Lady Forester Community 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. The provider also provided personal care only (domiciliary care) to people in the ten one bedroomed apartments adjacent to the nursing home called Forester Court.

At this unannounced inspection on the 30 and 31 August 2018 they were providing nursing and accommodation to 25 people and personal care to a further six people.

Lady Forester Community Nursing Home had a registered manager in place but they were not present during this inspection’s site visit owing to pre-arranged annual leave. 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 supported day to day by a manager who was present throughout this inspection.

Following our last inspection in October 2015 we published our report in December 2015. At that inspection we rated Lady Forester Community Nursing Home as ‘Good’ overall. However, we identified areas of improvement were needed to be made in the relation to the key question ‘Responsive’. Improvements were needed to be made in relation to engaging people in activities.

At this inspection, we identified three breaches of regulations. These were in relation to; lack of person centred care planning, failure to make the required notifications and ineffective quality monitoring and governance. In addition, we found other areas that required improvement.

People did not have up to date care and support plans that reflected their needs and preferences. The provider had failed to make the necessary notifications that they are required to do so by Law. The provider’s quality monitoring systems were not sufficient enough to identify and make improvements when they were needed.

People and staff members sometimes felt that they were rushed and that there was not enough time to spend positively interacting with those receiving care and support.

People could not be assured that their rights were upheld in relation to the Mental Capacity Act 2005 (MCA) as the provider did not follow recognised best practice when assessing people’s needs.

When needed people had individual assessments of risk based on their medical needs. However, some of these assessments incorrectly calculated meaning some people had an inaccurate indication of the care they required.

People did not always receive support at times when they were upset and distressed.

People did not have information presented to them in a way they could access and understand as the provider had not implemented the principles of the Accessible Information Standards.

People’s human rights and protected characteristics, like faith and disability, were not fully supported or promoted as important information regarding their lives so far had not been included in their care planning.

People were safe from the risk of abuse and ill-treatment as staff knew how to recognise and respond to concerns. Any concerns raised with the management team were acted on appropriately. The provider followed safe recruitment procedures when employing new staff members. People received their medicines, as prescribed, with the assistance of staff who were competent to safely support them.

New staff members received an introduction to their role and were equipped with the skills they needed to work with people. Staff members had access to on-going training to maintain their skills and to keep up to date with changes in adult social care.

People’s privacy was respected by those providing assistance. People a

The inspection was carried out on 21 October 2015 and was unannounced. At our previous inspection on 25 June 2014 we found that they were meeting the Regulations we assessed them against.

Lady Forester Community Nursing Home provides accommodation and personal care with nursing for up to 25 older people. The provider also provides personal care only (domiciliary care) to people in the ten one bedroomed apartments adjacent to the nursing home called Forester Court. There is 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 who lived at the home and in their apartments felt safe and secure with staff to support them. People had been assessed before moving to the home or receiving a domiciliary care service, so they knew what they needed help with. Care records contained details of people’s preferences, interests, likes and dislikes.

Staffing levels and the skill mix of staff were sufficient to meet the needs of people who lived in the home and apartments and to keep them safe. Staff recruitment was thorough with required checks completed prior to staff commencing work. People who received a domiciliary care service had attention day and night and they were safe.

Medication was stored and administered safely. Nursing staff dealt with one person at a time in the home to minimise risks associated with this process. Care staff had received formal training to ensure they were confident and competent to assist people with their medicines in their apartments.

People were happy with the variety and choice of meals available to them. Regular snacks and drinks were available between meals to ensure people received enough to eat and drink. People who lived in their own apartments could take a meal in the home’s dining room and so were welcomed as part of that community.

People who lived at the home were encouraged and supported to maintain relationships with their friends and family members. Relatives and visitors were always made welcome when they visited their loved ones.

The care plans were centred on people’s healthcare needs and gave staff direction to provide effective care. Most people were confident that their care was provided in the way they wanted.

Staff provided some group activities and there were opportunities for social stimulation from visiting entertainers. The registered manager acknowledged that they could do more to meet individual preferences for people in addition to providing group activities.

A number of audits were in place to monitor quality. The provider acted on shortfalls identified. Records of audits did not always document the outcomes in order to reflect and learn from them as part of the overall monitoring of the service.

The provider had annual and ad hoc surveys in place to obtain the views of people who received a service. The general manager and registered manager spoke with people individually on a daily basis to seek their views about their care.

A single inspector carried out this inspection. The focus of the inspection was to answer the five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

Is the service safe?

People felt safe because their rights and dignity were respected when making decisions about any risks that they may wish to take. People were safe because the provider had a system to manage accidents and falls and learnt from them, so they were less likely to happen again. For example, the provider kept records that analysed and monitored falls. They also detailed what actions were taken to assist people to maintain their safety after a fall.

Staff understood about the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and how they would be put this into practice. No DoLs applications had been submitted but the provider was undertaking a review of this.

CQC monitors the operation of the Deprivation of Liberty Safeguards 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 people living in the home were protected from avoidable harm, abuse and breaches of their human rights.

