This inspection took place on 25 May 2017 and was unannounced. At the previous inspection on 25 April 2016 we rated the service ‘Requires Improvement’ in two of the key questions we asked of services, ‘Is the service safe?’ and ‘Is the service responsive?’. Therefore the service was rated overall as ‘Requires improvement’. We however did not find any breaches of regulations at that inspection.

Milverton Nursing Home provides nursing care for up to 30 older people, some of whom were living with dementia. There were 28 people using 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.

Our findings showed that the provider managed risks to people using the service and those relating to the premises well. However, risks relating to bed rails were not always well managed as some risks had not been appropriately risk assessed and mitigated. The registered manager told us they would take immediate action regarding these risks.

The registered manager had improved processes for recording incidents since our last inspection to ensure action in response to incidents was appropriate. In addition the registered manager had improved the complaints process to ensure all complaints were recorded and reviewed as part of improving the service.

The activities available to people had been extended since our last inspection to consider the needs of people who spent much time in their rooms to reduce the risks of social isolation. The activities officer organised activities based on people’s interests. These included weekly outings, entertainers and group activities.

A programme of renovations to extend and improve the home was in place and included provision of a new conservatory and staff facilities.

The provider managed people’s medicines safely as staff followed robust procedures in all aspects of medicines management.

Staff understood how to safeguard people at the service and had received training in this area. Staff knew the signs people may be being abused and the registered manager responded to concerns appropriately to keep people safe.

There were enough staff deployed to meet people’s needs. The provider carried out appropriate checks to ensure only staff who were suitable worked with people. These checks included previous work experience and qualifications, including PINs for nurses, identification, right to work in UK and health conditions. A programme of induction, supervision, appraisal and training was in place to help staff understand how to respond to people’s needs. Staff felt supported by the registered manager.

Staff supported people with their healthcare needs including accessing healthcare professionals. Staff knew the people they supported. People’s care plans contained sufficient detail about their support needs, backgrounds and preferences for staff to follow in providing care to them.

People were involved in decisions about their care and staff understood the importance of the Mental Capacity Act 2005 to their role, such as how to respond when people lacked capacity to consent to their care. The registered manager applied for authorisations to deprive people of their liberty appropriately under Deprivation of Liberty Safeguards (DoLS). DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

People were provided with a choice of food and were positive about the food they received. The chef ensured food was prepared in accordance with people’s specific dietary and health related needs.

People, relatives and staff tol

We undertook an unannounced inspection on 25 April 2016. At our previous inspection on 18 November 2015 the service was meeting the regulations inspected.

Milverton nursing home provides accommodation, personal and nursing care for up to 30 older people, some of whom have dementia. At the time of our inspection 27 people were using the service.

The service had 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.

Some aspects of the service required improvement. We saw that processes for recording incidents were not sufficiently robust. The incident reports did not capture the action taken to support the person at the time of the incident, and the response to the incident. Therefore the provider could not demonstrate they were learning from these and taking action to protect people from similar incidents recurring. The complaints process did not capture all complaints, and there was a risk that these concerns would not be learnt from.

A range of activities were provided at the service and there were opportunities to access the local community to stimulate people using the service and protect them from social isolation. People’s views were gathered about what activities they would like delivered at the service. However, there was little opportunity for people who preferred to spend time in their room or did not want to engage in group activities to have one to one activities, and there was a risk that these people may become socially isolated.

People received the support they required with their personal care and health needs. Each person had a care plan which detailed what support they required and how that support should be delivered. The care plans also referred to risk management plans and preventative measures in place to reduce the risks to people’s health and safety.

Staff were knowledgeable about the people they supported. This included being aware of their preferences, their interests and their life experiences. Staff used this information to provide people with the support they required and to build meaningful relationships with people.

People were involved in decisions about their care and the support they received. They were able to choose how they spent their time and were involved in decisions about daily life. Staff were aware of who was able to make decisions and who did not have the capacity to make complex decisions about their care. Where people did not have the capacity to consent to their care, staff adhered to the Mental Capacity Act 2005 and ‘best interests’ decisions were made on people’s behalf.

