This inspection took place on 14 and 20 November 2018 and was unannounced.

The Wells 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 home is registered to care for up to 40 people. At the time of the inspection there were up to 31 people were living at the home. Some of the people living at the home complete short stays and then return to their own home. The home specialises in caring for older people who require nursing and personal care needs. People live across two floors in the home and on the ground floor there are communal spaces including a living room and dining room.

Although there was registered manager in place to run the home they were no longer the person responsible managing the service. 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 was a new manager who was running the home.

People were not always safe living at the home even though they thought they were. Medicines were mostly managed safely and improvements had been made in the cleanliness of the home. There were systems in place to monitor health and safety and fire. However, improvements were required in relation to keeping people safe who required specialist diets, pressure care and risk assessing. Records for people were sometimes inconsistent or lacked guidance for staff.

People were protected from potential abuse because staff understood how to recognise signs of abuse and knew who to report it to. There were recruitment procedures in place. However, these had not always been followed when staff were recruited. Staff had not always received supervision and training to be able to meet people’s needs and wishes.

The management were striving to make improvements when shortfalls were found in their auditing systems. There was external scrutiny provided by the provider and when additional bodies found concerns this had led to improvements. However, statutory notifications were not completed in line with legislation to inform external agencies of significant events.

People and relatives continued to tell us they liked living at the home. People were being encouraged to provide feedback on the home and make suggestions to improve the service they received. Their complaints were listened to and action taken when it was required.

People were supported to have choice and control over their lives and staff supported them in the least restrictive way possible. However, records did not reflect the processes which had been followed to ensure it was in line with current statutory guidance.

Most people enjoyed the food they were served at the home. People told us their healthcare needs were met and staff supported them to see other health professionals. However, there were occasions other health professionals had not been contacted in a timely manner.

Improvements could be made because care plans did not always reflect people’s current needs and wishes. The service needed to ensure all parts of care plans were updated when there was a change in a person’s needs. Although some people had their end of life needs and wishes considered, this was not consistent.

People and their relatives told us, and we observed, that staff were kind and patient. People’s privacy and dignity was respected by staff. People, or their representatives, were involved in decisions about the care and support they received. The staff tried to ensure care and support was personalised to each person which ensured they could make choices about their day to day lives. People were consul

The Wells Nursing Home is registered to provide care for up to 40 people. The home specialises in the care of older people with nursing and personal care needs. There were 35 people living at the home when we inspected.

A registered manager was responsible for the home. 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.

This inspection took place on 16 and 17 May 2016 and was unannounced.

At the last inspection on 29 April and 1 May 2015 we found the provider to be in breach of Regulations 9 and 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s care and treatment did not always meet their current or changing needs and people could not be assured that care and treatment would be provided with the consent of the relevant person. We also found improvements were needed in how mealtimes were organised. At this latest inspection we found the necessary improvements had been made.

Staffing levels were good and people also received good support from health and social care professionals. People's medicines were managed safely. Staff had built trusting relationships with people. People were happy with the care they received. One person said “They look after me wonderfully.”

Staff understood people's needs and provided the care and support they needed. People said the home was a safe place. One person said “Safe? One hundred percent. No faults whatsoever.” There were organised activities and trips out; people were able to choose to socialise or spend time alone.

People interacted well with staff. There was a relaxed, homely atmosphere. There was laughter, chatter and friendly banter. People made choices about their day to day lives. They were part of their community and were encouraged to be as independent as they could be.

People, and those close to them, were involved in planning and reviewing their care and support. There was good communication with people's relatives. One visitor said “I’m always phoned by staff to advise of changes to” their relative’s condition. People’s friends and relations visited regularly and felt their views were listened to and acted on.

Staff recruitment was safely managed. Staff were well supported and well trained. Staff spoke highly of the care they were able to provide to people. One staff member said “We do absolutely the best we can for people. I think you have to aim for perfect but know there is always room for improvement.”

People liked and trusted the registered manager. All staff worked hard to provide the best level of care possible to people. The aims of the service were well defined and adopted by the staff team.

