Warren Park Nursing Home is registered to provide nursing care for up to 40 people. It is situated in the Blundellsands area of Liverpool. The home has four floors with lift access to three flours and stair access to the administrative office on the fourth floor. The home is accessible to people who use a wheelchair. At the time of our inspection, there were 37 people living in the home.

At the last inspection on the 9 February 2016, the service was rated Good however we identified a breach of Regulation 12 (Safe care and treatment) due to concerns regarding the safety and storage of medication. Following the last inspection, the registered provider completed an action plan dated 15 April 2016 to tell us what they would do and by when to improve the safety of medicines. At this inspection, we found that registered provider remained in breach of Regulation 12 because medicines were not managed safely at the service and we identified a breach of Regulation 17 (Good Governance).

A registered manager was in post at the service, however, they were not present on the day of our unannounced inspection. 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. During our inspection, we were assisted by a nurse and two directors at the service. We discussed how the contingency arrangements in the registered manager’s absence could be developed to ensure records were more easily accessible by other members of the management team because we found that some records were not available during our inspection site visit.

At the last inspection on 9 February 2016, we found that the registered provider was in breach of Regulation because medicines were not stored safely and securely at all times. The registered provider assured us they would audit the storage of medication and introduce regular spot checks during the medicine rounds to ensure that they were compliant with policies and procedures. At this inspection, we found that medication was still not stored securely and the recording of medication was not always accurate. Furthermore, we identified that audit processes were not sufficiently robust to identify errors and quality assurance procedures had not picked up on the issues we identified during our inspection. The registered provider remained in breach of the Regulations.

People told us they felt safe and secure living at the service. We received positive feedback from people and their relatives regarding the atmosphere in the home. Comments included; “There’s a feeling of security. There’s a feeling of contentment and a lot of fun” and said “It’s always nice and clean and visitors are always made welcome.”

Staff were recruited safely and pre-employment checks were carried out before they started work at the organisation to ensure they were suitable to work with vulnerable people. Staff were aware of how to protect people from avoidable harm and were aware of local safeguarding procedures to ensure that any allegations of abuse were reported and referred to the appropriate authority.

Our review of staff rotas showed there were appropriate numbers of staff employed to meet people's needs in accordance with the registered manager's dependency tool. Nevertheless, we received some mixed feedback from people and their relatives regarding the staffing levels at the service. We raised this with the registered provider’s representatives at the time of our inspection who agreed to review the deployment of staff within the home.

Risks to people's health, safety and well-being were assessed and information was available to guide staff on how to mitigate risks. Support plans had been completed for everyone who was receiving care to help ensure their needs were met a

This unannounced inspection of Warren Park Nursing Home care home took place on 9 February 2016.

Situated in a residential area of Blundellsands, Liverpool, the home is registered to provide nursing care for up to 40 people with general nursing needs. The home has four floors with lift access to three flours and stair access to the administrative office on the fourth floor. There are large accessible gardens to the rear of the building and car parking to the front. The home is accessible to people with limited mobility and wheelchair users.

There were 39 people living at the home when we carried out the inspection.

A registered manager was 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 said they felt safe living at the home and were supported in a safe way by staff. Staff understood what abuse was and the action they should take to ensure actual or potential abuse was reported. Staff understood and adhered to the principles of the Mental Capacity Act (2005).

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults. People and their families told us there was sufficient numbers of staff on duty at all times.

Our review of a selection of care records informed us that a range of risk assessments had been undertaken depending on people’s individual needs. These included a falls risk assessment, lifting and handling assessment, nutritional and a skin integrity assessment. Care plans had been developed based on the outcome of risk assessments and they provided good detailed guidance for staff on how to support each person thus minimising the risks.

People told us they received their medication at a time when they needed it. We found that the medicines were not always stored in a safe way. You can see what action we told the provider to take at the back of the full version of this report.