People received their medicines as prescribed and there were sufficient stocks of medicines at the service. Staff supported people to access healthcare professionals and ensure their health needs were addressed. Staff were knowledgeable about people’s dietary requirements and people who required support at mealtimes received it.

There were sufficient staff on duty to meet people’s needs. We observed staff being attentive to people and responding to requests for support promptly. Staff received the training and supervision they required to have the knowledge and skills to meet people’s needs. Staff received refresher training to ensure they stayed up to date with good practice. Staff worked with other healthcare professionals to further develop their skills, particularly in regards to end of life care.

There was visible leadership and management at the service. Staff, people and relatives felt comfortable speaking with the management team and felt able to express their views and opinions. There were processes in place to obtain people and relatives feedback. Systems were also in place to

We carried out an unannounced comprehensive inspection of this service on 10 February 2015 at which two breaches of legal requirements were found. We found that induction processes were inconsistent with unclear training goals. Staff and care records were not easily accessible and were incomplete, this included supervision records, wound management plans and Mental Capacity Act (2005) assessments. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirement in relation to staffing and good governance.

We undertook a focused inspection on the 18 September 2015 to check that they now met legal requirements. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Milverton Nursing Home’ on our website at www.cqc.org.uk.

Milverton Nursing Home is registered as a care home for up to 30 people. It provides accommodation for people who require personal care and nursing, some of whom have dementia. At the time of the inspection 29 people were using the service.

At our focused inspection on the 18 September 2015, we found the registered provider had followed their plan and legal requirements in relation to staffing and governance had been met.

Staff were inducted to the service, including shadowing experienced staff and familiarising themselves with people’s needs. Staff were assessed as competent before undertaking duties independently and staff received any training identified as necessary during the induction process. Staff received regular supervision sessions and records were kept of these.

Staff records and people’s care records were stored securely and were easily accessible.

People’s care records were up to date and complete, including Mental Capacity Act 2005 assessments, wound management plans and ‘person-centred profiles’ outlining peoples likes, interests and preferences.

This inspection took place on 10 February 2015 and was unannounced. At the last inspection on 18 September 2014 we identified that the provider had breached six regulations. We found the provider had not ensured people's consent was always obtained, or acted in accordance with; the planning and delivery of care and treatment did not always ensure people's welfare and safety; people were not protected against identifiable risks of acquiring an infection and were not always protected from the risks of unsafe equipment. In addition the provider did not have effective arrangements to ensure that only suitable applicants were chosen to work in the home and their quality assurance systems were ineffective.

At this inspection we found improvements had been made in relation to the breaches identified previously. However, during this inspection we found breaches in relation to good governance and supporting staff.

Milverton Nursing Home provides accommodation and personal care with nursing for up to 30 older people some of whom have dementia. The home accepts a number of people who require end of life care, although this is not a specialism of the home. On the day of our visit there were 27 people living in the home.

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.

There was no clear programme in place to ensure staff received a suitable induction to enable them to meet people’s needs. Staff were supported by the registered manager and received appropriate training to carry out their roles, except for induction training. Staff knew how to recognise if people were being abused and how to respond to keep them safe.

The registered manager understood their requirements under the Deprivation of Liberty Safeguards (DoLS). These safeguards are there to make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom. Services should only deprive someone of their liberty when it is in the best interests of the person and there is no other way to look after them, and it should be done in a safe and correct way.

Where decisions needed to be made in people’s best interests, there was not always suitable guidance for staff to deal with these. For example the medicines policy did not cover covert medicines administration which meant there was no clear, consistent process for staff to refer to, to ensure medicines were only administered in this way when it was in people’s best interests.

The registered manager was gathering people’s views, or the views of their relatives, as to how they wanted their care to be delivered and what was important to them where possible. In this way staff would have the necessary information to refer to, to provide care in the ways people preferred.

Risks to people were well managed with care plans and risk assessments in place to minimise these. Staff understood people’s individual needs and preferences.

