The inspection took place on 8 and 9 February 2017 and was unannounced.

St David’s Nursing Home provides accommodation and care for up to 35 people, many of whom may be living with dementia. At the time of our inspection 34 people were living in the home.

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.

During our previous inspection on 5 and 6 January 2016 we found that the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was required to take action to address the concerns we found. During this inspection on 8 and 9 of February 2017 we found that these actions had been completed.

There was a lack of recorded systems in place to monitor and assess the quality of the service being delivered. Whilst the manager carried out a yearly quality assurance audit, there was nothing formally recorded to demonstrate that the manager regularly audited all areas of the service. We recommend that the manager implements formal systems to monitor and assess the quality of service being delivered.

There were regular opportunities for people, their relatives and healthcare professional to give their feedback about the service via the use of surveys. The manager looked at people’s responses and took action to address any suggestions for improvement.

The manager was approachable and open to discussion. They spent much of their time working alongside staff and they were a visible presence in the home. Staff felt supported in their work through regular supervision and training. Staff had received training relevant to their role and there was a training manager in place to support staff with completing their training.

Staff understood the principles of the Mental Capacity Act (2005) and knew how to communicate with people according to their individual need so they could offer people choices about their care and treatment. Appropriate applications had been made to deprive people of their liberty to the relevant authorising authority.

Steps had been taken to reduce people’s individual risks and people’s care plans and risk assessments were reviewed and updated on a regular basis. Action had been taken to mitigate and manage environmental risks and the utilities such as gas, electricity and fire safety were monitored and maintained.

Staff knew how to protect people from harm and abuse and knew who they would report their concerns to if they had any. Staff had also received training safeguarding. There were safe recruitment processes in place and this ensured that suitable staff were recruited to support and care for people at St David’s.

People’s medicines were stored and administered safely and people were given their medicines as prescribed.

Where there were concerns about a person’s physical health or wellbeing, we saw that timely referrals were made to relevant healthcare professionals. People who required support with maintaining a healthy nutritional intake were referred to the speech and language therapy team. People’s nutritional and fluid intake were monitored where necessary. Kitchen staff were aware of people’s dietary requirements and people’s meals were prepared according to their needs.

People were supported to follow their interests and hobbies and a variety of activities took place in St David’s and outings to local towns were arranged for people. People could have their relatives and friends visit without restrictions and staff welcomed people’s visitors.

There was a complaints procedure in place. People and their relatives felt able to raise a complaint if needed.

Staff were caring and attentive to people’s wants, needs

The inspection took place on 5 and 6 January and was unannounced.

St David’s Nursing Home provides residential and nursing care for up to 35 people. Accommodation is over two floors with most bedrooms having en-suite facilities. The home is situated in extensive grounds and is mostly purpose-built. At the time of the inspection 33 people were living in the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s human rights were not always protected. We also found one breach of the Care Quality Commission (Registration) Regulations 2009. This was because the registered persons had not consistently reported incidents to the CQC that affected people’s safety.

People were supported by staff who were safely recruited, well trained and committed to their role. They felt well supported by the management team and demonstrated an open and honest approach. There were enough staff to safely meet people’s individual needs.

Staff understood how to prevent, identify and report abuse. People received their medicines on time and in the manner the prescriber intended. The storage and administration of medicines was safe and appropriate. The risks to people and the premises had been identified, assessed and regularly reviewed in order to keep people safe.

Staff received support, induction and on-going training to ensure they had the skills and competencies to support people in an individualised way. New staff were undergoing the Care Certificate and had received a training session on emergency procedures within the home. Staff demonstrated that the training they had received was reflected in the way they cared and supported people.

People benefitted from a staff team that worked well together and were committed to the service they provided. The service encouraged an open approach and was fully aware of its strengths and the areas where improvement was required. Staff were happy working at St David’s Nursing Home and showed they knew the people they supported well.

Staff demonstrated kindness and compassion when assisting people and interacting with each other. People’s independence was promoted and choice and privacy were respected. Staff respected people’s dignity and understood the importance of it.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. The service was not consistently working to the principles of the MCA DoLS and staff knowledge was variable. Some DoLS applications had been made to the supervisory body but no record of best interest decisions were in place. However, staff fully understood the need for consent and gained this when assisting people.

Care plans were detailed and easily accessible for staff. They sometimes lacked person centred detail, however staff demonstrated that they knew people’s needs and preferences well. Whilst no formal process was in place to review people’s care with them, people told us they had been involved in this.

People‘s health and wellbeing was promoted by having access to a variety of healthcare professionals. Staff demonstrated knowledge of people’s medical needs and gained specialist advice as required.

The service encouraged people to maintain relationships with those important to them and visitors could visit at any time. A room with en-suite facilities was available to family members if required. The service provided activities but these were limited and did not always meet people’s individual needs.

There was a registere

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service safe?

• Is the service caring?

• Is the service responsive?

• Is the service effective?

• Is the service well led?

Below is a summary of what we found. The summary is based on our discussions with eight people who used the services, four family members and six staff members. In addition, we looked at four people's care and support plans.

Is the service safe?

Risk assessments were in place to ensure that as far as reasonably practicable people were safe in the home and that staff were safe in their working environment. Where risks to people had been identified measures had been taken to minimise or remove them. Appropriate vetting of staff combined with on-going support and appraisal meant that the provider took reasonable steps to ensure that vulnerable adults were protected from the risk of abuse. We looked at staff rotas and found that there were enough qualified, skilled and experienced staff to meet people's needs throughout the day and night.

Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to all care services. At the time of the inspection no applications had needed to be submitted. Proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when a DoLS application should be made, and how to submit one.

Is the service caring?

People we spoke with said that staff treated them with respect and consideration. They felt that staff listened to them and took time to explain things. People also told us that they were consulted about the care and support they received.

People’s needs were assessed by staff and care and support was planned and delivered in line with their individual care plans. The care plans we looked at were personalised and detailed and provided a good level of information for the staff providing the care.

During the inspection we observed that staff were kind and caring in their interactions with people.

Is the service responsive?

The provider had a system of dealing with complaints. We found that people’s complaints had been dealt with in a timely manner. People knew how to make a complaint if they were unhappy about the service they received. The complaints process was displayed in the entrance hall, making it easily available to people and visitors to the home. Where shortfalls or concerns were raised these were addressed by the provider.

People told us that the provider responded to their changing needs in a timely manner. This meant that personal and nursing care needs were assessed and reviewed on a monthly basis or as and when needed. We looked at people’s medical observation charts and found these to be accurate and up to date. Where medical observations were outside normal ranges we noted that senior nurses or matron were informed. Where changes occurred, the service referred to health professionals for advice and guidance if required. All changes were accurately documented and recorded.

People who used the services and their family members or representatives, were asked for their views about the care provided and these were acted on by the provider.

Is the service effective?

People using the service that we spoke with said, or indicated to us, that the care and support provided of good quality. From our observations we saw that care and support, both personal and medical, was effective and consistent.

Where practicable people were supported to be as independent as possible.

We saw that staff knew the people they were supporting and that the people receiving the care and support were happy. We noted that if something was not right that staff responded quickly to resolve matters.

People told us, or indicated to us, that they liked living at St David's and that staff were kind and caring.

Staff explained how they were able to communicate with people who were not able to express themselves verbally.

Is the service well led?

Views of people using the services and, where possible, of their families were obtained and opportunities were in place for social gatherings where further views and opinions of the services, and staff, could be gained by the provider.

Staff told us that they felt supported and had received sufficient training to carry out their role effectively. They added that if they felt they needed further or additional training or support that they were confident this would be arranged by the provider.

There were quality monitoring systems in place and regular audits and spot checks took place.

Staff were clear about their roles and responsibilities. They spoke of how they worked as a team with the needs of the person central to the work they did.

We had received some concerns regarding the service and because of these we followed up with an unannounced inspection to the service. We spoke with nine people in private who lived at St David's, seven members of staff, the manager, one visitor and the local authority stakeholder team.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People told us: "The nurses look after me very well, I need a lot of care and the care staff are marvellous." "I want for nothing."

A visitor told us: "The staff are very competent, they have compassion and always pop in to make sure my relative is okay."

People were provided with a choice of suitable and nutritious food and drink. People told us: "The meals are very tasty, I have put on quite a bit of weight." "I prefer a sandwich for my tea, they make a variety every day to choose from." Food is always good and you are given a choice." "They do you a cooked breakfast some days, it's like a hotel and there's freshly squeezed juice too."

There were enough qualified skilled and experienced staff to meet people's needs. There were occasional shifts when staff were one person short, however the manager made sure that the staff were supported by additional bank staff who regularly worked with people at the service. We checked staff training records and spoke with staff who verified that on occasion a shift was short for some of the time but the manager either helped out with care or arranged for bank staff to help for part of the shift.

The manager made available all the records we asked to see during our visit.

During our visit we spoke with eight people living at St Davids as well as five staff members who worked there. We observed how people were treated and how staff interacted with them. We saw staff knocking on bedroom doors before entering and how they treated people respectfully. We saw one member of staff asking a person if they wished for an extra cover for their legs and went to get this and placed their drink, the call bell and the TV remote within their reach before leaving. People appeared relaxed and content within their surroundings.

People told us: "The staff make it bearable for my last few years here, they're friendly and help lift my mood when I feel a little low." Another told us: "The lady who does my laundry is excellent, my clothes come back in really good condition. I receive excellent care and the staff encourage me to make my own decisions. I am happy I made the right choice to come to live here."

We saw some people walking in the garden, while others preferred to stay in their rooms. Staff were seen popping in to speak to people on their own and check they had things within reach.

We observed lunch being served and how a new person was introduced to people who were sitting at their table. Staff helped those who required assistance with their food in a discreet manner. This sociable event was not rushed and people were given choices throughout. Two people commented: "The food is lovely. We have a good selection to choose from the menu."

During our visit to St David’s on 01 February 2012 we spoke with a number of people. They told us that they were involved in the life of the home. They told us that the manager keeps everyone up to date and knows everyone well. They said they felt well cared for and that they were spoken to respectfully. They told us they liked to have peace and quiet and that the staff knew and would respect that by taking them to a quiet area of the home.

Throughout this visit we received numerous comments from the people living in the home about the staff being good and caring. They told us that they knew what was required and how they would support them to do what they could for themselves but that they can ask for help when tasks become too difficult.

When we spoke with people about how they spend their day we were told that they were happy to carry on with watching the television, joining in activities when they wanted, or having places to go to be quiet when they wanted. All those people spoken with said they were content with their life and did not want for anything more.

When people were asked about the quality of the service they gave us comments and opinions that were positive. They told us they would not want to live anywhere else.