We carried out the inspection on the 17 January 2017. The inspection was unannounced. We asked for additional evidence in a number of key areas and revisited the service on the 7 February 2017. The additional evidence led us to conclude that the service was outstanding in a number of areas.

The last inspection to this service was in October 2014 and it was rated good overall but concerns were identified with the safety of the service in relation to medication practices. Following the inspection the provider sent us a detailed action plan telling us how they would address this. The provider has consistently provided good outcomes for people using their services and is happy to engage with us to demonstrate continuous improvements.

The service provides accommodation with nursing for up to 34 mainly older people some of whom may have a diagnosis of dementia. At the time of our inspection there were 32 people using the service.

The service had a registered manager in place. 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.

We found the service was very well managed with a number of outstanding features. We observed a good rapport between the manager and deputy manager. However the manager had recently returned after a period of absence and the deputy manager was about the go on extended leave. They told us how they planned to cover the duties undertaken by the deputy manager in their absence. The service had a full complement of nurses with the necessary skills to meet the needs of the people using the service. This meant people received continuity of care from highly skilled staff. In addition there was a well-established management team who regularly supported and audited the service to ensure it provided high quality care. The providers were constantly seeking new and innovative ways to improve the outcomes for people using the service. There was a full complement of staff and the providers actively over recruited to ensure they did not have vacant posts. This also meant new staff were supernumerary until they felt confident to work independently.

The service was brightly decorated and stimulating for the people living there. The communal areas of the service were clean and well-furnished with a homely feel. People’s rooms were individualised, with personal items such as ornaments, photos and furniture. The outside area was accessible with paths and benches, and had different areas of interest such as a memory garden.

There were lots of planned activity for people and we saw that the service was responsive to the needs of individuals. Care was personalised around individuals need and staff were visible and caring.

The service had good recruitment processes and staffs performance and conduct was monitored to ensure all staff were delivering care to the highest and expected company standard.

There were enough staff and they were managed to meet the assessed needs of people using the service. The staffing levels meant people received personalised, timely care and opportunities for regular engagement. People were kept stimulated and engaged and the providers helped ensure that people continued to live as full a life as possible and to have their wishes fulfilled.

People received their medicines as intended and there were clear processes to support staff to be able to undertake this task safely.

People felt safe and the staff were trained in key elements of their role to promote people’s health, safety and well-being. They did so in conjunction with the nurses on duty and other health care professionals. People’s needs were assessed and reviewed in line with people’s needs. This helped ensure people received the support they needed.

This inspection took place on 22 October 2014. It was unannounced.

Risby Hall is a care home with nursing, providing personal and nursing care to up to 34 mainly older people. Some people living in the service are living with dementia.

The service had a registered manager in place. 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 living in the service told us it was a good place to live and they felt safe. We saw that the service provided training for staff in how to recognise and report abuse. The service had procedures in place to ensure there were sufficient staff to meet people’s needs.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure that the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code or practice to supplement the main MCA code of practice. The registered manager and staff had a good understanding of MCA and DoLS. At the time of our inspection the local authority and authorised four applications by the service under the DoLS. We saw that the service recorded and reviewed these appropriately.

Medication was administered effectively. People were supported to receive their medicines when they required them. However, storage of medicines was not safe.

People received care which met their needs and were supported to live as they wanted. People were supported to continue activities which interested them. Some people had chosen to be involved in the running of the service and were assisting the maintenance person with internal redecoration.

We observed staff providing care with compassion and in manner which supports people’s dignity. People were involved in their care planning and are routinely listened to.

The service supported people to access the local community and involved relatives and friends in activities.

People living in the service, relatives and staff told us that the management were open and approachable. There were systems in place to monitor and review the quality of service.

We visited the service on the 7 August 2013 to follow up concerns identified at a previous inspection on the 1 February 2013. This was in regards to unsafe medication practices. We looked at other standards during this inspection as a result of a notification and other information of concern we had received. We spoke with five people using the service, one relative and four staff. We observed the care being provided and looked at records relating to the care people received. We looked at staff recruitment processes, medication administration practices and quality assurance systems to see how the service was keeping people safe.

Some people were not able to tell us about their experiences at the home because of long term conditions which affected their ability to communicate with us.. We spent time observing the interaction between staff and people using the service. People were supported appropriately with their manual handling needs, meals and fluid intake. Staff skilfully intervened with minor conflicts that arose between individual residents. We observed people being occupied in meaningful ways with lots of positive social engagement and people being treated with affection.

We inspected four people’s records. These were person centred and told staff how to meet people's needs in a way that respected their wishes and preserved their dignity. Daily notes were informative and identified changes to people’s needs. However these changes were not identified in the care plans and although we saw evidence that records were reviewed it was not clear how changes in need or potential risk were recognised and addressed. We found the risk assessments gave poor attention to detail and we could not find risk assessments for falls for everyone where we would expect them to be in place.

Practices in medication had improved and we noted that staff had received additional training and their competencies had been reassessed to ensure they were suitably skilled to administer medication safety. We noted some gaps in recording but felt this was more an issue of record keeping rather than people not receiving their medication safely.

We inspected five staff records and found staff selection and recruitment processes thorough and ensured that only staff who had been properly vetted worked at the service.

There were systems in place to obtain the views of people using the service and demonstrated that they were proactive in identifying areas for improvement.

We spoke with a number of people who lived at Risby Hall, and some of their family members. People told us they were happy with the service being provided. One person said, “It’s like home, I’m well looked after. The food is good, I can choose what I want.”

Another person told us, “It’s very nice. The staff are lovely and look after me well. If I ring the bell, they always come quickly”.

On the day of our inspection there was a very relaxed, homely atmosphere at the home, with people who lived there and the staff getting on well and enjoying each other’s company. Staff treated people with respect and supported them to remain as independent as possible.

Care records were personalised and gave staff clear guidance on meeting each person’s individual needs. Potential risks to people had been assessed and plans put in place to minimise the risks.

There were sufficient numbers of staff on duty to meet the needs of people who lived at the home. Staff had been through a thorough induction process and had received a wide range of training to equip them to do their job well. Training included safeguarding vulnerable people: staff we spoke with knew how to recognise if people were at risk of harm and to whom to report any concerns. People knew how to complain should they have needed to.

However, medicines were not managed well enough to ensure people received their medicines safely and as they were prescribed.

The people living in Risby Hall Nursing Home and their family members told us that they liked living there, that the care staff showed them respect and worked hard to look after them. They also told us that they were comfortable in the home. One person told us that they were glad to be in the home, saying, “I feel safe now.”