This inspection was unannounced and took place on 26 April 2017. Stubby Leas is registered to provide accommodation with nursing support for up to 48 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection, 40 people were using the service. Our last inspection visit took place 26 August 2016, and the service was rated as Good. At this inspection visit, the service remained Good.

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.

People continued to receive care that was safe, and were protected from harm by staff that understood how to promote people’s safety. Risks to people were assessed, monitored and reviewed to minimise potential harm. There were enough staff to meet people’s needs and there were effective systems in place to ensure staff were suitable to work with people. Medicines were managed safely, and people were protected from any risks associated with them.

Staff had the knowledge required to carry out their roles effectively and they received training to develop their skills. People were supported to make decisions, and when they were unable to, any decisions made were seen to be in people’s best interests. When people who lacked capacity to make decisions were seen to be restricted, this was done legally.

People were supported to maintain a balanced diet and were able to access healthcare service when needed. They were supported by staff who were caring, kind and compassionate. Staff understood people and promoted their independence, dignity and privacy. People were able to maintain relationships that were important to them.

The care that people received was personal to them and met their individual needs. They were involved in the assessment and planning of their care. People were able to take part in activities they enjoyed and the provider encouraged people to give feedback about their care. The provider listened to people’s views and acted on any concerns or complaints.

People were positive about their experiences of living at Stubby Leas. There was a positive, open culture promoted, and staff enjoyed their work and were motivated in their roles. There was an effective quality assurance system in place, and this was used to drive continuous improvements within the home.

We inspected this service on 26 August 2015. This was an unannounced inspection. At our inspection in March 2014 the service was meeting the requirements of the regulations we checked.

The service was registered to provide accommodation and personal care for up to 48 people. At the time of our inspection, 39 people were living at the home. Most people were living with dementia and were not able to give us their views.

The service had a registered manager. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was not at the home on the day of our inspection.

Staff were kind and caring and people’s relatives told us they felt their relations were safe. Staff understood their responsibilities and the actions they should take to keep people safe from abuse. Risks to people’s health and safety were identified and plans were in place to minimise the risks.

Staffing levels were reviewed and adjusted to ensure they met people’s care needs at all times. The provider had a recruitment process that ensured people were supported by staff whose suitability had been checked. Staff were supported and trained to meet people’s individual needs. The manager promoted a positive culture which supported staff to raise concerns and reflect on their practice.

People received their medicines as prescribed and appropriate decision making processes were in place for people who lacked the capacity to make decisions about taking their medicines. People were supported to have sufficient to eat and drink to maintain good health and to access health care services when they needed to.

Staff acted in accordance with the requirements of the Mental Capacity Act 2005. Where people did not have capacity to make decisions themselves, we saw that mental capacity assessments were in place and records showed that decisions had been made in their best interest. At the time of our inspection, ten people were subject to a Deprivation of Liberty Safeguard.

People were supported to keep in touch with people that mattered to them. Staff kept people’s relatives informed when their needs changed. Staff respected people’s privacy and dignity and helped them maintain as much independence as possible.

We saw people were offered things to do and the provider had recognised that they needed to offer more personalised activities to meet people’s individual needs.  People's individual preferences were taken into account about how they received their care.

The registered manager investigated complaints and concerns and used them to make improvements to the service. People’s relatives had confidence in the way the home was run and were encouraged to share their opinions about the quality of the service.

The registered manager had systems in place to assess, monitor and improve the quality and safety of care people received.

During our visits to Stubby Leas Nursing Home in 2013 we found that improvements to the service were required. We issued warning notices regarding care and welfare of people who used the service, medication management and supporting staff. We noted at our visit in November 2013 that action had been taken to meet the requirements of the warning notice regarding supporting staff. The provider had taken some action to meet the requirements of the other two warning notices (care and welfare of people who used the service and medication management) but remained non-compliant. We conducted this inspection to check on all areas of non-compliance.

At this visit we saw that people's dignity was maintained. People were offered a choice of meal and drink.

Care plans had been reviewed and more detail was included. This would enable staff to provide appropriate care which met people's individual needs.

Medication systems and audits were introduced to try and reduce the number of medication errors previously identified.

