At our last inspection 5 April 2016, we rated the service good. At this inspection we found that there were areas that required improvement. These were in relation to safe medicines recording, fire safety, safe storage of cleaning products, confidentiality of records and governance systems.

Nightingale Nursing Home is a ‘care home’. People in care homes receive accommodation and 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.

Nightingale Nursing Home provides accommodation and nursing care for up to 34 older people, this included people living with dementia. At the time of the inspection there were 26 people living there.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

People, their relatives and staff were very positive about the registered manager and how the home was run. The registered manager had a hands on approach and met with staff frequently to ensure they had the information needed for their role.

There were systems in place to help identify issues and address them. Action planning systems needed to be more detailed. Staff knew what was expected of them and understood the ethos of the registered manager which meant good care outcomes for people.

The service worked with other agencies to help develop systems in the home. However, some actions raised by the local authority had yet to be fully completed. People had their individual risks assessed and this was shared with staff. However, some staff were not clear on some aspects. Medicines recording needed to be improved. Infection control was promoted.

Staff were recruited safely. However, the registered manager needed to ensure that employment gaps were explored. People were supported by enough staff who were trained and felt well supported.

People and their relatives told us that they felt safe and staff knew how to report any concerns Fire drills were completed but the documentation of these needed to be more robust to ensure all staff attended and knowledge was tested. The service required a fire risk assessment from a competent external agency. Following the inspection, we were told this was booked for the following week. The service was awaiting repairs following a five-year electrical inspection carried out in August 2018.

The staff worked in accordance with the principles of the Mental Capacity Act and people had access to health professionals. People enjoyed their meals and maintain a healthy diet.

The environment was clean but would benefit from improvements to the decoration to make it homelier. People and their relatives told us that staff were kind and friendly. People were involved in planning their care and privacy and dignity was always promoted.

People were happy with the care they received and their care plans were personalised. There were activities available for people.

There had been no recent complaints and people and their relatives felt confident to approach the registered manager or staff if something arose. People’s feedback was sought and responses were very positive.

This inspection was carried out on 5 April 2016 and was announced. At their last inspection on 4 September 2014 the service was found to be meeting the standards we inspected.

Nightingale Nursing Home provides accommodation and personal care for up to 34 people. There were 27 people living at the home on the day of our inspection.

The service had a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

People felt safe at the home and staff knew how to recognise and report abuse. Individual risks were mitigated and staff worked safely. There were sufficient numbers of trained and supervised staff to meet people’s needs and they had been recruited through a robust procedure. People’s medicines were managed safely.

People were supported to eat and drink enough to maintain their health and there was regular access to health care professionals. People were encouraged to make their own decisions but when they were unable the Mental Capacity Act was adhered to.

People were treated with care and kindness and their privacy was respected. Staff had developed positive relationships with people and confidentiality was promoted. People were involved in planning their care.

People received care that met their needs and care plans were in place to ensure that staff had the appropriate information to meet their needs. Activities were available and people were asked about hobbies and interests. People knew how to make a complaint, feedback was sought and their voices were listened to.

People, relatives and staff were positive about the management of the home. There were systems in place to monitor the quality of the service and the ethos of the home was people first.

At a previous inspection of Nightingale Nursing Home on 23 May 2014, we had found that the provider did not follow the requirements of the Mental Capacity Act 2005. They also did not ensure people lived in a clean and hygienic environment, and that people were protected from the unsafe administration of medicines.

We revisited Nightingale Nursing Home on 04 September 2014 to assess how the provider had achieved compliance. We found that improvements had been made in all areas we had previously identified.

The home manager had reviewed every person’s needs in relation to consent. Where appropriate, they had followed the requirements of the Mental Capacity Act 2005 where they felt a person lacked the capacity to make their own decisions.

The home had undergone extensive redecoration throughout and areas such as flooring and kitchen units had been replaced.

At our previous inspection we saw that people’s medicines were pre prepared and left unsupervised in an unsafe manner. At this inspection, people’s medicines were not pre prepared and we saw this was safely administered in accordance with published guidance.

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 23 May 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

What people told us and what we found

Inspectors gathered evidence to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Below is a summary of what we found based on the evidence gathered during our inspection carried out on 23 May 2014. This included speaking with people who used the service, and their relatives, and two members of staff who supported them. We looked at four people's care records.

Is it safe?

During our inspection we saw that people who lived at the home were treated with care and respect.

We noted that call bells were within people’s reach so they were able to request help and support if needed.

People told us that they were happy at the home and that staff were kind and attentive. People said that they felt able to raise their concerns. One person told us, “I either bring up any worries in the meeting, or just speak to [Manager] as they are always around and very approachable.”

The requirements of the Mental Capacity Act 2005 had not always been followed or implemented. This meant that consent may not always have been obtained in accordance with the relevant legal requirements. Staff had received training in relation to this, however, they were not aware of the basic principles of consent. This included the manager, who told us, “The needs of people have increased and all the residents are unable to walk, I wasn’t aware of DoLS, I was just keeping people safe.”

During our inspection we toured the home and found the environment was clean and free from malodour. However, we also found that the kitchenette area was poorly maintained, scorched and, in places, required replacing to ensure the surfaces could be kept clean.

