This inspection was unannounced and took place on 20 & 21 February 2018.

The Rosary 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 Rosary Nursing Home provides accommodation and nursing care to up to 102 people. At the time of the inspection there were 76 people living at the home. The Rosary specialises in the care of older people including older people living with dementia.

The home is made up of two main buildings. One part of the home, known as Primrose, provides general nursing care to people. The other building, called Snowdrop, provides care to people living with dementia.

At the last inspection in January 2017 we found that improvements were needed to ensure staff were effectively deployed so people received safe care which met their needs in a timely manner. We found improvements were needed to make sure everyone’s care was person centred and to ensure people were aware they were able to make choices about the care they received. We also found the providers’ quality assurance systems were not always effective in identifying shortfalls in the service provided to people.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive and well led to at least good. We also met with the provider to confirm the action being taken. At this inspection we found that improvements had been made in all areas and there was a commitment to on-going improvements.

There is 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.

There had been a change in the culture of the home which ensured staff worked in a way that respected people as individuals and took account of their needs and wishes. This led to a happy and relaxed place for people to live.

People were cared for by staff who were observant and ensured people were comfortable. People told us, and we saw, that staff were always kind and caring. . Comments from people included, “The staff look after me,” “I love it here. They [staff] are all so kind” and “The staff are pleasant and helpful.”

People felt safe at the home and with the staff who supported them. One person told us, “I feel safe here.” Staff were effectively deployed to make sure people’s needs were met and they had opportunities for social stimulation. Where people requested help this was provided in a timely manner.

People received their medicines safely from trained staff. The provider made sure that people at the end of their lives had the medicines they required to maintain their comfort and dignity. People who were being cared for in bed were regularly seen by staff to make sure they remained comfortable.

People received effective care from staff who had taken part in training which gave them the skills and knowledge they needed. One person pointed to staff and said, “Them [staff] know exactly what they are doing.” One visiting professional told us, “The staff are on the ball.”

People had access to a range of activities and care staff spent time socialising with people. There was a happy atmosphere in the home and most people were relaxed and animated.

The management team at the home had a commitment to continual improvement and seeking people’s views. They learned from things that did not go well and acted on suggestions where practicable. One visiting healthcare professional said they had been involved with the home for six years and told us, “It is much improved over the las

This inspection was unannounced and took place on 8, 9 & 10 January 2017.

The Rosary Nursing Home provides accommodation and nursing care to up to 102 people. At the time of the inspection there were 96 people living at the home. The Rosary specialises in the care of older people including older people living with dementia.

The home is made up of two main buildings. One part of the home, known as Primrose, provides general nursing care to people. The other building, called Snowdrop, provides care to people living with dementia. Primrose is divided into two areas called Chiltern and Polden. Snowdrop is divided into two areas called Quantock and Mendip.

The last inspection of the home was carried out in December 2015. At that inspection the service was rated as Requires Improvement. We found that improvements were needed to make sure the recording of medicines administration, including the application of prescribed creams, was clear and gave an accurate record of what had been administered to people. At this inspection we found that improvements had been made and records gave clear information about medicines which had been administered or refused.

In December 2015 we also found that the leadership within the home was not always clear. Staff were uncertain who was responsible for organising each shift. Some felt it was the senior carers and others thought it was the registered nurse. Feedback from people was that there was a lack of organisation when the registered manager and deputies were not on site. This was a particular issue at night and at weekends. We found that improvements had been made and registered nurses were taking full responsibility for shifts in each unit. A new on-call system for the registered manager and deputies ensured people had access to these people at weekends.

A number of concerns about the service have been raised with us since the last inspection. These have included concerns that there were insufficient staff to meet people’s needs, people waiting an excessively long period of time for staff to support them and general standards of care.

At this inspection we found improvements were needed to make sure quality monitoring processes were effective in identifying and addressing shortfalls in the service and improving the service people received. The provider had a very comprehensive system in place which included regular audits by the registered manager and senior management within the company. However these systems had not identified all the issues we found through observations within the home.

