This inspection took place on 15 November 2018 and was unannounced.

Malvern 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. The care home can accommodate up to 28 adults with complex mental health needs. The service is in a residential area of Bradford approximately two miles from the city centre. At the time of the inspection there were 15 people using the service.

The last inspection took place on 21 November 2017 and was rated as ‘requires improvement’ as we needed to see the improvements could be sustained over time. No breaches of regulation were identified. On this inspection we found improvements had been sustained and developed further.

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 were safeguarded from abuse and improper treatment. Well understood policies were in place to protect people from harm. Risks to people’s health and safety were well managed. Risk assessment documents were in place to guide staff. Staff we spoke with knew people well and the risks they were exposed to.

People had access to a range of professionals to ensure their healthcare needs were met. Medicines were safely managed and given as prescribed.

Improvements to the premises were on-going. People’s bedrooms were personalised and comfortable. The home was clean and odour free.

Staff were recruited safely and there were enough staff to provide people with the care and support they needed. Staff received a range of training and developmental opportunities and told us they felt well supported.

The service had a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards and acted within the legal framework. People were involved in decision making to the maximum extent possible.

People’s nutritional needs were met by the service. People had access to a suitable range of home cooked food and plenty of drinks.

Staff treated people with kindness and compassion and knew them very well. Activities were provided which were meaningful to people and group and individual trips out were organised.

People’s care needs were met by the service. Each person had a range of appropriate care plans in place and we saw evidence needs were being met. People’s likes and preferences were sought to ensure care was person-centred.

People who used the service and staff praised the registered manager, said they were approachable and wanted the ‘best’ for people who used the service. They all felt able to raise issues or make comments which were taken on board and used to improve the service.

We found a friendly and inclusive atmosphere in the home with all staff working well together and in the best interests of people using the service. Clear, caring values were in place and staff consistently worked to them.

The registered manager had good oversight of the home. There was a strong emphasis on continuous improvement of the service. People’s views and opinions were a key part of this.

This inspection took place on 21 November 2017 and was unannounced.

At our last inspection on 23 and 25 May 2017 we rated the service as ‘Inadequate’ and identified three breaches which related to privacy and dignity, person-centred care and good governance. This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Malvern Nursing Home provides accommodation and nursing care for a maximum of 28 adults with complex mental health needs. The service is located in a residential area of Bradford approximately two miles from the city centre. At the time of the inspection there were 17 people living at Malvern.

The home had a registered manager. 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.

We found the provider; registered manager and staff had worked hard to build on the improvements we had found at the last inspection. The increase in staffing levels had been maintained and was kept under review. The registered manager recognised additional staff were required at mealtimes and recruitment was ongoing. We saw staff worked well together as a team in meeting people’s needs.

The mealtime experience for people had improved significantly. Lunchtime was a pleasant, sociable occasion and we saw people were able to access their own meals and drinks in the dining area. People's weights were monitored to ensure they received enough to eat and drink. One person told us, “It feels like I am at home.”

The home was clean, bright and well maintained. Many bedrooms had been redecorated. People had been involved in these discussions for example choosing their own colours and pictures.

People’s care plans were more personalised and the home’s electronic care record system was in place for all care plans. People had access to healthcare services such as GPs, district nurse, dentist and chiropodist.

Staff understood safeguarding procedures and knew how to report any concerns. Safeguarding incidents had been identified and referred to the local safeguarding team and reported to the Care Quality Commission. Risks to people were assessed and managed to ensure people’s safety and well-being.

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. Care plans showed where people had made the choice whether to have their own keys for bedrooms. People who smoked had the choice of when to smoke and these had been recorded appropriately. We observed people had access to their own cigarettes.

People told us they liked the staff and described them as kind and caring. People told us they were treated with respect and this was confirmed in our observations. People looked clean, comfortable and well groomed. We saw people enjoyed activities both in the home and out in the wider community.

We saw improvements in the overall audits of the home. Further work in relation to who and when the action was to be completed by was in process at the time of inspection. This documentation had been implemented and shown to the inspectors at the end of the day to start immediately.

