The inspection took place on 5 and 10 July 2018. The first day of our inspection was unannounced. We informed the provider we would be returning to the service the following week but did not specify a day or time.

Old Wall Cottage 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. Old Wall Cottage is a nursing home which accommodates up to 33 people in one adapted building. The building is divided into two units. There were 26 people living at Old Wall Cottage at the time of our inspection.

There was no 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 last registered manager left Old Wall Cottage in October 2017. Since this time the service has been managed by an existing staff member (acting manager) with support from the regional management team.

Sufficient staff were not deployed to meet people’s needs. People were left waiting for their care on occasions and there were not always sufficient staff present in communal areas to monitor people’s safety. Staff employed did not always receive the training they required to meet people’s needs. Clinical staff training had not been regularly updated although a programme of training had been organised. Staff had not always received regular supervision although systems to ensure this took place had been implemented.

Risks to people’s safety were not always adequately monitored and records of risk monitoring were not accurately maintained. People did not always have access to a call bell in order to summon assistance when required. Infection control practices were not monitored and some areas of the service were not clean. Medicines were not always managed safely. The temperature of medicines storage was higher than recommended limits and action had not been taken to minimise this risk. People had not always received their medicines in accordance with prescription guidelines and topical creams were not appropriately managed.

Quality assurance processes were not always effective in ensuring that any shortfalls in the care people received were identified and acted upon. Although staff told us they felt supported in their roles, there was a lack of management oversight and the values of the service were not consistently upheld. Complaints were responded to although were not reviewed to ensure they did not happen again. We have made a recommendation regarding this.

People’s legal rights were not always respected as the principles of the Mental Capacity Act 2015 were not always followed. People’s capacity to make specific decisions was not always assessed and restrictions in place were not always discussed to ensure they were in people’s best interests. People were not always treated with dignity as elements of people’s personal care were not always attended to. People’s care was not always personalised as people’s preferences and past lives were not always taken into account. Care plans regarding the care people wanted when reaching the end of their lives lacked detail. There was a lack of activities for people to be involved in. We have made a recommendation regarding how people were supported with food choices although people’s nutritional needs were met.

In other aspects of people’s care staff demonstrated a caring approach and responded to people’s needs positively. People were supported to maintain their independence and interacted positively with people. Visitors were made to feel welcome and there were no restrictions on visiting times. People and their relatives wer

Old Wall Cottage Nursing Home is a privately owned nursing home providing accommodation and nursing care for up to 33 older people some of whom are living with dementia or other associated disabilities. There were 30 people living at the service on the day of our inspection. Bedroom accommodation is arranged predominantly on one floor, and a recent refurbishment programme has included an enclosed secure garden for people. Several lounge and dining areas are located throughout the home. There is also ample car parking available at the front of the service.

The service did not have registered manager in post on the day of the inspection visit. ‘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.

There were sufficient numbers of staff who were appropriately trained to meet the needs of the people who lived at the service. Staff received annual appraisals and regular formal supervision. .

Staff recruitment procedures were robust to ensure that staff had appropriate checks undertaken before they commenced employment.

The guidelines to minimise the risk had been reflected in people’s care plans to help keep them safe. Risks were well managed and assessments of risk to people were reviewed and updated on a regular basis.

People were protected from the risk of abuse. Staff had received training in safeguarding adults and were able to evidence to us they knew the procedures to follow should they have any concerns. They told us they would report anything they were uneasy with to the nurse in charge. The staff we spoke to knew of types of the different abuse and where to find contact numbers for the local safeguarding team if they needed to raise concerns.

Medicines were well managed and people had their medicines when they needed them. All medicines were administered and disposed of in a safe way.

Where people were not able to make decisions for themselves we checked whether the staff were working within the principles of the MCA. We read whether any conditions on authorisations to deprive a person of their liberty were being submitted appropriately and found that they were.

People were encouraged and supported to be involved in their care. People’s bedrooms had been decorated to a good standard and were personalised with their own possessions.

Health care needs were being met. People had access to a range of health care professionals, such as the GP, a community psychiatric nurse, dentist and opticians.

People told us the food was very good and there was lots of choice. We saw people had access to drinks and snacks at any time during the day or night.

