The inspection took place on 20 December 2017 and 04 January 2018 and was unannounced. Wrenbury Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection. Wrenbury Nursing Home is registered to provide care and accommodation for up to 36 people. At the time of the inspection there were 28 people living at the home.

The home had a registered manager who was present throughout the 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.

At the previous inspection on 01 and 04 March 2016, the overall rating for the service was Requires Improvement. We found some of areas of practice which needed to improve and two breaches of the regulations. This was because the provider had not ensured that people received person centred care and records were not always complete, accurate or contemporaneous. The provider sent us an action plan explaining how they would meet the requirements of the regulations. At this inspection we found that they had taken action to address the breaches of regulations and the quality of the service had improved.

People were positive about the care and support they received at Wrenbury Nursing Home. People felt safe and told us that they received the support that they needed, in a way that respected their wishes. We found that there were sufficient staff, who ensured that they supported people in an individualised and unrushed way. Improvements had been made to the way that staff were deployed.

Care files contained individual risk assessments which identified any risks to the person and gave instructions for staff to help manage the risks. However we found that on occasion staff had not followed guidance to mitigate risk. Some clinical records in relation to skin care needed to be more robust.

Staff had received training in safeguarding and understood their responsibilities to protect people from harm and abuse. Staff knew how to report concerns and told us that they felt able to raise concerns appropriately. The registered manager maintained a safeguarding file and where necessary, referrals had been made to the local authority to report safeguarding concerns. We found that the outcome of these had not always been recorded within the file, but the registered manager was able to provide this information verbally.

We found some minor shortfalls in the recording of medication administration, but overall medicines were administered safely. People were cared for in a clean and well maintained environment.

Staff had an understanding of The Mental Capacity Act (2005) and this was usually followed where necessary. However, we found there were occasional gaps in the staff’s knowledge around MCA and the accurate completion of assessments had not always been carried out.

We saw that staff received an induction and regular training was provided. Staff told us that they received the training and support they needed to carry out their roles effectively. Staff were also supported through supervisions and staff meetings. We found that people’s nutritional needs were being met. People’s views on the quality of the food varied but were generally positive.

People and their relatives told us that staff were kind and caring in their approach. We observed that staff were very attentive and people were treated with dignity and respect. People looked well cared for and well presented. However, we found that nail care could be improved.

People received care that was personalised and responsive to their needs. Care plans

The inspection took place on the 1 and 4 March 2016 and was unannounced.

Wrenbury Nursing Home is located in the rural area of Wrenbury in Cheshire, which is close to the town of Nantwich. It provides accommodation and nursing care for up to 33 older people. There were 30 people living at the home when we visited. It is a two-storey building and people live on both floors. Access between floors is by stairs and a passenger lift.

At the time of our inspection there were two registered managers 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 who used the service told us that they felt safe and were cared for. People received their medicines in a way that protected them from harm. Staff understood their responsibility to keep people safe from abuse and harm. However, not all staff knew how to report a concern outside of their organisation. The registered manager ensured that immediate action was taken to address this issue.

Staff were not always deployed in way to meet people's individual needs in a timely manner. This occurred during the morning. People were sometimes left waiting in the dining room until staff were available to support them. The registered manager had already started to identify ways to address this concern.

The provider had carried out some refurbishment to the home and plans were being made for further improvements. The home was clean and the premises were safely maintained.

Staff received induction and training. A thorough and robust training programme had recently been implemented. Staff had regular supervision meetings and team meetings to effectively support them in their role.

Staff had an understanding of the Mental Capacity Act 2005, and where a person was being restricted or deprived of their liberty, applications had been appropriately made to the supervisory body under Deprivation of Liberty Safeguards.

People and relatives were very complimentary about the staff. Staff supported people in a kind and patient manner and it was evident that relationships between people and the staff had developed. People's privacy had not always been maintained because people's care records had not always been kept securely and could have been read by visitors. The registered manager addressed the security of the records immediately.

Records did not always provide an accurate reflection of the care that had been provided. The daily charts were not always completed and were not completed at the time that the care was provided. Care plans were in place and had been regularly updated, the detail of personalised information varied but they reflected the support that people needed so that staff could understand how to care for the person appropriately. We saw that staff responded to people's changing needs and sought involvement from outside health professionals as required. The GP visited the home every week to review people’s health needs on a regular basis.

The home employed an activities coordinator who had developed a programme of activities, one to one support was also provided. Entertainers and other visitors from the local community supported the home.

The home had two registered managers. People and relatives felt that the management team were approachable, communicated well and would respond to any concerns raised. Staff felt well supported.

Systems were in place to monitor the quality of the service. Audits were carried out on a regular basis and a monthly managers' report was completed. The provider carried out a monthly audit. The management had identified areas for on-going improvement prior to the inspection.

We identified two breaches of the relevant legislation in respect of person centred

During this inspection we spoke with nine people who use the service and five of their friends or relatives. We looked at two care files in detail as well as other care documentation and daily and other records used to manage the care provided in the home. We spoke with one of the registered managers, and five care staff. We also spoke with a management consultant who had been engaged by the registered provider to develop new management systems in the home. We looked around the home and with their permission visited some people in their bedrooms. We spent time with the people who used the service during lunch and in one of the lounges in the afternoon.

