About the service: Warmley Nursing Home is registered to provide personal and nursing care for up to 58 people. Some people may have a diagnosis of dementia. At the time of the inspection there were 31 people living in the home. The home was divided into three areas to support people with dementia, nursing needs and residential.

What life is like for people using this service: Throughout the inspection we received mixed views from people and relatives about the service. Care was described by one person as ‘mediocre’ and this reflected our findings. There was a sense of frustration from relatives because things had been slow to improve.

¿ Although there had been improvements in managing medicines since the last inspection, further improvements were required.

¿ Staffing levels were not adequate at the last inspection. We received mixed views about staffing levels at this inspection. Frustrations about staffing levels could not be judged on the numbers of staff alone. We had to consider other reasons why people and relatives might feel there were not enough staff. This included the lack of overall leadership, how each shift was led and the lack of cohesion amongst the whole staff team. We have asked that the provider continues to monitor this closely and to seek the views of everyone who uses the service as part of their ongoing quality monitoring.

¿ It was recommended that supervision for staff was reviewed, so that it was more meaningful and effective.

¿ Although improvements had been made to record and monitor fluid intake, there was a failure to ensure adequate nutrition that respected personal choices. The way in which people received their meals was not acceptable.

¿ The adaptation and design of the dementia unit required improvement.

¿ Although the home was clean, there was an unpleasant, stale odour in some bedrooms which needed to be addressed.

¿ People did not always receive care that was respectful or dignified. Person centred care and choice was not always promoted or supported. Care delivery had become task orientated at times particularly around personal care and at mealtimes.

¿ Complaints were not always managed well so that people felt they were listened to.

¿ Systems to monitor and audit the service was not effective and had not identified the improvements that were required.

¿ The service had not been consistently well led which had attributed to the failure to improve the service.

¿ The provider had continued to fail to identify or act to mitigate the risks to people of receiving care that was not consistently safe and of a high quality.

Rating at last inspection: Requires Improvement. (Report published January 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. We saw small improvements had been made since our last inspection. However, we found further improvements were still required and this meant the rating remained as Requires Improvement. This is the fourth consecutive time this service has been rated Requires Improvement.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure the provider improves the rating of the service to at least Good. We will revisit the service in the future to check if improvements had been made.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on 20 and 21 December 2017 and was unannounced. The last Care Quality Commission (CQC) comprehensive inspection of the service was carried out in December 2016.

Warmley House Care Home is registered to provide accommodation and nursing or personal care for up to 56 older people, including people living with dementia. There were 49 people when we inspected the service.

The home is divided into three separate units. The three units are known as the Coach House, the Nursing Unit and Sunflower. The Coach House provides mainly residential care for people who do not require on-going nursing input. The communal living area of this unit is on the ground floor with some bedrooms at ground floor level and others on the first floor. Sunflower is home to people living with dementia and is on the top floor of the home. The Nursing Unit is spread over two floors.

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 2008 and associated Regulations about how the service is run. After having been the acting manager in the home since 22 November 2016, the manager registered with CQC on 1 November 2017.

As a result of our last inspection we rated the service overall as requires improvement.

At this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and have again rated the service as requires improvement.

There was not always sufficient staff working to keep people safe and meet their needs. The management of medicines was not consistently safe. Individual risks to people had not always been adequately assessed with plans then put in place to keep them safe.

People were not always given choices about what they wanted to eat. Food and fluid charts were not completed thoroughly in order to ensure people received enough to eat and drink. Mealtimes did not always provide a comfortable and dignified experience for people.

People did not always receive a service that was in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Their capacity to make specific decisions had not consistently been assessed and, the provider did not have a system in place to ensure any deprivation of liberty was identified and, the correct authorisations sought.

Care plans were not person centred and did not always provide enough detail for staff on how to meet people’s needs. As a result people were at risk of their needs not being met.

Parts of the home were being redecorated when we visited. However one corridor had an offensive smell of urine which the service was planning to sort out early next year. Staff understood how to keep the risk of cross infection to a minimum. However we found several bed rail bumpers in use which were unhygienic, unsightly and disrespectful to the people who were using them.

Quality audits carried out by the registered manager and other senior staff employed by the provider had not been effective in identifying shortfalls in the safety and quality of service provided to people. This was the third consecutive inspection resulting in an overall rating of ‘requires improvement’.

