We inspected Royal Bay Nursing Home on 7 November 2018. Royal Bay Nursing Home 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. Royal Bay Nursing Home is registered to provide care and accommodation for 35 older persons with nursing, residential care and physical care needs. Accommodation is provided over two floors. There were passenger lifts to provide access to people who have mobility issues. On the day of our visit 30 people were living at the service. We previously inspected Royal Bay Nursing Home on 11 and 13 July 2017 and found areas of practice that needed improvement in relation to staffing levels, medicines management and management support for staff. At this inspection, we found improvements had been made in some areas, but identified further areas of practice that needed improvement.

There was 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.

Staffing levels did not routinely meet people’s needs, and we received negative feedback from people and staff in relation to their preferences being met.

Care plans were not routinely person centred and did not detail people’s likes dislikes and preferences.

The provider carried out quality assurance reviews to measure and monitor the standard of the service and drive improvement. However, systems of quality monitoring and governance had not ensured that staffing levels were suitable and that care plans remained up to date and person centred.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were encouraged to express their views. People said they felt listened to and any concerns or issues they raised were addressed. Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where the management team was always available to discuss suggestions and address problems or concerns.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. People were treated with dignity and respect, and they were encouraged to be as independent as possible.

Risks associated with people’s care, the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People chose how to spend their day and they took part in activities. They enjoyed the activities, which included, arts and crafts, exercise, quizzes and visits from external entertainers. There were representatives from local churches, so that people could observe their faith. People were also encouraged to stay in touch with their families and receive visitors.

People were cared for in a clean and hygienic environment and appropriate procedures for infection control were in place. Healthcare was accessible for people and appointments were made for regular check-ups as needed. People’s end of life care was discussed and planned and their wishes had been respected.

When staff were recruited, their employment history was checked and references obtained. Checks were carried out to ensure new staff were safe to work within the care sector. Staff had received essential training and there were opportunities for additional training specific to the needs of the service, such as the care of peopl

The inspection took place on 11 and 13 July 2017 and was unannounced.

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 18 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives.

At the last inspection of 29 and 30 November 2016 we rated the service as Inadequate and it was placed in Special Measures which meant we monitored and reinspected the service within six months. This was due to concerns we identified at the inspection regarding the following:

• The provider had not ensured the risks to service users were adequately assessed and action taken to mitigate the risks.

• The provider had not ensured staff always had the required qualifications to provide safe care.

• The provider had not ensured medicines were safely managed.

• The provider had not ensured equipment was safe for people to use.

• The provider had not ensured people’s nutritional needs were met.

• The provider had not ensured there were systems to assess, monitor and improve the quality and safety of the services provided.

• Care records were not always secure.

We took enforcement action in the form of warning notices regarding these failures to meet standards.

We also found the provider had not met the required standard for the following:

• The provider had not ensured that care and treatment met the needs and preferences of

people. This included failing to ensure needs were always assessed and that the design of

care and treatment met service user's needs and preferences.

• The provider had not ensured staff received appropriate training, support, and supervision.

We issued a requirement for these failures to meet standards to be addressed.

The provider sent us actions plans of how these matters were to be addressed. We carried out an inspection on 7 February 2017 to check if the provider had taken sufficient action regarding the warning notices we issued. We found the provider had taken sufficient action for us to judge the matters highlighted in the warning notices had been addressed. At this inspection we found the provider had continued to make improvements. The requirements made at the inspection of 29 and 30 November 2016 were now met. We judged sufficient improvements have been made that the service no longer needs to be in Special Measures.

At the inspection of 29 and 30 November 2016 we also found the service did not have a registered manager and that management arrangements were unclear. For example, there was a lack of clarity regarding who made decisions regarding nursing care. Since then the provider has appointed a manager who is now registered with the Commission. 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 service now has a deputy manager who is a registered nurse and has responsibility for decision making regarding nursing care. There was a management team of: the registered manage and a deputy manager who a lead responsibility for coordinating nursing care as well as a head of care. The management team were committed to making improvements.

Whilst we noted considerable improvements have been made to the service we judged sufficient time has not elapsed for us to say these changes were fully sustained and embedded. We also took account of the fact the service only accommodated 18 people when it is registered for up to 35. We were therefore only able to assess the performance of the service at just 50 per cent occupancy.

Sufficient numbers of care and nursing st

We carried out a comprehensive inspection of this service on 29 and 30 November 2016. Breaches of legal requirements were found. After the comprehensive inspection, we issued three Warning Notices and the provider wrote to us to say what they would do to meet legal requirements in relation to breaches of Regulations 12 (safe care and treatment), 14 (meeting nutritional and hydration needs) and 17 (good governance).

