This unannounced inspection took place on 26 January 2017. At our last comprehensive inspection in June 2016 although the provider was not in breach of the regulations, we identified a number of areas that required improvement. On this our most recent inspection we found that overall these improvements had been made.

Wood Green Nursing Home is registered to provide accommodation, nursing and/or personal care for up to 40 older people. At the time of our inspection 31 people were using the service.

The manager in post at the time of our inspection was in the process of registering with us. There was a registered manager for the service, but they had left this post and as yet had not deregistered as manager of the home with us. 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.

Staff were knowledgeable about the types of abuse and harm people may experience and were able to describe how they would deal with and report any concerns they had. Potential risks to people were assessed in relation to their individual health and support needs. Incidents that occurred were reported to the appropriate external agencies and bodies, including the Care Quality Commission [CQC]. The provider ensured sufficient skilled staff were available and employed in order to meet people’s individual needs and keep them safe. The systems in place ensured that staff recruited had the right skills, experience and qualities to support the people who used the service. Staff effectively administered medicines and supported people to take them appropriately.

Staff were caring towards people, frequently asking about their well-being and ensuring they were comfortable. People or their representatives were involved in decision making and received a good level of level of communication from the provider. Information was available and displayed for people in relation to local advocacy services. Staff were patient and took time to ensure that people understood what was said to them. People received care that was delivered by staff in a respectful and dignified manner.

People using the service and their relatives were involved in the assessment of needs and planning of care and support. People were supported to follow their interests and take part in social activities. The home had a friendly and homely environment and people received care that was personalised to their particular needs and wants. People were clear about how to make their views known and information was displayed about how to make a complaint. People were supported to maintain relationships with those important to them.

The provider had made the necessary level of improvement in relation to medicines and the analysis of incidents that was required in relation to our findings at our last inspection in June 2016. Recommendations made in relation to areas of fire safety at the home had not all been addressed and some issues identified remained a potential hazard. Staff were well supported in their role and demonstrated a clear passion for their work. Management of the service provided staff with the support required for them to deliver effective care. Staff benefitted from regular supervision and meetings. People were actively encouraged to provide suggestions and opinions about the service, this included through regular meetings and surveys supplied to them for their completion. Staff could make suggestions and give their opinions openly to the manager or provider.

This unannounced inspection took place on 15 June 2016. At our last comprehensive inspection in January 2015 we found the provider was in breach of the regulations as they had failed to report to the Care Quality Commission (CQC) incidents that had resulted in, or had the potential to result in harm to a person using the service. On this our most recent inspection we found that improvements had been made.

Wood Green Nursing Home is registered to provide accommodation, nursing and/or personal care for up to 40 older people. At the time of our inspection 29 people were using the service.

The manager was registered with us as is required by law. 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.

We found that medicines management within the service was not robust and checks being completed were not always effective in identifying issues, omissions or errors.

Staff were trained in how to protect people from abuse and harm; they knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risks to people were assessed and included measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. The recruitment process was robust and the provider was as sure, as possible, that staff employed at were suitable and safe to work with people who were cared for by the service. We found that there were a suitable amount of staff on duty.

Formal staff supervision was not always regularly undertaken and in line with the contract agreed with its employees; however staff told us they could access the support they needed when they needed it. Staff attended regular training in areas that were relevant to the needs of people using the service. However, training and updates in relation to end of life care was lacking. People enjoyed their meals and were supported by staff to eat and drink enough to keep them healthy. People were supported to access input from health care professionals as and when they needed it. Evidence of any support provided whilst people waited to be seen by healthcare professionals was not consistently demonstrated.

Staff interacted with people in a positive and caring manner. People were satisfied with the way staff communicated with them and the information they were provided with. We found that staff were respectful and maintained their privacy and dignity whilst supporting them. People were encouraged to remain as independent as possible by staff. Information for staff and people in relation to how to access advocacy services needed to be sourced.

Activities available within the service were limited and not always centred on people’s interests. People were clear about how to make their views known and information was displayed about how to make a complaint. People described to us how staff supported them to maintain relationships with their friends and families.

People were positive about the leadership of the service and had confidence in the registered manager. The provider’s quality assurance systems were not always effective in identifying issues or demonstrating how improvements to the effectiveness and safety of the service would be actioned. Peoples’ feedback in relation to the quality of the service and complaints were acted upon and improvements made as a result.

The provider is registered to accommodate and deliver nursing and personal care to a maximum of 40 older people. At the time of our inspection 20 people were living there.

