This inspection took place on 18, 19, 21 and 25 July 2017 and was unannounced on the first day. We told the registered manager we would be returning over the next three days. At the last comprehensive inspection in October 2014, with the inspection report being published in March 2015, the service was rated as ‘Good’.

The Chiswick Nursing Centre is a 146 bedded care home with nursing and provides care, accommodation and support for older people and younger adults, people who are living with dementia, people with mental health needs, people with complex neurological conditions, people with physical disabilities and people with learning disabilities. At the time of our inspection 141 people were living in the home.

There was a registered manager in post at the time of our inspection. 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.

People’s risks were managed and care plans contained appropriate and detailed risk assessments which were updated regularly when people’s needs changed. The service had a robust recruitment process and staff had the necessary checks to ensure they were suitable to work with people using the service. Recruitment was ongoing with the aim to reduce the number of agency workers.

People who required support with their medicines received them safely from staff who had completed in-depth training in the safe handling and administration of medicines, which was refreshed annually. Staff completed appropriate records when they administered medicines and these were regularly checked to minimise medicines errors.

The majority of people who used the service and their relatives told us they felt safe using the service and all staff had a good understanding of how to protect people from abuse. Staff were confident that any concerns would be investigated and dealt with. All staff had received training in safeguarding adults from abuse and had a good understanding of how to identify and report any concerns. One person felt they were at risk in relation to fire evacuation procedures because of their poor mobility. The provider had consistently reassured them that there was a plan in place to manage any emergency and their potential evacuation.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the importance of asking people for consent and the need to have best interests meetings in relation to decisions where people did not have the capacity to consent to their care. The provider was aware when people had restrictions placed upon them and notified the local authority responsible for assessment and DoLS authorisations.

Staff were aware of people’s dietary needs and food preferences and provided support to those who required it during mealtimes. If people had questions or concerns about their food the provider met with them to discuss their preferences and to find alternative options.

Registered nurses and care assistants told us they contacted other health and social care professionals, such as occupational therapists, psychiatrists and speech and language therapists, if they had any concerns about people’s health. We saw evidence of these referrals in people’s care records. People had regular access to a GP who visited at least three times a week, was available for emergency ‘house calls’ on a daily basis and was also available outside of normal surgery hours.

There was a comprehensive induction and training programme in place to support staff in meeting people’s needs effectively. New staff shadowed more experienced staff and had their competency signed off by senior staff before they started to deliver personal care or s

We carried out an unannounced comprehensive inspection of this service in October 2014. After that inspection we received concerns in relation to night time staffing levels, moving and assisting people who used the service and access to primary healthcare. As a result we undertook a focused inspection to look into these concerns. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Chiswick Nursing Centre on our website at www.cqc.org.uk

The Chiswick Nursing Centre is a 146 bedded care home with nursing and provides accommodation, care and support for older people and younger adults, people who are living with dementia, people with mental health needs, people with physical disabilities and people with learning disabilities.

A registered manager was 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.

We found that core staffing levels were maintained and there was always a nurse on duty on each floor. Occasional gaps within the rota were mainly due to care staff phoning in at short notice to say they could not cover the shift for which they were booked. We saw that the provider tried to find cover in this situation, but was not always successful. However, when this happened the size of the service enabled the nurse in charge to redeploy staff between floors to meet people’s needs. The provider was recruiting to fill vacancies.

On one floor of the building we observed some practice which put staff convenience before the preferences of the people who used the service, as some people were assisted to get up earlier than they wanted to. This was brought to the attention of the registered manager who said they would ensure this arrangement did not persist.

With regard to moving and assisting people with mobility needs, we saw that staff were trained in the correct techniques and their practice was monitored by in-house physiotherapists and a visiting occupational therapist. Appropriate equipment was available on each floor.

People who used the service were able to access their GP and other healthcare practitioners when they had a need to do so.

We did not revise the rating given at our comprehensive inspection in October 2014. Any identified shortfalls reflected only a small part of the care provided by The Chiswick Nursing Centre so it did not impact on our overall judgement.

We carried out this inspection as part of our on-going monitoring of standards that we had judged to be non-compliant following our inspections of 25 March 2013, 9 May 2013 and 3 and 4 September 2013. During our inspection we spoke with 16 members of staff including senior managers, suite managers, nurses and care staff. We also looked at 10 people's care plans, observational charts and spoke with nine people who used the service and/ or their relatives.