Staff had been trained in safeguarding adults at risk. They understood their duty to observe and report any concerns they had about people if they thought they were at risk of abuse. Following concerns previously raised, there had been a safeguarding plan by the local authority in place. The provider had worked with the local safeguarding team to address issues and ensure people were protected.

Staff received a range of training to equip them to meet people’s needs; they also received regular supervision from senior members of staff. The provider had effective recru

Warmley House Care Home is part of the Four Seasons Brand and is situated on the outskirts of Warmley, South Gloucestershire. The home can accommodate up to 58 people who require nursing care. The service also provides care for people who have a diagnosis of dementia.

At the time of our inspection 46 people were using the service.

The service was arranged as three units. Fourteen people who required residential care were using ‘The Coach house’. Seven people living with dementia were using ‘Sunflower’. Twenty five people requiring nursing care were using ‘The Nursing Unit’.

This inspection was unannounced and took place on 20 and 21 December 2016.

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 2008 and associated Regulations about how the service is run. However the provider had placed an acting manager in the home on 22 November 2016 to cover for the absence of the registered manager. A new regional manager had also been appointed.

The provider had made a number of improvements since our last inspection in May 2016. The manager’s overall leadership and management of the service, the safe management of medicines and the use of the internal quality assurance systems had all significantly improved. These improvements now need to be sustained and built upon.

However, we identified some areas that require improvement. These were; the day-to-day leadership and oversight provided by the qualified nursing staff and senior care workers, staff training and the availability of staff at meal times, people’s individual food choices and preferences not being catered for and record keeping around food and nutrition. The provider had also not submitted sufficiently detailed and accurate notifications to CQC as required by law.

The day-to-day leadership and daily oversight provided by the qualified nursing staff and senior care workers was not effective in promoting high quality, person centred care. The newly appointed regional manager and the acting manager had brought an open, honest and transparent management style to the service. People, relatives, staff and health and social care professionals said this had been successful. However, nurses and senior care staff did not always take responsibility for ensuring this culture was reinforced.

We identified some care staff had not received the required training on moving and handling people. Training in this area ensures staff have the necessary knowledge and skills to keep people safe. When this was brought to the attention of the acting manager, they took action resulting in staff receiving this training within 48 hours of our inspection. However, the provider’s systems should have identified this training was required.

There was not always sufficient numbers of staff available to people.

People’s individual food choices and preferences were not always catered for. People’s food and fluid intake was not monitored consistently.

The acting manager and staff team understood their roles and responsibilities to keep people safe from harm. Staff knew how to raise concerns regarding people’s safety. The service complied with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People received a caring service. Staff gave people the care and attention they wanted or needed. People received care from staff who knew them well many of whom had worked at the service for a number of years. People were able to maintain contact with family and friends. People’s wishes were respected about their end of life care.

The service was responsive to people’s needs. Care plans were more person centred with greater detail recorded about people’s hobbies, interests, likes and dislikes. There were more activiti

Warmley House Care Home is part of the Four Seasons Brand and is situated on the outskirts of Warmley, South Gloucestershire. The home can accommodate up to 58 people who require nursing care. The service also provides care for people who have a diagnosis of dementia.

At the time of our inspection 57 people were using the service.

The service was arranged as three units. Seventeen people who required residential care were using ‘The Coach house’. Ten people living with dementia were using ‘Sunflower’. Thirty people requiring nursing care were using ‘The Nursing Unit’.

This inspection was unannounced and took place on 12 and 13 May 2016.

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 2008 and associated Regulations about how the service is run.

People were not kept safe from the risks involved in the management of medicines. Medicine administration records were not completed accurately, medicines were not always stored safely and guidance on the administration of medicines was not always available to staff.

The provider had not ensured there was enough staff. The provider used a staff dependency tool to calculate staffing levels. However, people and relatives said there were not enough staff and, we saw there were not enough staff to safely meet people’s needs.

People were not kept safe from the risks of infection. Staff used shared ‘slings’ to move people who required hoisting, hand washing facilities were not available in sluice rooms where commode pans were washed and, some equipment was not clean.