The building was clean, well-lit and clutter free. Measures were in place to monitor the safety of the environment.

Families we spoke with told us the manager and staff communicated well and kept them informed of any changes to their relative’s health care needs. People said their individual needs and preferences were respected by staff. They were supported to maintain optimum health and could access a range of external health care professionals when they needed to.

People spoke highly of the meals and the general meal time experience. They told us the food was very good and they got plenty to eat and drink.

People and families described management and staff as caring, considerate and respectful. Staff had a good understanding of people’s needs and their preferred routines. We observed positive and warm engagement between people living there and staff throughout the inspection.

Although staff said there was a need for formal supervision, they told us they were well supported on a day-to-day basis and through the induction and appraisal processes. They said they were up-to-date with the training they were required by the organisation to undertake for the job.

The culture within the service was open and transparent. Staff, people living there and families said the registered manager was approachable and inclusive. They said they felt listened to and involved in the running of the home.

Staff were aware of the whistle blowing policy and said they would not hesitate to use it. Opportunities were in place to address lessons learnt from the outcome of incidents, complaints and other investigations.

A procedure was established for managing complaints and people living there and their families were aware of what to do should they have a concern or complaint. We found that a complaint last year had

We considered all the evidence we gathered under the outcome we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found –

Is the service safe?

Arrangements were in place to protect people living at the home against the risks associated with the unsafe use and management of medicines.

We spoke with two people who lived at the home. Both told us they received their medication when they needed it. One person told us, “They are pretty good at giving me my tablets on time. I know what the medication is for. The nurse told me.” The other person said, “I get my medication at the same times every day. It’s like clockwork.”

Is the service effective?

This was a follow-up inspection to check if the provider had made improvements to an area of non-compliance identified at the previous inspection. We did not look specifically at this area.

Is the service caring?

This was a follow-up inspection to check if the provider had made improvements to an area of non-compliance identified at the previous inspection. We did not look specifically at this area.

Is the service responsive?

This was a follow-up inspection to check if the provider had made improvements to an area of non-compliance identified at the previous inspection. We did not look specifically at this area.

Is the service well led?

This was a follow-up inspection to check if the provider had made improvements to an area of non-compliance identified at the previous inspection. We did not look specifically at this area.

This unannounced inspection involved following up on an area of non-compliance identified at our previous inspection in August 2013. The inspection also set out to answer our five questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives, staff providing support and looking at records.

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

Is the service safe?

The people we spoke with told us staff were caring and treated them with kindness and respect.

Systems were in place to ensure staff were informed about, and learnt from, events such as incidents, complaints and the outcome of audits (checks).

The home was clean, hygienic and odour free. Measures were in place to ensure the environment was safe and suitable for the people who were living there.

Although a busy home, both people who were living there and staff told us there was enough staff on duty to ensure people’s safety.

The daily checks of the medication fridge temperatures showed the fridge frequently recorded a minimum temperature of 1°, which is outside of the acceptable range of 2-8° advised by the pharmacy providing medication to the home. This meant the advice provided by the pharmacy had not been taken into account in the routine monitoring of the fridge temperatures. In addition, there is a risk that medication requiring refrigeration may lose its effectiveness if stored at the incorrect temperature. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the management of medicines.

Is the service effective?

People’s health and care needs were assessed with them and/or with a family member. People and family members told us staff communicated well about care needs and any changes were discussed with them. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People’s care plans reflected their current needs.

Is the service caring?

People told us they were supported by kind and attentive staff. We observed staff supporting people in a caring, friendly and respectful way. A person living there said, “Sometimes I feel overwhelmed by their [staff] kindness.” Another person told us, “I can only praise the staff. They are busy but also patient and give you the time you need.”

Staff were knowledgeable about people’s preferences, interests and diverse needs so care and support was provided in accordance with people’s wishes.