Work had been undertaken to refurbish parts of the home. New furnishings and flooring had also been purchased.

Staffing levels had been increased. People we spoke with praised staff saying that they were friendly and helpful.

Improvements had been made to quality assurance systems, to include introducing satisfaction surveys, relatives meetings and audits of systems and practices. Complaints received were logged and action taken to address issues raised was recorded.

Improvements were noted to records held at the home. Work had been undertaken to ensure records were up to date and in good order.

This inspection was undertaken to check the service's compliance with warning notices issued regarding care and welfare of people who use the service and supporting staff that work in the service. Walsall and South Staffordshire Local Authorities have ongoing concerns about Stubby Leas and have suspended all new placements at the home until required improvements can be maintained.

During our visit we looked at the care files of six people who lived at Stubby Leas. We found that there were some improvements in relation to the care and welfare of the people who used the service. The manager told us that a lot of work had been undertaken to try and make care plans more 'person centred' and to bring them up to date. However, a failure to ensure that all information in care plans was up to date and was available to clearly demonstrate the care to be given meant that the requirements of the regulations and our warning notice were not met. This meant that sufficient steps had not been taken to ensure that each service user was protected against the risks of receiving care or treatment that was inappropriate or unsafe.

We looked at staff files and saw that a new system of staff supervision had been introduced. In addition to supervision sessions, other staff support mechanisms introduced included staff meetings and staff training. We found that sufficient improvements had been made to meet this warning notice.

We visited Stubby Leas to check on issues for action identified at our last inspection, including following up on the warning notice issued regarding medication management. This visit was unannounced.

People's dignity and privacy was not always maintained. We saw two people wearing food stained clothing and another person with urine soaked trousers.

Staff did not always act in accordance with the instructions recorded in people's care files. Inappropriate moving and handling techniques could put people at risk of injury.

Improvements were noted to medication management, although further work should be undertaken to become fully compliant.

Improvements had been made to infection control within the home. Further work was required regarding cleaning, cleaning records and staff training.

Some areas of the home were in need of maintenance.

Staffing levels had increased recently. However sufficient staff should be on duty to monitor those people with behaviour that may challenge so that staff and people who live at the home are safe from harm. Supervision of staff had not taken place recently and regular staff meetings had not been held.

Systems were not in place for auditing and monitoring the quality of the service provided to reduce the risk of people receiving inappropriate or unsafe care.

The complaint log did not record details of investigations undertaken and action taken to address issues raised.

Records were not all available or up to date.

We visited Stubby Leas on 7 May 2013 at 7.20am, an expert by experience accompanied us on this visit. We continued this visit on 28 May 2013 at 5.30am. We did not hold conversations with people that lived at the home due to their dementia care needs. We observed the interaction between staff and people that lived at the home. We could not see records that demonstrated that people had a choice in aspects of their daily life at the home.

We saw staff practices that did not meet infection control standards. Staff were not clear on the approved practice for cleaning commode pans.

We identified medication errors at our visits of 7 and 28 May 2013. Staff were not always ordering medication in a timely manner to ensure that medication was available as required.

We spoke with staff and looked at staff records. We were told that staff did not receive training in dementia care. Staff said that they had requested other training. Records seen confirmed this.

We observed that there did not appear to be sufficient staff on duty to ensure that everyone's nutritional needs were met. Staff did not always take people to the toilet in a timely manner. Staff said that they had raised concerns with the management about this.

There was limited evidence to demonstrate that complaints made were acted upon in a timely manner and that people's concerns were responded to appropriately.

Records were not all up to date, clearly written or made available to us during this inspection.

We visited Stubby Leas on Tuesday 29 January 2013. We met with the manager who was new in post since our last visit.

We last visited Stubby Leas in July 2012. At that time, we found that assessments were not in place to identify whether people who lived at the home had the mental capacity to make important decisions. We saw that "do not attempt resuscitation" orders were not always fully completed. People, and where appropriate their families, can make the decision that they do not wish to be resuscitated in the event of severe illness. Medication systems did not fully protect the people that lived there. The home sent us an action plan following this visit. This recorded the action that they would take to improve upon the medication systems and practices in place. This visit was undertaken to check on improvements made.

