South Wold Nursing Home is registered to provide accommodation for up to 16 people requiring nursing or personal care, including older people and people living with dementia.

We inspected the home on 6 and 13 November 2018. The inspection was unannounced. There were 13 people living in the home at the time of our inspection.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers (‘the provider’) 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.

In January 2018 we conducted a comprehensive inspection of the home. We found the provider was in breach of legal requirements in four areas. We rated the home as Inadequate and placed it in ‘special measures’. We also imposed an additional condition of registration preventing the provider admitting anyone to the home without our written permission. This was to give the provider an opportunity to focus fully on the needs of the people already living in the home and ensure they were receiving the service they were entitled to expect.

On this inspection we were pleased to find significant improvement had been made. All four breaches of regulations had been addressed and the home is no longer in special measures. The overall rating is now Requires Improvement, reflecting the need for further action in a small number of areas. Our additional condition of registration remains in place but we have advised the provider that we are now prepared to permit new admissions to the home, so long as this is done in an incremental and sustainable way which does not jeopardise the progress made.

Action was required to ensure the premises were fully safe for people’s use; to improve the recording of some recruitment decisions and to ensure quality monitoring systems were consistently effective. But in all other areas, the provider was meeting people’s needs.

There were sufficient staff to keep people safe and meet their care and support needs. Staff worked well together in a mutually supportive way. Training and supervision systems were in place to provide staff with the knowledge and skills they required to meet people’s needs effectively.

Staff were kind and attentive in their approach. People were provided with food and drink of good quality that met their individual needs and preferences. There was a programme of regular activities and events to provide people with physical and mental stimulation. Staff provided end of life care in a sensitive and person-centred way.

People’s medicines were managed safely and staff worked closely with local healthcare services to ensure people had access to any specialist support they required. Systems were in place to ensure effective infection prevention and control. People’s individual risk assessments were reviewed and updated to take account of changes in their needs. Staff knew how to recognise and report any concerns to keep people safe from harm.

There was some evidence of organisational learning from significant incidents and events. There were very few formal complaints and any informal concerns were handled well. There was an ongoing programme of improvement to the physical environment and facilities in the home. People were invited to give feedback on the quality of the service and the provider acted in response.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection the provider had been granted a DoLS authorisation for two people living in the

South Wold Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide accommodation for up to16 older people and people living with dementia.

We carried out our first comprehensive inspection of the home in November 2014. At this inspection we identified shortfalls relating to fire safety, medicines management and the monitoring of service quality. We rated the service as Requires Improvement.

In August 2016 we undertook a second comprehensive inspection. We found a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because of concerns about the safety of the premises. We also identified continuing shortfalls in organisational governance relating to the auditing and monitoring of service provision. The rating of the service remained as Requires Improvement.

In March 2017 we conducted a focused follow up inspection to check whether the provider had taken action to address the breach of regulations identified at our August 2016 inspection. We found that the provider had made improvements to the premises and was no longer in breach of regulations. However, some issues remained outstanding and further action was required to ensure the premises were fully safe for people’s use.

We conducted this third comprehensive inspection of the home on 10 and 16 January 2018. The inspection was unannounced. There were 16 people living in the home on the first day of our inspection.

At this inspection we found the registered provider had failed to address issues for improvement identified at previous inspections. We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because of continuing shortfalls in organisational governance; a failure to properly assess and mitigate risks to people's safety and a failure to ensure sufficient staffing to meet people’s need for emotional support and to keep them safe. We also found the registered provider was in breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 due to a failure to notify us of serious injuries sustained by people living in the home.

In other areas, the registered provider was also failing to provide people with the effective, caring and responsive service they were entitled to expect. People were not supported consistently in a person-centred way and did not receive sufficient physical and mental stimulation to meet their needs. Care staff were not always aware of changes to people’s care plans and people’s right to privacy was not consistently protected. Senior staff were not always prompt in seeking advice from external healthcare professionals.

Staff did not receive supervision in line with the registered provider's policy requirements and there was no effective system in place to ensure staff received the training essential to their role. There was little evidence of organisational learning from significant incidents.

The registered manager was well-liked. However, the registered provider employed insufficient management and administrative resources which had a negative impact on the running of the home.

The overall rating for the home is 'Inadequate' and the home is therefore in 'Special Measures'.

We have taken action against the registered provider to ensure that they make the necessary improvements to become compliant with legal requirements. You can see what action we told the provider to take at the back of the full version of this report.

In some areas the registered provider was meeting people’s needs.

Staff worked well together in a mutually supportive way. Staff were kind and caring in their approach and encouraged people to maintain their indep

We carried out an unannounced comprehensive inspection on 9 August 2016. A breach of a legal requirement was found. After the inspection, the provider wrote to us to say what they would do to meet the legal requirement in relation to the breach.

At the last inspection on 9 August 2016 we found that the provider was not meeting the standards of care we expect in relation to the upkeep of the premises and there was no maintenance plan in place.

