We carried out this unannounced inspection on 16 April 2018. The Green nursing home is a care home with nursing. 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 Green provides care and support for up to 59 older people who require nursing or personal care, and who may be living with dementia. On the day of the inspection 35 people were living at the home.

At our last inspection in September 2017 we identified improvements were needed throughout the service. Following this inspection we used our enforcement powers and restricted admissions into the home and imposed conditions on the provider’s registration. We also required the provider to send us evidence of audits undertaken each month along with a summary of actions taken particularly in relation to people’s skin or wound care. This was because we found people were at risk of harm. We judged the home as ‘Inadequate’ in two of our key questions and ‘requires improvement’ in three of our key questions. We rated the home ‘inadequate’ overall and we identified four breaches of the Health and Social Care Act.

Following our September 2017 inspection we placed the home in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

This most recent inspection we found the improvements had been made in the quality of care provided to people and the service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. We found the service was now meeting the regulations. However, we will continue to monitor the service to ensure the improvements have been sustained and will review this at our next inspection.

Since our last inspection the home has 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 told us they felt safe. Staff understood how to recognise abuse and knew how to escalate any concerns. Risks to people were assessed and care records in place to meet their needs. People received their medicines as prescribed and systems used for the management of medicines were safe. People were supported by adequate numbers of suitably recruited staff. People were protected from the risk of infection and any incidents or accidents were reviewed to ensure learning if things went wrong.

Staff were trained and demonstrated the skills and knowledge to meet people’s needs. People were asked for their consent before care was provided. Where people’s rights were restricted this had been completed lawfully. However improvements were required in the understanding of the principles of the MCA when submitting applications to deprive people of their freedom. People received sufficient amounts of food and drink and staff made referrals to healthcare professionals to support people’s health needs when required.

People received support from caring staff who gave people time to make choices and decisions. Staff treated people with dignity and respect. People were supported to maintain their independence. Relatives and visitors were made welcome at the home by staff who knew them.

People sat for periods of time without stimulation and activities were not always person centred. People and their rela

This inspection took place on 19 and 20 September 2017 and was unannounced. The Green Nursing Home provides accommodation for up to 59 older people who require nursing or personal care, and who may be living with dementia. At the time of our inspection there were 46 people living at the home.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered nominated individuals, 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 registered manager of the service had left in July 2017 and the home was being managed on a day to day basis by the Nominated Individual who is a person who has legal responsibilities to ensure the service runs safely and well, and is the representative of the provider. At the time of our inspection there was also an acting manager who told us they planned to apply to become the Registered Manager. They were volunteering their time at the service and had not yet been employed by the company.

The home was last inspected in May 2017 when we found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated four as Requiring Improvement and the key area of Safe as Inadequate. We spoke with the provider’s representative and the registered manager following our inspection in May 2017. We asked them to send us an action plan detailing what actions they would take to improve the service. We returned to the service to undertake this comprehensive inspection six weeks before the work detailed in this action plan was due to be completed. We expected to see that improvements were well underway and to gain confidence that the improvements would be completed within the time scale on the action plan. At this inspection we did not find that improvements had been made in line with our expectations. This inspection found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated three as Requiring Improvement and the key areas of Safe and Well Led as Inadequate. The provider had failed to secure adequate improvements to improve the safety and quality of service provided to people.

Prior to our inspection we had received a larger than expected number of safeguarding alerts in relation to The Green Nursing Home. We worked closely with the local Clinical Commissioning Group (Part of the NHS) who were providing nursing support and visiting the home regularly. They provided us with information about the safeguarding concerns and how they had been addressed. During our inspection we found that when a safeguarding alert had been made it was dealt with appropriately. However we were not confident that all areas of concern had been identified by the service as safeguarding issues. We found that four peoples care was not safe and had not been recognised as such by staff. The poor management of wound care was highly concerning and people were experiencing inadequate care and medical intervention. After the inspection safeguarding alerts were made to the local authority by the inspection team in relation to these concerns. We are awaiting the outcome of these.

The provider had failed to consistently notify us when they were legally required to do so.