There were systems in place to share information and seek people's views about their care and the running of the home. There were many positive comments from people about the service overall. These included “I’m very happy here; I could not have chosen a better place.”

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:

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

This is a summary of what we found:

Is the service caring?

Our observations of the care provided by staff and our discussions with people who lived in the home showed the service was caring.

We observed staff treated each individual with dignity and respect. They spoke to people in a caring, polite and friendly manner. One person said “I like it here very much. Everyone is so nice”. Another person said “They do everything they can to make you happy”.

People who lived in the home were complimentary about the staff. One person said “The staff are very good. They do their best to take care of us”. Another person said “The staff are lovely and kind. I’m looked after very well thank you”.

Is the service responsive?

The service was responsive to people’s preferences and choices. People told us they were asked about their likes and dislikes prior to moving to the home. We saw care plans detailed people’s preferences regarding personal care routines, food, hobbies and interests.

One person said “I’ve got everything here I want. If I need anything I just have to ask”. Another person said “The food is lovely and we always get a choice”. A third person said “It’s a wonderful place here, I’m very happy”.

We observed people could decide where and how they spent their time. They were free to move around the home and the scenic gardens as they wanted. One person said “I go for walks in the garden most days” another person with mobility difficulties said “Staff will push me outside if it’s a fine day”. People told us they could decide to have their meals in their rooms, in the dining room or on a tray in the TV lounge.

People were able to express their views at quarterly 'Residents and Relatives meetings’. Records of the meetings showed they were well attended by people and their friends or relatives. We saw a wide range of topics were covered and ideas for improving the quality of people’s experiences in the home were taken on board.

An annual customer care questionnaire was sent to people and their relatives. We looked at a sample of the returned questionnaires and they predominantly showed people were ‘very satisfied’ with all aspects of the service.

Is the service safe?

People who lived in the home told us they felt safe and they were well treated by staff. When asked if they had ever been treated badly or witnessed anyone else being treated badly, one person said “Not at all, they are all extremely nice and willing to help you. Matron wouldn’t stand for anything like that”. Another person said “The staff treat me very well. They are all very nice. If I didn’t like anything I would tell the matron but I haven’t had any problems”.

We spoke with the manager (also known as matron) and six other members of staff. They all knew about the different forms of abuse, how to recognise the signs of abuse and how to report any concerns.

The manager told us they always carried out relevant employment and criminal record checks when new staff were recruited. This helped protect people from the risk of abuse.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people’s freedom and human rights. The manager said they had not needed to submit a Deprivation of Liberty Safeguards application to-date. However, the manager was aware when an application should be made and knew who to go to if an application was required.

There were arrangements in place to deal with foreseeable emergencies such as utility failures. People had individual evacuation plans to follow in the event of a fire. Staff received fire safety and first aid training. They knew to call the emergency services or the GP practice if they had any worries.

Environmental risk assessments were in place for fire safety, buildings and equipment. These were carried out by the home’s maintenance staff or specialist external contractors as appropriate. We observed the environment throughout the home looked in good condition.

Is the service effective?

The service was effective in meeting people’s care and treatment needs. People told us they were very happy with the care and treatment they received. One person said “I’m very well. I’m happy with the care I’ve had up to now”. Another person said “It’s lovely here, we’re well looked after”.

We observed people had call bells in their rooms to call for staff assistance whenever needed. People said they did not have to wait long for assistance. One person said “They don’t take very long to come, usually a few minutes”.

We saw care plans included a range of individual risk assessments and actions for managing these risks. These included assessment of people's risk of developing pressure ulcers, risk of malnutrition and risk of falls. The GP or a dietician was consulted if there were any concerns. The nurses who worked in the home said external advice was available whenever needed from specialist health care professionals.

Staff told us they were provided with the skills and knowledge to provide a safe and appropriate standard of care. We saw training and development records to confirm this.

People were supported to engage in social activities and interests. They went out for trips to places of interest with their family members or with support from the staff. Within the home people could participate in group activities like singing, films and reminiscence sessions. Staff regularly organised afternoon teas in the home’s scenic gardens.