Medicines were managed safely. Robust recruitment procedures were in place which helped ensure staff were suitable to work in the care service. Staff received the training and support t

We inspected Malvern Nursing Home on 23 and 25 May 2017. The inspection was unannounced on both days. There were 18 people using the service when we inspected. At the last two inspections we rated the service as inadequate. At the previous inspection in November 2016 we rated the service as inadequate; we found the provider was in breach of four regulations which related to safe care and treatment, person centred care, governance and meeting nutritional and hydration needs.

At this inspection we found the provider had improved the service sufficiently to meet two of the regulations. They needed to make further improvements to ensure the service was consistently safe, effective, caring, responsive and well-led. The provider was still in breach of two regulations relating to person centred care and governance and we identified a further breach in relation to privacy and dignity.

Malvern Nursing Home provides accommodation and nursing care for a maximum of 28 adults with complex mental health needs. The service is located in a residential area of Bradford approximately two miles from the city centre.

At the time of the inspection the service had a registered manager. 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.

At this inspection we found medicines were better organised than at the previous inspection. There was a system of monthly and more frequent ‘mini’ audits to check that staff were following the medicine policy.

People told us they felt safe and most people were satisfied with the care they received. People’s nutritional needs were maintained and weight charts were effective. Not all risks were managed effectively.

Staff told us there were improved opportunities to receive training and support from the management team, including regular supervisions. All the staff we spoke with told us the quality of training was good and it had helped them understand how to do their job well.

At this inspection we saw people were still not encouraged to retain their independence and people had a poor dining experience, however on day two of our inspection we saw an improved experience for people in relation to how the tables were set and how staff reacted to people in the home. We were told by the deputy manager this was due to our findings at inspection on day one.

We saw some examples of good care practice. Staff were observed to be mostly caring and kind in their interactions with people. However we saw evidence of poor practice by some staff. Staff we spoke with told us they now all worked as a team to support people in their home. However this was not always evident during the two days we inspected. We spoke to the management team who told us this would be looked into straight away. People who used the service and visitors were mostly complimentary about staff.

The provider had improved their care planning system. A standard paper format was used as well as using an electronic version. This was to ensure the information was transferred over to the electronic copy and no information was lost. Care plans were written for a range of needs, however, the quality of information varied. This included details around people’s preferences, likes and dislikes.

People who used the service and staff all told us the service had improved over the past few months. We saw evidence of a more robust approach around the governance of the home. However the provider needed to ensure people’s choices and preferences in relation to accessing their rooms and the restrictions on cigarettes. We found the process for managing Deprivation of Liberty Safeguards was not always effective.

The overall rating for this service is ‘Inadequate’ and the service theref

.Malvern Nursing Home provides accommodation and nursing care for a maximum of 28 adults with complex mental health needs. The service is located in a residential area of Bradford approximately two miles from the city centre.

We inspected Malvern Nursing Home on 17 and 30 November 2016. Both visits were unannounced. There were 19 people using the service when we inspected.

Our last inspection took place on 12 May and 22 June 2016 and at that time we found the home was not meeting five of the regulations we looked at. These related to safe care and treatment, dignity and respect, meeting nutritional and hydration needs, person centred care and good governance. The service was rated ‘Inadequate, and was placed in special measures. This inspection was therefore carried out to see if any improvements had been made since the last inspection and whether or not the service should be taken out of ‘Special measures’.

Following the last inspection we met with the registered provider and they informed us they were still committed to appointing a Registered Mental Nurse (RMN) to become the registered manager and improving the standard of care and facilities provided. They also told us they intended to employ a consultant to assist them to achieve compliance.

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.

At this inspection the registered provider told us although they had appointed a manager they had resigned after only a short period of time and they had re-advertised the post. They confirmed in the absence of a manager the recently appointed deputy manager would manage the service on a day to day basis assisted by the clinical lead nurse and assistant manager.

