We carried out this inspection to see if the provider had complied with a warning notice served by CQC on 18 June 2014. On 6 November 2014 we found that improvements had been made in relation to the safe support and care and welfare of people.

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?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service and with staff who supported them.

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

Is the service safe?

During our inspection we spoke with eight people who used the service. They all told us that they were happy with the service they received and considered that staff met their needs in ways that they preferred. We saw how staff supported people sensitively and discreetly. One person told us, “It’s nice here. The staff are lovely and gentle.” Another person told us, “The staff are lovely. They make you feel safe.”

We saw four people who used the service being moved using a hoist from one seat to another. We saw that staff were gentle and reassuring. They were mindful of not catching people's head or legs and gave people time to adjust and be comfortable before beginning to move them. Staff told us that they had all now received moving and handling training and that they were confident to move people safely. Training records reflected that staff had all received training with only two exceptions and they were on site on the day of the inspection receiving their training. One person who we saw being moved told us afterwards, “Yes its ok. Better now.”

We saw how care plans reflected people's dietary requirements and this information was also kept by kitchen staff. Staff told us that they worked with the kitchen staff to ensure people had the food and drink that they liked and what they needed to maintain their health and wellbeing. People who used the service said that they liked the food at the home and one person told us, “They know what I like and what I can’t eat."

We saw that risks were documented and actions were in place to reduce these risks.

Is the service effective?

We found staff were effectively meeting the care and support needs of the people who used the service. We saw care staff respond promptly when call bells sounded and when people asked them directly for support.

We found that people who used the service felt well supported and care plans reflected people’s care and support needs. Staff told us that these were useful documents that enabled them to see at a glance the care and support required by each person.

We saw that the care and support of people who used the service was now being effectively planned and delivered. Staff told us that they had read care plans and senior staff told us how they were regularly reviewed to ensure they reflected people's current needs. One person told us that they had sat with staff while they completed their plan. They told us, “They asked me how I like to be looked after.”

Is the service caring?

At the time of our last inspection on 9 June 2014 we found that not everyone was treated with dignity. At the time of this inspection we saw how improvements had been made that had had a positive impact on the people who used the service.

We saw that all staff had received training in relation to dignity. We also saw that, as a team, they had identified what dignity meant to them. We saw that each staff member now carried a card with them with this information on it. Staff were very proud of their cards and said how they had made positive changes as a result of revisiting the core values of care. During this inspection we saw people being treated with dignity and respect. Changes had also been made to the environment to ensure better privacy for people when using communal bathrooms. This showed how the provider had acted upon our previous findings and invested in both the staff and the layout of the home to ensure people’s needs were met appropriately.

Is the service responsive?

At the time of our last inspection we were told that sometimes people had to wait to be supported. The people who spoke with us during this inspection said that they received prompt support. The manager and area manager told us how they had reviewed call bell response times to ensure everyone was attended to in a timely way. Staff told us that, although they were busy, they responded to support people as soon as they were made aware that they needed support. We saw that people who were in their beds had their call bells to hand should they need assistance. People who could not use these had regular checks. Staff who spoke with us knew who these people were and said that they received regular checks.

Records also showed that people’s needs were being met and that appropriate checks were taking place and being recorded to monitor support and care needs.

We saw how audits that had been carried out by the manager and senior managers had been responded to. We saw that actions taken had been recorded to demonstrate that they had acted upon requirements made.

Is the service well-led?

The staff who spoke with us at the time of this inspection all felt well supported by senior staff and managers. They said that they had regular supervision and monitoring. The registered manager told us how they spent time every day walking round the home, speaking with people and observing practice. We saw that senior managers also did this as part of their monitoring visits. Records also showed that they spoke with people who used the service and staff.

We saw that audits were in place to monitor the development and review of care plans and also to check working practices. We saw that when audits had been completed actions had been identified and delegated to staff members for completion. We saw how these records were also being audited by senior managers.

Staff who spoke with us said that communication was good and we saw information provided to care and kitchen staff to ensure people’s needs were met throughout the day.

Prior to our visit we reviewed all the information we had received from the provider. During the visit we spoke with eight of the 44 people who used the service and five visitors and asked them for their views. We also spoke with four care workers, a nurse, the quality assurance manager and the registered manager. We also looked at some of the records held in the service including the care files for five people. We observed the support people who used the service received from staff and carried out a brief tour of the building.

The inspection team who carried out this inspection consisted of two inspectors to answer five key questions; is the service safe, effective, caring, responsive and well-led. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found people’s care and support was not planned and delivered in a way that ensured their safety and welfare. This included care plans not being read by care staff and a lack of evidence to show people had been involved in planning their care. We saw staff assisting someone with their mobility using an unsafe and prohibited lifting technique. We also saw a person was not using a pressure relieving cushion they needed to use to protect their skin integrity. Another staff member was not aware someone had a soft diet due to the risk of choking on more solid food. We found there were systems in place to ensure people received their medication safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found staff were not always effective at meeting the care and welfare needs of all the people who used the service. We saw care staff did not attend promptly to people’s needs, for example we saw a staff member twice left a person they were supporting to attend to other people, and also when someone needed to go to the toilet.