Risk assessments were not always in place and those that were, often lacked sufficient detail to safely provide care or, on occasions, were incorrect.

The registered manager and staff team understood their role and responsibilities to keep people safe from harm. Staff knew how to raise any concerns regarding people’s safety. Pre-employment checks were carried out on staff before they started work to assess their suitability to work with vulnerable people.

The service did not always provide effective care and support. Some staff had not received training on caring for people living with dementia. The service was adhering to the principles and requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

People seemed to enjoy the food and menus were planned in advance. People did not always have easy access to drinks. People’s food and fluid intake or their weights were not monitored effectively. Arrangements were made for people to see their GP and other healthcare professionals when they needed to do so. We have recommended the provider seeks advice on providing a suitable environment for people living with dementia.

People did not always receive a caring service. Staff did not always give people the care and attention they wanted or needed. People received care from staff who knew them well many of whom had worked at the service for a number of years. People were able to maintain contact with family and friends. People’s wishes were respected about their end of life care.

The service was not always responsive to people’s needs. Care plans were not person centred and lacked the detail required to provide consistent, high quality care and support. There were not enough activities for people. The provider investigated concerns and complaints and made changes as a result.

The service was not consistently well-led. Quality checks were in place. However, these audits had not identified shortfalls in areas such as medicines management, record keeping and the correct use of some equipment.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and

The purpose of the inspection was to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. This was a responsive inspection as we had received concerns from relatives and a social worker. This included people not being supported with having baths, lack of support at meal times, staffing levels in respect of supporting people living with dementia and answering call bells.

The inspection was conducted by three inspectors. The inspectors were accompanied by an expert by experience a person who has had experience of using services.

Warmley House was split into 3 areas, a nursing unit, a residential care area called The Coach House and Sunflower which was an area supporting ten people with dementia. Sunflower was situated on the third floor above the Coach House.

The summary is based on our observations, a review of records and discussions with 15 people who used the service, eight relatives, a regional manager, two nurses, six care staff and two domestic staff.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found not all aspects of the service were safe.

CQC have a duty to monitor the use of the Mental Capacity Act 2005, which includes the Deprivation of Liberty Safeguards (DoLS). The purpose of DoLS is to make sure that people are looked after in a way that does not inappropriately restrict their freedom. We were told that no person in the home had an authorisation under DoLS to do this. We spoke with staff about their understanding and three care staff we spoke with had no understanding about these safeguards that protect people’s human rights.

We spent time on Sunflower, where people living with dementia were supervised by staff and a key pad was place. There had been no applications in respect of these people to ensure they were not being deprived of their liberty and these restrictions on their freedom were the least restrictive. When we asked staff if people could leave the unit they told us only with staff support and often they do not have the staff to support people outside the home.

We had received concerns from relatives and the social workers. These included the home was not clean, bedding was stained and there was often an odour. We found the home was not clean and hygienic. There was an odour in some parts of the home. The staff were not following the appropriate guidance, equipment and facilities was not in place. This meant that people who used the service were not safe or protected from the risks associated with cross infection.

Staffing in the part of the home caring for people living with dementia was not sufficient to meet their needs. This was because the numbers of staff on duty had resulted in restrictions on people so that they did not get opportunities to go out of the building and their personal care needs were not being met consistently.

We were shown around the home we saw that some of the areas of the home were not safe and suitable in relation to the fixture, fittings and furniture. This was because some furniture was broken and unsafe. Light fittings in people’s bedrooms had no shades protecting them from the exposed light bulbs.

Is the service effective?

We found not all aspects of the service were effective.

When we spoke with staff they were knowledgeable about the people they cared for and their needs. The majority of the staff we spoke with told us that they tried their best but they rarely had time to spend time with people unless engaged in providing personal care or assisting with meals. One staff member told us, “It’s the attention to detail we are lacking, we only have time to provide the basics, we never seem to have time to spend quality time with people”.

Some care plans only contained brief information and guidance about the care and support people required. They did not show that people had been involved in developing their own care plans so that the staff could provide them with personalised care.

The needs of people living with dementia had not been considered with regards to their environment. There were no signs that would help people move around independently. Equipment was stored in en suites and in communal bathrooms and toilet facilities. This meant that people could not move around freely and safely.

