This unannounced inspection took place on 31 October 2018.

We last inspected Nynehead Court in December 2017, during that inspection we found people’s legal rights were not always understood and upheld because the service did not work in accordance with the Mental Capacity Act 2005. We also found medicines were not always managed safely and the governance systems were not fully effective.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective and well led to at least good. During this inspection we found that improvements had been made in some areas, however we found some concerns which resulted in continued breaches in two of the regulations.

Nynehead Court 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.

This service also provides care to people living in specialist 'extra care' housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought, and is the occupant's own home. People's care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people's personal care service.

Nynehead Court accommodates up to 44 people (in 38 bedrooms currently all used for single occupancy) in a three-storey historic building with a purpose-built wing for people who are living with dementia. At the time of the inspection there were 32 people using the service. There were two people in receipt of personal care who were living in the extra care housing.

There was 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.

Whilst we found some areas of medicines management had improved, there were still areas that required improvement. Risks to people were not always being identified and management plans put in place to mitigate any risks.

Care plans lacked some specific details to guide staff on how to meet people’s needs and they were not consistently person centred. Staff however knew people well and were able to describe how they supported people.

Some improvements were required to the processes in place where people lacked the capacity to make decisions for themselves. The systems in place to monitor the quality and safety of the service still required some improvement.

Staff knew how to recognise and report abuse and felt confident concerns would be acted upon. Staff told us they felt supported in their roles. There were enough staff on duty to meet people’s needs.

The provider had procedures in place to ensure that suitable staff were recruited. Staff received on-going training to ensure they were competent to carry out their roles

There were systems in place to protect people from the risk of infection. There were a range of checks in place to ensure the environment and equipment in the home was safe.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm.

We received some mixed feedback regarding the choice of meals in the home. There were systems in place for people to give feedback regarding the food and we saw this was acted upon. The home sourced locally produced food and grew their own vegetables and fruits.

People were supported to

Nynehead Court 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.

This service also provides care to people living in specialist ‘extra care’ housing. Extra care housing is purpose-built or adapted single household accommodation in a shared site or building. The accommodation is bought, and is the occupant’s own home. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for extra care housing; this inspection looked at people’s personal care service.

Nynehead Court accommodates up to 44 people in a three storey historic building with a new, purpose built wing. At the time of the inspection there were 35 people using the service, five of whom were receiving respite care. There were two people in receipt of personal care who were living in the extra care housing.

There was 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 the last inspection in November 2015 the service was rated Good.

At this inspection we found concerns relating to safety, effectiveness and governance. The service has been rated as Requires Improvement.

Why the service is rated Requires Improvement.

There were systems in place which should have ensured adequate quality monitoring but not all areas which required improvement had been identified through that monitoring. Some records were incomplete which posed a risk of staff not responding in a timely manner. This had increased risk to people using the service.

There was some good practice in supporting people to receive their medicines in a safe way but the record of a meeting showed that not all medicines had been taken. Staff had been reminded to report medicines found to care staff straight away. Temperature records of medicine storage areas complete, although this had been highlighted twice through a pharmacist inspection. We observed the medicine trolley being left open and unsecured on one occasion during our inspection.

People’s legal rights were not always understood and upheld because the service did not work in accordance with the Mental Capacity Act 2005 – people were not fully supported to make decisions about their care.

Care staff had a good understanding how to protect people from abuse, but, until our feedback, non care staff had not received that training and were unsure how to recognised and report abuse. This training was quickly instigated.

People had their needs assessed and their care planned, with theirs, or their representative’s involvement. Some care plans had included standard phrasing and lacked detail so were not person centred. We have recommended a comprehensive review of care planning at the service. Some care plans did contained good detail, from which staff could understand and provide the required care. Staff were providing person centred care and were conscientious in their work.

Staff received training in subjects relevant to their work. This had not led to all staff feeling confident or competent in the work.

People were treated with kindness and respect. Their dignity and privacy were upheld.

People were very happy with the service they received and spoke unanimously about the good care and support they received from staff and the registered manager. None had any negative comments to make. A health care professional said they had “No major concerns” and staff would “Go above and beyond” for the people using the service.

Staffing numbers and deployment had ensured there were enough staff to keep

This inspection was unannounced and took place on 26 & 27 November 2015.