We carried out an unannounced comprehensive inspection of this service on 8 May 2014 and 26 January 2015. A breach of legal requirements was found. The issues relating to the breach placed people at risk as the provider had failed to handle, store and administer prescribed medicines in such a way as to maintain and promote peoples good health. As a result of this continued non-compliance the provider was served with a warning notice for regulation 13 of the Health and Social Care Act 2008. The warning notice required the service to be compliant with the management of medicines by the 1 April 2015.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to Regulation 13 and the management of medicines.

You can read a summary of our findings from both inspections below.

Comprehensive Inspection of 26 January 2015

The registered manager had left the service in August 2014. 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. The provider had appointed a new manager in November 2014 who told us that they were in the process of applying for registration with us.

We found that medicines management within the service were unsafe. The provider had failed to handle, store and administer prescribed medicines in such a way as to maintain and promote peoples good health. You can see what action we told the provider to take at the back of the full version of the report.

There were systems in place to protect people from abuse and harm. Staff had a clear knowledge of how to protect people and understood their responsibilities for reporting any incidents, accidents or issues of concern. However, the provider had failed to send notifications to the Commission and other external agencies about incidents or allegations of abuse that had occurred within the service.

The provider ensured that there were suitable number of staff on duty with the skills, experience and training in order to meet people’s needs at all times.

Staff had access to a range of training to provide them with the level of skills and knowledge to deliver care safely and efficiently. Staff were encouraged by the provider to undertake training in addition to the standard level of training they were routinely provided with.

The provider supported the rights of people subject to a Deprivation of Liberties Safeguard (DoLS). Staff were able to give an account of what this meant when supporting the person and how they complied with the terms of the authorisation.

People’s nutritional needs were monitored regularly and reassessed when changes in their needs arose. Staff supported people in line with their care plan and risk assessments in order to maintain adequate nutrition and hydration.

Staff were responsive to people when they needed assistance. Staff interacted with people in a positive manner and used encouraging language whilst maintaining their privacy and dignity. People were encouraged to remain as independent as possible.

People and their relatives told us they were provided with written and verbal information about the service and their care and treatment. People were supported to continue to maintain their religious observances.

Although people were provided with and information was on display about how to make a complaint. The provider had failed to respond in a timely manner and in line with their own policy to complaints received since our last inspection.

Activities that were on offer to people considered people’s interests and hobbies through consultation with the individual. People, their relatives and stakeholders were asked to provide feedback about the service through questionnaires and meetings.

People, their relatives and staff spoke confidently about the leadership skills of the new manager. Structures for supervision allowing staff to understand their roles and responsibilities were in place.

The provider’s quality assurance systems had failed to identify a lack of appropriate reporting and some analysis of incidents within the service and ineffective complaints handling that may have put people using the service at risk.

Focused Inspection of 14 April 2015

We undertook this focused unannounced inspection on 14 April 2015 to check that they had followed their plan and to confirm that they now met legal requirements. This inspection focused on the management of medicines from 1 April 2015. We found that sufficient improvements had been made.

The service had a registered manager. 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 2008 and associated Regulations about how the service is run.

We found that medicines were being handled and administered in a safe manner, in line with the prescribing practitioner’s instructions. Systems in place for the storage and safe disposal of medicines were effective.

This report only covers our findings in relation to our follow up of the breach and warning notice issued in relation to medicines management. You can read the report from our last comprehensive inspection by selecting the all reports link for Wood Green Nursing Home on our website at www.cqc.org.uk.

This unannounced inspection took place on 26 January 2015.

Our inspection of May 2014 found that the provider was not meeting four of the regulations associated with the Health and Social Care Act 2008 which related to; the care and welfare of people who use services, the management of medicines, assessing and monitoring the quality of service provision and records. Following the inspection we asked the provider to take action to make improvements. The provider sent us an action plan outlining the action they had taken to make the improvements. During this inspection we looked to see if these improvements had been made and found that they had not all been completed.

Wood Green Nursing Home is registered to provide accommodation, nursing and/or personal care for up to 40 older people. At the time of our visit 22 people were using the service.

The registered manager had left the service in August 2014. 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. The provider had appointed a new manager in November 2014 who told us that they were in the process of applying for registration with us.

We found that medicines management within the service were unsafe. The provider had failed to handle, store and administer prescribed medicines in such a way as to maintain and promote peoples good health. You can see what action we told the provider to take at the back of the full version of the report.

There were systems in place to protect people from abuse and harm. Staff had a clear knowledge of how to protect people and understood their responsibilities for reporting any incidents, accidents or issues of concern. However, the provider had failed to send notifications to the Commission and other external agencies about incidents or allegations of abuse that had occurred within the service.

