About the service: Waltham Hall Nursing and Residential Home is a care home providing personal and nursing care and accommodation for up to 81 people, some of whom have dementia. There were 52 people living at the service at the time of our inspection.

People’s experience of using this service:

•People felt safe living at Waltham Hall Residential and Nursing Home and with the staff team who supported them. The staff team were aware of their responsibilities for keeping people safe from abuse and avoidable harm.

•Risks associated with people’s care and support had been assessed, managed and regularly monitored. Checks had been carried out on the environment and equipment to ensure it was safe and fit for purpose.

•People felt that, overall, there were enough staff on duty to meet their care and support needs. However, people told us they sometimes had to wait for their call bell to be answered. The matron acknowledged this but was confident a new way of working would address this.

•People using the service were involved in the recruitment of new staff to ensure they were suitable to work there. The staff team received the training they required to meet people’s care and support needs.

•People received their medicines in a safe way.

•People were provided with a clean and comfortable place to live and there were appropriate spaces to enable people to either spend time on their own, or with others.

•People were supported to access healthcare services when they needed them and they were supported to eat and drink well. Food and fluids records had not always been completed accurately or totalled to show the recommended fluid levels had been met.

•People had plans of care in place and whilst some were more comprehensive than others, the staff team knew the people they were supporting well.

•People were supported to have the maximum choice and control of their lives and staff supported them in the least restrictive way possible; the polices and systems in the service supported this practice.

•People were involved in making decisions about their care and support whenever possible and their consent was always obtained.

•The matron ensured information was provided to people in a way they found accessible.

•People were treated in a kind way and their privacy and dignity were maintained and respected.

•Lessons were learned when things went wrong to improve the service provided.

•People’s personal preferences within daily living had been identified and they were supported to attend activities they enjoyed.

•People were involved in how the service was run through meetings, the use of surveys and day to day conversations with the matron and the staff team.

•People were supported with compassion and kindness at the end of their life.

•Systems were in place to monitor the quality and safety of the service being provided. A complaints process was in place and people knew who to talk to if they had a concern.

•The matron worked in partnership with others to ensure people received the safe care and support they required.

More information is in the detailed findings below.

Rating at last inspection: Good (report published 7 September 2016) all the key questions were rated Good and the service was rated as Good overall.

Rating at this inspection: The rating for this service has not changed and the service remains Good.

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our re-inspection schedule for those services rated Good.

The inspection site visit place on 1 August 2016. Our visit was unannounced. At our previous inspection which took place on 23 January 2015 and 3 February 2015 we found the provider was meeting the requirements of regulations but we identified improvements that were required to make people using the service safer. At this inspection we found that improvements had been made.

Waltham Hall Nursing & Residential Home is registered to provide care and support for up to 81 older adults with a variety of needs. The home has two floors with a number of communal areas and extensive gardens available for people to use. At the time of our inspection 56 people were using the service.

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 using the service told us they felt safe. Relatives we spoke with confirmed this. Staff understood their responsibilities to keep people safe from abuse and avoidable harm. No person we spoke with felt there were not enough staff to meet their needs. Some said that when staff were particularly busy they sometimes waited longer for support. Staff told us they felt enough staff were on duty. The provider had introduced a system for determining safe staffing levels since our last inspection.

Risks to people’s health and well-being were identified and plans were in place to manage those risks.

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 to be able to support people using the service. Staff were supported through supervision, training and appraisal. Nursing staff had support for their continuing professional development.

Medicines were safely stored and administered and people received their regular medicines as prescribed.

Management and staff were aware of their responsibilities under the Mental Capacity Act 2005. Staff obtained people’s consent before they provided personal care and support. Where people lacked mental capacity decisions were taken in their best interests and in line with the Deprivation of Liberty Safeguards.

People with capacity to be involved in the planning and delivery of their care and support had opportunities to be involved. Where people lacked capacity, their relatives were involved. People were treated with kindness and respect. We saw a single instance of a person being left to wait for nearly two hours outside the home’s hair dressing salon, though this did not cause the person discomfort.

People were well supported by a staff team that understood their individual needs. Their privacy was respected, although we found that the volume of the call alarm system was very high and could have an intrusive impact on people whose rooms were close to the `speakers’. A staff tannoy system was also potentially intrusive. The registered manager had already raised these issues with the provider.

People’s nutritional and dietary requirements had been assessed and a nutritionally balanced diet was provided. People had choices of meals though the registered manager was looking into providing people a wider choice.

People were supported with their health needs. They were supported to access healthcare services when they needed them. The service worked closed with health care professionals who visited the service.

People’s individual and specific needs were assessed and plans were in place to meet their needs. People knew how they could raise concerns and they were confident they would be listened to. People’s complaints and issues of concern had been responded to promptly and appropriately.

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As part of this inspection we spoke with ten people who used the service, four people’s relatives, six care assistants, two nurses and the registered manager. We were accompanied by an expert by experience to help us understand the experiences of people who used the service.

We looked at a number of records including people’s personal records, staff records and records in relation to the management of the service. This is a summary of what we found and more detailed evidence can be found in the full report.

Is the service safe?

The majority of people we spoke with told us they were listened to, treated with respect and felt their care needs were being met. People had not always been asked for their consent regarding the care and treatment that was being delivered.

There was a good understanding of the Deprivation of Liberty Safeguards (DoLS). Although nobody using the service was under a DoLS authorisation at the time of our inspection we found they had been used appropriately in the past. There was a reasonable understanding of the Mental Capacity Act (MCA), however, the implementation of the MCA was inconsistent and confusing. This meant that where people lacked the capacity to consent their legal rights may not have been upheld.