We arrived at the home at 6.45am. We saw that 20 people were dressed and seated in the two lounges. We looked to see if people's preferred routines regarding rising and retiring were recorded. We could not see any documentary evidence to demonstrate that people's preferences were taken into consideration when planning care.

We looked at documentation regarding mental capacity. We could not see any evidence to show that people's mental capacity to make important decisions had been assessed.

We looked at medication, storage and records. We saw that there had been some improvements but medication errors were identified at this inspection.

We carried out this review to check on the care and welfare of people using this service. We visited Stubby Lees Nursing Home in order to up date the information we hold about the service and to establish whether the service had made any improvements since we last visited. The visit was unannounced which meant the provider and the staff did not know we were coming.

We spent some of our time in a lounge area observing the care and support experienced by people living at the home. We met with four people living at the home and five visitors, we discussed people's care with staff and observed a medication round. The manager, nursing and care staff provided us with information throughout our visit.

People we met spoke positively about the service, we were told, "The staff and management are approachable and helpful. There is nothing that could be improved apart from a new coat of paint." "Staff are very good, they treat him like a king, the staff are great with him, some days his dementia is bad and some days he is ok. He has his off days, he seems happy enough, hasn’t asked to go home like he did when he was in hospital." "When mum first moved into the home she had a lot of water retention in her legs but the home have sorted that out, there are no problems with that now."

We saw that staff were attentive to people's needs, staff were busy trying to maintain people's dignity and keep them safe.

During our last visit we had concerns that the home were not assessing people's capacity to make important decisions. The home were also completing do not attempt resuscitation on inappropriate forms and the home had not assessed people's capacity to make this decision. We did not see any up to date records for assessing a person’s capacity to consent to the care and treatment in any of the care plans we looked at. We were told by the manager that this would be completed and we were shown the assessment form that would be used. We saw that some care files contained do not attempt resuscitation forms, some of which had not been fully completed. We saw that some information had been completed on the new forms provided by the primary care trust and others were on the old style forms. The manager told us that they were in the process of changing all information on to the new style forms.

We saw that some people were offered a choice of meal or drink. This did not happen for one person in the lounge and records show that this person had not eaten a lunchtime meal. This person's care plan recorded that their food intake should be monitored as they were loosing weight.

People in the lounge area appeared to have had their hygiene needs met and we did not notice any unpleasant odours in any of the areas visited in the home.

Medication records checked were not all up to date and some medication that had been signed for as being given had not been. This meant that medication records were incorrect and the person had not received their medication on some occasions. There was no explanation why medication had not been given.

During the inspection we looked at the process the service had in place to monitor the quality of the service provided at the home. We found that there were some systems in place to audit the service and seek feedback from the people who used the service.

We visited Stubby Leas because concerns had been identified about the care of one person. During this visit we were accompanied by an expert by experience. Experts by experience are people of all ages, with different experiences, from diverse cultural backgrounds who have used a range of care services. Our expert by experience looked at what happened around the home and saw how everyone was getting on together and what the home felt like. They took some notes and wrote a report about what they found and details were included in this report.

We spoke with some people who used the service and some people who had special communication needs. Where people were not able to express their views to us, we observed interaction between people and staff and saw how people chose what activities to do and how to spend their time.

We saw staff talking to people and spending time with them in a respectful and friendly way. Personal care issues were discussed sensitively and discreetly. We saw in care records there was information about people’s care needs including their preferences and how they wanted care provided.

People were dressed in their own style and if they needed support, staff helped individuals dress and take a pride in their appearance. Activity staff were supporting people to have a manicure during our visit, and people could choose to have nail polish applied.

We saw that activities were personalised and were on a one-to one basis rather than group activities. Staff told us this was considered more appropriate for individuals due to their complex needs. People told us they liked to go out shopping with staff and listen to staff reading. We saw staff sitting with people reading and discussing a magazine article.

The home displayed some of the work produced by people including a collage, and there were bright paintings and art-work on walls. There were visual images to illustrate the shower and the toilet on doors. People and visitors told us this helped people to find where they were going in the home, as people may have dementia and did not always recognise areas of the home.

Relatives were able to continue to play an active role and support people and provide care. When important things happened, people told us that communication was good.