This inspection took place on 12 and 13 December 2018. It was an unannounced visit to the service.

We previously inspected the service on the 27, 28 and 29 September 2017. The service was rated requires improvement. At the last inspection we found breaches of the Regulations of the Health and Social Care Act 2008. We found there was a danger of people not receiving the right support. Records relating to people’s support, level of risk and medicines were not accurate and were not always updated when changes occurred. The registered persons had failed to be open and transparent when serious injuries had occurred. At the last inspection we found the service to be in breach of The Care Quality Commission (Registration) Regulations 2009. The registered persons had failed to notify the Care Quality Commission (CQC) about important events they legally required to do so.

We asked the provider to complete an action plan to show what they would do and by when to improve the key questions, Safe and Well-Led to at least good. At this inspection we found ongoing concerns about records relating to people’s care and support and ongoing lack of notifying CQC about events.

The Leonard Pulham Nursing home is a ‘care home’ which provides nursing support. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate up to 34 people. At the time of our inspection 31 older adults lived at the home.

The service did not have 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. The registered manager had left the service in September 2018. The provider had been proactive in recruiting and a new manager was due to commence employment in January 2019.

At the last inspection we made a recommendation to the service, to ensure staff followed the core principles of the Mental Capacity Act 2005 (MCA). At this inspection we found people were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). People who did not have capacity to agree to restrictive practice for instance, the use of bed rails, had not been referred to the local authority for a DoLS assessment.

At the last inspection we made a recommendation about the management of medicines. At this inspection we found improvements had been made. The service was working with a member of the Clinical Commissioning Group (CCG) pharmacy team. We received feedback from the CCG that improvements had been made in the management of medicines.

We found there were not enough staff to provide person-centred care. People told us “The problem is when you want to use the toilet and it takes too long to be attended to. Sometimes you ring the bell and you have to wait for too long to have someone to assist you” and “When I want to use the toilet, I ring the buzzer and it takes time for me to get someone; it takes 15 to 30 minutes.” We discussed our concerns with the deputy manager who told us “I know we are short staffed.”

People were not always protected from avoidable harm. We found environmental risks were not always identified. We found hot pipes were exposed and radiator covers were loose. We highlighted this to the provider. The maintenance staf

This inspection took place on 27, 28 and 29 September 2017. It was an unannounced visit to the service.

We previously inspected the service on 24 & 26 November 2014. The service was meeting the requirements of the regulations at that time.

The Leonard Pulham Nursing Home is a care home with nursing for older adults. It is registered to provide accommodation for 34 people. At the time of our inspection 34 people lived at the home. The home is located within a rural location within the Chiltern Hills. Accommodation is over two floors.

The service did not have 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. A new manager was in post and had submitted an application to the Commission to be the registered manager. The manager had a wealth of experience and skills in health and social care.

People described the home to us as warm, welcoming and friendly. Comments included, “I only have high praise of the nursing home. I think they are doing a great job,” “The staff are always cheerful, friendly and helpful.”

People had developed positive working relationship with staff. We observed a number of positive interactions between staff and people who lived at the home. One person described staff as “I think they’re absolutely lovely.”

We found mixed practices around the management of medicine. People told us they received their medicine on time and we observed staff were professional and confident in the administration of medicines. However improvements were required in the training of staff, stock control and record management relating to medicines. We have made a recommendation in the report about this.

We found there was mixed practice around ensuring people were treated in line with legislation. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Staff were able to tell us how they supported people to make decisions about their care. However care plans and records relating to people’s mental capacity did not always follow best practice. We have made a recommendation about this in the report.

We found a number of records relating to the care and treatment of people were not always accurate or contained enough detail to provide staff with sufficient guidance on how to support people. There was a reliance on verbal handover meetings. Staff did not always have time to read care plans.

One person had fallen which resulted in a fractured arm. The service had not notified CQC of this and it was legally required to do so. We discussed this with the manager and they were unaware they should have informed us of this. There is a requirement for services to be open and transparent when things go wrong. We call this duty of candour (DOC). There are clear responsibilities on registered services. We checked if the requirements had been met. At the time of our inspection the manager told us they were not aware of a DOC policy. After the inspection we received confirmation from the provider a policy was in place. However the policy had not been followed for one event which met the DOC threshold.

People were supported by staff with the right skills and experience; there was a programme of induction, training and on-going support for staff. The provider recognised some of the required pre-employment checks needed to be in place for all new staff appointed.

People were supported to maintain a healthy diet. The home had been complemented by the local authority for their work to support people with their nutritional and hydration needs. The manager had written an article for the local authority quality team newslett

One inspector carried out the inspection. They gathered evidence against the outcomes we inspected to help answer two out of the five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service caring? During our previous inspection on 18 and 19 February 2014 the service was found to be caring. This was not reviewed during this inspection.