We undertook this focused inspection on 16 March 2017 to check that they had followed their plan and to confirm they now met the legal requirement. During this inspection on the 16 March 2017 we found the provider had made improvements in the area we had identified.

This report only covers our findings in relation to that requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for South Wold Nursing Home on our website at www.cqc.org.uk.

South Wold Nursing Home provides care for people who require nursing and personal care. It provides accommodation for up to 16 people. At the time of the inspection there were 15 people living at the home.

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.

On the day of our inspection we found a maintenance person had been employed and there was a system in place to ensure the premises were being kept to a suitable standard. Problems with the hot water system had been resolved, areas of the home had been refurbished and window restrictors placed on all windows which required this device.

We inspected South Wold Nursing Home on 9 August 2016. This was an unannounced inspection. The service provides care and support for up to 16 people. When we undertook our inspection there were 16 people living at the home.

People living at the home were older people. Some people required more assistance either because of physical illnesses or because they were experiencing difficulties coping with everyday tasks, with some having loss of memory.

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.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of our inspection there were two people subject to such an authorisation.

We found that there were sufficient staff to meet the needs of people using the service. The provider had taken into consideration the complex needs of each person to ensure their needs could be met through a 24 hour period.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way through the use of a care plan. People were involved in the planning of their care and had agreed to the care provided. The information and guidance provided to staff in the care plans was clear. Risks associated with people’s care needs were assessed and plans put in place to minimise risk in order to keep people safe.

People were treated with kindness and respect. The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives. People were supported to maintain their independence and control over their lives.

Staff had taken care in finding out what people wanted from their lives and had supported them in their choices. They had used family and friends as guides to obtain information.

People had a choice of meals, snacks and drinks. Meals could be taken in a dining room, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

The provider had not ensured that suitable measures had been taken to ensure the premises were safe to live in. Maintenance of the building was not planned and not all staff trained in fire safety.

The provider used safe systems when new staff were recruited. All new staff completed training before working in the home. The staff were aware of their responsibilities to protect people from harm or abuse, but not all had received updated training. They knew the action to take if they were concerned about the welfare of an individual.

People had not regularly been consulted about the development of the home and quality checks had not been completed to ensure services met people’s requirements.

We inspected South Wold Nursing Home on 25 November 2014. This was an unannounced inspection. Our last inspection took place on 15 April 2014 during which we found there were no breaches in the regulations.

The service provides care and support for up to 16 people, some of whom may experience memory loss associated with conditions such as dementia. When we undertook our inspection there were 16 people living at the service.

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.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection some people had their freedom restricted.

We found that people’s health care needs were assessed, and care planned and delivered in a consistent way through the use of a care plan. The information and guidance provided to staff in the care plans was clear. Risks associated with people’s care needs were assessed and plans put in place to minimise risk in order to keep people safe. However, some of the those risks associated with people’s care needs were not always up dated. We also found medicines were not always managed safely and appropriately.

We found people were happy with the service they received. They said staff treated people with respect and were kind and compassionate toward people. People and the relatives found the staff and manager approachable and that they could speak with them at any time if they were concerned about anything.

Staff had the knowledge and skills that they needed to support people. They received training and on-going support to enable them to understand people’s diverse needs.

The provider had systems in place to regularly monitor, and when needed take action to continuously improve the quality and safety of the service. However, the provider’s quality assurance processes required improvement, particularly in regard to environmental audit records and medication. If robust quality audit and monitoring systems had been in place the issues we identified during our inspection could have been identified and rectified sooner.

We visited the home to check if the provider had made any of the required improvements to the issues we highlighted during our last inspection of the service completed on 29 January 2014.

This summary is based on a review of the action plan sent to us in response to our last inspection, our observations during our visit, our discussions with people who used the service and the staff who supported them. We also spoke with people’s visiting relatives and health and social care professionals.

During our inspection we looked at four care records and observed care being given by staff. We spoke with four people who used the service and four relatives who visited the service. We also spoke with the home owner and four staff members, two nurse assessors, a social worker and a dietician who visited the service during our inspection.

We considered the findings of our inspection to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found:

Is the service caring?

People and relatives we spoke with told us staff were respectful, kind and attentive.

Is the service responsive?

We saw people's individual care needs were assessed and met. This also included people's individual choices and preferences about how they wanted to be cared for at the home.

Is the service safe?

We found people were treated with respect and dignity by staff. People told us they felt safe living at the home. We saw safeguarding procedures were in place and staff understood how to safeguard the people they supported.

Systems were in place to ensure the manager and staff learned from events such as complaints, concerns and investigations. This reduced the risks to people and helped the service to continually improve.

The home had proper policies and procedures in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made. This meant people would be safeguarded as required.

Staff understood their roles and responsibilities to ensure people were protected from the risk of abuse. People told us they felt safe living at the home. We saw safeguarding procedures were in place and that staff understood how to safeguard the people they supported.

People were assisted to take their medicines. People were protected against the use of unlawful or excessive control or restraint because the provider had made suitable arrangements.

