This inspection took place on 21 September 2018 and was unannounced.

Prince of Wales is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Prince of Wales provides nursing and care for up to 20 people. The home is set in a large purpose built building. There were 20 people living at the home at the time of our inspection, most of whom were older people including those living with dementia.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

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.

People felt comfortable around staff and received continuity of care from familiar staff. People and their families understood if they had any concerns about their personal safety they could speak with staff or the registered manager and a system for recording and sharing concerns was in place. Risks to people’s health were recorded for staff to refer to and reviewed and updated in line with people’s needs. Staff were available at the times people needed them and staffing levels were reviewed and monitored by the registered manager. Adjustments to staffing levels were made in response to people’s assessed needs. Staff had worked at the home for some time and where agency staff were used, regular agency staff were employed. Staff new to the home had their background checked before commencing work at the home to ensure it was safe for them to work there. Accidents and incidents were reviewed and analysed and learning shared with staff so that people’s experience of care was adjusted and the chances of accidents and incidents would be reduced. Staff understood the importance of minimising the risk of the spread of infection.

Staff received training and guidance in response to people’s individual needs. Where training was needed to care and support specific medical conditions, staff received the training needed. People liked and valued the care staff supporting them. People knew they could receive the support they needed from staff that understood their individual needs. People were treated with dignity and respect by staff that supported them to remain as independent as possible. People and their families were supported to incorporate the arrangements they preferred in end of life care planning.

People expressed their wishes about their care and this was recorded in care plans that staff could refer to. People and their families were involved in updating their care plans through discussions with staff and meetings. People were treated with dignity and respect by staff who could empathise and understand their needs. People and their families felt able and comfortable speaking with staff about any concerns they had and understood the process for complaining if they needed to.

The registered manager worked closely with the registered provider and staff to involve people and their families in their care and the running of the service. People’s care was reviewed and updated to reflect people’s changing care needs and wishes. Staff working at the home felt assured they could seek advice and guidance from the registered manager as well as discuss issues that were important to them. The registered manager worked with other stakeholders in the area to share best practice and develop ideas of improving people’s experience o

This inspection took place on 7 January 2016 and was unannounced.

Prince of Wales nursing home provides nursing care and accommodation for up to 20 older people. There were 18 people living at the home at the time of our inspection and most people lived 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.

Staff were available at the times people needed them and had received training so that people’s care and support needs were met. This included training about dementia care. Staff understood their responsibility to safeguard people from harm. Where risks associated with people’s health and wellbeing had been identified, there were plans to manage those risks. Risk assessments ensured people could continue to enjoy activities as safely as possible and maintain their independence.

People were involved in decisions about their care and told us that they received support in the ways they preferred. People told us that staff encouraged them to remain as independent as possible and that they were supported to pursue their hobbies and interests. People were supported to maintain relationships with people important to them and visitors were welcomed at the home.

People and their relatives told us that staff were caring and that people were afforded privacy and treated with dignity and respect.

People received a nutritious diet, had a choice of food, and were encouraged to have enough to drink. People were referred to external healthcare professionals to ensure their health and wellbeing was maintained. Medicines were managed so that people received their medication as prescribed.

Staff understood the principles of the Mental Capacity Act (MCA), and care workers gained people’s consent before they provided personal care.

There were processes to monitor the quality and safety of the service provided and to understand the experiences of people who lived at the home. This was through regular communication with people and staff, surveys, checks on care workers to make sure they worked in line with policies and procedures and a programme of other checks and audits. Arrangements were in place so that actions were taken following concerns raised, for the benefit of people who lived at the home. Systems were in place to drive continuous improvement at the service for the benefit of the people who lived there.

Eighteen people were living at the home on the day of our inspection. Many of them were not able to describe how they were cared for and supported because of their complex diagnoses. We observed how care was delivered and talked with four people about what it was like to live at the home. We spoke with the manager, a cleaner, a nurse and a care assistant.