As part of our inspection we looked at a number of people’s individual risk assessments. We found that risk assessments recorded the potential risks to people and any action that should be taken to minimise the risk. Risk assessments had been regularly reviewed and updated to take into account people’s changing needs.

Is the service effective?

We spoke with people who used the service and the majority were satisfied with the delivery of their care. One person told us “The staff are really lovely, they can’t do enough for you”. We told the manager about any concerns that had been raised and they agreed to investigate these issues.

People’s needs had been comprehensively assessed and care plans were up to date and contained accurate information. However, care plans did not contain sufficient information about how staff should meet people’s needs to ensure their safety and welfare. This meant that people may have been at risk of receiving care that was inappropriate or unsafe.

People were supported to maintain good health by on-going monitoring and referral to appropriate health professionals when necessary but monitoring charts had not always been completed consistently or reviewed. This meant that changes to people’s well-being may not have been identified.

Staff had a good understanding of the needs of people who used the service.

Is the service caring?

People were supported by kind and attentive staff. Staff showed consideration for people’s individual needs and people who used the service were very complimentary about the staff team describing them as hardworking and friendly. Some staff were more skilled than others at interacting with people and others were more task focused in their approach. During lunch time observations we noted that staff were patient and attentive when supporting people with their meal.

However, some practices at the home did not always promote people’s dignity. For example, in both of the homes dining rooms we found there was a noticeboard entitled 'feeds'. The names of people who required support from staff at mealtimes were then written below this.

Is the service responsive?

Consideration had been given to supporting people to engage in activities but some people and their relatives felt activities could occur more often and be more varied.

Care plans did not always record people’s preferences, choices and wishes in how they would like their care and support to be delivered but most relatives felt involved in what was happening at the service. The service gathered people’s views in a number of ways including questionnaires and residents meetings but it was not always evident what action was being taken as a result.

The service had an appropriate complaints policy and responded to concerns and complaints effectively.

Is the service well-led?

Most people we spoke with felt the manager and staff team were approachable and they were able to speak to them about any problems or concerns.

Many people, their relatives and the staff team told us that staffing levels were inconsistent and that people sometimes had to wait for their care. One person said “It is busy in the morning obviously as everyone wants to get up, but the girls do their best”. We observed that call bells were ringing constantly in the morning of our inspection and staff were not always able to respond to people promptly because they were supporting other people. On several occasions we had to find a staff member to assist someone as they were calling for help and had not been heard. The service did not have an effective system in place for deciding how many staff were required in order to meet the needs of people using the service at all times.

There was a system in place to monitor the quality of service being received which included audits and checks. However, implementation of this was inconsistent and ineffective. This meant that the risks associated with the delivery of care may not have always been monitored and responded to.

During our inspection we met a number of people using the service at Waltham Hall and spoke in detail with eight of them and with four relatives who were visiting the home. People we spoke with were satisfied with the care and support they received at Waltham Hall. One person told us, “The staff cannot be faulted. They are brilliant.” Another commented, “The staff are very good, they have a laugh with me and I like that.”

Nutritional assessments had been completed for each person using the service which had taken their weight and health into account. These assessments had been reviewed on a regular basis and used to identify any specific needs people had.

People also told us that they were satisfied with the cleanliness of the building and with the facilities available to them. All bedrooms were single occupancy with en suite toilets, washbasins and, in some cases, showers.

Staff we spoke with told us that they received good support from senior staff and colleagues.

People’s confidentiality and privacy was taken into account when records were completed. Staff were careful with confidential information and understood the importance of ensuring that people’s privacy was protected.

During our inspection we spoke with six of the people who used the service and with four groups of relatives who were visiting their family members at the time of our inspection.

People told us they were satisfied that the care and support that was provided and felt it met people’s needs and took their preferences into account. Their comments included;

“I told the staff I like to get up early so they changed things. Now they bring me a cup of tea and breakfast to my room nice and early.”

“The kitchen staff know what I like and don’t like, so they sort my meals out for me.”

“It is very good here.”

“I am OK, I am being well looked after.”

“It could not be any better. They have looked after her very well and I haven’t had to worry about her.”

An unannounced inspection took place on 23 January 2015 and we returned on 3 February 2015 in order to complete our inspection. Our previous inspection of 14 May 2014 found the provider was not meeting four regulations at that time. These were in relation to consent to care and treatment, care and welfare, staffing 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.

Waltham Hall Nursing & Residential Home provides care and support for up to 80 older adults with a variety of needs. The home has two floors with a number of communal areas and extensive gardens 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 needs were being met. People were treated with kindness and respect and felt safe using the service. Relatives we spoke with confirmed this. People felt involved in the planning and delivery of their care and had opportunities to be involved in the development of the service.

We saw that people were well supported by a staff team that understood their individual needs. We observed that staff were friendly, kind and treated people with respect although the intrusive impact of the homes’ tannoy system on the people living there had not been properly considered. Staff we spoke with had a good understanding of people’s needs and felt valued.

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 but there was no formal system to determine how many staff were required to ensure people’s individual needs were being met.

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.

The requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards 2008 had been met and improvements made in this area.

Medicines were safely stored and administered and people received their regular medicines as prescribed. However, there may have been inconsistency with the administration of medicines that were given ‘when required’.

Improvements had been made in the planning and delivery of people’s care and people had received the care the 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. People were supported to access healthcare professionals whenever they needed to. 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. However, the call bell system was often reported as broken and we were concerned that people may not have always been able to call for help when required.

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.