The premises and equipment were clean and safe, with regular health and safety checks carried out. Specialist equipment such as pressure relieving mattress’ and cushions and hoists were used appropriately.

Staff treated people with dignity and respect, kindness and compassion.

People’s health needs were met and people received the right support in relation to eating and drinking. Referrals to specialists were made when necessary. For example referrals were made to speech and language therapists when people had difficulties swallowing, and staff followed their advice.

There were enough staff to support people effectively, and recruitment procedures were thorough to help protect people from staff who were unsuitable.

The manager listened to suggestions to improve the service and acted upon them. People knew how to make complaints and were confident the registered manager would respond appropriately to any issues they raised.

The registered manager and staff were aware of their roles and responsibilities. The registered manager ensured a range of audits were carried out to check the quality of service, taking action where issues were identified. Regular meeting involving people using the service and their relatives took place so they could feedback on the quality of service.

Records in relation to staff supervision, wound management and Mental Capacity Act assessments were not always accurate or able to be located promptly when required.

We inspected this home in response to concerns raised anonymously about standards of care. It was carried out by two inspectors. Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with eight people who used the service and four of their relatives, the registered manager, two nurses, and four other members of staff. We looked at people's care plans, staffing records and other records relevant to the management of the service.

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

We considered our inspection findings to answer five questions we always ask:

• Is the service safe?

• Is the service caring?

• Is the service responsive?

• Is the service effective?

• Is the service well led?

Is the service safe?

Parts of the service were not safe. Equipment such as pressure relieving mattresses and cushions were not always available to people who required them. Air mattresses were not always used correctly, at the right setting, to provide effective pressure relief. Bed rails were not always used effectively to reduce the risk of people falling out of bed. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to equipment.

Standards of cleanliness and infection control in the kitchen were not sufficient to prevent people from acquiring food-borne infections. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to cleanliness and infection control.

Staff recruitment procedures were not robust as gaps in employment records were not always explored, and the home did not appropriately assess whether people were suitable to work in the home in terms of their physical and mental health. There were enough suitably competent staff on duty to meet the needs of the people who lived at Milverton Nursing Home. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to requirements relating to workers.

The home and gardens were adequately maintained.

Is the service effective?

The service was not always effective. The care provided to people did not always ensure their welfare and safety in relation to wound management and protecting them against the risk of malnutrition. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to care and welfare.

People were provided with a choice of suitable and nutritious food and were supported to eat when necessary.

Is the service caring?

Parts of the service were caring. Staff were not rushed and spent time talking and interacting with people. However, staff did not always treat people with respect when entering their rooms.

Is the service responsive?

The service was not always responsive. Mental capacity assessments were not always carried out appropriately. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to consent.

The service had proper policies and procedures in relation to the Deprivation of Liberty Safeguards (DoLS) and the manager had made several applications, which meant that people were not being deprived of their liberty inappropriately.

Is the service well-led?

The service was not well-led in all areas. Systems were not in place to effectively assess and monitor the quality of the care, issues relating to respect and consent, equipment, cleanliness and recruitment at Milverton Nursing Home. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to assessing and monitoring the quality of service provision. However, systems were in place to monitor health and safety. Also, the home regularly sought the views of people using the service.

We spoke with twenty people using the service who told us that they were well treated by staff, they felt safe living at the home and their health needs were well met, although this was to a lesser degree regarding social needs. This was confirmed by relatives. One relative we spoke with said "Very kind to them, they are treated with respect and dignity".

"The physical care is good. The home is warm and welcoming. However, emotional care is very patchy and some staff appear to be lacking in empathy and are sometimes reluctant to engage with residents who are in distress. There is also an issue with staff's lack of knowledge and their English is sometimes hard to understand for people".

People who used the service and their relatives told us they were involved in choosing the type of care and support they needed and when they needed it. We were told "We visited and had a look around before our relative moved in". People told us their opinions were sought and generally acted upon regarding the care and support they received and activities they wished to pursue. "My mother has received very good treatment. The staff are very kind and compassionate and are well trained and respectful. I am very happy that my mother is well looked after and always looks clean and content". We saw that the service provided was of good quality regarding people's health and cleanliness needs.