We reviewed three staff files and two care plans. We looked at records of complaints, cleaning schedules and quality assurance audits. We saw the results of surveys undertaken by the provider of people who lived at the home and their relatives.

We used the evidence we gathered to answer the five key questions: is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

The care plans we looked at showed that risks to people’s health and well-being were assessed. Care plans described the actions staff should take to minimise the identified risks.

People were cared for in an environment that was safe, clean and hygienic. People’s medicines were managed, stored and administered safely.

Staff personnel records contained all the information required by the Health and Social Care Act 2008. This meant the provider checked that the staff employed to work at the home were suitable and had the skills and experience needed to support the people who lived at the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The deputy manager knew about a recent judgement by the Supreme Court in relation to (DoLS), and was taking action to ensure they complied with any changes in the local authority’s policy and procedures. One DoLS application had been submitted at the time of our inspection and was awaiting agreement from the local authority. The manager was assessing whether they needed to make a further six DoLS applications.

Is the service effective?

People told us they were happy with the care they received and their needs were met. It was clear from our observations and from speaking with staff that they understood people’s care and support needs and that they knew them well. One person told us, "It is very, very nice here. I felt welcome”, and “There are very few bells at night and they always come promptly.” We saw relatives had commented positively in a comments book in the hallway.

Is the service caring?

People were supported by kind and attentive staff. People told us they were able to get up and go to bed when they wanted to, and always had a choice of meals. We saw people were supported to follow their own interests and join in group activities if they wanted to. One person told us, “I can talk to the staff, they are interested in my life stories.”

We saw care workers were patient and encouraged people to make their own decisions. A care assistant told us, “Nurses find out about people’s likes, dislikes and preferences at their assessment. We try to make it home from home for them.”

Is the service responsive?

People’s needs and abilities were assessed before they moved into the home. The care plans we looked were regularly reviewed and changed as people’s needs changed. We found that staff supported people to see other health professionals, such as doctors, dentists and opticians when they needed to.

The manager listened to people’s comments and suggestions and took action to resolve issues straight away. People we spoke with told us they felt comfortable about raising any issue with the staff or manager because they always got a positive response.

Is the service well led?

The manager conducted internal quality reviews and actively consulted with people and their relatives through surveys and meetings. We saw complaints were investigated thoroughly and actions were taken to provide a satisfactory resolution.

Staff had a good understanding of their role and responsibilities for delivering a quality service. Staff told us about the quality assurance checks they made and the actions they took when they identified any issues. A care assistant told us, “Any problems always get sorted. It is like a team.”

The atmosphere of the home was calm and pleasant. Interactions between the staff and people living there was more purposeful in comparison to the last inspection in July 2013. Staff understood what was required of them during their shift and had more direct supervision from the nurse in charge.

The standards of care were much improved. People were more involved in the running of the home and the service they received. Choice and options were given throughout the day and individual and group activities took place during our visit.

The basic care needs such as nutrition, hydration, pressure area care and moving and handling were taken care of throughout the day by friendly, caring members of staff.

Safeguarding issues such as mental capacity assessments and best interests meetings need to be addressed to ensure the home is maintaining people’s rights safely and lawfully.

We bought this inspection forward after receiving information of concern about staffing arrangements. We found that people were not involved in decisions about their care or in their care planning process. Staff were not taking action in respect of pressure area care or following care plans. Care staff were kind and well intentioned but lacked direction and supervision by the qualified nurse on duty and the acting manager. Observations of the staff indicated that they lacked insight into the risks associated for older frail people, in relation to nutrition and hydration.

People were not protected against the risks associated with medicines. The provider had inappropriate arrangements in place to manage and store some medicines. Lack of consistency in nursing staff across shifts resulted in medicines issues not being addressed promptly.

There were not enough skilled and experienced nursing staff employed by the home. Care staff were not supported or directed to deliver safe and effective care.

Quality assurance systems required further development to ensure safe and effective care was given to the people living at the home.

