This was an unannounced inspection which took place on 22 February 2017.

The Meadows is a purpose built residential and nursing home situated in the village of Thringstone and is within walking distance of the local amenities. Accommodation and communal space is over two floors and all rooms are for single occupancy. There are suitable shared areas and a secure garden. The home provides accommodation for up to 34 older people some of whom may be living with dementia. There were 32 people living at the home when we visited.

The home had a suitably qualified nurse who had been the registered. 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 last inspected this service on 23 March 2015 where we judged the service to be rated as ‘Good’

Staff understood how to protect vulnerable people from harm and abuse. Staff had received suitable training.

Risk assessments and associated management plans were in place to support people.

Medicines were appropriately managed in the service. People saw their GP and health specialists whenever necessary.

People were encouraged to be as independent as possible by staff who were suitably inducted, trained and supported.

The provider’s recruitment process was robust and included checking prospective staff before they started to work at the home. This helped the provider to make safer recruitment decisions.

Staff understood the requirements of the Mental Capacity Act (2005) and understood how to obtain people’s consent before they offered care and support. Staff knew how to support people to make decisions for themselves. Where people may have lacked the capacity to make their own decisions, the provider had followed the requirements of the Act.

People were being supported by staff who cared. They had built relationships with staff that were meaningful. People’s dignity and privacy was being promoted and maintained by staff.

People enjoyed the food that was offered to them and were supported to maintain a healthy diet. They could choose what they ate and their preferences and requirements were known by staff.

Any accidents or incidents had been reported to the Care Quality Commission (CQC) and suitable action taken to lessen the risk of further issues.

Assessments and care plans were up to date and met the meets of people in the service. Staff were very centred on the needs of individuals. Nursing processes were being carried out appropriately.

People were happy with the activities and entertainments on offer. People were given the opportunity to follow their own interests, where possible.

Staff were clear about their roles and responsibilities. They knew how to raise concerns if they had needed to about the practice of a colleague. Staff were able to make suggestions for how the service could improve.

The provider had a suitable quality monitoring system in place and action had beentaken where improvements were needed.

An unannounced inspection took place on 23 March 2015. Our previous inspection of 22 July 2014 found the provider was not meeting five regulations at that time. These were in relation to consent to care and treatment, care and welfare, staffing, management of medicines and assessing and monitoring the quality of service provision. Following that inspection the provider sent us an action plan to tell us the improvements they were going to make. At this inspection we found that the actions we required had been completed and these regulations were now met.

The Meadows provides care and support for up to 34 older adults with a variety of needs including people who require nursing care. At the time of our inspection there were 31 people using the service. The home has two floors with a number of communal areas and a garden available for people to use.

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 and associated Regulations about how the service is run.

People and their relatives were satisfied with the care and support provided and all felt their individual needs and wishes were known and understood. Staff had a good rapport with people and were kind and gentle in their approaches. People felt involved in the planning and delivery of their care and had opportunities to be involved in the development of the service. People were confident approaching staff and were comfortable raising any concerns or issues they may have.

We saw that people were well supported by a staff team that understood their individual needs. We observed that staff treated people with respect and promoted people’s dignity and independence. Staff we spoke with had a good understanding of people’s needs and were clear about the care and support people required.

Staff recruitment procedures were robust and ensured that appropriate checks were carried out before staff started work. Staff received a thorough induction and felt they had received appropriate training. Nursing staff had sufficient support for their continuing professional development. Improvements had been made to staffing levels and people’s care and support needs were met promptly.

Staff were aware of how to protect people from avoidable harm and were aware of safeguarding procedures to ensure that any allegations of abuse were reported and referred to the appropriate authority. This meant that care was provided in the safest way.

People had been asked for their consent to care and treatment and their wishes and decisions respected. The requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards 2008 had been met.

Medicines were safely stored and administered and people received their regular medicines as prescribed. We found one discrepancy with stock levels which was responded to on the day of our visit.

Improvements had been made in the planning and delivery of people’s care and people had received the care and support they required. People’s needs were assessed and plans were in place to meet those needs. Risks to people’s health and well-being were identified and plans were in place to manage those risks. We found good practice in relation to wound management and food and fluid recording.

People were supported to access additional healthcare professionals whenever they needed to and their advice and guidance had been incorporated into people’s care plans. People’s nutritional and dietary requirements had been assessed and a nutritionally balanced diet was provided.

The home had been well maintained and offered a pleasant environment for the people living there. People’s bedrooms had been personalised and people were encouraged to spend their time where they pleased.

There were effective systems in place to assess and monitor the quality of the service. This included gathering the views and opinions of people who used the service and monitoring the quality of service provided. People’s complaints and issues of concern had been responded to promptly and appropriately.

As part of this inspection we spoke with eleven people who used the service, three relatives and four members of the care team. We also spoke to a registered nurse on duty at the time of our visit, the registered manager and the provider’s head of compliance, who arrived at the service during our visit. We looked at records including people's personal records, medication records and records kept in relation to the management of the service.

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. This is a summary of what we found:

Is the service safe?

Ten of the eleven people spoken with told us that they felt safe living at The Meadows and that they were treated well. One person told us that they hadn’t always been cared for in a safe way. One person explained: “I am more than satisfied, they treat me very well.” Another person told us: “You can’t fault the staff, I do feel safe here.” One person explained: “If they hit my legs on the bed or the hoist, they say sorry. [When staff were transferring them from their chair to their bed] A relative told us: “I feel mum is safe, if I can’t come at least I know she’s looked after.”

We talked to staff to determine whether there were enough staff on duty to meet the needs of those in their care. We were told there were not. One care worker told us: “No there could be more, mornings are a very busy time. More people need one to one help and more people need two carers now, it’s hard.”