We undertook a focused inspection on 7 February 2017 to check that they had followed their plan and to confirm that they now met the requirements of the Warning Notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Royal Bay Nursing Home on our website at www.cqc.org.uk

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 17 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives.

At this inspection we found improvements had been made and that the shortfalls identified in each of the three Warning Notices had been rectified.

The service did not have a registered manager but a new manager was recently appointed and they intended to apply to the Commission for registration. 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 service has been without a registered manager for over a year and at the previous two inspections we identified there was a lack of leadership at the service. The new manager was motivated and committed to improving the service. A new deputy manager had also recently started work at the service; this person was a Registered General Nurse (RGN) and her role involved taking a lead responsibility for nursing care in the service. We found the deputy manager was also motivated to improving the service and had a good knowledge of nursing procedures. The service also had another manager who worked alongside the manager and deputy manager, who referred to themselves as the interim manager.

The provider had taken action to address the shortfalls identified in a Warning notice regarding the safe care and treatment of people. This included the provision of first aid training for staff and taking measures to reduce the risks of injury to people by maintaining equipment correctly. Action had been taken to ensure risks of pressure injuries to people’s skin were consistently addressed. Action had also been taken to rectify the concerns we found regarding the safe management of medicines. People and their relatives told us they received safe care and treatment. We spoke to health and social care professionals who identified improvements in how risks were managed.

The provider had taken action to address the shortfalls identified in a Warning Notice regarding meeting people’s nutrition and hydration needs. We saw improvements had been made regarding the assessment of people who were at risk of possible malnutrition or dehydration and that referrals were made to relevant health care professionals for advice and support regarding food and fluids. We observed people were supported to eat and drink. People told us they liked the food.

The provider had taken action to ensure there was a system of assessing, monitoring and improving the quality of the services provided which was identified in a Waning Notice as in need of significant improvement. Audits and checks were carried out to identify where improvements were needed. People were able to expres

The inspection took place on 29 and 30 November 2016 and was unannounced.

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 30 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives..

The service did not have a registered manager. At the last inspection in January 2016, the service did not have a registered manager and it was unclear then who was managing the service at that time. Since then the provider had not confirmed in writing who was managing the day-to-day operations of the service. Therefore the provider was in breach of the Registered Manager condition of their registration which requires them to have 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.’

The provider lacked oversight of the service and there was poor quality monitoring. Some of the concerns found at the previous inspection continued to be areas of concern at this visit. At the last inspection we found the system to assess, monitor and improve the quality and safety of the service was not adequate and we made a requirement for this to be addressed. The provider submitted an action plan to say how they would meet this regulation. At this inspection we found this regulation was still not met. There were shortfalls in how care was coordinated and sufficient action was not taken to ensure people received safe care and treatment. We were concerned about the lack of consistency in the management of the service since the last inspection. Care records were not securely stored.

At the last inspection we found the provider had not ensured people’s nutritional and hydration needs were met and made a requirement for this regulation breach. The provider sent us an action plan of how this was to be addressed. At this inspection we found sufficient action was not always taken where people were at risk of malnutrition and dehydration. This is regulation was still not met.

Providers are required to notify the Commission of certain events or incidents affecting service users and the safe operation of services.

At the last inspection we found the provider had failed to notify us that the heating system was not working. At this inspection we found incidents were not always notified to us, namely, a safeguarding investigation being carried in conjunction with the local authority safeguarding team. This regulation was still not met.

At the last inspection, we found the provider had not ensured the home was adequately heated. The provider sent us an action plan of how this was to be addressed. At this inspection, we found the heating was generally working but that one person’s radiator did not work which was repaired at the time of the inspection visit. This regulation was now met.

Whilst some staff told us they were supported and could seek advice when they needed there was a lack of formal supervision of staff and registered nurses.

Sufficient action had not been taken to ensure the equipment in the service was safe. This included a hot water dispenser, supplementary heating in bedrooms and servicing of the portable electrical appliances. Sufficient numbers of staff were not trained in first aid. Medicines procedures were not always safe and people did not always receive the correct medicine.

Care plans and assessments did not always include sufficient detail of how care needs were to be met, including end of life care.

People told us they felt safe at the service. We saw people were clean an

On this occasion we inspected the home to check on progress with compliance actions that we set at a previous inspection. We spoke with the manager and looked at records. We also looked around the home to assess whether the home was meeting with the required standards for infection control. On this occasion we did not speak with people who used the service.

We found that the home was clean and that staff were taking infection control seriously.

We also found that care was delivered that met with people's needs.

Everyone who we spoke with told us that they were very happy with the care they received at the Royal Bay Nursing Home. People living at the home, and some of their relatives, told us that the care they received was very good. One person said “I was frightened of moving into a care home after I fell and went to hospital, I needed more help. I didn’t feel safe anymore at home. The staff here have changed all that and I am much more confident again now”.