Is the service effective?

People knew how to make a complaint if they were unhappy. One person we spoke with told us, "The manager and staff are always around to speak with if we have any worries."

A relative we spoke with said, “There is information clearly set out showing how complaints procedures can be accessed. I don’t think there have been any complaints about the home.”

We spoke with the manager who confirmed any concerns raised had been addressed straight away and found responses had been open and timely.

There were details available for people who lived in the home and their relatives should they need to contact an advocacy service so that they could access additional support.

People could therefore be assured that informal concerns were addressed and systems were in place to make sure more formal complaints are investigated in the right way.

Is the service well led?

The manager had a quality assurance system in place and records seen by us showed that shortfalls were addressed promptly. As a result the quality of the service was improving.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

We visited the home to check if the provider had made any of the required improvements to the issues we highlighted during our visit in November 2013.

We saw some staff did not always knock on the door before entering a bedroom. We asked one person if staff knocked on their door before they entered their room, they told us, “It varies, sometimes they just walk in.”

We saw there were two tables and seven chairs in the dining room. There were 16 people living in the home. This meant some people were not given a choice of where to sit to take their meals. We saw several people had their lunch in their bedroom.

We saw some improvements had been made to the content of the care files. A new format had been introduced for care plans which meant the care plans were more person centred and some had been signed by the person or their representative.

We asked people what it was like to live in the home. Most people were positive about their experience. One person said, "I am very comfortable and I do feel safe here.” Another person told us, “The carers are very pleasant.”

We found the security arrangements for medicines had improved in that cupboards and the fridge used to store medicines in the office area were locked when not in use and when the office was unattended.

We looked at all areas of the home. We found some improvements had been made since our last inspection. For example, the clutter had been removed from the bathroom and it had been decorated.

We saw staff had been provided with a trolley where a supply of linen, waste bags and protective aprons and gloves were stored. We saw the trolley was clean and tidy.

We found the hot water in the kitchen, all toilet areas and several bedrooms was too hot to wash our hands under. There were no signs alerting people to the danger of hot water.

We saw the provider had identified training needs for staff and training in moving and handling and dementia awareness had been scheduled for all staff.

We saw a copy of a partially completed quarterly health and safety risk management audit. However we found there were no relevant action plans or agreed dates for areas of weakness that were identified.

We spoke with visiting relatives. One person’s relative told us, “I am one hundred percent happy with the home.”

We visited on 5 August 2013 because we had received information of concern about staffing levels within the home.

During the visit we spoke to the nurse in charge and the provider. The provider is also the registered manager and works shifts within the home in the capacity of manager and as a registered nurse.

We also looked at staff duty records.

We found there were enough suitably qualified and experienced staff employed within the home to meet the needs of the people who lived there.

We saw the duty rota did not accurately reflect the hours worked by the provider/manager. They said they would take action to address this issue.

We observed positive interactions between staff and people living in the home. We saw staff offered people choices in how care was to be delivered and they took their time to explain care tasks to people. We observed staff were proactive in ensuring people’s privacy and dignity was maintained. People said, "We get the best of attention here," "The staff are good” and "If I was not satisfied with anything I would tell the manager."

We found the planning and delivery of care did not always reflect people's needs and this put their health, safety and welfare at risk. However relatives we spoke with were complimentary about the care. One relative told us, “I find the care excellent, the staff keep me up to date and I have no concerns.”

We looked around the premises and found people who used the service were not always protected against the risks of unsafe or unsuitable premises because of inadequate maintenance.

We found people were not regularly consulted about the service provided and there was little evidence their views were acted on. This meant they did not always have opportunities to discuss meals and activities provided or have the opportunity to raise any concerns or suggestions that they may have.

We carried out a visit to the service on 11 August 2012 after we had received anonymous concerns about the home admitting more people than it is registered to take. We carried out a further visit to the service on the 15 August 2012 to collect further information to support the occupancy at the home.

During the visit on the 11 August 2012 we spoke with three people who used the service. They all told us they were satisfied with the care support they received. One person told us, "It's alright here." Another person said, "I think I’ve been staying here a long time, I’m happy here.”

We visited the home to check if the provider had made any of the required improvements we highlighted during our last visits in September and October 2013.

During this visit we spoke with people who lived in the home and the staff who looked after them. We also spoke with the provider and the administrator for the home.

One person who lived in the home said, “The personal care and the patience the staff have is unbelievable, I could not do it.” Another person said, “I do not feel safe here. I want to move.”

During this visit we found people’s privacy and dignity were not effectively maintained and they were not routinely involved in making decisions about their care.

We saw care plans did not always reflect the care that people received and did not always reflect peoples expressed wishes.

We saw people were not protected from the risk of infection because appropriate guidance had not been followed and people were not cared for in a clean, hygienic environment. We also saw they were at risk from equipment and fittings within the home which were not appropriately maintained.

We found there were not effective systems in place to support staff or monitor the quality of the service.

We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the obtaining, recording, handling, safe keeping and safe administration of medicines.