People who lived at the home and their relatives had the opportunity to participate in an annual satisfaction survey and could also provide feedback via the resident’s and relative’s forum. Where shortfalls or concerns were identified these were addressed through an action plan developed by the provider.

Is the service responsive?

People knew how to make a complaint or raise a concern if they were dissatisfied with something. A family member told us the manager listened and responded promptly to concerns raised.

From our discussions with people and family members and through observation of care records, we could see that the approach to care and support was revised as people’s needs changed. This was particularly evident with changing medical and nursing care needs.

Following our last inspection in August 2013 we made a compliance action (requirement to improve) that the service needed to respond to and address. We found that this had been addressed and the improvements made.

Is the service well-led?

The home had systems in place to regularly monitor the quality and safety of the service provided. Records we looked at demonstrated that action plans were developed to address identified shortfalls in a timely way.

Staff we spoke with said they received good quality training, had an annual appraisal and received regular supervision. This helped to ensure that people received a good quality service at all times.

The people using the service who were able to tell us said that they were happy living in the home. Comments included; “This is the next best thing to being at home”, “[I would] be lost without this place”, ‘’very good to you’’, ‘’happy enough living here’’, ‘’staff are kind.’’

A visiting relative told us “This is a fantastic place, it is like a family unit, the care is 100% and I am always made to feel welcome.”

Although the people we spoke to generally made positive comments about the food they were eating one person did make a negative comment; we passed this on to one of the home’s directors during the feedback session that took place at the end of our visit.

We spoke with six people who use the service about their medicines and one visiting relative. Nobody raised any concerns about how medicines were handled. One person said ‘’staff are kind’’ and I am ‘’well looked after.’’

Another said ‘’carers are nice’’ and I am ‘’happy enough.’’

We received wholly positive comments about the staff members from the people using the service and from the visiting relatives we spoke with. Comments included; “The staff are respectful”, “The staff members are happy and great”, “The staff are smashing and are looking after me well”, another person said their relative was always treated with dignity and respect.

One person we spoke to said that they thought that the home was short staffed, they told us, “I don’t think there are enough staff on duty.” They said they had raised this with one of the home’s directors.

We spoke with five people who use the service about their medicines. However their feedback did not relate to this standard and they raised no concerns about the care they received.

People who used services at this home referred to in this report as ‘residents’ reported positive comments for the care, treatment and support they received. They told us staff were ‘kind’, ‘caring’ they said they felt ‘safe’ and that they were ‘well cared for’. A number of family members were also interviewed and they too gave positive comments about the care their family members received.

We interviewed six residents about their medicines. Five of these said they were happy and settled living in the home and the other person was not able to speak with us because they found it difficult to talk due to their health condition. All said they had their medicines given to them properly at a time that fitted into their normal daily routine. Some of these people were having creams applied by care staff and they said this was done properly, in a dignified and professional way.

Residents and family members told us that all staff were competent, we were told that residents were well cared for but a number of people told us that staff were ‘very busy’ and ‘rushing about their work’.

We spoke with five people who live in the home and two visiting relatives about how medicines were being handled. No major concerns about medicines were raised.

We spoke with three people who were living in the home who were able to tell us about their views and experiences of Warren Park Nursing Home. Overall people were satisfied with the care and support provided to them. One person said, “Some of the staff are really good. They take their time and will have a chat. However, sometimes staff seem to be in a very big rush” Another person said “Everybody is very kind and helpful. I would like to be at home but here is pretty good.”

We spent time with people in the dining room while lunch was being served. We observed staff supporting people to eat their meals. One person showed little interest in their meal and they were offered an alternative, which they accepted. The food looked appetising and people told us they were offered a choice of what they would like to eat each day.

We found that staff had received training and were supported appropriately, which enabled them to deliver care and support effectively. Staffing levels were adequate at the time of the inspection. At our last inspection in July 2012 we had concerns that care plans and risk assessments were not being updated consistently. At this inspection we found these concerns had not been addressed.