We last inspected Moorlands Nursing Home on 24 April and 10 May 2017 and found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. We issued requirement notices relating to good governance and staffing.

At our last inspection, the service was rated 'Requires Improvement'. Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all five key questions to at least Good. At this inspection on 15 May 2018 we found there had been improvement and rated the service as Good.

Moorlands 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.

Moorlands Nursing Home provides nursing care and accommodation for up to 30 older people, some of whom are older people living with a dementia. The service also provides short term care (up to six weeks) for people who are unwell and are unable to manage at home. People can also be cared for on a short-term basis for assessment and recovery on discharge from hospital to allow recuperation and reablement before they are able to return home safely. At the time of the inspection there were 19 people who used the service.

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.

The provider had an effective quality assurance process in place. People who used the service, relatives and staff were regularly consulted about the quality of the service through meetings and surveys.

Staff understood the procedure they needed to follow if they suspected abuse might be taking place.

Risks to people were identified and plans were put in place to help manage the risk and minimise them occurring. Medicines were managed safely with an effective system in place.

Most people and relatives told us there were suitable numbers of staff on duty to ensure people’s needs were met. Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with people.

The registered manager had systems in place for reporting, recording, and monitoring significant events, incidents and accidents. The registered manager told us that lessons were learnt when they reviewed all accidents and incidents to determine any themes or trends.

People were supported by a regular team of staff who were knowledgeable about people’s likes, dislikes and preferences. A training plan was in place and staff were suitably trained and received all the support they needed to perform their roles.

People were supported with eating and drinking and feedback about the quality of meals was positive. Special diets were catered for and alternative choices were offered to people if they did not like any of the menu choices. Nutritional assessments were carried out and action was taken if people were at risk of malnutrition.

The registered manager and staff demonstrated an understanding of the Mental Capacity Act (2005). Where people lacked capacity, decisions made in the best interests were appropriately recorded and kept under review.

The home was clean and suitable for the people who used the service. The provider had procedures in place for managing the maintenance of the premises and appropriate health and safety checks had been carried out. Refurbishment was ongoing at the time of our inspection.

People were treated with kindness and respect. Staff knew the people they were supporting well and respected the choices they made about their care. The staff knew how peopl

We inspected Moorlands Nursing Home on 24 April and 10 May 2017. The first day of the inspection was unannounced, which meant that the staff and provider did not know we would be visiting. We informed the provider of our visit on 10 May 2017. When we last inspected the service in March 2015 we found that the provider was meeting the legal requirements in the areas that we looked at and rated the service as Good. At this inspection the provider was not meeting all the legal requirements and we rated the service as Requires Improvement.

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.

Moorlands Nursing Home provides nursing care and accommodation for up to 30 older people, some of whom are older people living with a dementia. The service also provides short term care (up to six weeks) for people who are unwell and are unable to manage at home. People can also be cared for on a short term basis for assessment and recovery on discharge from hospital to allow recuperation and reablement before they are able to return home safely. At the time of the inspection there were 26 people who used the service.

We looked at the arrangements in place for quality assurance and governance and found them to be ineffective as they did not identify the areas we highlighted as needing improvement during our inspection. The health and safety audit was a tick box and did not inform staff of the checks they should be making. The accident and incident audit only stated facts and did not identify any patterns or trends. The provider visited the service on a regular basis; however, they did not have effective systems in which to check the service was safe, effective, caring, responsive and well led. This meant systems and processes to identify where quality and / or safety were compromised.

Staff told us they felt well supported; however formal supervision sessions with staff were not taking place regularly.

Staff had received training in safeguarding, fire, health and safety, moving and handling, first aid and infection control. The council had responsibility to educate and train care home staff to support people with their reablement, however, up until the time of the inspection this had not happened. The provider told us until this training had been provided they would not be providing reablement support and therapy to people who used the service.

The registered manager told us staff had received training on PEG feeding and evidence of staff competence in PEG feeding was submitted to us after the inspection. However, some care staff were responsible for taking the blood sugar of those people who were diabetic but there was no evidence to support that staff have received training or had their competency assessed in the taking of blood sugars.

The records of those people receiving short term care did not detail what support care staff needed to provide to people in between visits from physiotherapists and occupational therapists. For example support with moving and handling.

Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Risk assessments covered areas such as falls, choking, moving and handling and the use of equipment. This enabled staff to have the guidance they needed to help people to keep safe.

Checks of the building and maintenance systems were undertaken to ensure health and safety.

People were protected by the services approach to safeguarding and whistle blowing. People who used the service told us they felt safe and could tell staff if they were unhappy. People told us staff treated them well and they were happy with the care and servic

We inspected Moorlands Nursing Home on 23 March 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting. At the last inspection we found the Moorlands Nursing was not meeting requirements of five regulations.

