurance processes in place to drive improvement. Feedback was sought from people, their relatives on how the service could be improved.

Further information is in the detailed findings below.

This inspection took place on 10 and 11 October 2016. It was an unannounced visit to the service.

Hulcott Nursing Home is a nursing home for adults some of whom are living with dementia. It is registered to provide accommodation for 49 people. At the time of our inspection 30 people lived at the home. The home is located in a small village in Buckinghamshire.

We previously inspected the service on 4 June 2014. We found the provider was not meeting one of the five standards checked at the time. We found breaches of Regulation 15 of the Health and Social Care Act 2008. People were not always protected from environmental risks. The home was not adequately maintained. The provider sent us information to tell us what action they were taking to ensure it improved. At this inspection we found the provider had completed a programme of remedial work to improve the environment. Risk assessments were in place for further work planned.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

We received positive feedback about the home; people told us it was warm, friendly and a homely environment. People spoke highly of the registered manager and the staff team. Comments included, “Caring staff, proactive manager, good atmosphere, good quality care,” and “The carers in this home are extremely excellent.”

Providers and registered manager are required by law to tell CQC of certain events or incidents that occur as a result of people receiving care and support. We call these notifications. One event services are required to tell us is about when a decision had been made about an application to lawfully deprive a person of their liberty. We found this did not always happen.

Services we regulate should ensure that records are kept and maintained securely. We found not all the records we asked to review were readily available and did not provide an accurate record of what checks had been carried out. We have made a recommendation about this in the report.

People told us they received kind and compassionate support from staff that were knowledgeable about them. People told us “I am very pleased with the staff, they have made me so welcome, they are all very friendly,” and “The caring in this home is very good indeed.” Care plans detailed people’s likes and dislikes.

People were protected from avoidable harm, as staff had received health and safety training. Staff knew how to recognise signs of abuse and what to do should a concern be raised.

The service had robust recruitment processes in place, which ensured only people with the right skills and attributes were employed.

People had good access to healthcare and any changes to health were reported promptly to healthcare professionals.

People were supported to engage in activities of their choice, and an activities co-ordinator spent time with people in groups and on a one to one basis.

People and their relatives were able to give feedback to the service at resident and relative meetings.

Staff told us there was clear leadership from the registered manager. People told us the registered manager was visible and approachable.

We found a breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

The inspection visit was carried out by one inspector. We spoke with five people who lived in Hulcott Nursing home, three visiting relatives and with a GP. We spoke with the manager, deputy manager, regional manager and three members of the care staff team. We observed the interactions between staff and people who lived at Hulcott Nursing home. We also carried out a SOFI observation over lunch to observe staff interactions and engagement with people who were unable to communicate verbally with us. This was to assess the quality of care those people received. We looked at some records, including people's care plans files, rotas and quality monitoring checks. We walked around the home.

We considered the evidence we had gathered under the outcomes we inspected. We used this information to answer the questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

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

Is the service safe?

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLS). The manager told us at the time of our inspection there was no person with a DOLS application in place, but they understood when it would be required.

We looked at care plans and spoke with staff. We found there were risk assessments in place to identify and manage risks to people's health, safety and welfare. We saw pressure area care was well managed and addressed. The GP told us how staff had done a fantastic job of caring for a person with a pressure sore. They said as a result of the care provided the pressure sore was now almost healed. This meant people's safety was promoted.

We saw issues identified at the previous inspection in relation to the environment were being addressed. A refurbishment and redecoration schedule was in place to update the home and to make the environment more suitable for its intended purpose.

These findings demonstrated to us that the service was safe.

Is the service effective?

We looked at three care plans. We saw they were detailed, specific and informative as to how people were to be supported with all aspects of their care. We saw records of fluid and food intake were recorded and outlined people's total daily fluid intake. We saw turning charts were in use and completed to indicate people in bed had been turned as required. We saw people's health needs were met. A relative told us that they felt staff were really good at picking up changes in people's conditions and that they were kept informed of changes and action taken.

These findings demonstrated to us that the service was effective.

Is the service caring?

We spoke with five people who lived in Hulcott Nursing home. People told us they were happy with their care and support. Two people and a relative were very complementary of two particular carers. They said they were very good and described them as being "extremely kind and caring". Relatives and people who used the service also commented on how the manager was "hands on" and had a visible presence in the home which they liked. They described the manager as being gentle, kind, caring and compassionate who was approachable and made themselves available to them.

Throughout our visit we observed positive interactions between staff and the people who used the service. Staff were kind, caring, gentle and reassuring. We saw staff maintained good eye contact with people whilst providing reassurance throughout the task they were assisting them with.

These findings demonstrated to us that the service was caring.

Is the service responsive?

We saw the manager regularly carried out visual observations of staff practice. Records were maintained of their findings and action taken to address any concerns identified. These were followed through in one to one sessions.

The GP told us they felt staff were responsive to changes in people's needs. They said the GP practice was kept informed of changes in people and staff carried out the agreed actions from their visits.

We looked at the rota and spoke with people who used the service and staff. We saw the desired staffing levels were being maintained through the use of bank and agency staff. The manager told us they had reassessed the staffing levels. As a result they had agreed with the provider to increase staffing levels during the day and employ two more nurses to enable them to provide a better service to people and to provide further clinical support for staff.

These findings demonstrated to us that the service was responsive.

Is the service well led?

Staff told us they felt suitably supported and they felt the home was well run. They said the manager was accessible and responsive to their feedback. We saw people and relatives were provided with regular meetings to enable them to raise any issues about the service. Requests and actions from those meetings were responded to in a timely manner.

We saw that a range of audits took place and issues highlighted in the audits were addressed. We saw the provider carried out checks on the home and action was taken to address findings.

These findings demonstrated to us that the service was well-led.

We spoke with four people who used the service, two relatives and three staff. People and their relatives told us they were happy with their care. A person commented "I am well looked after, staff treat me well and they are very kind". A relative told us there were lots of activities provided and they were able to be involved in supporting their relative on some recent outings. They commented that "Staff are really good. They all know me, all say good morning, all smile, all cheerful and I know they would inform me if anything was wrong”.

We observed positive interactions between staff and people who used the service. We also observed practices which did not promote people's choices, dignity and decisions in relation to their care and treatment.

People's care and welfare needs were assessed. Care plans and risk assessments were in place which ensured people received safe and consistent care. Medication was appropriately managed which meant people received their medication in a safe way.

Areas of the home were in need of refurbishment and items needed replacing to ensure people were cared for in a safe environment.

Staff told us they were inducted, trained, supported and supervised in their roles. This ensured people were supported by staff who were suitably trained and supervised. Quality monitoring systems were in place which meant people could be confident the service was being effectively monitored.