Is the service responsive? During our previous inspection on 18 and 19 February 2014 the service was found to be responsive. This was not reviewed during this inspection.

Is the service safe? During our previous inspection on 18 and 19 February 2014 the service was found to be safe. This was not reviewed during this inspection.

Is the service effective? We have judged the service was not effective. This is because the provider had not supported all staff through the use of annual appraisals and the provision of mandatory training. A training plan for all staff to complete mandatory training started on the day of our inspection 1 July 2014 and would be completed in November 2014.

We found on this inspection amendments needed to be made to the system used for recording staff training to enable the provider to identify gaps in training and to take appropriate action.

We found on this visit improvements had been made to the supervision offered to staff. We found records showed supervision was carried out frequently for all nursing and care staff.

We have asked the provider to tell us how they will make improvements in relation to the training matrix to ensure they can identify the training needs of staff. What actions they will be taking to ensure all staff receive all the mandatory training and annual appraisals.

Is the service well led? We judged the service to be well led. This was because staff told us they had been impressed with the new head of care and nursing. One staff member told us they felt they “Very much led by example, and they had got the confidence of everyone in the building, the team is beginning to gel.” Another staff member told us the head of care and nursing treated each staff member as an individual and as a result the team had improved. This helped to ensure that people received a good quality service.

During our visit we saw that people were being treated with dignity and respect and people’s independence was encouraged. People we spoke to told us that they were very happy with the care provided. One visitor said, “the care is excellent here and staff are very kind”.

We saw that people experienced safe and effective care based on detailed care plans that encouraged independence. There were risk assessments that met individual needs and provided guidance to staff to minimise potential risks. We saw that good nutritional care was provided in a way that met people’s needs and preferences.

People using the service were protected from abuse as they were supported by staff who had appropriate knowledge and training on safeguarding adults. People we spoke to told us if they had any concerns they would report them to the manager or senior person on duty.

Staff we spoke to and records we reviewed demonstrated that there were the appropriate number of staff on duty at the right times to meet people’s needs. Staff were appropriately inducted and supported and received ongoing training and supervision which provided them with the skills and knowledge to meet changing needs.

The provider had effective systems in place to monitor and assess the quality of the service. The provider regularly collected the views of families and they were very positive about the service. There was good evidence that the service made changes as a result of assessing quality.

People told us that they had been given the opportunity to visit the home before they moved in to ensure it met with their needs and expectations. They said that the staff treated them as individuals and respected their views and choices. People told us that they felt safe and that staff looked after them well.

This inspection took place on the 24 and 26 November 2014. At the last inspection on 1 July 2014 we asked the provider to take action to make improvements in how they supported staff to carry out their role and this action has been completed

At the time of this inspection the manager had been in post for nine months and was in the process of applying to the commission to become the 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.

At the last inspection in July 2014 we asked the provider to take action to make improvements in how they supported staff to carry out their roles, this action has been completed.

The home provides residential and nursing care for up to 33 older people. At the time of our inspection there were 31 people living in the home. People told us they were happy with the care provided to them, and they felt safe living in the home. Systems were in place to ensure their safety and wellbeing. For example, assessments of people’s needs were completed before they moved into the home. Care planning and risk assessments took into account the persons preferences, likes and dislikes. Risks to people and staff were assessed, documented and updated.

The home was clean, tidy and well maintained. Staff were carrying out good infection control measures such as wearing gloves and aprons, however there was no infection control audit in place. This meant the provider was not able to easily identify where they could minimise the risk of infection to people. We have made a recommendation about the prevention and control of infections.

Medicines were administered safely and all records were up to date and accurate. However, we had concerns about the safety of how medicines were stored, as the medicines trolley was left open and unlocked at lunchtime when medicines were being administered.

The home had sufficient numbers of staff to support people and respond to their needs in a timely manner. People told us they had time to chat with them, and we observed lots of laughter and jokes between staff and people.

The home employed a nutritional support carer whose responsibility was to ensure the nutritional needs of individuals were met. People told us they liked the food in the home, and we saw people enjoyed their mealtime. People’s health was monitored, and where their needs changed staff responded quickly and appropriately.

Staff were caring and showed respect for people. They spoke knowledgably about the people they cared for. They knew how to communicate with people and how to reassure them when they became anxious or upset.

People were cared for with dignity at the end of their life. One person told us their relative moved into the home shortly before they died. They described to us how their relative and their family were supported by compassionate and professional staff.

People told us they were encouraged to remain as independent as possible. Where potential risks were identified, these were managed in a way that respected the person’s choice. Staff knew how to protect people’s dignity and treated everyone as an individual. Each person could choose whether they were cared for by male or female staff.

The home provided activities to meet people’s social needs. These included outings and in house activities such as sherry and piano sessions, exercises and films. Where people had difficulty in accessing the community, specially adapted taxis were hired to enable them to visit family or friends.