People told us they felt safe. We saw safe techniques were used to move people. Staff understood the risks to people’s health and safety but risks such as support to people who had skin wounds were not always managed well. Recording of these risks was not always evident. There were sufficient staff to meet people’s needs, although some people felt that more staff were needed on occasion. The provider operated a safe recruitment system which meant people were supported by suitable staff. Staff understood their responsibility to raise concerns regarding potential abuse

This unannounced comprehensive inspection took place on 16 and 17 May 2017. We last inspected this service in December 2016 when we looked specifically at the three key questions of safe, caring and well led.

We undertook the inspection in December 2016 to ensure that shortfalls we had identified in our last comprehensive inspection had been fully addressed. In December 2016 we found that the registered manager and registered provider were ensuring people received support that was safe and caring. However we found further improvements were required to ensure the home was well led. At this inspection in May 2017 we found that people could no longer be confident they would receive safe care and that the improvements that had started to increase the effectiveness of monitoring systems had not been sustained.

The Green Nursing Home is registered to provide nursing care to up to 59 older people who may also be living with dementia. At the time of our inspection there were 56 people living at the home. The home has a registered manager and they were present throughout our 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.

Feedback from people living at The Green and their relatives was that they felt safe at the home. People went on to describe the kind and caring interactions they experienced from staff. We saw individual staff supporting people with kindness and compassion. However we had concerns about the management of people’s medicines, staff were not always available at the times people needed them, action had not been taken to protect people from injuries and incidents of a safeguarding nature had not always been reported.

People were offered and supported to eat a wide range of nutritious and tasty meals. People told us they enjoyed the food. The food we saw looked and smelt tasty. Adjustments people needed to their food and drinks to ensure they could eat and drink safely had been made. However we could not always be sure that people were supported to eat and drink enough to maintain their health.

Staff had received training in the specific needs of the people they were supporting, as well as safe working practices. Some of this knowledge had been applied to staff practice, however we observed staff working in ways that were not always consistent with good practice guidelines, or which would keep people safe.

People were offered the opportunity to make a wide range of every day choices. We saw and heard people being asked about what they would like to wear, to do, to eat and drink for example. Processes to help people make bigger decisions were not all established, and there was a risk people would not get the support they required.

Some aspects of people’s healthcare were well met, and we saw staff providing people with equipment and special cushions for example that would reduce the chance of them getting sore skin. There were good relationships between the staff working at the home and local health care professionals. Changes in people’s healthcare were noted and the relevant support was sought for people. We looked in detail at some people’s care and found that other parts of their healthcare were not as well planned, and the staff responsible for planning and providing this care were not all fully informed about people’s needs. We observed that this placed people at risk of receiving unsuitable or unsafe care and treatment.

Individual staff demonstrated kindness and compassion in their interactions with people. We saw some staff offer people a hug or reassurance when they were anxious or confused. We saw this brought the person comfort. On other occasions we observed that there were no staff in the areas where

We carried out an unannounced comprehensive inspection of this service on 01 June 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to Regulation 17, Health and Social Care Act 2008 (Regulated Activities) 2014.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. 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 The Green Nursing Home on our website at www.cqc.org.uk

This inspection took place on 15 December 2016 and was unannounced. The inspection was focussed and concentrated on three of the areas that we look at, safe, caring and well led. The breach of regulation in June 2016 identified that the provider did not have effective systems in place to assess, monitor and mitigate the risks to health, safety and welfare of people who used the service. At this inspection we found some significant improvements had been made.

The Green Nursing Home is registered to provide care and support for up to 59 older people who have needs relating to their age or dementia. Nursing care is provided. On the day of our inspection there were 54 people at the home and two other people were in hospital.

The registered manager was present during our 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.

People told us that they had no concerns about their safety. People were supported by staff who had received training on how to protect people from abuse. Risk assessments had been completed to minimise the risk to people. People told us that there were adequate numbers of staff on duty to meet their personal needs. Medicines were managed well.

People told us and we observed that staff were kind and compassionate in the way they supported and cared for people. People were given support to make their own decisions about their individual care and support needs. We saw that staff respected people’s privacy and dignity. Some areas of confidentiality could be improved.

All the staff we spoke with said that the registered manager was supportive and approachable. The registered manager had continued to make improvements so that people were supported better than at the previous inspection. However people were not as involved in their care and the running of the home as they could be. A quality assurance process had been completed but the registered manager had not consistently taken the actions identified within it. The registered manager had developed and used a variety of internal audits which helped to ensure the service being offered was safe and of good quality.