During this inspection we found improvements were needed to make sure staff were suitably deployed to meet people’s needs in a timely way and ensure their safety. On two occasions we observed people waited for 40 minutes for their requests for assistance to be carried out. We also found that some people in communal lounge areas received very limited support, supervision or social stimulation. At lunch time a number of people waited for long periods of time for their meal and between courses.

Improvements were also needed to make sure everyone received person centred care and had opportunities for social stimulation. This was a particular concern regarding the care of some people living with dementia who were unable to make their day to day needs and wishes known. Care plans contained very limited information about people’s preferred daily routines which meant staff did not always have the information they required to ensure care and support was provided in accordance with people’s wishes and preferences. Although long term staff knew people well the home had a number of new staff and regularly used staff from agencies who would not be expected to have personal knowledge of each individual.

There is 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’. Register

This inspection was unannounced and took place on 22 & 23 December 2015.

The Rosary Nursing Home provides accommodation and nursing care to up to 102 people. At the time of the inspection there were 97 people living at the home. The Rosary specialises in the care of older people including older people living with dementia.

The home is made up of two main buildings. One part of the home, known as Primrose provides general nursing care to people. The other building, called Snowdrop, provides care to people living with dementia. Primrose is divided into two areas called Chiltern and Polden. Snowdrop is divided into two areas called Quantock and Mendip.

There is 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 last inspection of the home was carried out in February 2015. At that inspection the service was rated ‘Requires Improvement’ and two requirements were made. We found improvements were needed to ensure there were enough staff available to assist people with meals and social stimulation. We also found some people were not receiving their prescribed medicines at the correct times and there were some gaps in the recording of medicines.

At this inspection we found that improvements had been made in staffing levels and the safe handling of medicines. However we found further improvements were required to make sure medicines were correctly recorded. We also found improvements were needed to ensure the home was well led at all times.

Since the last inspection staff had been recruited but there were still some occasions when the home was short staffed when staff were absent at short notice. There was always a registered nurse on duty in each part of the home. This meant there was always a trained and experienced member of staff to monitor people’s care and well-being. In addition to the registered nurse there were also senior carers. There was some confusion about who organised each shift and made sure everyone received care to meet their needs. One visiting relative said “When there are no managers here there is definitely a lack of leadership.” Another visitor said “The biggest problem is the nurses don’t have the leadership skills they need.”

There had been improvements in the lunchtime experience for people. The provider had implemented a two sitting option. This meant that people who wished to eat in their rooms were served first and received the support they needed. There was a later sitting for people who choose to eat in the dining rooms and staff were able to support people to eat in a relaxed and unhurried manner. One visiting relative told us “Big improvements at lunchtime. There’s enough staff to do the job properly.”

People felt safe at the home and with the staff who supported them. The provider had a robust recruitment procedure which minimised the risks of abuse to people. Staff knew how to report any concerns and the registered manager worked in partnership with appropriate organisations to make sure any concerns were fully investigated.

People told us staff were kind and caring and we saw many examples of this during this inspection. Staff took time to talk with people and offer reassurance where necessary. When people refused support they respected people’s choices. When they assisted people with care they made sure people’s dignity was protected.

Staff received adequate training to make sure they had the skills and knowledge needed to safely support people. One person told us “The staff are very good.” Another person said “I’m not in the best of health but the staff look after me well.”

Each person had a care plan which gave clear information to staff about how to meet people’s indivi

This inspection was used to follow up on concerns identified at the last inspection which was carried out in December 2011.

At the time of this visit the main part of the home, Primrose, was closed to visitors due to a possible healthcare associated infection. Therefore all evidence in this report was gathered from the part of the home known as Snowdrop. Snowdrop cared for people who had a dementia and many people were unable to fully express their views. We therefore spent time talking with staff and observed care practices in the home.

Throughout our visit we observed that staff interacted with people in a kind and polite way. All assistance was provided in a dignified, sensitive manner. We saw that staff knocked on bedroom doors before entering to protect people’s privacy.

We saw that staff supported people in a kind and skilled manner.