The provider ensured that there were suitable number of staff on duty with the skills, experience and training in order to meet people’s needs at all times.

Staff had access to a range of training to provide them with the level of skills and knowledge to deliver care safely and efficiently. Staff were encouraged by the provider to undertake training in addition to the standard level of training they were routinely provided with.

The provider supported the rights of people subject to a Deprivation of Liberties Safeguard (DoLS). Staff were able to give an account of what this meant when supporting the person and how they complied with the terms of the authorisation.

People’s nutritional needs were monitored regularly and reassessed when changes in their needs arose. Staff supported people in line with their care plan and risk assessments in order to maintain adequate nutrition and hydration.

Staff were responsive to people when they needed assistance. Staff interacted with people in a positive manner and used encouraging language whilst maintaining their privacy and dignity. People were encouraged to remain as independent as possible.

People and their relatives told us they were provided with written and verbal information about the service and their care and treatment. People were supported to continue to maintain their religious observances.

Although people were provided with and information was on display about how to make a complaint. The provider had failed to respond in a timely manner and in line with their own policy to complaints received since our last inspection.

Activities that were on offer to people considered people’s interests and hobbies through consultation with the individual. People, their relatives and stakeholders were asked to provide feedback about the service through questionnaires and meetings.

People, their relatives and staff spoke confidently about the leadership skills of the new manager. Structures for supervision allowing staff to understand their roles and responsibilities were in place.

The provider’s quality assurance systems had failed to identify a lack of appropriate reporting and some analysis of incidents within the service and ineffective complaints handling that may have put people using the service at risk. You can see what action we told the provider to take at the back of the full version of the report.

During the inspection we spoke with seven people that lived at the home, three relatives, the provider, the deputy manager, and four members of staff.

Overall most people that lived at the home felt they were being looked after. One person told us, “As far as I know I am being looked after.” We found that care and treatment was planned in a way that was intended to ensure people's safety. However, care was not always delivered in a timely manner and with sufficient social activities to fully maintain people's well-being.

We saw that people generally enjoyed their meals and choices were available. We found that people’s nutritional needs were being met.

People told us that they were safe in the home. However, we found that people were not fully protected from the risk of abuse, because the provider had failed to recognise where there was a risk of abuse.

We found that people were for, or supported by, suitably recruited and qualified staff.

Overall people were satisfied with the care they received. One person living at the home told us, “I can’t find fault with it.” We found that an effective system was not in place to monitor the quality of service that people received.

We found that significant events affecting the care of people were not being reported to enable a full assessment of these events.

We found that confidential information about people's care was not kept securely.

During our inspection we spoke with three people that lived at the home, three of their relatives and three members of staff.

People told us that their privacy and dignity was respected and that they had choices.

People and their relatives that we spoke with were happy with the care they received at the home and felt that their needs were being met. One person told us, “Oh yes my needs are being met.” We found that people’s needs were being met.

People told us that they enjoyed their food and got enough food to eat. We found that people were not always supported to eat and drink in a timely manner.

People told us that they received their medication when needed. We found that systems were in place to ensure that people received their medication safely.

People told us that there was usually enough staff to meet their needs. One person told us, “Always plenty staff around and if you ask them for something it’s done and never ignored.” We found that there was sufficient staff to support the needs of the people currently living at the home.

People that we spoke with were confident that they could tell staff about any concerns they had and it would be addressed by the manager.

People who use the service told us they were happy with the care and support they received. One person told us "the staff here are very kind, nothing is too much trouble". A gentleman told us “I can’t complain, they are very good, and the food is quite good to.” Other people told us they liked living in the home and that staff were very caring. We observed very positive relations between people being cared for and the staff. Some staff had worked at the service for a number of years and clearly knew the people they cared for very well. Some people who were not able to express their full opinion verbally, were able to indicate their satisfaction with their care, and clearly related well to the staff supporting them.

Our inspection was conducted over two days. There were 33 people living there when we inspected. We spoke with 14 and five relatives about their experiences. We also spoke with four staff, the newly appointed manager and the deputy manager. Some people had limited verbal communication skills so we observed their interactions with staff and their body language to understand their experiences.

Below is a summary of what we found. We used all the information to answer the five questions that we always ask

Is the service safe?

We saw that the people had an assessment of their needs and associated risks. A plan of care was completed which enabled staff to offer care and support to them. Some care plans did not reflect the level of care that was being given because reviews and checks had not identified gaps such the lack of risk assessments for specific health conditions or out of date pain management systems. This meant that staff did not always have the information they needed to meet people's needs safely.