This inspection took place on 1 June 2016 and was unannounced. The home was last inspected in November 2015. This was a focussed inspection and the provider was found to be requiring improvement in three areas. During this inspection we found that some areas had made some improvements.

The inspection team comprised of one inspector, a specialist advisor and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The specialist advisor had experience in nursing care.

People, their relatives and staff told us they felt people were safe in the home. Staff were aware of the need to keep people safe, but not all staff knew how to report allegations or suspicions of poor practice. We saw that people were happy around staff and with the support they were receiving. Staff were not always available to meet people’s needs in a timely manner. We found that people were kept waiting for care for longer than they found acceptable.

People were protected from possible errors in relation to their medication because the arrangements for administration and recording of medication were good and there were systems for checking that medication had been administered in the correct way. We saw that there were some concerns relating to the safe storage of medication.

People told us that they were very happy with the care provided. People had opportunities to participate in a range of activities in the home. People’s relatives and friends were encouraged to visit and made welcome by staff.

Staff were appropriately trained, skilled and supervised and they received opportunities to further develop their skills.

The registered manager and most staff had supported people in line with the appropriate legislation when the care and support they received may have deprived them of their liberty. We saw that consent to care was not always gained before staff supported people. Staff did not always ask people how they wanted to be supported. In some cases people were not treated with dignity and respect. We saw that staff communicated well with each other.

People were provided with a good choice of food in sufficient quantities and ate meals which met their nutritional needs and personal preferences. The registered manager sought and took advice from relevant health professionals when needed.

The registered manager did not have robust systems or processes that monitored the quality of care consistently through observation and regular audits of events and practice. You can see what action we asked the provider to take at the back of the full version of the report.

We carried out an unannounced comprehensive inspection of this service in April 2015. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We also checked areas where we had received some recent concerns, to include concerns about staffing arrangements. This report only covers our findings in relation to these areas. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Green Nursing Home on our website at www.cqc.org.uk

The Green Nursing Home provides care and support for up to 59 older people with physical health needs and people who live with dementia. At the time of this inspection 56 people were living in the home.

The home had 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 and the relatives of people using this service told us they felt their relatives were safe. Care staff understood how to protect people from abuse. There were processes to minimise risks associated with people’s care to keep them safe.

Staff had received induction training when they first started to working at the home and received some on-going training. Improvements were planned to the training and supervision arrangements of staff to make sure they received the training and support and develop their skills and knowledge to provide people with appropriate care and support.

Staff sought consent form people and asked their opinion of how they wanted to be supported. When people were thought to lack mental capacity the provider had taken the appropriate action to ensure their care did not restrict their movement and rights. This ensured people were supported in line with the principles of the Mental Capacity Act 2005 (MCA).

People could choose what they wanted to eat and told us they enjoyed it. There was a wide choice of food available and people could choose where they wanted to eat.

We saw evidence that some incidents had been used to learn from mistakes but that a detailed analysis of all incidents and accidents was not undertaken. This would have assisted in identifying any patterns or themes.

Some records required for the effective running of the service were not readily available or up to date. Systems used to quality assure services and manage risks were not fully effective but the services of a care consultant had recently been engaged by the provider to help the registered manager identify and action improvements.

On the day of our unannounced visit, 56 people were living at this nursing home. We subsequently spoke to seven people who lived there, five of the friends and relatives, four members of care and nursing staff and the manager of the home.

People were complimentary about the staff who supported them and their living environment. Comments included, “I’m fine thanks, the staff are very good and I’m well looked after” and “I can’t fault them, the food is good, my room is comfortable.”

We examined care plans and found that people’s needs were properly assessed and that care and support was planned and delivered in line with their individual care plans. From our observations it was apparent that care staff were attentive, polite and sought consent before providing care and support.

We examined staff training and recruitment records and spoke to care and nursing staff. We found that people who lived at this home were safe and their health and welfare needs were being met by staff who were fit, appropriately qualified and competent.

The provider had effective monitoring systems and processes in place to identify, assess and manage risks to the health, safety and welfare of people who lived, worked and visited the home. We found that care was provided in an environment that was safe, accessible and suitably designed and adequately maintained.

We concluded that The Green Nursing Home was a comfortable, well maintained home that was safe, caring and well led.

There were fifty six people living at the home at the time of our visit. We spoke with four of these people, four relatives and the staff that were supporting them.