Overall, there had been significant improvements, noticed by both staff and people and/ or their relatives. Two relatives we spoke with described how their relative's condition had improved, which they felt was down to the care provided and the "detailed" approach of staff. One person described nursing staff as "superb," whilst another stated staff had a "lovely attitude". People felt able to raise concerns and had confidence in them being dealt with. Staff were also positive about recent changes and felt it was an enjoyable place to work.

The provider had done all that was practicably possible to ensure that people and/ or their relatives had been involved in developing their care plans and had consented to it. People and/ or their relatives had signed their care plan, risk assessments and any care specific consent forms. Where people lacked capacity, staff had acted in accordance with the law. People received care in line with their individual care plan and we found no discrepancies in the recording of observations.

We carried out this inspection as part of our on-going monitoring of standards that we had judged to be non-compliant following our inspections of 25 March 2013 and 9 May 2013. We arrived at the service at 22:00 on 3 September 2013 and stayed until 17:00 on 4 September 2013. During our inspection we spoke with 29 staff, including 27 care and nursing staff, the manager, Director of Nursing and an activities co-ordinator. We also spoke with 10 people who used the service and/or their relatives and looked at 35 records in relation to consent and 31 records in relation to the care and welfare of people.

Most people we spoke with were complimentary about the service and felt that their needs were being met. There were now systems in place to monitor the quality of service provided and to enable people to provide feedback. Whilst we observed that there had been improvements made, we continued to find examples of where care was not being delivered in line with people's care plan and where gaps in recording meant that we could not be assured that people were getting the care they needed when they needed it.

Most staff had received Mental Capacity Act 2005 training, but they were unable to demonstrate how they would apply what they had learnt in practice. Staff continued to sign people's consent forms and care plans "in the person's best interest" and there was a lack of documentary evidence to show that staff had acted in accordance with the law where people lacked capacity.

We carried out this inspection to test compliance with a Warning Notice in relation to outcome 4 and compliance actions in relation to outcomes 9 and 13 that were issued following our inspection of 25 March 2013. We also inspected outcomes 2 and 16. We looked at 15 people's care records, spoke with 12 people and/ or their relatives and spoke with 12 members of staff, including the registered manager.

Most people we spoke with were satisfied with the care provided. However, the Care Quality Commission had been contacted by relatives who were concerned about the care being provided. We found that the provider was not meeting the Warning Notice and that care was still not being delivered in a way that ensured people's safety and welfare. Whilst new systems and observational tools had been put in place, staff continued to record their observations retrospectively and documents were not being fully completed.

There were consent policies in place, but these were not being followed. Staff had little understanding of the Mental Capacity Act 2005 and how it linked to consent. Where people lacked capacity to consent, the provider had not acted in accordance with legal requirements.

The necessary improvements had been made in relation to medicines management and staffing levels. On the day of our inspection we saw no evidence of a system to monitor the quality of service provided. We requested additional documentary evidence from the provider, which we did not receive.

We looked at the care records of 16 people who used the service, spoke with ten people and/ or their relatives and 18 members of staff.

There were insufficient staff to meet people's needs. People we spoke with were complimentary about the staff describing them as "caring" and "kind", but felt that they were "overstretched". People told us that staff took a long time to answer their call bells, particularly at night and whilst they got their medication on time the delivery of care was sometimes "erratic". There were no systems in place to monitor the hours that staff were working and we were told there were occasions when staff were sleeping at night.

Care was not delivered in a way that ensured people's safety. There were inadequate systems in place to ensure that staff responded appropriately if a person's condition deteriorated and there was no allocated time for a formal handover between shifts. In people's care records, we found care notes and observations were not being completed contemporaneously. Most staff told us that they completed them at the end of their shift and so we could not be assured that they were accurate. People were not always protected against the risks associated with the unsafe management of medicines. We found discrepancies in people's medication records, which meant that they may have not been given the prescribed dosage.

Overall, there had been improvements at the Chiswick Nursing Centre. We observed positive interactions between staff and people who use the service. People's privacy was respected and people's needs were met by sufficient numbers of suitably skilled staff.

The provider told us that care plans had been reviewed in collaboration with people who use the service or their relatives. We spoke with relatives who confirmed that they had been involved in developing their relative's care plan. However, one relative told us that staff were not following the care plan. In addition, the provider had not used alternative means of communication to support those with communication difficulties to make decisions about their care.