The daughter of one person told us they were upset that their parent was becoming more frail but that the staff had helped them cope and see that it was the best thing. They said their parent had been isolated and lonely living alone and had become depressed. Since moving into the home they had “got their second wind” and enjoyed the activities and company of others.

Staff were described as very kind and helpful. We were told that the senior staff and management were approachable and sorted out any small issues before they became problem. One group of people that we spoke with said they really enjoyed chatting to the “young girls” as it made them feel young again.

We spent time observing care and saw that, on the whole, people’s needs were being met but that the records did not always reflect this. We did identify some areas where improvements were necessary to ensure compliance with the regulations and people were put at some degree of risk because of lack of oversight of care by the trained nurses.

People we spoke with told us that they were happy living in the home; they said that they were well cared for by staff that were friendly and helpful.

One person said, “The care here is excellent”.

Another person said, “I am very happy here, the food is excellent”.

Another person said, “If I have to be in a home for the rest of my life, I would choose this home.”

Royal Bay Nursing Home provides accommodation for up to 35 people. It provides a service for people with nursing needs and people living with dementia.

There was no registered manager in place at the time of the 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.

There was no registered manager in post. There was a deputy manager and head of care and they shared the responsibility for managing the service. From our discussions with the deputy manager and the head of care it was not always clear who was responsible for tasks and addressing concerns within the home. The deputy manager told us that the provider was in the process of recruiting a new manager who will apply it CQC to become the registered manager; however at the time of the inspection they had not appointed a suitable candidate.

Systems were in place to identify risks and protect people from harm; however for some people these risk assessments were not reviewed regularly to ensure that people’s records reflected their needs in relation to mitigating risks.

Premises were not properly maintained as the provider had not ensured that there was a supply of hot water. On the day of our inspection we noted that there was a limited supply of hot water within the home and this had been a persistent issue since December 2015. There were three bathrooms within the home and two of these bathrooms did not have access to hot water. This meant that people were not able to have a bath or shower when they preferred. Some people within the home had been receiving bed bath and they told us their preference was for a bath. The provider had not notified the Commission of the failure of the hot water supply as an event that could prevent the service was carrying on the regulated activities safely or in accordance with registration requirements.

People’s hydration needs were not always met. Fluid charts were in place, however we reviewed the fluid charts of two people who spent their time in their room and saw that they had not received the amount of fluid as set in the daily intake target in their care plan and the guidance for staff on ensuring sufficient hydration was not sufficiently clear.

We saw that the monitoring processes in place had not identified and taken action to address the concerns we found at this inspection including food and fluid charts and concerns with the premises.

There were sufficient numbers of staff on duty to keep people safe and meet their needs. We reviewed the rota and the numbers of staff on duty matched the numbers recorded on the rota. Staff told us they felt there were enough staff on duty however staff raised concerns about the high number of on agency staff in the evening and weekends. The rota showed that there was a high level of agency staff used over the four week period. We saw that in the week starting the 4 January 2016 14 shifts were covered by agency staff, the following week there were 10 shifts covered by agency staff. From our observations staff responded to people promptly however people we spoke with told us the high use of agency staff had affected the quality of the care at night and the weekends.

Staff were aware of their responsibilities in relation to keeping people safe. A member of staff told us, “If I saw a colleague doing something they shouldn’t I would let the manager know”. Staff felt that reported signs of suspected abuse would be taken seriously and knew who to contact externally should they feel their concerns had not been dealt with appropriately.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. We observed people receiving their medicines in the afternoon of the first day of our inspection and saw staff administered medicines safely.

Consent to care and treatment was sought in line with legislation and guidance. Where people did not have capacity to consent to their care and treatment this had been assessed in line with Mental Capacity Act 2005. We spoke with staff and were told that they had recently completed Mental Capacity Act training and they were able to speak with us about consent, people’s rights to take risks and the importance of acting in someone’s best interests.

New staff undertook a comprehensive induction programme which included essential training and shadowing of experienced care staff. Staff had undertaken appropriate training to ensure that they had to skills and competencies to meet people’s needs.

People were supported to maintain good health and had access to health professionals. People told us they were able to see a doctor when they needed to.

People spoke positively of the caring approach of staff and one person told us, “The staff are kind and caring, they’re very helpful”.

We saw that care plans contained guidance for staff and reminded them to encourage people to make choices about what they would like to wear. People’s care plans contained information about their life history and staff spoke with us about the importance of knowing people’s history.

There were planned and meaningful activities available to people. There were scheduled external entertainers who visited and offered activities such as reminiscence classes.

People and their relatives told us knew what to do if they were not satisfied with the service they received or if they wished to make a complaint.

Relatives and staff spoke highly of the deputy manager and felt they would be able to approach them with any concerns.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the report.