Individual activities such as aromatherapy and hand massage were offered to people who were being nursed in bed. The activities organiser said they spent as much one to one time as they could with people who were restricted to their rooms.

Is the service well led?

People who lived in the home and the staff we spoke with all said the manager of the home was very good.

The home was managed by a person who was registered with the Care Quality Commission as the registered manager for the service. People who lived in the home told us they could talk to the manager (also known as matron) or the other staff about any issues and they always did their best to meet their needs. A typical comment was “I can have a chat with matron anytime, she is lovely. She always sorts things out”.

Staff told us the manager was very fair and approachable. One member of staff said “If you have any problems or concerns you can discuss them with matron. She is very approachable and always gives good advice and support”. Another staff member said “Matron is very fair and is good at resolving any disputes”. One of the nurses said “The manager is in uniform for some shifts. She has her finger on the pulse and keeps a close eye on the care provided. When needed she reminds staff what is expected”.

Decisions about people’s care and treatment were made by the appropriate staff at the appropriate level. There was a clear staffing structure in place with clear lines of reporting and accountability. The manager supervised the nurses and the nurses supervised the care staff. Care staff we spoke with said everyone worked well together as a team and supported each other. They were able to seek advice from the nurses and report issues directly to the manager whenever needed.

The manager told us they received excellent support from both the owner and the area support manager. The manager said “The owner is brilliant. She visits most weeks and wants high end care provision for the residents”.

People were not protected against the risk of unlawful or excessive control or restraint. Care plans and risk assessments were not in place to support the use of any form of restraint. Staff had not been trained in how to support people who displayed difficult or aggressive behaviour or how to use restraint in a planned, safe and effective way.

People could be confident that deaths of people who used the service were reported to the Care Quality Commission so that, where needed, action could be taken.

People were encouraged and supported to make decisions about their care and how they spent their time. There were a range of activities provided for people who lived in the home. One person said "I have my own routine really and they respect that. I like to stay up late and lie in a little in the mornings. I always have. It’s no problem here."

People said they were very well cared for and that staff were available when they needed them. They said staff were very patient and were kind to them. Comments from people included “I would say it’s first class here”, “The staff here are very kind. They do as much for me as they can” and “It’s a lovely home. We are so well looked after.”

People told us they felt safe and were well treated by staff. They said they were very happy with the home and had never had cause to complain. Staff spoken with knew how to recognise signs of abuse and how to report any concerns.

There were safe and effective recruitment and selection processes in place. Appropriate checks were undertaken before staff began work which ensured people were protected from the risk of being cared for by unsuitable staff.

Staff said they felt competent, trained and well supported to carry out their roles. Staff training and supervision had improved since our last inspection.

People could not be confident that deaths of people who used the service were reported to the Care Quality Commission so that, where needed, action could be taken.

There were 39 people living at the home at the time of our inspection. We spoke to six people and two relatives to get their views on the care provided.

Everyone we spoke to was complimentary about the home. One person told us "I was dreading coming here and now I wouldn't want to be anywhere else...I feel lucky to find a home a like this". Another person told us "I'm very happy here".

People told us staff asked their permission when caring for them. One relative told us how staff communicated with the person to ensure they had their consent "if (person) indicates they understand. I think staff understand because they've had more experience".

We observed care being delivered in line with people's individual care plans and staff monitored people's health. One relative told us "(person) had problems swallowing, now they have a new diet".

People told us they always got their medicines on time and we observed staff administering medicines competently and safely.

People told us staff were "caring", "good at their jobs" and "friendly". Staff did not receive regular supervision or appraisals to ensure their personal development and we could not be assured that staff had completed mandatory training in line with the home's protocol.

People told us they had "no complaints" but were aware of how to raise concerns. One person told us "I wouldn't change a thing...I can't find one thing to complain about...I can talk to matron about anything".

We spoke with several people who lived in the home who told us that staff provided the care and support they needed. They said staff were very patient and were kind to them. One person told us “they are very kind and patient. They stick to a regular routine with me and that’s what I want”. Another person told us they chose how their care was provided by staff and that they were able to do some things for themselves and staff respected that. “I have a routine which I have got into and I like it. It’s my choice entirely”.