Nynehead Court provides accommodation and personal care for up to 44 people. The home specialises in the care of older people including people living with dementia. In the grounds of the care home there are 11 houses and bungalows, known as The Mews, where people live independently but receive care and support from Nynehead Court. At the time of the inspection there were 28 people living in the house and two people living in The Mews were receiving personal care.

The last inspection of the home was carried out in July 2014. No concerns were identified with the care being provided to people at that inspection.

There is 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.

The registered manager was qualified and experienced to manage the home. They had been at the home for a number of years and were well respected by staff and people who used the service. One person told us “There’s great management and it goes all the way down.”

Nynehead Court was very much part of the local community which enabled people to maintain links with people and have access to a wide range of social activities and events. Some facilities at the home were used by people from outside the home and the village church was in the grounds. There was a wide range of activities available which took account people’s personal hobbies and interests. The home had two vehicles which enabled people to go out shopping regularly and take part in social trips to places of interest. One person told us “There’s lots of activities. Something for everyone.”

There were sufficient numbers of well trained and experienced staff to support people safely and ensure people were not rushed with their care. Staff told us there was good team work and support from senior staff and management. This all helped to create high staff morale which led to a happy and relaxed atmosphere for people.

The provider had taken reasonable steps to minimise the risks of abuse to people. There was a thorough recruitment process which ensured all staff were fully checked for their suitability to work with vulnerable people. Staff knew how to recognise and report abuse and all were confident action would be taken to protect people if they raised any concerns.

People told us they felt safe at the home and with the staff who supported them. One person said “Yes I feel safe here. I have no worries about safety.” People told us staff were always kind and caring and helped them with personal care in a way that respected their privacy and dignity.

People received effective care and support which promoted independence where possible. People’s healthcare needs were monitored and they were assisted to attend appointments with relevant healthcare professionals according to their individual needs.

People’s nutritional needs were assessed and they were provided with meals that met their needs. People were complimentary about the food served at the home. Comments included; “The food is wonderful,” “Food is excellent” and “The food here is very good indeed.”

People were involved in discussions about their care and all said they would be able to talk with staff if they had any worries or concerns. Where people had made complaints, or raised issues these had been addressed.

There were quality assurance systems in place to enable the provider to monitor care and plan on-going improvements. People’s views and suggestions were sought to make sure changes were made in line with people’s wishes where appropriate.

An adult social care inspector carried out this inspection. We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five 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:

Is the service safe?

The provider had taken reasonable steps to ensure the safety of the people who used the service.

Risk assessments were in place to make sure that risks to people who lived at the home were minimised.

There was a recruitment procedure which minimised the risks of abuse to people.

The service had an up to date policy about how to recognise and report any suspicions of abuse. Staff spoken with were confident that any concerns raised would be listened to and action would be taken to protect people.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. While no applications have been submitted relevant staff have been trained to understand when an application should be made, and in how to submit one. People’s rights were therefore properly recognised, respected and promoted.

Is the service effective?

People received effective care and support to meet their needs.

Staff we spoke with had a good knowledge of people’s individual needs and preferences. We saw people received care in line with their assessed needs and wishes.

The service made appropriate referrals to make sure people received effective treatment to meet their healthcare needs. People told us staff assisted them to attend appointments outside the home.

Is the service caring?

People told us staff were kind and caring. One person we spoke with said: “Staff are helpful and kind.”

Throughout our visit we saw that staff supported people in an unhurried and respectful manner. We noticed that call bells were answered promptly which meant that people did not wait long when they required assistance.

Is the service responsive?

Staff we spoke with had a good knowledge of the people they cared for and demonstrated that all care was provided in a very personal way. One person who lived at the home told us: “You can really please yourself. Staff are very flexible and fit things around you.”

We observed that people were always asked for their consent before any support was given.

There were systems in place to seek people’s views on the quality of the service offered. People told us they would be comfortable to share any worries or concerns with a member of staff or the manager.

Is the service well led?

The service was well led because there was a registered manager in place who was open and approachable. The manager was very visible in the home which meant they were available to monitor practice and respond to any concerns. One person told us: “The manager is always about. She is very efficient and approachable. I feel you could raise anything with her.”

There were various audits to monitor practice and plan ongoing improvements.

All records containing personal information were securely stored to protect people’s confidentiality.

This was a scheduled inspection to check compliance. We also followed up on non-compliance found at an inspection in March 2013. At the last inspection we found there was one area of improvement that the provider needed to put in place. This was in regard to the standard of record keeping.