The records and care practices we saw showed us that peoples' preferences, choices and wishes were recorded and where possible met to an extent although not in a particularly person centred way. The activities provided were focused on a group rather than individual environment and therefore people's individual preferences tended to defer to the group activity taking place. The home acknowledged this and we were told that they were developing a more person centred approach to the way they delivered the service .

We saw that people using the service received the care and support they needed to sustain a healthy and reasonable quality of life in a safe and comfortable environment, although work was required to provide more person centred, individual care. A relative we spoke with said "The home provides safe and good quality care. However the majority of the residents have varying degrees of dementia and although they are treated with respect and kindness, I feel that the staff and carers do not have enough time to spend chatting to residents for any length of time because of their many duties. I feel more interaction is needed as it is a long day when living in a home".

We saw that the home endeavoured to work with other providers to deliver a cohesive and joined up service, by providing relevant information in a timely way.

We spoke to five people who live at the home and six members of staff, including care staff and catering / domestic staff.

People we spoke with were complimentary about the care and facilities at the home. One person told us that the meals should be given "10 out of 10" and another told us that the food was very good. People also commented positively about the attitude of staff. One person told us that the home had "some staff who cared more than others" and explained this by saying that some staff seem to be more involved than others.

At the time of the inspection we found that there was a mix of care staff, nursing staff, domestic and catering staff. The home was clean and decorated for the Christmas season and most people were up and dressed appropriately for the day. Some people were receiving visitors and others were seated in the lounge.

We found that the meals provided to people allowed for a balanced and nutritional diet and provided the opportunity of choice. We found that people's care needs were being adequately met by staff who interacted with people in a polite and respectful manner.

During the visit to the home we spoke to service users, relatives and visitors. Those service users who were able to communicate were complimentary about the cleanliness of the home and the food. They also commented positively about the staff and their manner, and occasional outings.

Visitors and relatives commented favourably on the cleanliness of the home and the attitude of staff, as well as having the opportunity to attend meetings both with the home management as well as with the separately organised “Friends of Milverton” support group.

Both service users and relatives commented that the staffing levels were an issue which impacted negatively on the care provided and the opportunities that people were enabled to enjoy. The increasing number of people admitted with high dementia needs meant that staff were often busy with tasks rather than being able to spend time with people. Examples of how this affected people were described as “having to wait a long time for staff to arrive when I call”, “being bored during the day” and “going on outings depends a lot on whether relatives can help out”.

During our visit we spoke with several of the people who live in the home and also with a number of their relatives who were visiting.

All of the feedback we received was very positive with people telling us “it’s a good place to live” “we are all very happy here” “there’s lots of things to do, if you want to, something different every day”.

One relative explained “the owners are always trying to improve things for people who live here”. Another said that they liked the emphasis on getting people out of the home, while a resident added “I particularly like the trip to the pub every week”.

All of the people we spoke with told us that should they have any concerns they would tell the staff and they were confident that it would be addressed. In addition, they have regular meetings with the manager and provider where they are encouraged to voice their views and offer suggestions as to how they would like to see things done.

Visitors to the home said that they were happy with the care provided for their relatives. One person said ‘I think it’s an excellent home’.

Many people who live at the service said that they were satisfied with the care they received. Other people said they felt staff were busy and this sometimes meant that they did not always receive the help they needed at the time they needed it.

One person said that they had raised an issue of concern with the manager and this was resolved to their satisfaction.

People told us that they enjoyed the meals.

We were told by people who visit the home that staff ‘interact well’ with the people who live there. Other comments that we heard were that staff are ‘very busy’ and some people said that ‘there aren’t enough staff’. Another person said that it sometimes takes longer than she would like to be assisted after meal times because this is a very busy time.

People visiting the home told us that they feel staff are well managed and supported. They told us that they were impressed that English lessons were provided for overseas worker who wished to improve their English as this will benefit the people who live in the home.

People said that they are asked their opinions about the care provided. Relatives are invited to meetings where they can make their views known, and they are able to have meetings with the Registered Manager.