This inspection was undertaken on 10, 15 and 16 January 2019. The first two dates were unannounced which means the provider did not know we were coming. The final visit was announced.

The Meadows Nursing Home is a ‘care home’. 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 Meadows accommodates up 36 people in a large adapted property with more modern extensions. The home is split into three units. The Pines and The Willows provide nursing care for people and are located on the ground floor. The Beeches provides care for people living with dementia and is on the first floor. Communal areas as well as bathrooms and toilets are provided on both floors. There were 34 people living at the home at the time of the inspection.

At our previous inspection on 04, 05 and 13 October 2017 we rated the service as ‘Requires Improvement’ in each of the five key questions as well as overall. We identified five breaches in regulation. These included people did not always receive care that met their care and preferences. People’s dignity was not always maintained. The provider had not consistently ensured risks to people had been assessed and the risks mitigated. People’s medicines were not always stored and administered safety. The provider did not always have effective arrangements in place to monitor and improve the quality and safety and welfare of people. The management and deployment of staff did not always ensure there were sufficient staff to safely meet the needs of people at all times.

Assurances were given following the previous inspection regarding staffing.

We undertook this inspection to see whether the provider had made the necessary improvements.

At this inspection we found some areas continue to require improvement.

The provider had a registered manager 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.

The provider did not have effective systems to ensure all statutory notifications were sent to the Care Quality Commission. The provider had failed to notify us of Deprivation of Liberty Safeguard authorisations as they are required to do by law.

Since our previous inspection improvements have taken place in areas such as medicines, staffing, staff knowledge and governance. The registered manager showed a passion to make further improvements at the home.

We identified shortfalls in how medicines were managed. These were discussed at the time of the inspection. Personalised care was provided however care records did not always indicate what action staff had taken to meet people’s needs in monitoring documentation.

People were cared for by the staff who had knowledge of how to keep people safe and what to do if they believed people to be at risk. People’s wishes were taken into account to ensure people’s preferred life styles were met.

People who lived at the home as well as relatives and staff were complimentary about the care provided and were confident in the registered manager and the improvements made.

People had a range of fun and interesting things to do and were involved in deciding in these. People were able to take advantage of outings to interesting places.

People were supported to have maximum choice about their lives and were supported in the least restrictive way possible. Staff spent time with people talking about important things in their life and had developed a caring relationship. People were encouraged to make decisions about their day to day life. People’s privacy and dignity was respected.

People’s needs were assesse

This was an unannounced comprehensive inspection which took place on 3, 4 and 13 October 2017. This inspection was in to response to information of concerns received, and raised by relatives of people living at the home.

The provider of The Meadows is registered to provide accommodation with personal and nursing care for up to 36 people. Care and support is provided to people with dementia, personal and nursing care needs. Bedrooms, bathrooms and toilets are situated over two floors with stairs and passenger lift access to each of them. People have use of communal areas including lounges and dining rooms. At the time of this inspection 35 people lived at the home. The home is split into different areas The Pines and Willows provide nursing care for people and on the first floor The Beeches specialises in dementia care.

There was a manager who had just started their employment but was not yet registered with the Care Quality Commission. They were present at the three days of 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People did not always feel safe because there were insufficient staff to care for them. Many were agency staff who people felt did not always understand or know their needs. People's daily records were not completed promptly. People were not always given a choice of food. The monitoring of people’s fluid and food intake was not always completed in a timely manner.

Staff did not always receive supervisions, so were not given opportunity to reflect on their practice and identify their training needs. Not all staff had the skills or training to support people living with dementia. People were not supported to maintain their hobbies and interests. There was a lack of specialist activities available for people living with dementia.

People’s consent was sought by staff and where necessary people and their families had been consulted on their care.

People told us they didn’t always enjoy the food on offer. A care staff member was standing in for the cook, as there was a staff vacancy. The food offered was sometimes difficult for people living with dementia to eat. The monitoring of people's fluid and food intake was not always completed in a timely manner.

People liked the staff that cared for them; however people felt the inconsistency of staff made it difficult for staff to understand their care needs. People’s privacy and dignity was not respected.

People and their relatives knew how to make a complaint.

Staff reported accidents and incidents to the office however; the management team did not review them to ensure appropriate action had been taken and to reduce the risk of incidents happening again.

Frequent changes in the management of the home left staff feeling unsupported. Staff changes meant that regular checks of the home did not happen. Systems in place to assess and monitor the quality of the service provided were not effective. The provider failed to identify risks and keep people safe.

During this inspection we found significant shortfalls in the quality of the care being provided. We found the registered provider to be in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This inspection took place on 25 July 2016 and was unannounced .

The provider of The Meadows Nursing Home is registered to provide accommodation and nursing care for up to 36 people. The facilities within the home are arranged over two floors and divided into three units, Pine, Willows and Beeches. Pine and Willow units are on the ground floor and care for older people with mainly nursing care needs. The Beeches unit is located on the first floor and cares for people with dementia related care needs. At the time of our inspection 20 people lived at the home.

The provider is required to have a registered manager in post. Since our previous inspection a new manager had been recruited and is currently in the process of applying to become 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.