The people considered they were kept safe and were listened to. We observed that people were free to go about their daily routine as they wished. One person told us, “I feel happy here. The staff are always on hand to help me and I can do as I please.” A relative said, “Since my mother has deteriorated the staff have helped me enormously. They communicate well with me and I know my mother is safe.”

Is the service effective?

People we spoke with said they felt confident discussing their health needs with staff. They said their health was regularly monitored to identify any changes that may require additional support or intervention such as referral to the GP or dietician. We looked at records that showed referrals were quickly made to health services when people’s needs changed. Records noted that relatives were kept informed. A relative commented, “I was informed of all visits made by GPs and the recommendations made by them.” Another said, “ X improved, thanks to the swift action taken by the staff at the time, calling the doctor and keeping me fully informed and updated at all times. I was confident X was receiving appropriate, dignified and gentle care day and night.”

Staff we spoke with demonstrated they had the skill and knowledge to meet people’s assessed needs, preferences and choices at all times. Staff had discussed and recorded important issues around consent to care and when people did not want to be treated. They had also explored whether people’s family were to be included in decisions and this was respected. People told us they were happy to discuss their personal preferences with staff. They said that staff kept an eye on them and got help very quickly if they were unwell. This meant people were supported to maintain good health, have access to health care services and received on-going support.

Is the service caring?

The people we spoke with told us they felt that their dignity was respected and they were assisted to live their life as they wished. Staff took the time to find out people’s personal social histories. Staff we spoke with knew people’s needs well and how they wished to be cared for. This meant that staff cared about the person as an individual and were concerned about their well-being.

People and those that mattered to them were encouraged to make their views known about their care. A relative we spoke with confirmed that staff considered their views were important and were respected. This meant that people were listened to and they felt that their views mattered.

Is the service responsive?

The registered manager and the team of staff demonstrated a clear understanding of the importance of communicating with people and their relatives to find out their aspirations, preferences and diverse needs. Care records detailed how people’s individual needs were regularly assessed and met. Detailed nutritional records were kept with clear instruction for staff.

Staff told us that a situation would be considered under the Mental Capacity Act 2005 if people did not have capacity, so that decisions would be made in their best interests. The way staff interacted with people showed that they actively sought and listened to people’s views and decisions. This meant people were supported to express their views and be actively involved in making decisions about their care and support.

Is the service well led?

The management and staff demonstrated values that included involvement, compassion, dignity, respect and independence. Staff we spoke with showed they understood this as they discussed their role and responsibilities in their work. This meant the service promoted an open culture that was centred on the individual and empowered them to take control of their life as they were able.

Developments in guidance and best healthcare best practice were used as an opportunity for learning and improvement. For example, the service was exploring how they could provide dementia care for people. This would mean people would be assured of appropriate management and decision making on their behalf if they developed a dementia related illness.

Concerns were listened to. The provider hadn’t received any complaints but people told us they would “Go straight to the manager” if they were unhappy.

The provider had systems in place to assess and monitor that staff had the right competencies, knowledge, qualifications, skills and experience to meet the needs of people. This meant staff were motivated to carry out their role and to meet people’s needs.

People that lived at the home and the relative we spoke with were happy with the care provided at the home.

At our inspection we found that people who used the service and their relatives were involved in the care and there were suitable measures in place to ensure people's nutritional needs were met. Staff had a good understanding of the care needs of individual’s living at the home.

People told us that they enjoyed the food and drink provided within the home. They were able to choose what they wanted to eat from the menu and where they preferred to eat a meal.

Building works were in progress to improve the facilities at the home. The home was clean, tidy and well maintained. Regular safety and maintenance checks were being carried out to make sure that the premises were safe and suitable for people's needs.

People who lived in the home or used the domiciliary serviced said that they were well looked after. They told us that the staff always asked them how they would like things to be done, always respected their privacy and treated them with respect. They said staff talked to them about how they liked their support to be provided.

Staff provided health and social care support well. Community services were accessed to support people when necessary.

People who lived in the home or used the domiciliary serviced told us that they felt able to raise any issues with the manager or staff should they have any concerns. Staff spoke of their awareness of how to keep people safe from harm. Staff told us about the training that the service had arranged for them to attend so that they would recognise abuse and how to report it.

People told us that staff were always available when they needed help. People’s relatives told us that staff were around and available to talk to when they visited. They said that the staff were friendly and always acted professionally. One person said that, “It’s a very nice place to be” and another said, “The staff are very helpful”.

People we spoke with said their comments were listened to. A visitor said they would not hesitate to talk to staff if something was wrong. The home’s management held regular meetings with the people who use the service to find out what people thought about how their care was delivered.

People told us that they were content. They told us that they were consulted about their care, that their views were taken into account in the way the services were provided and delivered.

People said their privacy and dignity was very much respected and their independence promoted.

People told us that the care delivery was well organised by the manager and her staff. They said that they wouldn’t hesitate to ask questions or request help with any aspect of their care. “The staff are caring and I couldn’t choose a better service now I need help”.

People in the care home told us they were happy with their bedrooms and that they could either remain in the privacy of their own room or join other people in the choice of communal areas available. They said their rooms were kept clean and when they moved in they were encouraged to bring in some of their personal belongings if they wished.