People's nutritional needs were met and staff were aware of those with particular dietary requirements. Most people confirmed that they were given a choice of food and were supported to drink sufficient amounts. People who use the service told us that they felt safe living at the home and told us that staff were gentle when delivering care. Staff were able to demonstrate awareness around the importance of meeting people's needs. Staff we spoke with felt that there were enough staff each shift to ensure people were well cared for.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an "expert by experience"; people who have experience of using services and who can provide that perspective and a practising professional.

We spoke with twelve people using the service and most said that they were happy with the service. There were some people who told us that they had not been involved in decisions about their care. Others felt that their privacy and dignity was not always respected. All the people we spoke with told us that they were always given a choice of what to eat and that they had plenty to drink. People who use the service told us that they felt safe living at the home and knew how to raise concerns. We also spoke to relatives and looked at seven care plans.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. At the Chiswick Nursing Centre there are a number of people who have dementia or find it difficult to communicate verbally.

We spoke to people and their familes that used the service, inspected the home and reviewed the actions submitted by the home. People told us that the home was clean and that they were generally happy with care they received. We observed staff engaging in activities with people that used the service.

On this occasion we did not speak to people who used the service. We observed staff caring for people and treating them with respect.

People who use the service told us that the home was very nice and that staff were respectful and caring. They were happy to be in the home and enjoyed their independence. Some of the people that use the services did report they sometimes got bored during the day. Generally the people enjoyed the food in the home. Their relatives could visit at any time.

We did not speak to services users on the visit.

This inspection took place on 14 and 15 October 2014. The first day of the inspection was unannounced and we told the manager we were returning on the second day. At our previous inspection on 13 December 2013 we found the provider was meeting regulations in relation to the outcomes we inspected.

The Chiswick Nursing Centre is a 146 bedded care home with nursing and provides care, accommodation and support for older people and younger adults, people who are living with dementia, people with mental health needs, people with physical disabilities and people with learning disabilities.

The service was managed by 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives felt the service was a safe place to live. There were individual risk assessments in place which were based on how to keep people safe, taking into account their needs whilst promoting their entitlement to independence and choice. People and relatives told us they felt there were enough staff on duty to keep people safe. We saw that staff answered call bells and attended to people in a timely manner. Staff recruitment was robust, although we noted that full details of prospective employees’ previous employment dates were not sought on the service’s application form. The systems for managing and auditing medicines were thorough and staff told us they had suitable training.

People received effective care from staff, who had appropriate training and supervision. People were provided with choice in regard to food and drinks, and their nutrition and hydration was monitored. People had access to visiting health care professionals, including GP’s, dentists, opticians and dietitians. The service employed a physiotherapist and two physiotherapy assistants, and people told us this was beneficial. Staff were aware of the requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS), which care homes are required to meet. The service acted within the legal requirements when determining whether people needed to be deprived of their liberty in order to keep them safe.

We observed that people and their representatives had positive relationships with staff, who demonstrated their understanding of people’s diverse needs and their life histories. People were spoken with and treated by staff in a respectful and kind manner and their privacy and dignity were promoted. For example, we saw staff knock on bedroom doors before entering and close doors when providing personal care. People’s end of life wishes were recorded and the service was working with people, their representatives and medical professionals to make sure that resuscitation instructions were discussed and recorded where required. Staff had some training regarding how to meet palliative care needs, although the provider was seeking additional training for staff.

Care plans were regularly reviewed, involving people and their representatives. People and their representatives told us they were asked for their views about the quality of the service and had an opportunity to express these, for example, through attending meetings and completing surveys. There were opportunities for people to take part in a wide range of activities and entertainment within the service, and to go out on local trips. People received visits from local ministers of worship and a service was held each week at the home. During the inspection we saw that staff had enough time to respond to people’s needs in a timely way. People and their representatives knew how to make complaints and said they were confident that complaints were taken seriously.

The manager was described by people and their representatives as being visible and approachable. We saw the manager interacting well with people who used the service and people confirmed they regularly spoke with the manager on his visits to the individual suites. The staff told us they felt well supported by the management team and they felt the manager had positively changed the culture within the service. Staff were supported through regular formal meetings and also used ‘handover’ meetings between shifts, which meant any concerns and important information could be shared with colleagues. There were systems in place to monitor the quality of the service and there was evidence that learning took place from the results of audits and complaints investigations.