The risks to people’s safety had been reduced by the improved measures which had been introduced since our last inspection. The home environment was checked and action was taken to identify any hazards to people’s wellbeing and safety so these could be removed.

People were supported by staff that knew how to identify harm and abuse and how to act to protect people from the risk of harm. Staffing numbers had been assessed to make sure they were available to support people’s individual needs and keep them as safe as possible. The manager actively listening to where staffing arrangements needed to be reviewed to ensure they were enough staff on all shifts including during the night shift.

People had their prescribed medicines available to them and staff followed safe medicine practices. This included staff always signing to show they had applied people’s prescribed cream and this now needed to be sustained by staff checking this was consistent practices.

Staff had received the training they needed to fulfil their roles and had improvements had been made to their caring practices which had positive impacts for people. Staff were supported to have opportunities of more specialised training to assist them in continuing to improve their practices for the benefit of people they supported.

Staff respected people’s rights to make their own decisions and choices about their care and treatment. People’s permission was sought by staff before they helped them with anything. When people did not have the capacity to make their own specific decisions these were made in their best interests by people who knew them well. Where people may have restrictions on their liberty and freedom in order to keep them safe applications had been made to the local authority to make sure people were not unlawfully restricted.

Staff were knowledgeable about people’s needs and how to meet those needs and care records were in the process of being improved to accurately reflect the care people received. The care records showed the personalised care people required to help staff consistently meet people’s needs and we saw staff followed these.

People were provided with appropriate food and drink to meet their health needs. People were happy with the food offered. Mealtime experiences had improved to assist people in meeting their eating and drinking needs. Staff showed they were eager to continue to develop and enhance their mealtime practices. This included focusing upon the needs of people with dementia so people’s personal preferences could be met.

Staff were caring and respectful towards people with consideration for people’s interests and life histories when chatting with people. People’s right to private space and time to be alone with their relatives and friends was accepted and respected.

People were supported to have interesting and fun things to do. Further work w

There were 35 people living at The Meadows Nursing Home when we carried out our inspection. We looked at how care was provided to people with dementia who lived on the unit known as Beeches. There were 13 people who lived on Beeches at the time of our inspection.

During our inspection we found that many of the people were not able to tell us about their experiences of living on Beeches. However we were able to speak with two people, one family member and we received 11 comment cards where people gave their views about the care and treatment that people received.

We found that the people who lived on Beeches that we spoke with were happy with the care that was provided. One person told us: “It’s nice here the staff are very good to me, they support and care for me.” One family member gave us their views about the staff: “They are patient, caring and compassionate and they interact well in talking and trying to stimulate and get my relative to relax.”

We saw that before people came to live at the home their health and social care needs were identified. This included information about people’s dementia care needs and what their daily routine preferences were. This was completed with people themselves as far as possible and with people’s representatives to ensure that they felt part of the person’s care. However we identified some examples where the risks to people’s care and wellbeing were not always being reduced in practice.

The care records that we looked at showed that staff were responsive to the changes in people’s needs. We saw that health and social care professionals were consulted with and staff worked with other providers. This made sure that people received the right care at the right time to meet their individual needs.

We found that the registered manager had some systems in place to enable the quality of care to be assessed, monitored and improved.

We spoke with two people who used the service who lived on the ground floor of the premises. They spoke positively about the home, the staff and the care they received. One person said, "I like it here." Another person commented, "I can't complain about anything."

We were not able to hold conversations with most people. To obtain more information about people's experiences about living at the home we used our Short Observational Framework for Inspection (SOFI) tool. We used SOFI to observe how staff interacted with people. We found that staff treated people with respect and responded to them in a helpful and courteous way.

During our inspection we looked at the arrangements for staff training and how staff were supervised in carrying out their roles. Since we last inspected the service in August 2012 we found that improvements had been made in providing training for staff and in making sure that staff supervisions were carried out regularly. Some staff had received specialist training and some had been booked to undertake extra training so that they were equipped to care for people with specialist needs. We spoke with two staff who told us that the range of training courses provided for them had improved.

We checked the systems for monitoring the quality of the services that were provided to people. We found that the registered manager made sure that there were monitoring processes in place so that improvements could be made when necessary.

We spoke with four people who used the service who lived on the ground floor in Pine and Willows unit which provided nursing care. Overall they spoke positively about the home and told us that they felt safe and cared for. One person told us “I do have good attention”, another “I am looked after well” and another person said “Staff are very kind”.

We observed staff respecting people’s privacy and dignity. Each person who lived in the home had their own room and we saw people moving about the home making choices about where and how they wanted to spend their time. This meant people had somewhere private to spend time if they wished.

People’s rooms appeared homely and were personalised and we could see that people had been able to bring in personal items of their choosing.

Part of the living space at the service was called Beeches. This unit was used to provide care for people with dementia related illnesses. When we walked around the unit we saw that there were items on display to encourage reminiscence and staff told us that they had been making improvements to the environment to make it more stimulating for the people who lived there. This meant that consideration had been given to provide an environment that supported their needs.