Staff told us and records sampled showed that they had received training and support to enable them to deliver care safely.

We saw that people generally received good and safe care and the majority of the relatives spoken with told us that they were happy with the care provided. The relative of one person said, “They are brilliant here, staff are very caring. Mum’s safe and loved here.” However one relative did say, “If I had any complaint it would be that my relative waits too long for staff to assist her in using the toilet and, at times I had to ask staff for their help.”

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes and hospitals. No applications to restrict anyone’s liberty had been made. The majority of staff had received Mental Capacity Act 2005 and DOLS training and understood their role in protecting people’s rights.

We saw in some care plans that assessments of people’s mental capacity were needed along with reviews of their advanced instructions for emergency medical situations. This meant that the manager and staff understood how this legislation applied to people and protected their rights but that people’s safety wasn’t protected in an emergency because updates and reviews planned for had not taken place.

All staff had been given the knowledge and information to be able to be alert to the signs of, or potential for abuse of vulnerable adults. All people spoken with told us that they were safe in the home. However, we found that people were not fully protected from the risk of abuse, because staff had failed to recognise and record unexplained bruises and scratches and ensure that they were adequately investigated. The manager had not appropriately reported all important events that affected people's welfare, health and safety to us and act on incidents that were classified as safeguarding. This meant that the provider had not taken action to fully protect people.

We saw that the systems that were in place to make sure that learning took place following accidents, incidents, complaints and investigations were not sufficiently robust to protect the safety and welfare of the people who lived there. Some staff spoken with were not aware of the providers reporting system.

We looked at the management of medicines and raised a number of concerns with the management team about the administration of some medicines. We found that the home did not have a system to record where the analgesic patches had been applied to the body, and that instructions to administer some medicine prescribed with specific administration times had not been adhered to. This meant that people did not always receive their medication as prescribed by their GP to protect their health and wellbeing.

Is the service effective?

People’s care and health needs were assessed and planned in a personalised way. We saw that people’s changing needs were not always monitored and care and support appropriately adjusted. This meant that people’s care was planned but not always delivered in line with their individual needs.

We saw that people weight was recorded regularly. This is important as a significant loss or gain of weight could be an indicator of an underlying health need. Referrals had been made to external professionals so that people got the support they needed to maintain their health and wellbeing and we saw that staff followed their advice.

We saw that information was displayed about activities that were planned for. We also saw that residents meetings took place regularly and people who lived here were involved in menu planning and choices for entertainment and activities. Some people told us that they enjoyed the activities that took place. One person told us, “I enjoyed the barbeque. We have a lot of fun here.” This meant that group activities were planned for and took place.

Is the service caring?

Some staff spoke with people in a tone that expressed friendship and support and offered people choices throughout the day whilst other staff were observed to ignore the presence of residents and failed to engage in conversation with them when they delivered care or gave support with meals. Some staff told us that they felt there weren’t sufficient staff to support people who had dementia with all of their needs.

Most people we spoke with told us they were happy and the carers were nice and worked hard. One person said, “I am very happy here. It’s beautiful and we do lots of things. The staff are so kind. Nothing is too much trouble.”

Is the service responsive?

We saw that there was a system to review people’s care plans and risk assessments on a regular basis to ensure that their changing needs were planned for. However these reviews did not always identify peoples changed needs so that staff appropriately adjusted their care and support.

We saw that actions were taken to protect people’s health as needed. We saw that staff acted on peoples deteriorating health and liaised with doctors and other professionals regularly. One relative said, “Any concerns are dealt with straight away. They are great and always keep me informed about mum.” This showed that the service was responsive and kept relatives informed about people’s health.

We observed that some staff responded to some people’s needs in a caring and appropriate way. However, people told us and we observed that care was not always delivered in a timely manner to all people. We also observed that people who were nursed in bed on the upper floor spent long periods of time without the stimulation of conversation or activity. Some people did not have call bells close at hand. This meant that some people did not have their health and well-being promoted and protected by interactions or social activities.

Is the service well led?

The manager at the home is newly appointed and we have not registered them to be responsible and competent to manage the home. The registered provider was reminded of their legal obligation to have a registered manager in place in compliance with their registration requirements.

People were consulted about the quality of service they received. Comments and suggestions were analysed to identify where improvements were needed.

Whilst people and relatives spoken with had few or no concerns about the service they received. We found that effective systems were not in place to monitor the quality of the service. This has led to shortfalls in a number of the regulations that we assessed.

We saw that some care records and medication administration records lacked relevant, up to date information. This meant that people may not always receive safe and effective care that met their needs. We saw that confidential information about people's care was in the main kept securely.