Most of the people using the service were unable to speak with us because of their medical conditions. Therefore, we observed the care and support being provided to these people.

We observed that staff supported people in a respectful manner and that they were available at the times that people needed them. Staff offered people choices of how and where they wanted to spend their time. A person using the service told us “If I need support with anything I ask the staff and they sort it out for me.”

People told us that they were happy with the choice and quality of food provided. The relative of a person using the service told us “My wife’s meal is pureed and it is good that all of the portions are pureed separately. This encourages her to eat well.”

People told us that they felt safe living at the home and that they or their relatives would speak to the manager or staff if they had any concerns. The relative of a person using the service told us “If we have any slight problem the manager sorts it out, no messing about. She is so helpful.”

Systems were in place to monitor the quality of service provided at the home. People using the service and their relatives were involved in this. The relative of a person using the service told us “I would give this place 110% for quality.”

Some people who lived in the home were not always able to verbally communicate with us but we spent some time speaking with visitors to the home. We also observed how staff supported people within their daily lives so that we could gain an insight into the experiences of people who lived at The Green.

We found that the home environment appeared to be clean with no obvious lingering unpleasant smells with specialist seating and equipment such as hoists and pressure relieving mattresses available. We spoke with a relative who told us that they visited the home everyday and said it was lovely and clean. This relative also told us staff, ‘’Always do some great things for them.’’ A visitor commented that a person who lived in the home was happy with the standards of care provided. We observed people to be clean and tidily dressed in clothing to suit their own personalities for the time of year. We also saw staff supporting people, and this was done in a kind and caring way.

Care records showed that appropriate referrals were made to health care professionals to make sure that advice and support is obtained so that people who lived in the home remained healthy and well. We also spoke with the doctor who was visiting the home. The doctor said that there were, “No problems, don’t come very frequently but when I do come, they (staff) are quite proactive’’ and ‘’Nurses appear to know people's conditions and needs.’’

We observed bingo being set up and it appeared to be a regular event for people to take part in as they chose. A person indicated to us that they fed the fish in the pond and helped to establish the garden pots. We spoke with a visitor about activities for a person who lived in the home and they commented, “There is a list in his bedroom about what he likes’’ and ‘’They’re (staff) alright, they play him up”. A person who lived in the home, who had limited abilities when communicating, was present when we were speaking with their visitor and we saw that they were nodding and smiling in confirmation.

We observed relatives assisting family members who lived in the home to eat their meals. We also spoke with relatives visiting the home, and they told us ‘’Meals are good’’ and ‘’Yes, like it here and come every afternoon.’’ We also spoke with some staff about meals and comments were, ‘’Meals are brilliant, really good’’ and ‘’Cook will always cook something else separately if people want’’

The inspection was unannounced and took place on 27 April 2015.

The Green Nursing Home is registered to provide accommodation for personal and nursing care for a maximum of 59 people. There were 52 people living at home on the day of the inspection. There was a manager in place in charge of the day to day running of the home, but they were not registered with us.

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 felt safe and free from the potential risk of abuse. Staff knew how they kept people safe and were aware of their support needs. People received their medicines as prescribed and at the correct time. People had assistance from staff and were available when needed.

Assessments of people’s capacity to consent and records of decisions had not been completed in their best interests. The provider could not show how people gave their consent to care and treatment or how they made decisions in the person’s best interests. Therefore, people had decisions made on their behalf without the relevant people being consulted.

People told us they liked the staff and felt they knew how to look after them. Staff were provided with training which they told us reflected the needs of people who lived at the home. People were supported to eat and drink enough to keep them healthy. We found that people’s health care needs were assessed, and care planned and delivered to meet those needs. People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. People had not always been involved in the planning of their care due to their capacity to make decisions. However, relatives felt they were involved in their family members care and were asked for their opinions and input. People’s end of life wishes had not always been consistently recorded to ensure their choices were respected.

People had been supported to maintain their hobbies and interests and live in an environment that supported their needs. People and relatives felt that staff were approachable and listen to their requests in the care of their family member

The manager had made regular checks to monitor the quality of the care that people received and look at where improvements may be needed. These had not looked at how people’s consent had been sought and recorded. The staff team were approachable and visible within the home which people and relatives liked.

You can see what action we told the provider to take at the back of the full version of this report.