We asked staff about how they support people with dementia with choices about activities and food. They told us “it was a waste of time as people would not remember”. This did not demonstrate that the staff had an understanding of people with dementia so that they could meet their needs and provide appropriate care. .

Is the service caring?

We spoke with fifteen people who used the service and six relatives. They were complimentary about the staff telling us they were “caring and hardworking”. However they all told us there was “either not enough staff or that staff were very busy”.

People were not treated with dignity and respect at mealtimes. We saw people with food left in their laps following mealtimes; clothes were not always protected from spillages from food and drink. People’s clothes were left soiled.

It was a warm sunny day on the day of our inspection. Three people were taken out to enjoy the gardens and the fresh air, by their visitors. We asked a member of staff on the nursing unit why people were not sat outside. They told us, “There are not enough staff to supervise people outside and inside”.

We saw some staff that were attentive to people in the home and they were caring.

Is the service responsive?

We found not all aspects of the service were responsive.

People we spoke with told us there was very little in the way of activities. One person told us “I am bored; I sleep most of the time and hardly see anyone”. This person had spent all day in their bedroom, sleeping for much of that time with no social stimulation other than when staff provided care. This meant the staff had not been responsive to this person’s needs.

We observed call bells being responded to promptly. Where we observed that people required support staff promptly attended to their needs.

There were discrepancies around recording in people’s charts staff and people using the service could not be assured that food and drink intake monitoring was accurate. This meant that staff may not be aware when people were at risk of poor nutrition and hydration and take any necessary action.

Is the service well-led?

We found not all aspects of the service were well-led.

People who used the service were not protected from the risks of inappropriate or unsafe care and treatment. This was because the systems to assess and monitor the quality of service were not effective. Risks relating to people’s welfare and safety were not assessed effectively.

Evidence of breaches in regulations identified at this inspection demonstrated that there had been a failure to identify and manage risks for people across the home.

The home’s environmental audit had failed to identify the serious concerns we found during our inspection regarding the quality and safety of the environment, including problems with the cleanliness of the home. The audits did not identify risks to people who used the service in order to keep them safe from harm.

People could not be assured that there were sufficient staff. This was because there was no management tool to determine how many staff were required to support people in the home, based on their assessed needs taking into consideration the layout of the building.

The home had a registered manager. There was leadership from the registered nurses in the area of the home where nursing care was provided, this was less apparent in the other areas of the home where the majority of the shortfalls were found.

People told us they gave consent to the support they received. There were arrangements in place for assessing people’s capacity and the outcome of assessments were documented.

We spoke with one visitor who said they felt the care home was very friendly, that their relative “always looked clean, well cared for and as comfortable as they could be”. Another visitor told us they got on well with staff and thought Warmley House was “fine”.

We met a visiting social worker. This was their second visit to the home that they described as ‘open’ as they were given the opportunity to review two people’s care records. They said the staff were friendly and helpful and that the people’s family were happy with the service.

The home provided a service for people who required nursing or personal care and there was a dedicated unit for people with a diagnosis of dementia. A range of opportunities were available for people including trips. Assessment and care plans were well documented with people involved in the process.

There were arrangements in place for the management of medicines including an assessment of the competence of staff. Medicines arrangements were monitored by the supplying pharmacist.

Staff were allocated to the nursing and residential units. The staff of the residential unit also worked in the dementia unit. One visitor told us they thought there wasn't enough staff.

There was a system in place for the handling of complaints and the procedure was displayed.

We spoke with people who lived in the home. One of them told us that the staff were very kind to them. They were satisfied with the service they redeived and were comfortable. They told us that if they had cause for concern about anything they would speak to staff. Another person described the staff as “very nice” and said they got on well with the staff. They told us they felt respected.

We spoke with four visitors. One of them told us how their relative liked living at Warmley House and said they were made to feel welcome. They described staff as compassionate towards them and had no concerns.

We spoke with seven staff. They told us they found their work “rewarding” and “enjoyed caring”. One staff member said they aimed to ‘give their best’ to the people they worked with.

People were involved in decisions about their care and asked to give information so that staff would know them better. Their care needs were assessed and plans were drawn up so that staff knew how best to support people. People were given choices about how they spent their time and types of meals.