Moorlands Nursing Home provides accommodation and nursing care for up to 29 older people. The home is spaced over two floors with bedrooms on each floor. Communal dining and lounge facilities are located on the ground floor.

The home has not had a registered manager in post since October 2014. 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 provider has employed a new manager and they came into post mid-March 2015. The new manager confirmed they intended to submit an application to become the registered manager.

In August 2014 we completed an inspection and issued a formal warning telling the provider that by 31 December 2014 they must improve the following areas.

• Regulation 9 (Outcome 4): Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.
• Regulation 14, (Outcome 5): People were not protected from the risks of inadequate nutrition and dehydration.
• Regulation 24, (Outcome 6): People’s health, safety and welfare was not protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider did not work in co-operation with others.
• Regulation 21, (Outcome 20): People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

We reviewed the action the provider had taken to address the above breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We also checked what action had been taken to rectify the breach of regulation 13 (Management of medicines) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We found that the provider had ensured improvements were made in these areas and these had led to the home meeting the above regulations. We also found that medication practices had improved and staff were administering prescribed medicines safely.

People we spoke with told us they felt safe in the home and the staff made sure they were kept safe. We saw there were systems and processes in place to protect people from the risk of harm.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People’s needs were assessed and care and support was planned and delivered in line with their individual care needs. The care plans contained comprehensive and detailed information about how each person should be supported. We found that risk assessments were very detailed. They contained person specific actions to reduce or prevent the highlighted risk.

People told us that they made their own choices and decisions, which were respected by staff. We observed that staff had developed positive relationships with the people who used the service. Where people had difficulty making decisions we saw that staff gently worked with them to find out what they felt was best.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training and clearly understood the requirements of the Act which meant they were working within the law to support people who may lack capacity to make their own decisions. We found that action was taken to ensure the requirements of the act were adopted by the staff. The provider recognised that staff needed additional support to ensure they had the skills and knowledge to consistently work with the Mental Capacity Code of Practice.

The interactions between people and staff were jovial and supportive. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity.

We saw that the activities coordinator engaged people in a wide range of meaningful occupation and this was tailor made to each person’s preferences.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight and nutritional needs.

People and the staff we spoke with told us that there were enough staff on duty to meet people’s needs. One nurse and five care staff were on duty during the day, One nurse and four care staff were on duty from the late afternoon and a nurse and two staff were on duty overnight. In addition ancillary staff such as cooks and domestic staff were on duty throughout the week. The new manager and deputy manager, an activities coordinator worked weekdays and the provider was also based at the home. Three apprentices worked at the home.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. People we spoke with told us that they knew how to complain and felt confident that staff would respond and take action to support them. People we spoke with did not raise any complaints or concerns about the service.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Staff had received a wide range of training, which covered mandatory courses such as fire safety as well as condition specific training such as dementia and Parkinson’s disease. We found that the provider not only ensured staff received refresher training on all training on an annual basis but routinely checked that staff understood how to put this training into practice.

Regular surveys, resident and relative meetings were held and we found that the information from these interactions were used to inform developments in the home such as the introduction of free WFI access for people who used the service.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

The provider had developed a range of systems to monitor and improve the quality of the service provided. We saw that the provider had implemented these and used them to critically review the service. This had led to the systems being effective and the service being well-led.

We highlighted that the provider did need to ensure notifications were submitted in line with the requirements of The Care Quality Commission Registration Regulations 2009.

We carried out this inspection in response to concerns that were raised to us in respect of one or more outcomes. As a result of the concerning information we received we carried out an early morning visit to the home to enable us to address the concerns that had been raised.

Our inspector set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people using the service, the staff supporting them and looking at records.

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

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

We saw that where peoples care and treatment needs had changed staff worked in partnership with other healthcare professionals and implemented their advice into their delivery of care and treatment.

We found that people were not protected against the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to protecting people against the risks of unsafe or inappropriate care and treatment.

We found that people were supported to have adequate nutrition and hydration. Systems were effective in reducing the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration. When we asked people if they received enough food and drink they commented, “Yes, plenty”.

We found that staffing levels were consistent and offered people support when they needed it. We found the home were able to demonstrate that they had carried out a needs analysis and assessment as the basis for deciding safe, sufficient staffing levels. People we spoke with told us, “They (staff) are lovely”.

We found that in accordance with our Registration Regulations there was a registered manager employed to oversee and manage the service.

We spent time observing how staff supported people living at the home. We found staff were respectful in their approach treating people with dignity and courtesy. We saw that staff knocked on doors before entering ensuring people's privacy was respected. People we spoke to said they were happy with the staff. One person told us, "They look after you" and another person who had difficulty speaking gave a thumbs up when asked if they were happy living in the home. We spent time talking with several people and watched how staff provided support. We observed staff explaining what they were doing and asking people what they wanted. We saw that people generally looked clean, well presented and cared for.

