This inspection took place on 10 and 12 March 2018 and it was unannounced. At our previous inspection on 1 and 2 December 2016 we rated the service ‘Requires Improvement’ overall.

Following the last inspection we asked the provider to complete an action plan to show what they would do to ensure people’s care records were maintained accurately. The provider told us the improvements would be made by 30 September 2017. During this inspection we found people’s care records had been maintained and they contained accurate information about people’s care.

Improvements had also been made to staff recruitment, staffing numbers, and staff skills, which had improved how people were kept safe and supported. Changes in the management of the home had improved the overall governance of the service and resulted in positive results for people who lived in the home and the staff who worked there. This action and the improvements completed support the service’s overall rating of ‘Good’ awarded at this inspection.

Windsor Street Care Centre is a purpose built ‘care home’. People in care homes receive accommodation and nursing or personal care, as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

People, relatives and staff referred to the home as ‘Windsor Street’ so this has been done in this report. Windsor Street specialises in the care of those who live with dementia, but also provides nursing care to some people. There were four beds commissioned by the NHS, these were called ‘safe haven’ beds. These were used for people who required a short admission; either after a stay in hospital or to avoid a hospital admission. Referrals for these beds were made by people’s GPs. People’s medical care was temporarily handed over to the GP who attended Windsor Street. Once discharged, people’s medical care was transferred back to their own GP. In total 81 people can be accommodated in one adapted building. At the time of this inspection 63 people were receiving care.

People lived on 5 units referred to as ‘households’. Four households provided care to people who lived with dementia; one of these provided nursing dementia care. A fifth household also provided nursing care. Single bedrooms with private toilet and washing facilities were provided. Each household had a lounge, dining/kitchen area and additional adapted toilets and bathrooms. A passenger lift helped with access to upper floors. There was a secure, large garden and balconies for outside use. Car parking was available. The home had wheelchair access.

The home had a registered manager in post who had managed the home since May 2017. Previous to this they had been the home’s deputy manager and dementia care lead. 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.

Arrangements were in place to keep people safe and to protect them from abuse and discrimination. Improvements had been made to how the home was staffed. Staff had been recruited safely, providing the home with enough staff with the right skills, knowledge, experience and commitment. People lived in a clean home where good infection control measures reduced the risk of infection. The staff had support from the home’s visiting GP, which meant people’s health needs and medicines were reviewed and managed well.

Staff were trained and well supported. Robust assessment of people needs meant these were well identified and understood by the staff. Frequent reviews of people’s needs and their abilities meant staff were quick at identifying changes and deterioration in people. People and where appropriate their representatives, were involved in revie

This inspection took place on 1 and 2 December 2016 and was unannounced.

This care home was registered to accommodate up to 80 people and at the inspection there were 72 people living there. It predominantly provided care to the older person who had a physical illness or who lived with dementia. Six beds were designated to supporting people to return to their own homes following an accident, illness or surgery. These were called re-enablement beds.

People lived on different units; two of which provided nursing care and had nurses on duty. There were designated units to care for those who lived with dementia. The building was a new build when registered with the Care Quality Commission in 2013 and further adaptions had been made to meet the diverse needs of people. Each person had their own private accommodation comprising of a single bedroom, toilet with washing facilities. Each unit had its own care office, lounge area, dining room with kitchenette and communal bathrooms and toilets.

The care home’s personal parking space availability could be limited but there was ample parking in the road outside. The front door was secured as were the individual units. People who were not deprived of their liberty under the Mental Capacity Act 2005 were able to leave these areas. Outside there was a secure garden which could be safely enjoyed by people who used a wheelchair or who lived with dementia.

There was a registered manager in post although at the time of the inspection they were managing another of the provider’s care homes. Their deputy manager had become the care home’s acting manager. 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 this inspection we found the provider had not ensured the accurate maintenance of some people’s care and treatment records. People’s care was planned with them where this was possible and relatives were able to speak on behalf of their relative and be involved in this process if needed. Care plans and other care records were not however, always fit for purpose or giving staff necessary information. This put people at risk of unsafe or inappropriate care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

We were informed by the management staff that the care home was adequately and appropriately staffed. However, challenges in the recruitment and retention of nurses had compromised the continuity of nursing care. Staff on one unit told us there were not enough allocated staff to meet people’s needs. They had taken their own action to ensure people’s needs were met. Agency staff were used to help meet people’s needs. We recommended that the provider review their ability to safely provide nursing care under these circumstances.

Some improvements were needed to how the care home was being managed. Staff had not always felt able to raise their concerns about how some aspects of the care home had been managed.

There were systems in place to monitor the performance of the service and the standards of care. Audits were completed and an extensive action plan was seen to be in place. This process however, had not led to the accurate maintenance of some care records relating to some people’s health. These shortfalls were discussed at the time of the inspection and the operations manager was going to address these.

There were arrangements in place to protect people from abuse and poor practice. Risks to people and staff were identified, managed and monitored.

The recruitment of staff was on-going and safe recruitment processes ensured people were protected from those who may not be suitable to care for them. Several new staff had recently been r

An adult social care inspector carried out this inspection. The focus of the inspection was to follow up on actions required of the provider following an inspection on 6 May 2014 and to answer four of the five key questions; is the service safe, effective, caring and responsive?