People were protected from the risk of abuse because the home had taken steps to ensure people's safety. They were cared for by staff who were suitably trained and felt supported. There were systems in place to monitor the quality of the service provided at Warmley House.

We carried out this review to follow up on the compliance actions served after our last visit. This report should be read in conjunction with the report of November 2011.

We found that the provider had taken action to rectify the areas of non-compliance within the home. Overall we saw they had achieved compliance with the outcomes reviewed. Although we found that improvements had been made in the recording of the administration of medicines, some improvements were still needed in the recording of the application of creams and ointments prescribed by a doctor.

We did not speak with people who use the service as part of this review. However, we saw that staff treated people with respect, for example knocking on their door before entering, and that people were engaged in activities.

One person told us that they had settled well into the home, the staff were kind and supportive and the care was person centred. They said they felt safe and although they do not spend a lot of time in the communal area, staff regularly checked to make sure that they were happy or needed anything.

The people and relatives that we spoke with said "I am happy here been here a while – the staff are lovely", "My mother is well cared for – the staff keep us informed" and "I know they assist my mum as I can read the black folder it tells me what she has eaten or drunk".

The people we spoke with told us they felt safe within the home.

One person was able to look after their own medicines. Staff looked after and administered everyone else’s medicines.

One person told us they would not want to look after their own medicines and were happy with how staff looked after them. They said that staff gave them their pain relieving medicines when they needed them.

Another person said they had been too unwell to look after their own medicines but did look after and apply a prescribed cream themselves. They also told us they had asked staff to change the way another medicine was given so that directions for its safe administration were followed.

One person told us that staff always remembered to give them their medicines. But commented that the time they were given their medicines depended on the staff routines rather than their own needs.

People told us "The staff are kind they check me regularly – I rarely use my call bell but when I do they come quite quickly", "Some staff are better than others but most are good" and "Staff are lovely do not always know their names".

The relatives we spoke with told us the staff are good but they are often rushed and busy. They will answer questions and answer call bells reasonably promptly. One relative told us "We do not have concerns".

The purpose of this inspection was to follow up previous non-compliance where we identified serious failings in the home. Below is a summary of what we found. The summary is based on our observations during the inspection, seeking experience and views from people who used the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

People were protected from the risks of inadequate nutrition and dehydration. People were being supported at mealtimes so that they received sufficient amounts of food and drink.

The service was clean and hygienic. Appropriate guidance, equipment and facilities were in place for staff so that people were safe and protected from the risks associated with cross infection.

People lived in surroundings that were safe and promoted their wellbeing. Equipment provided to people was safe and properly maintained.

Additional cover was provided when there was any staff absence and new posts had been deployed to provide additional staffing. A staffing tool had been introduced to help determine safe staffing levels.

Is it effective?

Improvements had been made to ensure people received appropriate care and support by using effective systems to assess, plan, implement, monitor and evaluate people's needs.

People were involved when planning of their care. This ensured their needs were clearly identified and the support they received was personalised.

People were now being involved throughout these processes. This ensured their needs were clearly identified and the support they received was meaningful and personalised.

Additional training had been identified since the last inspection that was relevant to people's needs and to promote best practice. Training had been booked and some training had been completed.

Is the service caring?

Staff treated people kindly and they were receiving care in a way that respected their dignity and independence. People were being supported at mealtimes with patience and by staff that were sensitive to their needs.

People have benefited from care that is delivered in an individualised way that promotes their independence.

The keyworker system and "resident" allocation had increased staff awareness of individuals' needs. Staff we spoke with were knowledgeable about people's lives, their likes and dislikes.

Is it responsive?

Improvements had been made to ensure people were involved in making decisions about the care and support they received.

Additional activity hours had been deployed to cover seven days per week to help enhance people's experience.

It was evident that the home was making every effort to respond to the failings identified at the inspection of June 2014 in order to improve the quality and safety of service provided.

Is it well led?

The provider had deployed a deputy manager in order to address previous non-compliance and to help support consistency and leadership in the home.

The quality monitoring systems in place had improved and were more effective in identifying where improvements were needed.

New systems had been implemented. The registered manager had looked at ways that staff would feel valued and be able to effect positive change and equally feel supported. Nurse’s ideas and expertise were being sought through new bi-weekly meetings.