This comprehensive inspection of the Blackdown Nursing Home took place on 31 October and the 8 November 2018. The first day of the inspection was unannounced. This meant that the provider and staff did not know we were coming. The second day of the inspection was announced.

Blackdown Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection. The service provides care and accommodation for up to 33 people who may require nursing care or who are living with dementia. On the first day of the inspection there were 31 people staying at the service.

The home is a detached property located in the small town of Mary Tavy, near Tavistock. There are two lounges and a large dining room for people to use. There is a large garden with views of surrounding countryside.

At the last inspection in August and September 2017 we found the provider in breach of four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had not ensured people’s care and treatment were appropriate and their needs and preferences met. People had limited opportunities to take part in activities suitable to stimulate and engage them. The provider had not ensured the premises were safe for use and did not have effective systems in place to assess, monitor and improve the quality and safety of the service provided.

The service was rated as requiring improvement overall and in the safe, responsive and well-led domains. The effective and caring domains were rated as good.

Following the inspection, the provider developed an action plan to ensure improvements were made. The service had also worked in partnership with the local authority quality assurance and improvement team (QAIT) to improve their systems and processes and put in place a service improvement plan (SIP). At this inspection we found the provider had completed the actions and were no longer in breach of the regulations. They were continuing to use their SIP and had prioritised actions needed.

There was 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. The registered manager had been registered with CQC in July 2017.

The registered manager had put in place comprehensive quality assurance systems which identified when improvements were needed. The providers regularly visited the service and undertook quality checks and were kept informed about the running of the service.

The provider had made improvements which ensured people were protected from the risks of unsafe and unsuitable premises. Fire safety precautions were in place and followed. There were plans and procedures in place to safely deal with emergencies. Checks and audits were undertaken to ensure the environment was safe. Learning from incidents and accidents took place and appropriate changes were implemented.

There were appropriate infection control processes in place. The home was clean and homely. People received their prescribed medicines on time and in a safe way. Staff ensured people were referred promptly to health professionals when required.

The activity provision at the home had improved. A full-time activity person had been recruited. They had developed a programme of activities which people said they enjoyed doing. The programme included activities which were assessed and meaningful to people.

People felt safe living at the home and with the staff who supported them. There were sufficient staff on duty to meet people’s needs and keep them safe. Staff were kno

Blackdown Nursing Home provides care and accommodation for up to 33 people who may require nursing care or who are living with dementia. At the time of the inspection 31 people were living at the service.

The first day of the inspection was unannounced. We informed the registered manager of the date of the second day of the inspection so they could be present.

At the last inspection in December 2016 we found three breaches of regulation and the service was rated as requiring improvement overall and in the safe, effective, responsive and well-led areas. Caring was rated as good. As a result, requirements were made to ensure the service complied with the Mental capacity Act; to ensure risks to people’s health and safety were properly assessed, recorded and acted upon and aspects of medicines management were improved. A requirement was also made to ensure the quality monitoring systems in place were improved.

Following the inspection, the provider had developed an action plan to ensure improvements were made. The service has also worked in partnership with the local authority quality assurance and improvement team to improve their systems and processes. Prior to this inspection we met with the provider and registered manager to review their action plan. We found some improvements had been made at this inspection. However further improvements were still needed.

This comprehensive inspection was brought forward as prior to this inspection the registered manager had notified us of two incidents, which resulted in harm to people using the service. We wanted to ensure risks to people’s health and wellbeing were appropriately managed. We also received anonymous concerns about practice which indicated people’s preferences about when personal care was delivered may not be met.

A new manager was appointed at the service in May 2017 and registered with the Care quality Commission in July 2017. 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 received their medicines safely and when they needed them. However some medicine practices could be improved.

The registered manager had introduced a range of audits and systems to enable them and the provider to monitor the quality of the service provided. These were beginning to have an impact. However, the quality assurance system was not always effective because issues identified at the inspection had not been recognised. Improvements were needed to ensure people were protected from the risk of fire and that all parts of the premises were clean and odour free.

Improvements were required to ensure people’s daily personal care was always personalised and responsive to their needs. Mealtimes were not always well organised or sociable occasions. The physical environment of the service had not been adapted to meet the particular needs of people living with dementia and maximise their independence. People living with dementia would benefit from activities based on current good practice guidance for dementia care.

People said they felt safe. Improvements had been made to ensure assessments identified people’s specific needs or risks, and showed how risks could be reduced. There were systems in place to review accidents and incidents and the registered manager ensured action was taken where necessary to reduce future risks.

Staff had been trained to recognise abuse. The registered manager and staff understood their responsibilities to report any concerns. There were sufficient staff to ensure people’s needs were met, when there were no unplanned staff absences. Staff had opportunities for regular training to enhance their skills and knowledge.

Improvements had been made to ensure people’s ri

The inspection took place on 15 and 19 December 2016 and was unannounced. Blackdown Nursing Home provides care and accommodation for up to 33 people who may require nursing care and for people who are living with dementia. On the day of the inspection 32 people lived in the home.