We saw that people shared slings which were used to safely hoist people when providing personal care. Both the manager and staff confirmed that this was usual practice. This meant that people who required hoisting and assistance with personal care, and who were sharing a sling, were at increased risk of cross infection.

We observed when medicines were administered to people, that the staff member left the cupboard open with medicines displayed. This meant that medicines were inappropriately accessible to people who used the service. Controlled medicines were also not handled in a manner that was safe.

Is the service effective?

We saw that assessments had been completed and reviewed in relation to a wide range of issues relevant to people’s care needs. These included assessments relating to the management of people’s medicines, skin integrity and risks associated with pressure care, nutrition and hydration, mobility and the risk of falls.

We found that where people lacked mental capacity to make their own decisions the requirements of the Mental Capacity Act 2005 had not always been followed.

Staff we spoke with told us they felt supported by the manager. One staff member told us, "[Manager] is lovely, they are always available, and supportive of me, I am really happy here."

We found that staff received appropriate personal development and received key areas of training. However, we also noted that where plans were created to support a staff member's development, they lacked detail and were seldom formally reviewed. Staff we spoke with were not aware of how their development was being supported, and how this was formally reviewed.

Is the service caring?

We observed the breakfast and lunchtime meal and saw that staff provided appropriate levels of support where necessary to help people to eat and drink in a calm, patient and dignified manner that promoted their independence.

People told us they were happy living at Nightingale Nursing Home. One person told us that when staff supported them, they did so in a, “Gentle, kind and caring manner, and tend to me in a very professional way.”

We observed that staff interacted with people with warmth and respect. For example, we saw a staff assisting a person to transfer and noted they provided continuous re-assurance to the person, maintained their dignity at all times, and ensured they were comfortable and secure.

Staff we spoke with were able to demonstrate a comprehensive understanding of people’s needs through discussion. Where one person had been admitted to Nightingale Nursing Home on the previous evening, staff were able to tell us about their care needs in detail.

Is the service responsive?

We saw that people’s views, experiences and choices were taken into account in the way that care, support and treatment was delivered. The provider had collated people's views and experiences through surveys and meetings. These included people who used the service, relatives and professionals. We noted that people were generally satisfied with the care that they received.

Where people were at risk of dehydration or malnutrition, they were referred appropriately for specialist support from health professionals such as doctors or dieticians. We saw the recommendations were then followed, and regular checks of people's weights, nutrition, fluid intake, skin integrity and general wellbeing were carried out.

Where people were at risk of developing pressure ulcers, staff ensured the appropriate pressure relieving devices were used, such as mattresses and cushions.

Is the service well led?

We saw that people had access to relevant health care professionals where necessary including GPs, dieticians and occupational therapists.

We saw from records we looked at that the home took account of accidents, incidents and near misses and investigated them sufficiently.

The home had a maintenance plan in place which had identified some of the issues we found in relation to the condition of the home.

People were cared for by staff who were supported to deliver care safely and to an appropriate standard, however, staff development records had not recorded and reviewed people’s development needs.

Effective systems had been put in place to assess and monitor the quality of services provided or to identify, assess and manage risks posed to the health, welfare and safety of people who lived at the home.

We found that people were asked for their consent when support or treatment was offered and the provider acted in accordance with their wishes. One person told us, “In my last home I seemed to fit in with the staff, but here it is so different. I have my own routine and ways of doing things and the staff respect my wishes and they never have acted without my approval.”

People's care was focused on their individual needs and people and their relatives were involved in the development and review of their treatment plan. One person we spoke with told us, “[The staff are] ten out of ten in my opinion, they look after everything I could ever ask for, and make this place feel like a real home.”

People were provided with a balanced and varied diet, were provided with a daily choice of menu options. One person told us, “The food is top notch, better than a hotel I would say. We don’t have that frozen food here, it’s all freshly cooked and we can choose whatever we like in reason.” We also found that where people were at risk of malnutrition or dehydration the provider acted appropriately.

The home was clean and presentable and smelled fresh. We saw that staff had access to personal protective equipment, and had received training in infection control.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. One person told us, "The [staff] are so gentle and kind, they look after me so well with whatever I need. I have never felt that staff did not know how to care for me, or that they lacked experience."

The home had a complaints system in place which was made available to people and their relatives. People we spoke with were aware of how to make a complaint, although none had been received in the last twelve months.

We spoke with six people when we visited the service on 08 October 2012 who told us that they were very happy and well cared for. One person told us: “They are really good and look after me well. Staff are kind and listen to us. Food is very good. We can choose what we want. All in all we are well cared for, respected and listened to and quite happy here.”

People told us that they or their relatives were involved in their care planning and that they received care and treatment according to their individual needs. People also told us that staff were knowledgeable, well trained and “Know how to do their job.”

People said they felt safe at this home and we saw that the staff knew how to identify and respond to potential abuse.

We found that staff were up to date with training that was relevant to their roles and that they were supported by an effective supervision process.

We found that the provider had in place systems to monitor the quality of the service that included surveys, staff and ’residents’ meetings and regular audits. One person stated: “Sometimes I may talk too much about how good they are at the meetings, but they really deserve to be told. They are really good.”