About the service: Twin Oaks Nursing Home is a residential care home that provides nursing care and accommodation for up to 49 people. At the time of our inspection, 46 people were using the service.

People’s experience of using this service: There was enough staff on duty to enable people to remain safe and receive care in a timely way. The environment was safe and people had access to appropriate equipment where needed. People were supported to take their medicines in a safe way.

Staff were knowledgeable, they received good training and supervision to ensure they could carry out their roles effectively.

People and relatives told us that the service was caring and well led. Staff were kind, caring and promoted people’s dignity. Staff understood the importance of treating people with respect and ensured they did this. People were observed to have good relationships with the staff team. Staff actively ensured people maintained links with their friends and family.

The registered manager provided staff with leadership and was visible and approachable. Staff were motivated and enjoyed strong team work. Information from audits, incidents and quality checks was used to drive continuous improvements to the service people received.

Rating at last inspection: Good (Published July 2016)

Why we inspected: This was a scheduled inspection based on our previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

The Twin Oaks Nursing Home provides accommodation, personal care and nursing care for up to 49 older people including those living with dementia. Accommodation is located over four floors. There were 47 people living in the home when we visited.

This inspection was unannounced and took place on 9 June 2016.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff had received training and had an understanding to ensure that where people lacked the capacity to make decisions they were supported to make decisions that were in their best interests. People were only deprived of their liberty when this was lawful.

The provider had a robust recruitment process in place and staff were only employed within the home after all essential safety checks had been satisfactorily completed.

Staffing numbers were adequate to ensure people’s care needs were met.

Care plans whilst they did not always provide detailed information on how people’s care needs were to be met this had been identified through their quality monitoring system .Although staff were aware of people’s needs.

People’s privacy and dignity were respected at all times. Staff sought, and obtained, permission before entering people’s rooms to provide personal care.

People’s health, care and nutritional needs were effectively met. People were provided with a varied, balanced diet and staff were aware of people’s dietary needs. Staff referred people appropriately to healthcare professionals when this was needed. People received their prescribed medicines and medicines were stored in a safe way.

Wherever possible people or their families were involved in the planning of the care people received.

The provider had an effective complaints process in place which was accessible to people, relatives and others who used or visited the service.

The provider had effective quality assurance systems in place to identify areas for improvement and appropriate action to address any identified concerns. Audits, completed by the provider and registered manager, showed the subsequent actions taken, which helped to drive improvements in the home.

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with five people who used the service, the providers, three members of staff and a visiting GP. We also reviewed records relating to the management of the home which included, six care plans, daily care records, training records, support/supervision records of staff, quality surveys and audits.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

Is the service safe?

During our inspection we spoke with five people who used the service. They told us that they were happy with the care and support provided. One person told us that, "I feel very safe and secure here knowing I will be well looked after and all my (health) problems taken care of." Another person said, "I feel very safe, I trust all of the staff."

We looked at six sets of care records which included individual risk assessments. Measures had been put in place to minimise any risks to people who used the service that ensured they were supported safely. For example, risk assessments were in place to ensure that the environment in which care was provided was safe, that medication was safely administered and that people who needed to be moved with a hoist were transferred safely.

Risks to people’s health and well-being through malnutrition, falls or pressure ulcers were assessed and minimised.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. While no applications had needed to be submitted, policies and procedures were in place and under review. Relevant staff had been trained to understand when an application might be necessary and how to submit one.

We discussed staffing rotas which showed that there were sufficient numbers of trained and competent members of staff employed to provide people with safe and appropriate care as identified in their assessment and care plans.

Is the service effective?

People who used the service were treated with dignity and respect.

People who used the service were supported in making choices. For example, what to wear or what main meal they preferred. One person we spoke with said, "The food is great, but if you don't like what is on offer, they will always offer you something that is not on the menu." Where people found it difficult to make choices for themselves, staff supported them in making decisions based on ‘best interest’ principles. We spoke with five people who used the service. Four of the people we spoke with told us that staff discussed their care plans with them, two others were unsure.

Quality assurance measures were in place to identify the effectiveness of the service. This included questionnaires given to people who used the service, relatives and staff. We saw the results of a recent quality survey which showed that people who used the service and their relatives thought the service was effective.

Is the service caring?

We saw that people were cared for in an appropriate manner. Records we looked at showed that people’s needs had been assessed and details of likes, dislikes, routines and preferences were recorded.

During our inspection we spoke with five people who used the service. People we spoke with who used the service were happy with the care and treatment they received. One person said to us, "It's marvellous here, I couldn't wish for any better." Another person said, "They look after me really well." A third person we spoke with said, "They know about me and they know about my problems. They asked me all about this when I moved here."

