The inspection took place on 13 and 18 June 2018 and was unannounced. There was a registered manager in post, however they were not present on the first day of our inspection. We returned on a second day to obtain some further information from them to complete our inspection.

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.

Rose Hill is a care home, registered to provide nursing care and accommodation for up to 35 people. One the day of our inspection there were 24 people at the service, including some people on short term or respite care.

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.

At Rose Hill, the accommodation is arranged over two floors. A passenger lift provides access to the first floor. Rooms are single occupancy and some have en-suite facilities. There is a large garden to the side and rear of the service.

At our last inspection, in November 2015, the service was then rated as “Good”. However, at this inspection we found there were some aspects of the service that needed to be improved.

The premises needed to be made safer for people living with dementia. In particular, all windows were required to be risk assessed and made secure with restrictors that comply with Health and Safety regulations.

There were also parts of the building where cleanliness needed to be addressed, for example in the laundry and sluice rooms that staff used. The physical environment was not decorated to a consistent standard, and in some bedrooms the bedding and carpets looked stained.

Staffing levels were adequate and people’s needs were met. However, we were told that staffing levels were based on the numbers of people living at the home. We have made a recommendation to the registered provider to also take into account the needs of people to ensure there are always sufficient staff.

Medicines practice was safe and well administered. We noted a gap in recording and protocols that affected a small number of people. These have been corrected since the inspection.

Whilst people were involved in decisions about their care, staff understanding of the legal basis for consent was limited. We could not find sufficient evidence that the service was acting in line with the legal requirements of the Mental Capacity Act 2005 (MCA). There were gaps in people’s records on mental capacity assessments and where decisions were taken in a person’s best interests.

People’s needs had been assessed to provide effective health and social care. Information about people was stored on a relatively new care management system. People’s personalities and needs were known by staff, but some individual care records needed to be updated.

We heard positive feedback about the way the service was managed from staff and relatives, but there were aspects of service governance that needed improvement. The quality assurance system was not effective in reviewing the quality of the service provided. Audits did not identify any actions to mitigate the risks or address the shortfalls we found. Learning from accidents and falls across the service was not developed.

People were looked after by staff who were kind and caring. We heard from relatives who praised the kindness and attention that was shown. However, some staff did not communicate as well as others and appeared task focused. We have made a recommendation to the registered provider that all staff are supported to communicate to a required standard of English.

Staff were trained (apart from in the Mental Capacity Act), supervised and su

Rose Hill Nursing Home is registered to provide nursing care and accommodation for up to 35 older people some of whom are living with dementia. There were 27 people living at the service during our inspection. The home is located close to Dorking town and within easy access to local amenities and facilities. Bedroom accommodation is arranged over two floors. A passenger lift provides access to the first floor. Bedrooms are single occupancy and some have en suite facilities. There is a large garden to the side and rear of the service and a small car park is available at the front.

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

The home was run by a registered manager, who was present 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 2008 and associated Regulations about how the service is run.

Assessments were in place for identified risks. Risks were well managed and reviewed and updated on a regular basis. These had been reflected in people’s care plans.

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. Staff said they would report any concerns to the registered manager. The staff we spoke to knew the types of different abuse and where to find contact numbers for the local safeguarding team if they needed to raise concerns.

There were sufficient numbers of staff deployed who were appropriately trained to meet the needs of the people who lived at the service. Staff had the appropriate and up to date skills and guidance in relation to their role.

Procedures were in place for medicine administration. People received their medicine as prescribed. All medicines were administered and disposed of in a safe way.

Staff were aware of the home’s contingency plan, if events occurred that stopped the service running. They explained actions that they would take in any event to keep people safe. The premises provided were safe to use for their intended purpose.

Staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). DoLS authorisations had been submitted where restrictions were imposed to keep people safe. People’s best interests had been considered when they needed support to make decisions.

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

People had enough to eat and drink and received support from staff where a need had been identified. One person said “We have a choice of meals and can always ask for something different.” Specialist diets to meet medical, religious or cultural needs were provided. People had access to drinks and snacks at any time during the day and night.

People were treated with kindness, compassion and respect, and their privacy and dignity was respected at all times. 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.

People had individual care plans. They were detailed and updated regularly. We saw staff had the most up to date and appropriate information to enable them to respond to people effectively.

The registered manager operated an open door policy and we saw several examples of this throughout the day when staff, relatives and people who used the service sought their support and advice. People were aware of the complaint procedures and told us they would know how to make a complaint.

The registered manager had maintained accurate, complete and detailed records in respect of people and records relating to the overall management of the service.

The service had systems in place to record and monitor the quality of the service provided. Accidents and incidents were recorded and acted upon.

During our visit we met and spoke to most of the people who used the service and the staff on duty.

People's needs were assessed and care and treatment was planned and delivered according to people's individual care plans. One person and their relative who had recently moved into the home praised the staff for their help and support during the transition.

People who used the service told us they they liked living in the home and that the staff were kind and caring.

We saw that people who used the service were involved in the planning of their care as much as possible. One person told us that their family was also considered in this process.

The home was clean and hygienic and staff were aware of their responsibilities regarding infection control. Individual bedrooms were cleaned daily and all communal areas of the home were clean and well maintained.

Staff told us they liked working in the home. They said they had received the training and supervision necessary to undertake their roles.

We looked at at the provider's quality assurance and complaints procedures in place. We found there was a good range of monitoring systems used to audit the quality of the service being provided.

People told us that they were happy living at Rose Hill Nursing Home.

One person told us that they had everything they wanted in their room and that they were very comfortable.

People said that there was always sufficient staff on duty, and that they were kind and caring.

There was good feedback regarding the food. People told us that they enjoyed their meals and that there was always something on the menu that they liked.

People felt that there was always something going on to keep them occupied and that they could choose the activities of interest to them.

People told us that they were happy with the care and support that they receive. They said the staff are very good. One person said ‘they always help me when I walk’. Another person said ‘they look after me well and come when I call for assistance’.

One person told us that the home is more organised now. The person also told us that they were happy that they have moved to a new bedroom on the ground floor where they can see the garden.

Three people we spoke with told us that they enjoy their meals and that they are offered choice of food.

We spoke to six people who use the service and each person told us they were satisfied with the care provided.

Four people who use the service told us they enjoy their meals, that they are offered a choice and that meals are hot when they are served.

We were also told by four people using the service that they thought there were enough staff to meet their needs and that staff come when they use the call bell.

One person told us they might have to wait a short while if staff are busy with other people.

We spoke to some people who live in the home to gain their views about the care and support they receive. People told us a number of their concerns about staffing. They felt staff were not always responsive to their needs, citing slowness in responding when call bells were used. Others found it difficult to understand some staff whose first language is not English.

Some of the people expressed concerns about the provision of food, how it was presented and when it was provided. An example of this was that the evening meal is served as early as 5.20pm. The interval between lunchtime and the evening meal is short; therefore some people said they are not hungry when the evening meal is served. Comments included:-

“I don’t know why they give us spam, had enough of that during the war”.

"I don’t like sandwiches and they always give me sandwiches.”

“Meals are variable, some are better than others”.