Some people we spoke with told us they chose to live in this particular home; two people told us they had moved from other homes and were much happier living here. One person said “I had always heard such good things about this home so I asked if I could come here and luckily they had a room. I’ve been here over three years and I’m very happy to be here”.

We observed how staff interacted with people who lived in the home and all of the interactions we saw were kind and respectful. One person we spoke with said “There is no comparison with the other home I lived in. This home should be five stars; I wouldn’t want to live anywhere else. The staff are lovely, I like them all, they are very caring”.

People who lived in the home told us they felt well cared for and that staff were available when they needed them. When we asked people if staff helped them to do the things they needed help with, people said that they did. Comments from people included “the care is excellent, nothing is too much trouble”, “if I was living in my own home, I couldn’t be any better off” and “all the staff do very well and work very hard. They come in to care for me at regular intervals”.

All of the relatives we spoke with were very happy with the care that staff provided. One relative said “the staff always seem very kind and helpful. [My relative] always seems very well cared for. The home is spotless and [my relative] is very particular about this”.

People told us they liked the food served in the home and that they always had a choice of meals and snacks. One person said “the food is very good; it’s all home cooked. You have choices and there is a wide variety of meals”. One person we spoke with needed a soft diet and they told us “my meals are always prepared like this. I like to eat my meals in my own room; it’s my choice”.

People we spoke with said they thought the home was a safe place for them to live. One person said “yes I do feel safe living here. The staff work so hard, they are on day and night”. Relatives also told us they thought people were safe living at the home; one relative told us “it is a safe place” for their relative to live in.

People who lived in the home said staff were available when they needed them. One person said "there are always enough staff around to help you". People had a call bell which they could use when they needed help. We saw that when people used these they were answered quickly. One person said “if you ring the bell they always come quickly, you don’t have to wait”.

People spoken with during our visit were positive about the staff team. One person told us "all the staff are wonderful, they are very kind to me. They do everything they can for you. I’m very happy here".

The Wells Nursing Home is registered to provide care for up to 40 people. The home specialises in the care of older people with nursing and personal care needs. Accommodation is arranged over two floors. There is a registered manager who is responsible for the home. 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.

This inspection took place on 29 April and 1 May 2015 and was unannounced.

On both days of the inspection there was a homely atmosphere and we saw staff interacted with people in a friendly and caring way.

People said the home was a safe place for them to live. One person said “Yes I do feel safe here. There are always staff around.” Staff had received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff spoken with were confident any allegations made would be fully investigated to ensure people were protected.

People said they would not hesitate in speaking with staff if they had any concerns. People knew how to make a formal complaint if they needed to. One relative said “All the family who visit would be quite happy to make a complaint or raise a concern.”

Although people and their visitors made very positive comments about the care provided by staff, we saw that care was often based around completing tasks. There appeared limited opportunities for staff to spend quality time with people.

People were involved in planning and reviewing their care. Some people’s care plans did not accurately reflect their care needs. When people were unable to make all of their own decisions they could not be assured that care and treatment was always provided with the consent of a relevant person. Mealtimes needed better organisation. We recommend that the provider explores the relevant guidance on how to provide a good mealtime experience for people for people who live in a residential or nursing environment.

There were regular reviews of people’s health. People were assisted to attend appointments with appropriate health and social care professionals to ensure they received treatment and support for their specific needs.

Staff had good knowledge of people including their needs and preferences. Staff were well trained and supervised; there were good opportunities for on-going training and for obtaining additional qualifications. One staff member said “I am satisfied with the training. I have a feeling of progression here.”

People’s privacy was respected. Staff ensured people kept in touch with family and friends. Staff at the home had been able to build links with the local community.

There were quality assurance systems in place, although these were not fully effective. The management structure in the home provided clear lines of responsibility and accountability. The management team provided leadership and good support for the staff team.

People’s views were acted upon. In addition to the resident’s and relative’s meetings, the service used feedback forms, annual satisfaction surveys and reviewed complaints and compliments to continually develop the service.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.