Staff were kind and compassionate. We saw people were treated with and respect and their privacy and dignity was respected at all times. For example staff knocked on people’s doors before they entered their room.

People had individual care plans which gave clear guidance to staff on what support people needed. They were detailed and updated regularly. Relatives told us they had been consulted regarding people’s care plans and were able to attend reviews of care.

The manager operated an open door policy and we saw of this throughout the day when staff were able to have discussions with the manager. They also ensured they were visible on the floor as their office was not easily accessible to people with mobility needs.

People were aware of the complaint procedures and told us they would know how to make a complaint. A relative told us they were satisfied with the way their complaint was managed.

The manager had maintained accurate records relating to the care and treatment of people and the overall management of the service. The manager and deputy manager had systems in place to

As part of our inspection we spoke with five people who used the service about the care and support they received. We also spoke with the Registered Manager and four support staff. During the inspection we noted that staff interactions with people were positive and there was a friendly and relaxed atmosphere in the home. People told us they liked living at the home and were happy. Comments included, "I can't fault it" and “I'm happy living here and the staff treat me well and with respect.”

We were told that the staff respected people’s privacy and dignity and were instructed to knock on individual’s doors before entering a private room and to communicate appropriately with individuals. People who use the service told us that the staff were ‘very good’ and that they felt able to speak to them should they have any concerns.

Staff told us they were happy working in the home. One person said, "It's like a big family here" and another person said, “I'm very happy, I love it here.” People told us they had been made aware of the provider’s complaints procedure but they had no complaints about the service they received.

As part of our inspection we spoke with five people who used the service and their relatives about the care and support they received. We also spoke with the Registered Manager and four support staff. During the inspection we noted that staff interactions with people were positive and there was a friendly and relaxed atmosphere in the home.

People told us they liked living at the home and were happy. Comments included "I can't fault it" and "It's ok, I'm happy with it here".

We were told that the staff respected the privacy and dignity of people by knocking on doors before entering the room and speaking appropriately to them. People told us that staff were "Very good" and that they felt able to speak to them should they have any concerns.

People told us they were involved in their care and support. One person said "We have regular meetings with everyone to talk about the care here".

Relatives of people told us they are happy with the service and felt that people were safe. They told us that if they had a problem or a concern then they would know who to speak to about it. Comments included "I'm confident that my relative is safe here" and "If I have any concerns then I can speak to the staff or the manager and I know they will sort it out".

Staff told us they felt "Supported" and were happy working in the home. One person said "It's like a big family here" and another person said "I'm very happy, I love it here".

People who do not user verbal forms of communication we observed them showing relaxed body language and enjoying interacting with staff. Several people told us that they originally came to stay at the service for short term care and liked it so much that they decided to live their permanently. A person said “I have now been here a year, its very good, people are very supportive, friendly and they listen to you”. Carers spoke unanimously about the good standards of care their relative receives. They commented: “You cant fault the care at all or anything about the place” and “It is brilliant, they are so very attentive towards my mother”. We were consistently told by people and carers that it is like being part of a “family” living and visiting the service.

A person who lives at the service told us how staff were always respectful towards them. A person told us how they are able to meet their guests in the privacy of their own bedroom, that their guests are always made to feel welcome by being offered refreshments or invited to stay for meals. Carers consistently told us how the service promotes peoples dignity. A carer said “My mum always looks wonderful her clothes are colour coordinated, which is really important to her”.

A person told us that “the staff are always encouraging me to be mobile and do things for myself”. A carer noted the significant improvements in their relative’s mobility since moving to the service. This they felt was due to the individual attention and support provided. People consistently told us that they were encouraged to express their views and be involved in making decisions about their own care and treatment.

We received consistent feedback from people and carers as to the promptness at which medical intervention is sought. A person said “What does impress me is if I ask for the DR in the morning he would be here by 6pm” another person spoke about being diagnosed in the morning and having the prescribed medication with hours”.

People told us that they could eat their meals where and when they wanted to and consistently told us that there was always a range of meal choices available and how nice and plentiful the meals were. Many carers told us that they regularly eat meals with their relative, with a carer describing the food as “excellent”

People told us that they felt safe from abuse and felt confident to raise any concerns they had with the manager and felt that this would be dealt with promptly.