We considered all the evidence we 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?

Is the service safe?

The service was safe. People who lived in the home said they felt safe. They told us “I’m definitely safe”, and “I’m safe, staff look after me well.” We saw that the provider notified the Care Quality Commission and the local authority about safeguarding concerns. We saw records that showed that 90% of staff had completed safeguarding training and that the registered provider had a system for identifying those staff who required further training.

Is the service effective?

There were sufficient staff on duty to provide care for the people who lived in the home. Staff were well-trained and the provider kept their training requirements under review. People were provided with choice at mealtimes and received enough to eat and drink. When asked about this people told us “Food’s good and we get enough” and “Food’s good - can’t really complain.” Two other people said "It’s OK.” and “It’s quite nice, there’s enough for me”.

Is the service caring?

We saw staff providing sensitive care and attention to the people who lived in the home. People told us "“They help with whatever I require” and “If I ask they do things for me.” A third person told us “If I struggle they come across and ask can they help.” One visitor to the home described the care as “Excellent, very good care.” We saw that staff treated people with dignity when providing personal care.

Is the service responsive?

The manager and staff had clear information about people's preferences and requirements and used this to respond to their care needs on an individual basis. Activities were organised in a way which sought to address people's individual preferences and balance this with communal activities which some people might not enjoy.

Is the service well-led?

The registered manager and senior nurse were visible on the floor of the home throughout the day so that they were accessible to staff. The registered manager had put a number of arrangements in place including service audits which would enable her to monitor and improve the quality of care within the home.

We carried out this inspection to check on the improvements that the provider told us they had made following our visit in March 2013.

We found that the provider had carried out the necessary actions to ensure that the issues raised in the previous inspection were resolved to a satisfactory degree.

This included demonstrating that repeated issues raised in the provider’s own medicines audits were addressed and ensuring that records of variable dose medicines were recorded.

When we carried out our unannounced visit we spoke to five people living in the home. When asked about their experiences one said “it’s OK, quite happy here”. Another person said that things were “very good, (I’m) well looked after” and that they had these “carers that are very good”.

When asked about the food most people expressed satisfaction. One person said “the food is good” and another said they had “really good dinners”.

We looked at the kitchen facilities and how people with special dietary needs were catered for and we found them to be safe. All residents were regularly weighed and for those who needed it their dietary intake recorded.

We saw that improvements required since our last visit to protect people from infection had been carried out and that the home had effective infection prevention and control procedures.

Staff had been recruited properly and the necessary checks made on their backgrounds.

Training and staff supervision was now taking place as was effective quality control.

We had received information that people were not given their medicines safely. We observed the morning medicines being given to people in the dining area. The nurse ensured people were given sufficient time to take their medicines. They checked people had taken their medicines before signing the Medicine Administration Record (MAR) charts. We found that medicines were given to people correctly and safely.

We spoke with one person who lived in the service. They told us ‘’I don’t take many medicines. I am very happy here’’

We were told that the service undertook regular audits on medicines. We were shown copies of these audits, which detailed action points to improve medicine management. We found that some of the action points were found every month. It was not clear what action was being taken to prevent them happening again.

We found that appropriate arrangements were not always being undertaken in order to manage the risks associated with the unsafe use and management of medicines.

Our inspection in August 2012 found the provider non compliant with six outcomes and we issued four compliance actions and two warning notices.

During our follow up visit we spoke to six residents of the home. One person told us they liked living at the home, the staff were nice and they were looked after well. Other people did not raise significant issues of concern.

While people were treated with dignity and respect many interactions were task focussed meaning little time was spent in social interaction. We found that care planning, involvement of other healthcare professionals and care delivery had improved leading to better outcomes for people.

We saw that procedures for protecting people from abuse were improved and the provider was meeting its responsibilities to inform and work with relevant bodies.

We found significant concerns in respect of infection prevention and control because there were not adequate arrangements for staff to clean their hands in the treatment room and the staff lavatories and there was also insufficient separation of the laundry area from the sluice.

We noted improvements had been made to assure the safe disposal of medicines and that staff were now receiving appropriate supervision.

We found improvements in audit although it was too early to be sure these were yet effective. We saw that assessments were better identifying risks to people although the subsequent plans and control measures were not always appropriate.

When we visited the home we spoke with nine of the people who lived there. We asked them about their experiences of how the service involved them and kept them informed. The comments we received varied. One person told us that they knew about their care plans but others did not know what they were. Some people told us that they were always treated with respect but others told us that they were unhappy with the way they were treated. One person told us that the staff hurried them and put them under unnecessary pressure. Another person said “we are not looked after very well”.

We asked people about the arrangements made for their care. Comments varied; one person told us that they were very happy, they said “the home provides a good standard of care and food is well cooked and there is enough of it”. Another person told us that they did not get the assistance they needed to eat their food and another person said “we are not looked after very well”.

One person said “All we do all day is get up have breakfast, then sit in the lounge with the TV on. Have dinner then sit in the lounge again. Have evening meal then sit in the lounge again until we go to bed”. They said “it’s no good, no quality of life and no fresh air. This is what has made me poorly.”