About the service: Berwick Care Home provides accommodation, nursing and residential care for up to 60 people, some of whom have a dementia related condition. There were 34 people living at the home at the time of the inspection.

People’s experience of using this service: People and relatives were positive about the caring nature of staff. One relative said, “I wouldn’t hesitate to recommend it to anyone. I would be quite happy to live here myself.”

People were treated kindly and with compassion. Staff spoke positively about the people they supported. They said they would be happy for their relatives to live at the home because of the standard of care provided.

Effective systems were in place to ensure people’s safety. There were no ongoing safeguarding investigations. Risks were assessed and monitored, sufficient staff were deployed and safe recruitment procedures were followed.

A range of activities were organised to help ensure people’s social needs were met.

People, relatives and staff were complimentary about the changes the registered manager continued to make at the service. The service was going through a period of change. Another care company oversaw the management and day to day running of the service. They had regular meetings with the provider to feedback the results of their audits and checks.

Rating at last inspection: Requires improvement (previous report published 28 February 2018).

Why we inspected: This was a planned inspection in line with Care Quality Commission scheduling guidelines for adult social care services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

The inspection took place on the 10 and 16 January 2018 and was unannounced. This meant that the provider and staff did not know we would be visiting.

At our previous inspection in September 2017, we found five breaches of the Health and Social Care Act 2008. These related to safe care and treatment, safeguarding people from abuse and improper treatment, meeting nutritional and hydration needs, staffing and good governance. We placed conditions on the provider’s registration to minimise the risk of people being exposed to harm. This included imposing a suspension of admissions to the home. We rated the service as inadequate.

The provider sent us a weekly action plan to inform us what action they were taking to improve. They also sent us the required information we had requested in relation to the conditions which had been placed upon them.

At this inspection, we found the provider had met the conditions and was compliant with all the regulations we inspected. Following the inspection, we agreed that the conditions placed upon the provider’s registration, including the suspension of admissions could be removed. The provider sent us details of how they would safely manage and monitor new admissions to the service to ensure sufficient staff were deployed. Although improvements had been made in all areas, further improvements were required in certain aspects of the service.

Berwick Care Home is a ‘care home’ People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 50 people. There were 27 people living at the home at the time of the inspection.

A new manager was in place. She had started at the service seven weeks prior to our inspection. People, relatives and staff spoke positively about her leadership. She had commenced the application process to become a registered manager. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected.

There were sufficient staff deployed. Agency staff were still used at the service and the provider tried to ensure the same agency staff were requested for consistency. Some staff raised concerns about future staffing levels after the suspension was lifted. We have made a recommendation that staffing levels are kept under review.

There were safe systems in place to receive, store, administer and dispose of medicines.

Checks and tests had been carried out on the premises and equipment to ensure they were safe. The decor in certain areas of the home was worn and some of the paintwork was damaged. This damage meant it was difficult to keep these areas clean. In addition, not all aspects of the environment met best practice guidance relating to supportive environments for people living with dementia. We have made a recommendation about this.

There were risk assessments in place where people had been identified as being at risk. These had been reviewed and updated following our last inspection. We noted that these were now accurate and reflected people’s needs.

Staff told us that they felt supported in their roles. There was a supervision and appraisal system in place. However, clinical supervision had not yet been introduced. Clinical supervision is a formal process of professional support and learning which enables staff to develop their knowledge and competence. The skills and competencies of agency staff and permanent staff were not always available. The manager told us that these issues were being addressed. We did not have any concerns about the skills of nursing staff on duty at the time

This inspection took place on 12 and 13 September 2017. The visit on the 12 September was unannounced. This meant that the provider and staff did not know we would be visiting. We carried out a further announced visit to the home on 13 September 2017 to complete the inspection.

Ultima Care Centres (No 1) Limited had taken over the home in September 2016. This was our first inspection of the service under the new provider.

Berwick Care Home is a 50-bed home providing residential, nursing and dementia care. There were 41 people living at the home at the time of the inspection.

There was a manager in post who had applied to register with the Care Quality Commission as a registered manager. She had commenced work at the home in May 2017. A registered manager is a person who has registered with 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 and associated Regulations about how the service is run.

The manager was not a nurse and there was no clinical lead in post since the previous clinical lead had left. This meant there was no permanent professionally qualified member of staff to oversee the nursing care of people.

Following our inspection, the nominated individual informed us that the manager had resigned and they were in the process of identifying a suitable replacement. He told us that a clinical lead had been appointed and was due to commence employment on 9 October 2017.

The majority of nursing care provided was delivered by agency nurses. Records of their clinical skills and competencies were not available. There was a lack of evidence to demonstrate that staff were provided with up to date and accurate information which enabled them to meet people’s needs consistently, safely and effectively.

Most people, relatives and staff told us that more staff were required. The provider did not use a staffing tool linked to people’s dependencies to assess staffing levels. We found that there were insufficient suitably qualified, competent, skilled and experienced staff to meet people’s needs.

Safe recruitment procedures were followed. People told us that they received their medicines as prescribed. This was confirmed by the medicines administration records we viewed.

The training matrix contained gaps against certain training courses. It was unclear which training staff needed to complete. There was currently no system in place for clinical supervision.

Diet and fluid charts contained omissions and it was not always clear whether some people were receiving a suitable diet which met their needs.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The manager had submitted Deprivation of Liberty Safeguards [DoLS] applications in line with legal requirements. There was a delay in the authorisation of applications for people who had previously resided in Scotland. This was due to external factors and was not due to any oversight by the provider.

Evidence of consent was not always included in people’s care files.

We observed positive interactions between staff and people. Staff displayed warmth when interacting with people. They were very tactile in a well-controlled and non-threatening manner.

An effective system was not in place to monitor the quality and safety of the service and mitigate the risks relating to the health, safety and welfare of people. Records relating to people, staff and the management of the service were not always accurate, complete or securely maintained.

Following the inspection, we wrote to the provider to request a detailed improvement plan which stated what action they had taken or planned to take to address the concerns and shortfalls identified during the inspection.

We referred all of our concerns about the service to Northumber