We had serious concerns about this service, and the impact and risk to people living at the home. We have discussed our findings with the provider and other agencies. The provider has been asked to respond as soon as possible to show how they intend to provide safe and effective care to the people living at the home.

We spoke with over half of the twenty people living at the home. People living there require care and support because of either physical or mental frailties.

Responses we got from people were overwhelmingly positive. Comments from people living at the home included “everything is perfect here” and “very contented”.

We spoke with four relatives who were visiting on the day of our inspection, and got similarly positive responses.

One person said “it’s marvellous here!” Another said: “All very kind - Sharon marvellous”

One person noted there had been “a few hiccups” but that these had been responded to and resolved.

We also spoke with one visiting professional, who had been “impressed” with what they had seen.

We visited the Prince of Wales Nursing Home in March and June 2011. We found that the service was not compliant with regulations. People's health and personal care was not consistently good or monitored well.

A large number of the people living in the Prince of Wales Nursing Home had conditions such as dementia. This made it difficult for them to tell us what they thought about the care they received. The people that could tell us about their care said that there were specific areas of their care that needed to improve. We issued warning notices to the registered provider to improve the service following our visits in March and June 2011.

We visited the service again on 6 September 2011 to check if improvements had been made.

We found that improvements had been made. There were systems in place to sustain that improvement. People were getting better care, and monitoring of this care had improved.

At times people still did not experience consistent management of their care. Errors were made in the giving of medicines and how people were treated.

The planning of how people's needs were to be met did not include adjustments for how people like their care to be given or matched their previous lifestyle.

The registered provider has employed consultants to continue to improve the home. For this reason and because of recent improvements we are suspending further enforcement action. We will be monitoring this services performance.

People told us they were happy with the care they received. They had said in meetings that they wanted better activities and TV reception. They wanted to go out in the garden. We found that people were not always enabled to make choices about their care and lfestyle. We found that systems were not always in place to support people adequately and minimise risks to them.

"A couple of days ago I was got up at 5 am,” the person later said,” Usually I am got up at 7am I like a long day."

"I am got up at just after 7am and breakfast is at 9am." They told us the routine for the home which indicated that there was a set pattern to people's daily life in the home.

“Sometimes (careworkers name) gets me up, they take their time, I know I will be safe with them."

A person told us that care workers helped a person to walk. They said that the careworker had told them “if we keep assisting them to walk a little they will keep walking."

“We can call for help when we need it, there’s a red button on a cord and it is tucked down by my blankets."

"The food is good."

“We can have cornflakes, porridge, cooked breakfast, eggs. I like to have bacon sandwiches. The marmalade comes in those diamond packets; it’s very nice. They feed us well we always have orange juice (for breakfast).”

“The home is lovely and clean they vacuum every day"

"I'm worried that people will fall out of their wheelchairs, they lean forward. We are not strapped in you know."

Relatives told us: -

"My relative has been far happier than has been"... “.. have been encouraged into the lounge and are now speaking with other residents."

"The staff are very caring and kind and I have no concerns."

"The staff appear to be professional in their approach and caring."

"There is a good relationship between the staff and my relative."

"They make us feel welcome."

“The food is ok but everyday is a bit the same."

“There is plenty of food my relative lost weight at a previous home but they have started putting weight back on."

"Sometimes my relative is not wearing their own clothes. I have bought name tags for them but these have not been sewn in." "Laundry has got better and it is less in a muddle."

We were told by two relatives that they there were no relative meetings with the management to discuss "niggles with the service."

"They need more stimulation."

“I don't know what activities they do."

"There doesn't seem to be many activities.”

“I know my relative can be difficult on a night but they don't seem to over medicate."

"The building is tired."

"The building could do with some money spent on it. It’s dated and people do not have en suites"

"My relative has had a continuing care assessment said needed a different wheelchair that would give more support that was in November."

"Wheelchair is a bit small."

"The aerial needs sorting out so my relative can have a decent picture on the TV in their room"

"The outside aerial for the TV needs to be available in bedrooms."