During our inspection we used the Short Observational Framework for Inspection (SOFI).This is a specific way of observing care to help us understand the experience of people who could not talk with us. We used SOFI to observe how people living on Beeches were feeling and their engagement with staff. We found that people who used the service appeared calm and relaxed in the environment and overall responded positively to interactions with staff.

The service had designated dining rooms on each floor but people who used the service were able to choose where they wished to take their meals. During our visit we saw that some people chose to eat their meals in their rooms with other people choosing to eat in the dining rooms.

We spoke with four people who used the service who lived on Pine and Willows and asked them about the food and drink that was offered to them. All of the people told us that they received enough to eat and drink. One person told us “Food’s alright, could be better”. We saw that people were served ample portions of food and were appropriately supported by staff with their meal if they required it.

During lunchtime we spent time on Beeches watching how people were supported at mealtime and seeing how they were supported to make choices about what they wanted to eat and drink. We saw meals being plated up by staff and served to people and people being asked what vegetables they would like from the choices available.

An activities coordinator was working in the home each week day providing social and recreational opportunities.

We saw that people appeared well cared for and staff interacted well with people.

This inspection took place on 3 and 4 August 2015 and was unannounced .

At our last inspection on 30 and 31 October 2014 we asked the provider to take action to make improvements to protect people who lived at the home. The provider did not work within the guidelines of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty safeguards (DoLS). People could not be confident that their rights were protected because the Mental Capacity Act 2005 Code of practice had not been followed when people were not able to make their own specific decisions about their care. We saw that restrictive practices were in place in order to keep people safe. However, measures to make sure that these restrictions were lawfully applied had not always taken place. Following this inspection the provider sent us an action plan to tell us the improvements they were going to make. The required standards of the law related to the Deprivation of Liberty Safeguards (DoLS) were being met. This was because where it was felt people received care and support to keep them safe and well which may be restricting their liberty applications had been made to the supervisory body. These actions made sure people’s liberty was not being unlawfully restricted.

The provider of The Meadows Nursing Home is registered to provide accommodation and nursing care for up to 36 people. The facilities within the home are arranged over two floors and divided into three units, Pine, Willows and Beeches. Pine and Willow units are on the ground floor and care for older people with mainly nursing care needs. The Beeches unit is located on the first floor and cares for people with dementia related care needs. At the time of our inspection 33 people lived at the home.

The provider is required to have a registered manager in post. The former registered manager deregistered with us in October 2014. The provider had taken action and a new manager was appointed in June 2015 and is currently in the process of submitting an application to be 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.

Although the provider managed the risks to people by making sure the home environment and equipment were regularly maintained and serviced, the daily home environment checks were not always effective. There were hazards that potentially placed people’s safety at risk. These included items of equipment, torn flooring by a person’s room and a loose electrical plug socket. The manager took action when we pointed these out to them to reduce these hazards for the benefit of people who lived at the home.

People had their prescribed medicines available to them and these were administered by staff who had received the training to do this. The protocols for ‘when required’ prescribed creams for some people were not in place and staff had not consistently signed to confirm when people’s creams had been applied.

We saw staff did not always apply their knowledge gained from training in an effective way when responding to the individual needs of all people who lived at the home. This included their communication skills so that people’s mental health and emotional needs were consistently supported and met. The manager put into practice their skills and knowledge to reassure some people who lived at the home when they needed this on the day of our inspection. They viewed this as one positive method of guiding and supporting staff to provide good care.

We saw there were some missed opportunities where staff provided care which was focused upon a care task being completed as opposed to being responsive to people’s individual needs. This included supporting and enhancing people’s wellbeing by having opportunities to do fun and interesting things, as these were not routinely promoted. Recruitment was in progress for a member of staff to help promote people’s access to follow their social interests.

Staff knew how to protect people against the risk of abuse or harm and how to report concerns they may have. Checks had been completed on new staff to make sure they were suitable to work at the home. People told us there were enough staff to meet their needs although at times staff could be busy but they did not have to wait for assistance for too long. The manager had recently increased staffs opportunities to gain support to effectively carry out their caring roles and discuss any issues they had with weekly meetings where staff could meet with the manager.

People told us they were supported to access health and social care services to maintain and promote their health and well-being. A doctor visited people on the day of our inspection and spoke with staff about people’s changing health needs. When people needed support to meet their dietary and hydration needs a referral was made to the right health care professional so that people remained healthy and well.

People we spoke with told us they felt their privacy was respected and they felt safe. We saw conversations between staff and people who lived at the home were positive in that staff were kind and polite to people. People knew how to make a complaint and felt able to speak with the staff or the manager about any issues they wanted to raise.

People were getting to know the new manager and they felt they were approachable and visitors to the home felt that they were welcomed. The manager had introduced more opportunities for people and staff to make suggestions about the services people received. Staff understood their roles and responsibilities and felt that the new manager was trying to make things better for staff and people who lived at the home but they felt it would take time.

Since the new manager had been in post they had and were continuing to introduce a range of checks to make sure the quality of the services people received were of a good standard. From carrying out these checks the manager was working towards making key improvements such as strengthening staff support to promote good care. At the time of this inspection there was limited evidence to determine whether these improvements were effective and had had a sustained positive impact on the quality of care people who lived at the home received.