We found the care plans in place did not always provide accurate and up to date information and in some instances nursing staff had completed monthly care plan evaluations without making sure the care plan was still relevant to the person’s needs. We saw individual risk assessments which identified specific risks to people’s health and general well-being, such as falls, mobility, nutrition and skin integrity. However, we found they again did not always provide accurate and up to date information. This might lead to people receiving inappropriate care, treatment and support.

We also found that although medication policies and procedures were in place nursing staff did not always following the correct procedures which meant we could not be confident people received their medicines as prescribed.

We saw people were offered varied a range of homemade meals and a new dining room had been created which made mealtimes a more relaxed and enjoyable experience for people. People told us the food was good and our observations confirmed this. However, we had concerns about how staff monitored people’s weight and ensured their nutritional intake was sufficient.

People told us they were happy living at the home and we saw some caring interactions between staff and people living at the home. We found more emphasis had been placed on treating people with dignity and respect and staff encouraged people to take more pride in their appearance. We also found the registered provider was trying to change the culture within the staff team and stop the institutional practices observed at previous inspections.

We found although external consultants had been employed improvements were still required to the quality assurance monitoring systems in place as they were not robust and had not always identified the shortfalls in the service highlighted above and in the body of this report. The registered provider was not always able to demonstrate the service was managed effectively and in people’s best interest.

We

Malvern Nursing Home provides accommodation and nursing care for a maximum of 28 adults with complex mental health needs. The service is located in a residential area of Bradford approximately two miles from the city centre.

We inspected Malvern Nursing Home on the 12 May 2016 and the 21 June 2016. Both visits was unannounced. There were 23 people using the service when we inspected.

Our last inspection took place in August 2015 and at that time we found the home was not meeting four of the regulations we looked at. These related to staffing, person centred care, dignity and respect and good governance. We required the provider to make improvements and following the inspection they sent us an action plan outlining the action they intended to take including timescales.

Following the last inspection we met with the registered provider/manager and they informed us that they were stepping down from the role of manager for health reasons and were looking to appoint a Registered Mental Nurse (RMN) to become the registered manager.

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.

At this inspection the registered provider told us although they had advertised for several months for a Registered Mental Nurse (RMN) to take on the role of registered manager the position had still not been filled. They confirmed the clinical lead nurse continued to be the “acting manager” and would remain in that role until a new manager was appointed. However, the acting manager did not want to be considered for the post on a permanent basis.

Shortly after the inspection we received confirmation from the provider that they had decided to promote from within the existing senior staff team and the assistant manager had been offered and accepted the position of registered manager.

At this inspection we found staffing levels had been maintained and recruitment for additional support workers was ongoing. However, we found the staff recruitment and selection procedure was not always being followed which might allow people unsuitable to work in the caring profession to be employed. We saw a part time activities co-ordinator had also been appointed since the last inspection. The majority of people we spoke with told us this had had a positive impact on their daily life and enabled them to access more community based activities.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Capacity Act 2005 (MCA).

We saw the complaints policy had been made available to everyone who used the service. The policy detailed the arrangements for raising complaints, responding to complaints and the expected timescales within which a response would be received.

The care plans in place contained individual risk assessments which identified specific risks to people’s health and general well-being, such as falls, mobility, nutrition and skin integrity. However, we found they did not always provide accurate and up to date information which might lead to people receiving inappropriate care and treatment. We also found that although medication policies and procedures were in place nursing staff did not always follow the correct procedures which potentially placed people at risk of not receiving their medication as prescribed.

We saw people were offered varied a range of homemade meals but concerns were raised about how staff monitored people’s weight and ensured their nutritional intake was sufficient. We also saw examples of institutional care and routines which resulted in inadequate standards of care or poor practice which denied people choice or curtailed their independence. For example, although peopl

The majority of information in this report was provided by the assistant manager or qualified nurse on duty.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key 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?

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

Is the service safe-

People's needs were assessed and their care and treatment was planned and delivered in a way which ensured their safety and welfare. Staff always obtained people's consent before providing care and treatment and the process of establishing consent was rigorous and transparent.