We observed lunch in both dining rooms in Snowdrop. We found that the meal was a much more organised and relaxed occasion than on our previous visit. People sat at the same table were served at the same time meaning that people were not left waiting for their meal whilst others on their table were eating. Staff provided support to people who required physical assistance to eat. We saw that this support was given in a patient and respectful manner which ensured that people were not rushed with their food. Where people required specialist equipment to maintain their independence, such as plate guards, these were provided.

Everyone asked said that the food was good. We noted that there was limited waste and people were offered second helpings before their plates were removed.

We carried out this inspection to check that the home had made improvements against the outcome areas we had concerns about during our inspection in February 2011. We also looked at additional outcomes to ensure the home was compliant with other essential standards.

We observed that the home was decorated for Christmas which created a festive atmosphere. We read adverts for lots of Christmas events such as Christmas Carols.

People we spoke with said they were very happy with the care and support they received. One person told us “staff are very kind, it is better than living on your own”. Another person said “I can always talk to staff if I’m worried about anything and they always sort it out”. A third person said “staff are always polite and kind”.

We observed and heard that staff spoke with people in a respectful manner. They were cheerful, polite and kind. We heard a person telling a member of staff that they did not want to get up out of bed that day. The staff respected the person’s wishes but offered to help them with their personal care which the person accepted.

We asked people if they were involved in discussions about their care and the content of their care plans. Some people told us that staff discussed their care with them when they were admitted and often on a daily basis. People could not remember if they had read their care plan but said they were happy with their care.

Relatives told us that the home always kept them up to date with any changes in their relatives’ health. They said they were fully involved in the admission process and were invited to reviews of their relatives care.

Some relatives attended meetings held for the people in the home and relatives. They also told us that the home produced a monthly newsletter where they were kept informed of activities and changes in the home.

We observed that the majority of the time staff delivered care and supported people in an appropriate and skilled manner. However we observed some staff took people in their wheelchairs to the lounge and placed them behind a lounge chairs. This meant that the person could not see anything other than the back of the chair of someone else. We raised this with the deputy manager who said she would ensure this was resolved immediately.

We spoke with one of the part time activity staff. They worked mainly in Snowdrop. On the day of the inspection old tea time reminiscence took place. We observed that this was a popular event.

We observed another member of activity staff who completed a “life story” book but they did not involve the person the life story was about. The staff copied information from a care plan into the book and we did not see them attempt to speak with the person.

We observed people in the dementia unit in the morning. Five people were in the lounge and were either asleep or staring into space. We noted the TV was on but no one was watching the TV programme. When staff entered the room they spoke with people in a kind manner and asked if they were alright. We asked staff why there was no staff in the lounge to observe or talk to people. They said there was not enough staff because of getting people up. They told us there was always staff in the lounge in the afternoons. They said some mornings the activities staff came but found that people engaged better in the afternoons. We raised this with the activity coordinator and deputy manager. We were told that they would consider how staff could be better deployed.

We observed the lunchtime period in the dementia care unit upstairs and down.

In the upstairs unit we observed that staff gave people a choice of meals by showing them two plated up meals. These choices were, either steamed or battered fish. The menu stated that there were other alternatives available but we did not see or hear staff explain that. However, people seemed happy with the choices of fish. Staff told us fish was always popular. We saw that tables were laid nicely and condiments were on the table.

We noted that staff did not always serve meals per table. This meant that some people had to wait a longer time for their lunch while everyone else on the same table ate their meal.

Where people required assistance with their meals staff sat with them and helped in a patient and kind manner. We observed one person ate with their fingers despite cutlery being available. A lot of the food ended up on the person’s lap. We asked a member of staff if they were aware of this. They told us “oh yes, it’s better they remain independent even if it means they eat with their fingers”. We asked staff if this person’s abilities had been assessed by an occupational therapist to see if there was alternative equipment that might enable the person to eat in a dignified way. We were told they were not aware of any and had not been told they should use any specialist equipment.