Is the service caring?

Some people told us how they were treated in a sensitive and caring manner. A person said, “Staff check on me last thing at night, they bring me a hot drink.” However we found the care and welfare needs of people who used the service were not always met in this way. A person told us they felt some staff were a “little rough” when helping them. We saw people’s dignity was not always promoted for example someone was hoisted in front of other people in an undignified manner.

Is the service responsive?

There were sufficient care workers to respond to people’s health and welfare needs. But we found staff did not always responded appropriately to the care and welfare needs of people who used the service. A person said, “Sometimes I have to wait a long time to go to the toilet. We found one person did not have their hearing aid fitted to help with their hearing and another person who was cared for in bed did not have a call bell within their reach to summon for assistance if they needed it.

Is the service well-led?

We found staff were not as effective as they could be in order to meet people’s health and welfare needs. Staff told us they thought they were not as an effective team as they could be and felt more direction was needed.

Some staff also said they felt there was an atmosphere which made it hard to be able to say if anything was not right. A staff member said they did not feel able to raise or discuss difficulties between care and kitchen staff as they were not listened to.

We looked at the care plans and care delivery records for four people who used the service. We spoke with five people who used the service and one visiting relative. We spoke with six members of staff.

Our inspection found that the delivery of personal care and management of hydration was inconsistent, not effective and not managed well.

We found there were not enough staff to meet the needs of the people who used the service.

The majority of the people we spoke with felt that their needs were not always met in a timely way. Comments included, “It’s rough here now and it’s difficult to find someone to talk to. It’s difficult to be sociable with the staff because they are busy.” Another commented, “I want more staff that will talk to me.” And, “All the staff work hard all the time. They run around helping people. They are all good and care about people here, but there are just not enough staff on duty.”

We found that accurate and appropriate records were not maintained. The records we requested could not all be located promptly and security arrangements were not sufficient to protect people’s personal information.

During our visit to Beeches Care Home (Nottingham) on 14 February 2013 we spoke with ten people who used the service and some visiting relatives. People told us that they were treated well. One person said, "I wasn't sure about coming here, but it is the best thing I could have done." Another person said, "The staff are so kind, nothing is too much for them." Visitors told us that they were happy with the care their relatives received and they always felt welcomed into the home.

During our visit we saw people’s privacy and dignity was respected in the way staff spoke with them and provided care. On the day of our visit new communal furniture was being delivered and the old removed. Some of the people who used the service told us that they had been involved in choosing colours for the refurbishment. The delivery meant that peoples’ routines had been altered and they had to sit in wheelchairs in one area of the home for the morning. Everyone told us that the reason for the disruption had been clearly explained to them. Some people were enjoying the increased activity.

Staff were familiar with their responsibilities to keep people using the service safe and we saw information available which gave them clear instructions of their responsibility if they suspected an incident of concern within the home.

There were sufficient staff to meet the needs of the people using the service and staff were supported to attend training that enabled them to perform their roles.

This inspection took place on 27 and 28 January 2016 and was unannounced.

Accommodation for up to 54 people is provided in the home over two floors. The service is designed to meet the needs of older people. There were 48 people using the service at the time of our inspection.

At the previous inspection on 17 and 18 February 2015, we asked the provider to take action to make improvements to the areas of safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. We received an action plan in which the provider told us the actions they had taken to meet the relevant legal requirements. At this inspection we found that improvements had been made in all areas.

There is a registered manager and she was available during 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.

People felt safe in the home and staff knew how to identify potential signs of abuse. Systems were in place for staff to identify and manage risks and respond to accidents and incidents. The premises were managed to keep people safe. Sufficient staff were on duty to meet people’s needs and they were recruited through safe recruitment practices. Safe medicines and infection control practices were followed.

Staff received appropriate induction, training, supervision and appraisal. People’s rights were protected under the Mental Capacity Act 2005. People received sufficient to eat and drink. External professionals were involved in people’s care as appropriate. People’s needs were met by the adaptation, design and decoration of the service.

Staff were caring and treated people with dignity and respect. People and their relatives were involved in decisions about their care. Advocacy information was made available to people.

People did not always receive personalised care that was responsive to their needs. People were not being fully supported to follow their interests and take part in social activities. Care records did not always contain sufficient information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.

People and their relatives were involved or had opportunities to be involved in the development of the service. Staff told us they would be confident raising any concerns with the registered manager and that they would take action. There were systems in place to monitor and improve the quality of the service provided. The provider was meeting their regulatory responsibilities.