Each person's care file had risk assessments in place which covered areas of potential risk such as managing behavioural problems, mobility, falls and nutrition. When people were identified as being at risk, their plans showed the actions required to manage these risks.

The assistant manager and the qualified nurse on duty told us they were familiar with the requirements of the Mental Capacity Act 2005 (MCA). They also told us they were aware of the recent Supreme Court judgment on the Deprivation of Liberty Safeguards and the impact this had on service delivery.

We spoke with six people who used the service and they told us they were pleased with the standard of care and facilities provided by the service. One person said "I know what's going on and nobody does anything for me I don't like." Another person said "I like living at the home, my friends are all here and the staff are friendly and supportive."

However, we had concerns that the staffing levels at the home were not always adequate to meet people’s needs and people were not cared for in a clean and hygienic environment.

Effective -

People had an individual care plan which set out their care needs. We saw wherever possible people had been involved in the assessment of their health and care needs and had contributed to developing their care plan.

The home had a good working relationship with other health care professionals and followed their guidance and advice. The input of other health care professionals involved in people's care and treatment was clearly recorded in their care plan.

Caring –

People who used the service and their relatives told us they were happy with the care and facilities provided at Malvern Nursing Home.

We found the staff we spoke with demonstrated a good knowledge of people’s needs and were able to explain how individuals preferred their care and support to be delivered. They told us they encouraged people to remain as independence as possible within a risk management framework.

However, we observed some people displayed symptoms that involved loss of ability and enjoyment in life. We saw some people did not easily interact with others, many people said very little and some lacked motivation. It therefore might be useful for staff to reassess and re-focus some people's care needs regarding social interactions.

Responsive –

People’s needs were assessed and care and support was planned and delivered in line with their care plan. Care records contained good information about how care and support should be delivered.

Wherever possible people who used the service and/or their relatives were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

People knew how to make a complaint if they were unhappy and were confident if they made a complaint it would be investigated thoroughly and action taken if appropriate. There was evidence that learning from incidents/investigations took place and appropriate changes were implemented.

Well led –

We found that although the service had a quality assurance monitoring system in place it was not always used effectively to ensure compliance with the essential standards of quality and safety.

In addition, we were concerned that the home was running on minimum staffing levels which was impacting on service delivery. This had resulted in some staff feeling there was a lack of communication, leadership and direction from the senior management team which may ultimately lead to people not receiving appropriate care and treatment.

We have asked the provider to tell us what action they intend to take to address these shortfalls in the service.

People told us they were satisfied with the care, support and treatment they received. One person said “It’s lovely here” and another told us they liked living at the Malvern and they invited us to look at their bedroom which they said they really liked. A visitor told us they had no concerns about their relatives care and confirmed their relative received a Halal diet in accordance with their cultural needs.

People’s care was planned and delivered in a way that was intended to ensure people’s safety and welfare and people’s medicines were managed safely.

The service was generally clean but improvements were needed to the systems in place to detect, prevent and control the risk of infection.

There were suitable arrangements in place to make sure staff were checked for their suitability to work with vulnerable adults before they started work.

There were systems in place to monitor the staffing levels and make changes in response to changes in people’s needs. However, some staff said they did not always think there were enough staff to meet people’s needs in a timely way.

People were given information about the complaints system and where necessary were supported to make comments or complaints.

Work was in progress on developing an effective system to identify and manage risks to the health, safety and welfare of people who used the service and others.

Records relating to the management of the service were not always complete and/or up to date.

Our inspection on the 10 October 2012 found we had concerns that the staff had not had the necessary training to enable them to provide support safely to people with complex needs. Also the provider did not have suitable arrangements in place to protect people against the risk of unlawful or excessive control or restraint. Also the smoke room was not maintained properly. The provider wrote to us and told us they would take action to ensure they were compliant with these essential standards. They told us these actions would be completed by the end of December 2012. We carried out this visit to check improvements had been made.

We used a number of different methods to help us understand the experiences of people using the service. We carried out informal observations of how staff approached people; we looked at the care records and talked with two people who used the service, two health professionals, eight members of staff and two managers.