People who used the service expressed their concerns about the numbers of staff on duty. One person explained: “When you ring your bell for help, sometimes it’s 10 minutes, sometimes half an hour to 40 minutes, especially in the evenings when I want to go to bed.” This meant that the people who used the service were not always kept safe from possible injury and their dignity was compromised.

The manager completed a pre-assessment of people’s needs before people moved in to the service to make sure their assessed needs could be met. One person told us, “xxxx [the manager] came to see me and asked lots of questions.”

Records kept to monitor how much fluid people had consumed during each day were not up to date and repositioning charts (used for people unable to move themselves in bed) showed us that people were not being assisted as directed in their care plan. This showed us that people were not protected from the risk of dehydration and the development of pressure sores.

A safeguarding incident involving one of the people who used the service had not been reported to the local authority safeguarding team. This meant that it had not been investigated under safeguarding procedures to ensure that the person who used the service had been kept safe from harm.

Staff we spoke with knew what to do if they suspected that someone was being abused. One care worker explained: “You report it to your senior and the nurse, then the manager.” Another care worker told us: “I would report whoever was involved to the nurse or the manager.”

On checking the medication records we found that on one day, the registered nurse had failed to sign to say that they had dispensed two people’s medicine. On a second day they had failed to sign one person’s medicine. Medication that had been stored in the medication fridge was out of date. Forticreme [food to supplement people’s diets] were not being stored in line with manufacturer’s instructions.

Is the service effective?

We spoke with eleven people who used the service to find out if they were satisfied with the care and support they received. Some told us they were, others told us they were not. One person told us: “I would like to get out of bed more, I hate bed, I don’t know when I will get out today, it is up to the carers.” Another person explained: “The staff are alright, we pick out clean clothes every day and my teeth are sterilised in steredent every night.”

Relatives told us that they were happy with the care and support their relative received. One relative explained: “Mum always looks cared for and the carers are lovely.” Another relative told us: “The carers are brilliant, very kind.”

Care plans provided care workers with information about people’s care and support needs though these were not always accurate or had not been followed. This meant that people had not received the care and support they needed.

Although an assessment of need had been carried out for the people who used the

service, there was no evidence to confirm that they, their relative or their advocate, had given their consent to the care or support received.

Is the service caring?

We observed staff going about their work. They treated the people they were supporting in a kind and respectful way. Due to limited staff availability we found that not all the tasks that needed to be carried out had been. This included for two people their nail care and for another, the removal of dropped food from their bed sheets when they had finished their meal. This compromised the dignity of the people who used the service.

The people who used the service told us that, on the whole they were treated with respect and we observed staff knocking on doors and calling people by their preferred name. One person told us: “Some of them [care workers] treat us with respect, others not so. Some of them are really sharp.” Another person explained: “I am treated with respect; I have a laugh with them.”

Is the service responsive?

The needs of the people who used the service had been assessed before they moved into the service and they and their relatives/advocates had been involved in this process.

Relevant professionals had been involved in people's care. Records showed that visits had been arranged when necessary. These included visits from their doctor, their dentist, the local speech and language team and the tissue viability nursing team. This ensured that people who used the service received the care and treatment they required.

On checking the records belonging to one of the people who used the service we found that they had not been provided with the treatment they required for a pressure sore for over ten days. This was rectified on the day of our visit. The nurse in charge carried out the treatment and updated the records. The local safeguarding team were informed.

Is the service well-led?

A monitoring system was in place but the effectiveness of this was questioned because of the shortfalls that were identified during our visit.

Care plans had been reviewed on a monthly basis. This enabled the staff team to monitor people's needs. Where changes in people's health and welfare had been identified; these documents had been updated to reflect this. Risk assessments had not always been reviewed monthly. This meant that the people who used the service were at risk of having their health and safety compromised.

Staff meetings had been held. This provided the staff team with the opportunity to have a say on how the service was run. A meeting for the relatives and advocates of those who used the service had also been held. This gave relatives and advocates an opportunity to have a say about the service that was provided. The people who used the service were given the opportunity to discuss any concerns on a day to day basis. One care worker explained: “We ask them if they have any concerns and then we would take them to the manager.”

Staff on the whole felt supported by the management team and told us that they felt able to talk to someone should they have a concern of any kind. One care worker explained: “I feel 100% supported.” Another care worker told us: “You can talk to some of the nurses or the manager.”

We looked at whether people consented to treatment and care and people using the service told us that staff always checked what support they needed and asked them if they needed help. "When they come to me in the morning they always ask me what help I need."

We looked at care plans and saw that people using the service had assessments and plans in place to meet their needs and ensure their safety. Staff spoken with understood the needs of the people in their care. People told us they felt safe and well cared for. "It's not like home but the staff are kind and make sure I am safe."

We looked at the safety of the building and equipment. We saw records that showed the equipment and building was regularly maintained and safe for people using the service. People told us "I like my room I have new curtains and carpet it is lovely."

We looked at how staff were recruited and we saw records that confirmed only people who were safe to work with vulnerable people were recruited and the provider had a robust recruitment policy.

People told us that they were able to complain and felt if they complained to Silvana she would deal with it. "I would speak to Silvana and she would sort it out." We saw records that showed when complaints were made they were fully investigated using the providers complaints policy.

People we spoke with told us that they felt that their needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

"I like the food here."

"The staff are lovely and so helpful."

"I get my medication when I need it."

Overall people told us that they were generally happy with the care they received.

"Staff look after me very well".

People spoken with told us that they felt safe and the staff were kind and helpful. However people also told us "they are always so busy and" "I don't like to bother them".