About the service: Nightingale Care Home is a care home which was providing personal care to 34 older people at the time of the inspection.

People’s experience of using this service: At our last inspection, published 1 June 2018, we rated this service Inadequate overall with breaches of regulation relating to safe care and treatment, staffing, consent, good governance, safeguarding, person centred care, dignity and respect and the employment of fit and proper people. We placed the service into special measures and asked them to provide us with an action plan documenting how they would make the required improvements. At this inspection we found people’s experience had improved significantly but there were still some areas of concern which needed to be fully addressed.

People’s safety was compromised because some risks were not well managed. Procedures relating to choking, pressure care and infection control required improvement to ensure people were safe. Medicines were well managed and there were enough staff to meet people’s needs. Staff understood their responsibility to keep people safe from the risk of abuse and knew how to raise concerns. The service was clean.

Staff received good training but supervision and appraisal needed to be more structured. Some better monitoring of some people’s drinking and eating was needed to ensure that people were not placed at an increased risk of losing weight or not drinking enough. People’s health needs were well monitored and the provider made prompt referrals to healthcare professionals.

Although staff received training relating to consent their understanding of how the Mental Capacity Act 2005 needed to be improved. Records demonstrated that the provider had not always assessed people’s capacity to consent in line with legislation and some records needed review.

The environment had much improved since the last inspection and the service was warm and comfortable. Further improvements were planned to enhance the environment for those people living with dementia.

Staff were patient, kind and caring and relationships between staff and the people they were supporting and caring for, were good. Staff ensured people’s dignity was maintained and managed people’s distress, associated with their healthcare conditions, well.

The registered manager kept care records under review and they reflected people’s current needs. Care was person centred and there were activities to occupy people’s time, although further enhancement to these were planned.

There were good systems in place to monitor the quality and safety of the service. The registered manager and the regional manager constituted a strong team focussed on bringing about the required improvements at the service and remaining person centred. They were honest and open about work which still needed doing and worked well with the local authority quality assurance team. Some relationships with outside professionals were not good which had the potential to affect people’s care but we found a strategy was in place to address this.

There is more information is in the full report below.

Rating at last inspection: Inadequate with the key questions of Safe, Effective and Well-Led being individually rated Inadequate and the other two rated as Requires Improvement (report published 1 June 2018.)

Why we inspected: This was a scheduled inspection based on the previous rating.

Follow up: The rating for this service has improved to Requires Improvement. We will continue to monitor this service and inspect it again in line with our regulatory inspection schedule.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 6 March 2018 and was unannounced. We also returned on the 8 and 12 March 2018. The provider and manager were given notice of the other dates, as we needed to spend specific time with them to discuss aspects of the inspection and to gather further information. This inspection was prompted in part by information shared with CQC about the potential concerns around the management of people's care needs. This inspection examined those risks.

Prior to this inspection we carried out an unannounced focussed inspection of this service on 11 July 2017, we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had been alerted to an incident where, on the advice of a healthcare professional, one person's controlled drugs had been given to another person. This was not in line with the provider's own medication policy. This incident had placed the person at risk of harm and prompted our responsive inspection. We concluded that, not all medicines were managed safely. We also found audits had not identified the errors we found. Some audits could not be located and the registered manager at that time did not have clear oversight of all the issues related to the safe management of medicines.

Previous to the focused inspection we completed an unannounced comprehensive inspection of this service on 16 March 2017 and found the provider to be fully compliant with the Regulations. We rated the key questions is the service safe, effective, caring, responsive and well led as good.

At this inspection we found that insufficient improvements had been made following our previous focused inspection. We identified a continuing breach in the Health and Social Care Act regulations relating to medication and found additional breaches of Regulation.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Nightingale 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 accommodates people in one adapted building. Nightingale care home accommodates 47 people, some were living with dementia. At the time of the inspection there were 31 people living at the home.

A recently appointed manager was in post and had

We carried out an unannounced comprehensive inspection of this service on 16 March 2017.After that inspection we were informed about a serious incident relating to the unsafe management of medicines. We had additional concerns as the provider had failed to notify us of the incident, which they are required to do. This incident had placed people at risk of harm and we wanted to make sure that unsafe practice had not continued. We therefore decided to carry out a focussed inspection, which only reviewed this aspect of the service. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Nightingale Care Home on our website at www.cqc.org.uk

This inspection took place on 11 July 2017 and was unannounced.

The service provides accommodation for up to 47 people, some of whom are living with dementia.

A registered manager was 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.

This report specifically focuses on the key areas of Safe and Well-Led with regard to how medicines were managed at the service. This included a consideration of the safe ordering, storage, administration, stocktaking, disposal and auditing of medicines.