When we visited the home we looked at the safeguarding policy and we saw training records which showed that staff had received training in safeguarding. Staff were able to explain how they would recognise signs of abuse and what they would do if they had any concerns. One relative who we spoke to told us that they believed their mother was safe and if they had any concerns they would report them to the manager.

We saw evidence that staff employed had been through recruitment checks prior to commencing employment and that there was a programme of training in place to ensure that staff had skills to undertake their role.

We saw that people who used the service, relatives and staff were asked for their views about their care and treatment through regular meetings.

We carried out a comprehensive inspection of this service on 15 April 2014. A breach of legal requirement was found. As a result we undertook a focused inspection on 15 and 18 August 2014 to follow up on whether action had been taken to deal with the breach.

You can read a summary of both inspections below.

Comprehensive inspection on 15 April 2014.

At this inspection it was identified that people who used the service were not protected from the risks of unsafe or inappropriate care and treatment because the provider had failed to maintain accurate records about their care needs. We found that records were not subject to regular reviews and we saw that monthly evaluations had not been completed for a significant period. For example one set of care records had not been evaluated in over 12 months, another set in almost 10 months and the remaining between six to eight months. Records did not reflect the current care and treatment needs of people who used the service.

We asked the registered person to make improvements in this area and they informed us that these improvements would be completed by 9 May 2014.

Focused inspection on 15 and 18 August 2014.

The inspection team was initially made up of one ASC inspector who was completing an unannounced follow-up inspection checking the action the provider had taken to improve the care records maintained at the home. Whilst at the home the inspector noted a number of concerns about how staff delivered the care and treatment at the home. They extended the visit and were supported by a second inspector on the second day of the visit.

The concerns related to our questions; Is the service responsive? Is the service safe? Is the service effective? Below is a summary of what we found. The summary is based on our observations during the inspection, looking at a range of records and speaking with the registered manager, staff and people who lived at the service.

We looked at eight sets of care records relating to people who used the service. We looked at daily records, risk assessment tools, medication administration records and weight monitoring records. We spoke with four people who used the service and four visiting relatives of people who used the service. We also spoke with five members of staff, including two care staff, one care supervisor, the nurse on duty, the registered manager and the provider.

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

Is the service responsive?

We found that there were no meaningful activities undertaken to engage or offer stimulation to people who used the service. Research shows that holistic care approaches to people who are living with a dementia can have a very positive impact on their day to day living.

We found that input from visiting healthcare professionals was not actioned by the home when planning and delivering care and treatment to people who used the service. This meant that the on-going assessment and reflective action in respect of people's care needs had not been completed leaving people at risk of receiving inappropriate care and treatment.

Is the service safe?

We saw the home did not have effective systems in place to manage medicines. Records were incomplete or inaccurate and did not always reflect the medication administered to people. Incomplete record keeping meant we were not able to confirm that these medicines were being used as prescribed. Appropriate arrangements for ordering and obtaining people’s prescribed medicines was failing, which increased the risk of harm to people and resulted in people not having their prescribed medication available to them.

Is the service effective?

People were not supported to receive appropriate medical oversight in a timely manner. The care people received was not in line with best practice and in some instances staff practices would increase the risk that people may come to harm. When people required assistance to eat via percutaneous endoscopic gastrostomy (PEG) feeding staff were not following the recognised guidance. PEG feeding is sometimes used where people are unable to swallow or eat enough and need long term artificial feeding. Artificial nutrition is sometimes needed where a person has a medical condition which makes it hard to swallow food and enough fluids. We found that the staff administering this PEG feeding regime had not received training or been checked to ensure they were competent to undertake the test.

What people told us?

We spoke with four people who used the service and four visiting relatives of people who used the service. Each person we spoke with told us that they felt safe living at the home. Relatives we spoke with did raise some concerns with us about the care and welfare needs of their relatives.

One relative told us, “They are happy and content here. My only concern is that there are not a lot of social activities going on whenever I visit. There was a girl who did activities and provided entertainment, they said they would be replacing her but don’t appear to be.”

Another relative raised concerns about what they saw as a lack of stimulation for people who used the service. They told us that they felt their relative’s health decline coincided with the activities co-ordinator leaving.

Another relative told us that they were disappointed in having to approach the owner of the home to arrange for their relatives equipment to be repaired. They told us that they had approached staff and management on a number of occasions but ‘got nowhere’.

People we spoke with told us that they felt they were well looked after, comments included, “They (staff) do their best” and “Oh yes they look after me and feed me well”.