When we visited the home we were told there were few vacancies. There were three people living in the close care houses in the grounds who used the personal care service. We met and spoke with seven people who lived in the home and one who received support in their own home. We observed care and support provided to people. We spoke with 11 staff. We looked at documents relating to people’s care and support and records relating to the management of the service.

The people we spoke with confirmed they had the support and assistance they needed. One person said “I’m very happy.” Another told us they found the home, “Very comfortable, I want for nothing.” We spoke with people who lived in the home about the food, meals and drinks provided to them. We were told that they were “Enjoyable. Plenty to eat and nice.” Another person described the meals as “Traditional, like we had today such as liver, followed by ‘Spotted Dick’, lovely.”

People appeared to enjoy life at Nynehead Court, they were able to remain as independent as possible and provided with a variety of activities and occupations if they wished to participate.

We found there had been some improvements in the standard of record keeping since the last inspection process. However, at the time of the inspection there was insufficient evidence to demonstrate that compliance had been achieved. Improvements were required to the overall standard of record keeping.

People who lived at the home confirmed that they were able to make choices about all aspects of life at the home. People told us that they chose what time they got up, when they went to bed and how they spent their day. Comments included “we can do what we like really”, “you are never made to do anything you don’t want to do”, “the staff are lovely and they always respect your decisions”.

During our visit we observed that people moved freely around the home. Some people had chosen to spend the majority of their day in their bedroom. One person said “you can come to your room when ever you like and if you need help you just ring the bell and the staff come quickly”, “they check on me regularly and bring me cups of tea”.

People spoken with told us that the staff team knew them well. They said that they were always asked about the care they needed and of their preferences. One person said “the staff know me well and they know how much help I need”. Another person told us “I am always treated with respect by the staff and I never feel rushed”.

People appeared very comfortable in the presence of staff and it was evident that staff knew people well. They were skilled in recognising and responding to people’s needs even though some people were not fully able to make their needs known verbally. Staff interactions were noted to be kind and respectful. The atmosphere in the home was relaxed and inclusive and people were offered assistance with personal care in a dignified and discreet manner. Staff knocked on people’s bedroom doors before they entered.

People who lived at the home told us that they were very happy with the care they received. Comments included “It is excellent here and the care I receive is second to none”, “I can’t fault anything and I wouldn’t want to live anywhere else”, “If you want something, the staff have it for you before you have finished your sentence”.

People who lived at the home told us that they could see a doctor when they needed to. They said “the staff are very good and will always call the doctor if you don’t feel well” and “as soon as I mentioned that I was in pain, they got the doctor straight away”. People also told us that a chiropodist regularly visited the home and that they were supported to attend health care appointments outside of the home. All appointments with healthcare professionals had been recorded in care plans which demonstrated that people had access to healthcare professionals in line with their individual needs.

Everyone asked said that they felt there were always enough staff on duty to meet their needs. Comments included "There are plenty of staff and they are always quick to help" and "Staff will do anything for you, you only have to ask."

We observed that staff responded promptly to any requests for assistance. There was a relaxed atmosphere in the home and staff had time to socialise with people as well as undertake tasks.

All staff appeared confident and well motivated. People spoken with were very positive about staff at the home. They said “all of the staff here are so very kind and helpful”, “the staff are always so cheerful and their smiles make you feel better” and “I really can’t fault the staff, they are amazing really and so kind and patient”.

Staff turnover was low which meant that people living in the home received a consistent level of support as staff members were aware of their changing needs.

At the time of our inspection visit the home was not fully occupied as the new specialist wing with eight beds for people with dementia or similar disorders had recently opened.

We spoke with nine people who used the service. We spoke with nine staff who were on duty at the time of the visit. We looked at the care records for four people. We also reviewed records relevant to the management and the administration of the service. Before the inspection visit we obtained information about the service from healthcare and social care professionals who came in regular contact with the service.

People said that they had the care and support they needed. One person told us, “I was very unwell when I came here and wasn’t able to do anything. Now I do as much as possible myself.” People told us that they had found staff friendly and approachable. We saw from the many compliments received by the home that relatives and friends had observed that staff had good relationships with people in their care. One person had put that they thought the person they supported had experienced,” loving care” from staff. People told us that they were confident to speak to staff if they had any concerns or worries. One person told us, “Never had any problems, never needed to.”

We found that there was one area of improvement that the provider needed to put in place. This was in regard to the standard of record keeping. We made one compliance action to ensure that this is met.