As part of this inspection we spoke with the registered manager, six members of staff, one person who uses the services and one relative. We reviewed care records and other relevant documents such as audits/checks and staff training records.

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

Is the service safe?

The service was safe because, since our last inspection in May 2014, arrangements had been put in place to ensure people received the treatment they required. help staff assess if a person was in pain. The service was safe because systems used to monitor people's nutritional risks had been checked and were found to be working well.

Is the service effective?

The service was effective because staff had been given additional training. This meant staff were better able to assess, monitor and record people's pain symptoms. Staff also had a better understanding of people's individual nutritional needs. For example, why a person who had lost weight would need additional calories and how these would be provided.

Is the service responsive?

The service was responsive because when staff either suspected or assessed a person as being in pain the person was given pain relief. The service was responsive because people who were at risk of not maintaining a healthy nutritional state were given additional support to do this.

Is the service caring?

The service was caring because people felt cared for. One person who uses the service said, "They take care of me here." and another person's relative said, "Care here is top, they are all excellent." We also observed staff interacting with people in a kind and concerned manner.

The registered manager and senior staff were aware of changes in case law (March 2014) in relation to deprivation of liberty safeguards (DoLS). The registered manager and other senior staff knew how to manage DoLS referrals and authorisations. Staff had started to review people where they considered, under the new law, people may be deprived of their liberty.

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 safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This inspection was completed by two inspectors who visited the service for one day. The inspection predominantly looked at the care provided to people who had dementia. This is a summary of what we found after speaking with people who used the service, staff who worked in the service and representatives of the provider. We also observed care and support being delivered and inspected relevant records.

Is the service safe?

Arrangements were in place to identify, assess and monitor specific risks to people's health. Staff had been trained to understand what abuse may look like and what to do if an allegation of abuse were reported to them. Information was readily available to help staff report abuse appropriately.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no safeguards had needed to be applied to an individual, proper policies and procedures were in place. Senior staff had been trained to understand when an application should be made. The registered manager knew how to submit a DoLS application if needed.

Is the service effective?

One person said, "they're marvellous here" and "they're always around when you need them".

Care plans gave specific guidance for staff in relation to people's needs. Care was delivered in a way that met the person's individual abilities and needs.

The care plans inspected had been well maintained meaning staff received up to date information on people's needs. We observed staff using effective and skilled communication when managing more challenging situations. This helped to achieve people's well-being.

Where people lacked mental capacity there were effective arrangements in place to ensure their rights were protected.

Is the service caring?

We observed kind and patient interactions from staff. We observed momentary situations which included people becoming agitated and these situations were managed in a calm and understanding manner.

We observed care being delivered with warmth and a genuine desire to make people feel comfortable and cared for.

Staff were aware of people's diverse needs and were able to spend time with people who required additional support. A good example of this was seen with a person who had high levels of anxiety.

Is the service responsive?

We observed staff responding swiftly and effectively to the needs of individuals.

The majority of the care records inspected showed that staff had been proactive in seeking advice from and working alongside visiting health care professionals. In the majority of cases this had ensured people had been given access to health care specialist when required.

The service had not been responsive to one person's needs when they had exhibited pain over a period of time. There were other health related issues where the records and staff, at the time of the inspection, could not demonstrate that these had been addressed. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Where people lacked mental capacity the service had been responsive in ensuring their needs had been met by adhering to the law when making decisions in the person's best interest.

Equally so, where people could make decisions for themselves they were supported to do so.

Is the service well led?

Staff told us they felt supported and able to approach managers with any concerns or problems they may have.

The registered manager could evidence that he was fully engaged with his staff and people who used the service. On the day of the inspection he was observed walking around the home talking to people using the service, to staff and following up issues he was aware of. One member of staff said, "Oh he does that everyday".

The provider's arrangements for assessing and monitoring the performance of the service as well as the standard of services provided, were effective and resulted in a program of improvement. The registered manager had additional arrangements in place to more closely monitor certain areas of care. For example, although the provider audited the numbers pressure ulcers, the registered manager expected weekly reports from all units on the condition of people's skin. This enabled him to follow up the actions taken by staff for people who were 'at risk' of developing a pressure ulcer.

Staff had been robustly recruited and provided with adequate support to professionally develop. Staff were aware of their responsibilities and were actively encouraged and supported to enhance their knowledge.

There were arrangements in place to seek the views of those who used the service and their representative. These views were listened to and action taken to improve the service. A recent example of this had been changes to the menus following comments from people in a 'resident and relative' meeting.

We gathered evidence for this inspection by talking to two people who used the service. One person said “I can’t fault the staff, they are lovely”, the other confirmed they were treated with respect and their privacy was maintained. We also met people who were not able to tell us about their experiences so we used other methods to find out about the care they received and their experiences. We spoke to one relative and one visiting professional who both told us that people's wellbeing had improved since being admitted.

We found there were arrangements in place to protect people who lacked mental capacity and to protect people from potential abuse. There were enough staff in numbers and skills to meet people's needs. Staff were supported to develop the skills they required to meet people's needs. There were arrangements in place, both within the service and at provider level to monitor and improve services provided to people.