The two people who used the service told us “I have a nice room, like it here” and “nice in here”.

The health professionals told us they had been informed about the improvements the home had made following our inspection in October 2012.

We found the provider had made some improvements to the service.

Some people who used the service told us they enjoyed joining in activities while others felt there was little to do during the day. One person told us “there usually something going on at some point in the day if you want to join in but I have no interest in what they do.” Another person said “they do try to provide activities and I do join in but it’s not for everyone.”

The people we spoke with told us staff were good at getting them medical attention if they felt unwell and always gave them their medication on time. Comments included “if I need a doctor staff either call for one or take me to the surgery” and “the staff look after us well and always call a doctor if someone is unwell.”

We spoke with two health professionals who told us the staff were aware of peoples need's and people were provide with appropriate care and treatment. They also explained the staff were good at supporting people who had complex needs.

However, we found staff had not had the necessary training to enable them to provide support safely to people with complex mental health needs. The provider did not have suitable arrangements in place to protect people against the risk of unlawful or excessive control or restraint or to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. We also found the smoke room was not maintained properly.

During the visit, we had the opportunity to talk to people living in the home and the majority were able to tell us that they were comfortable living there. People generally enjoyed their meals and overall the choice and quality of food provided was good. They also told us that they had opportunities to participate in social events and trips out.

This inspection took place on 20 August 2015 and was unannounced. At the last inspection on 13 January 2015 we found three breaches in regulations which related to staffing, medicines and quality assurance. The overall rating for the service was “inadequate.”

Following the inspection we received an action plan from the provider detailing how improvements would be made including timescales. In July 2015 the provider informed us they had not met the original timescales and provided new timescale within which the necessary improvements would be made. On the 30 July 2015 we met with the provider and discussed our concerns about the service and their improvement plans. At this inspection we found some improvements had been made however we identified further breaches in regulation.

Malvern Nursing Home provides accommodation and nursing care for adults with complex mental health needs. There were 24 people using the service on the day of inspection. The service is located in a residential; area of Bradford approximately three miles from the city centre.

We found although some improvements had been made to the way medicines were managed some concerns still remained as we found the audit system in place had not highlighted one significant discrepancy we found on a medication administration record (MAR). We also found that although new medication policies and procedures had been introduced the protocol for medicines prescribed as and when required (PRN) fell short of the guidance given by the National Institute for Health and Care Excellence (NICE).

We found the staff recruitment and selection procedures were robust which helped to ensure people were cared for by staff suitable to work in the caring profession. In addition, all the staff we spoke with were aware of signs and symptoms which may indicate people were possibly being abused and the action they needed to take.

We saw that arrangements were in place that made sure people's health needs were met. For example, people had access to the full range of NHS services. This included GP’s, hospital consultants, community mental health nurses, opticians, chiropodists and dentists.

We found since the last inspection more emphasis had been placed on staff training and a new supervision and appraisals system had been implemented to ensure staff received the support required to carry out their roles effectively. However, we saw not all staff had yet benefitted from this new approach to supervision and appraisals.

We saw people’s care plans and risk assessments were person centred and the staff we spoke with were able to tell us how individuals preferred their care and support to be delivered. Care plans and risk assessments were reviewed on a regular basis to make sure they provided accurate and up to date information and were fit for purpose. However, we found inadequate staffing levels were significantly impacting on the ability of staff to consistently deliver good person centred care.

We found that although since the last inspection the provider had maintained the number of nursing hours required they had recently reduced the numbers of support workers on the afternoon shift by one. They had also delayed the appointment of an activities co-ordinator for financial reasons. This meant that people who required a staff escort were not always able to go out into the community and/or join in any meaningful social and leisure activities. In addition we saw examples of institutional care and poor practice which denied people choice or curtailed their independence.

We found since the last inspection the provider had improved the quality assurance monitoring systems in place and the there was evidence to show people who used the service were involved in the quality assurance process. There was also evidence to show that the provider had started to review all the policies and procedures in place to ensure they provided staff with accurate and up to date information.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of this report.