We had been alerted to an incident where, on the advice of a healthcare professional, one person’s controlled drugs had been given to another person. This was not in line with the provider’s own medication policy. This incident had placed the person at risk of harm and prompted our responsive inspection. At this inspection we concluded that, although some recent improvements in the administration of medicines had taken place, not all medicines were managed safely. In addition we were concerned that a full investigation into this incident had not taken place and lessons learned.

Staff managed people’s regular medicines well and people received their medicines at the correct times. Although medicines were made available to people promptly when newly prescribed, information on some medicines was not available to guide staff. Staff were not clear about how to administer one emergency medicine and had not received the required training.

Medicines were stored appropriately but some recording of the room temperature was missing. This meant we could not be assured that medicines were always stored in a way which ensured they were safe and effective to use. Medicine trollies and the medicine room were well organised.

Drugs stored in the controlled drugs cupboard were mostly well managed but stocks for one medicine did not tally with records. This meant there was a risk that a person had not received the correct dose of their medicine. One medicine had not been administered according to the manufacturer’s instructions which placed the person at risk of harm.

Audits had not identified the errors we found. Some audits could not be located and the registered manager did not have clear oversight of all the issues related to the safe management of medicines. Where errors had taken place, these had not been fully investigated by the registered manager or provider or notified to the Care Quality Commission or the local authority as a safeguarding matter.

We found a breach of regulation related to the management of medicines. You can see the action we took at the back of this report.

This inspection took place on 16 March 2017 and was unannounced. Nightingale Care Home is a care home providing personal care for up to 47 people, some of whom live with dementia. On the day of our visit 34 people were living at the home.

The home has had the current registered manager in post since September 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.

At the last inspection on 5 and 6 April 2016, we asked the provider to take action to make improvements to how they managed risks to people, how they deployed staff around the home and to their assessing and monitoring systems in the home. This action has been taken.

Staff assessed individual risks to people and took action to reduce or remove them. There was adequate servicing and maintenance checks to fire equipment and systems in the home to ensure people’s safety.

There were enough staff available to meet people’s needs and the registered manager took action to make sure there were staff available throughout the home at all times.

Good leadership was in place and the registered manager and provider monitored care and other records to assess the risks to people and ensure that these were reduced as much as possible and to improve the quality of the care provided.

Staff were aware of how to safeguard people from the risk of abuse and they knew how to report concerns to the relevant agencies. People felt safe living at the home and staff supported them in a way that they preferred.

Recruitment checks for new staff members had been made before new staff members started work to make sure they were safe to work within care.

People received their medicines when they needed them, and staff members who administered medicines had been trained to do this safely.

Staff members received other training, which provided them with the skills and knowledge to carry out their roles. Staff received adequate support from the registered manager and senior staff, which they found helpful.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The registered manager had acted on the requirements of the safeguards to ensure that people were protected. Where someone lacked capacity to make their own decisions, the staff were making these for them in their best interests.

People enjoyed their meals and were able to choose what they ate and drank. They received enough food and drink to meet their needs. Staff members contacted health professionals to make sure people received advice and treatment quickly if needed.

Staff were caring, kind, respectful and courteous. Staff members knew people well, what they liked and how they wanted to be treated. They responded to people’s needs well and support was always available. Care plans contained enough information to support individual people with their needs. People were happy living at the home and staff supported them to be as independent as possible.

A complaints procedure was available and people knew how to and who to go to, to make a complaint. The registered manager was supportive and approachable, and people or other staff members could speak with them at any time.

This inspection was unannounced and took place on 5 and 6 April 2016.

The Nightingale Care Home is a care home that provides accommodation and care for up to 47 older people who are living with dementia. On the day of our inspection, there were 37 people living within the home.

There was a manager working at the home who is registered with us. 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 and associated Regulations about how the service is run.

At this inspection we found three 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.

People did not always receive care in a timely manner to meet their individual needs. The staff had not been deployed effectively to enable them to do this. Risks to some people’s safety were not being mitigated effectively to protect them from the risk of harm.

The main areas of the home were clean but some equipment that people used was not. The principles of the Mental Capacity Act had not always been followed when some decisions had been made on behalf of people who were unable to consent to them.

Some staff were kind, caring and compassionate and they treated people with dignity and respect. However, other staff did not always act in this way.

Most staff had received training on how to provide people with safe and effective care. However, although their competency to provide this had been assessed, some staff provided people with poor care. The environment was not fully designed to promote people’s independence.

Some of the current governance systems in place were not effective at assessing and identifying improvements that were needed to the quality and safety of the care that was being provided. Improvements identified by an external body had not been fully acted on within the time-scales given.

The staff knew how to protect people from the risk of abuse and people received their medicines when they needed them. People received enough food to meet their needs. People were encouraged to participate in activities that complemented their hobbies, interests and that promoted their wellbeing.

There was an open culture where people, relatives and staff could raise concerns that were listened to and acted upon. Staff were happy working in the home.

We have made a recommendation in relation to providing an appropriate environment for people living with dementia.