We observed a person leave the table half way through their meal and wander around the dining room. The person went back to the table a few minutes later. A member of staff took the person’s plate with their half eaten meal and asked the person if they were finished. The person did not respond so the staff member took it away without trying other methods to ensure the person was finished.

In downstairs Snowdrop we found lunchtime was more disorganised and people waited a long time for their meals. Lunch was served at random, not per table.

Some people and relatives told us they had completed a survey on the care and services of the home.

Relatives spoken with said that if they had any concerns they felt able to raise them with staff and were confident that it would be dealt with properly. One relative told us that they were happy with the care their relatives received. They said that they had an issue a while back but as soon as they raised it, it was dealt with immediately. They said they have had no cause for concern since.

Many people in the Snowdrop unit are not able to express an opinion verbally about their care. People who were able told us that they were well cared for. We spent time observing care practices and looked at records of care. There was evidence that action was taken to improve care when concerns were identified.

Most people appeared to be at ease in the environment. They looked clean and well presented. If they were in bed they looked peaceful and comfortable. If they were mobile we heard that they were able to move freely about the home. Visitors came to the home whenever they wished and could stay for lunch.

We saw that all staff spoke kindly to everyone and made patient efforts to listen and understand what was being expressed to them. Some staff were clearly well known to the people living at the home and their approach or presence brought a smile to some faces.

We were told by two people living in the home and by a visiting relative that there was not enough for people to do.

We were able to see that people’s weight was monitored. Several people were able to tell us that the food was “alright” and that there was “plenty.” We observed that on the day of the visit to the home there was no choice of main meal or puddings at lunch time.

This inspection was unannounced and took place on 17 and 18 February 2015 and was unannounced.

The Rosary Nursing Home provides accommodation and nursing care to up to 102 people. It specialises in the care of older people including older people living with dementia. The home is made up of two main buildings. One part of the home, known as Primrose provides general nursing care to people. The other building, called Snowdrop, provides care to people living with dementia. Primrose was divided into two areas called Chiltern and Polden. Snowdrop was divided into two areas called Quantock and Mendip. At the time of the inspection there were 100 people living at the home.

There is 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.

Although people were happy with the care and support they received some people expressed concerns about staffing levels in the home. We found people had their physical needs met but some people waited for a long time for assistance to eat their meal or to be helped out of the dining room after their meal. Staff did not always have time to provide social stimulation to people who were unable to occupy themselves.

People told us staff were always kind and respectful, however we saw some incidents where staff were not respectful and did not ensure people’s dignity was respected. We also observed acts of kindness and compassion throughout our visit with staff taking time listen to people and include them in conversations.

Medicines were securely stored and administered by trained nurses. However some people did not receive their medicines at the prescribed time. There were gaps in the recording of medicines which meant we were unable to verify that people had been given their prescribed medicines correctly.

People received effective care and support because staff were well trained and had the skills to make sure their needs were met. People had access to appropriate equipment to promote their independence and minimise risks. People were happy with the quality of care provided. One person said “They do their very best for me. They are kind to me and I feel very well looked after. I can make choices and they respect me.” A visitor told us “It’s a really good home and the care is top quality.”

Risks of abuse to people were minimised because the home had a robust recruitment procedure which made sure all staff were thoroughly checked before they began work. Staff knew how to recognise and report any suspicions of abuse. All staff were confident that any allegations would be investigated to make sure people were safe.

The registered manager was open and approachable and people felt confident to raise their concerns. People knew how to make a complaint and staff viewed complaints as a learning exercise to make sure practice was improved.

People were able to make choices about their day to day lives and staff knew how to assist people who lacked the mental capacity to make decisions for themselves. There were systems in place to make sure people’s legal rights were protected.

People received good quality compassionate care at the end of their lives. The Rosary Nursing Home was accredited to the ‘National Gold Standards Framework.’ This is a comprehensive quality assurance system which enables care homes to provide quality care to people nearing the end of their lives. The home had been awarded ‘Beacon’ status which is the highest level of this award.

Staff felt well supported and told us they received regular training, supervision and appraisals. Staff were well motivated which led to a happy atmosphere for the people who lived at the home.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.