We looked at six sets of people’s care records. These detailed their care and treatment.

Is the service responsive?

The six care records we looked at showed that people's needs, choices and personal preferences had been assessed and planned for. Records we looked at during our inspection detailed the needs of each person and their individuality.

People’s health and social care needs were attended to. Information was available to staff about individual medical conditions to ensure that staff had up to date knowledge and were able to respond to the person’s needs.

Is the service well-led?

There were monitoring and reviewing systems in place to ensure that the quality of the care and support provided was high. We spoke with three members of staff who told us that they had the training and support they needed to safely do their job, which they said they enjoyed.

Members of staff and family members of people, who used the service, were provided with opportunities to make suggestions and comments to improve the quality of people’s support and care. These were developed into an action plan which identified the improvements made and ensured that the service was able to confirm when required improvements were completed.

Records we looked at showed that staff received regular support and supervision. This included an annual appraisal and three monthly spot checks to assess them in a practical setting whilst with people who used the service.

The providers managed the service themselves and spoke to people who used the service every day. This ensured that they were immediately aware where there were concerns and acted to address those concerns. Accidents and incidents were analysed to establish where measures could be put in place to prevent similar things occurring or to identify patterns. Where necessary support was provided by other health professionals and training

On 23 May 2013 we visited Twin Oaks to check whether improvements had been made as a result of our previous inspection on 03 and 07 January 2013. We found that improvements had been made.

We spoke to three people living at Twin Oaks. They told us that the care they received was good. One person told us “There is no place like this, the care is so good.” Another said “The carers are good, they know me.” The visitor told us that they came to see their friend weekly and had done so for some time. Their opinion was that the staff were friendly and competent and that their friend was well cared for.

We found that care plans and assessments were reviewed monthly. A new system for recording personal care had been put in place. Regular audits had been instigated to ensure that people's records were reviewed monthly and delivery of their personal care was being recorded consistently.

Food and fluid charts had also been reviewed and their use was being audited. Summary records were available for staff to show whether people required support with their food and fluid intake and what support was required. We found that people were being supported in accordance with this.

We reviewed staffing levels over the previous 28 days and found that sufficient staff had been available to care and support the people living at Twin Oaks.

All the people we spoke with said they liked living at this home. One person said, “I wouldn’t want to be anywhere else.” Another person said it was ’a great place to be.’

People said the food was good and that they could eat their meals where they liked. One person described the size of the meals as, “Very generous.” Another person said they liked pancakes and the chef was always happy to make them some on request.

People spoke very highly of the staff. One person said they were “Lovely.” Another person spoke of them and said, “Every one of them is kind and lovely.”

People we spoke with when we visited the service told us that their basic needs were being met, they felt well cared for and that staff were kind and caring in their approach. People said the food was good and they were always offered a varied choice of food at each mealtime.

When we talked to people about the staffing levels in the home they told us that at times there were not enough staff on duty, especially at weekends, to provide the care at times of their choice and when they needed a prompt response.

In November 2010 we received a copy of a letter of complaint made to the registered provider on the 20 September 2010 by a relative of a person using the service. The complainant expressed concerns that the service had not met the health, care and nutritional needs of their relative. They described some experiences their relative had encountered during their stay that suggested staff did not have sufficient knowledge of the person’s health and care needs to deliver appropriate care. They also stated that at times when they visited they were unable to find a member of staff to talk to. On another occasion when they visited the service in the evening, they found only one member of staff on duty.

We saw staff communicating with people in a warm and friendly manner. People living in the home remarked on how kind the staff were, one person said, “All the staff are lovely. They smile and do anything for you”.

People’s needs were assessed and described in their individual care plans. People using the service had been involved in the planning of their care. However the planned care, treatment and support was not always given in a timely manner. There was not always consistency in people’s documentation and we saw examples where the care records did not include enough up-to-date information about how people’s needs were being met.

There were choices from the menu at mealtimes and most people said they enjoyed the food. Nutritional assessments had been done but there was not always accurate and detailed information to show that people’s nutritional needs had been met.

We saw that the premises and environment were safe and clean. We observed health and safety information, and the staff we spoke with could explain how to reduce the risk of infection.

Although most people said they were happy in the home, the service had problems in ensuring adequate numbers of staff. At times, this meant that staffing levels were lower than required by the needs of people using the home.

This home had various methods that were used to assess the quality of the care given. Meetings, reviews and senior management audits were in place.