A registered manager was employed to manage the service. 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.

Our inspection in November 2015 found a breach of the regulations. People did not always give consent for care and treatment and the provider did not act in accordance with the Mental Capacity Act 2005. At this inspection we found staff told us they often made decisions in people’s best interests and records showed best interests decisions had been made on behalf of people. However, mental capacity assessments were not always in place to identify why the person was deemed unable to make the decision themselves, the rationale for decisions made in people’s best interests was not recorded and people’s care plans did not always contain information to guide staff about people’s preferences. Staff told us they sought consent from people but this was not always observed to be the case during the inspection.

People received their medicines on time from staff who were patient and understood their needs. However, people’s medicines were not always stored or disposed of safely and there was no audit in place to help ensure medicines administration followed best practice. Following the inspection, the provider sent us details of a new medicines audit to be used in the home.

People were observed to have their healthcare needs met but risk assessments were not always clear or reflective of people’s current needs; and actions taken to help mitigate any risks were not always recorded. Tools to monitor people’s health needs were not always complete or up to date and action was not always taken in response to possible concerns, for example weight loss or regular falls.

A record was kept in people’s rooms of their likes, dislikes and preferences but it was not clear that staff were using this information to provide meaningful activities for people. There was a programme of planned entertainment for people but outside of these times people were observed to have little to keep them cognitively active.

People and relatives described the service provided as being particularly caring and spoke highly of the staff and the support they provided. The provider had a clear philosophy that people should be treated as family members. This was reflected in the ways staff spoke about their work and comments received by relatives. Compliments received by the service stated, “I never ever saw anything but love for all the patients under your care” and “Thank you for the wonderful care and love you showed mum”

People were supported by staff who were knowledgeable about their needs and had regular training to update their skills and knowledge. Staff told us they felt well supported by the provider and registered manager. One member of staff told us, “If there’s something I’m unsure about, I can ask the manager or the owner for advice. I feel confident I can ask.”

People told us they felt safe using the service. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected.

People were kept safe by suitable staffing levels. Relatives told us there were enough staff on duty and we observed unhurried interactions between people and staff. This meant that people’s needs were met in a timely manner. Recruitment practices were safe. Checks were carried out prior to staff commencing

When we did our inspection on 18 March 2013 we found that the home was not compliant with five of the seven outcomes we inspected and this was having an impact on people's care despite many positive aspects of the care provided.

During this visit we found that the standard of cleanliness and infection control was improved. The premises were safer and afforded people more safe outdoor space. However, further work was needed as the extensive grounds remained mostly unavailable to people. Time out of doors without staff or family remains impossible without risk. One person said "Much better that the path is mended now."

The standards of care and treatment were high and there was evidence of nurse expertise which improved people's lives. People enjoyed engagement with staff instead of restrictions of movement from the lounge as we had seen at our last visit. We saw one person laughing, sharing a game with staff. Care plans were more person centred and included social needs and how they would be met. Most people were unable to tell us about the home but people's family told us "Marvellous. Everything she asked the staff for she got". This meant people were treated with respect.

For a second time we found that people were not always consenting to their care and treatment. We found staff were not following the legal requirements relating to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards when people were unable to consent.

We carried out an unannounced inspection on the 18th March 2013. There were three qualified nurses on duty and six care staff. We spoke with five members of staff and three relatives who were visiting. Two people who lived at the home were able to share their experiences with us. We also spoke with a local GP who attended to some of the patients at the home.

People told us, "it's wonderful here", "I'm well looked after and there is a feeling of friendliness". One person said, the food is "excellent - I'm putting weight on here!". Staff told us, "there is always someone to talk to". Relatives said, "staff do their best".

We found people were not always involved in decision making about their care and treatment. We found staff were not following the legal requirements relating to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

We found people's dignity, privacy and independence were not always upheld. We found people's care could be more individualised and promote positive risk taking and independence.

We found there were not systems in place to monitor cleanliness and hygiene in relation to equipment.

We found people were unable to move freely around the home and grounds because there were areas which were not safe for them alone.

We found people were cared for by staff who were trained and supported to deliver care and treatment safely.

We conducted an unannounced visit to Blackdown Nursing Home on 31 August 2011 spending six hours there. Most people were unable to make direct comments about their care so we spent a lot of the time observing what happened, especially in the two lounge areas where the majority of people spend their day. This gave us much information about people's experience of living at Blackdown Nursing Home. We also spoke at length to one person who uses the service, the family of two people, the manager and three care workers.

People who use the service are cared for as individuals of worth. Although most have difficulties in communicating their needs due to their condition, care workers try to involve them in decisions. Where this is not possible family or other representatives are consulted. Legal safeguards, for people unable to make decisions about their own welfare, are known by the manager and a senior nurse but not fully implemented. This is being progressed.

People generally receive respect and kindness. Their individual needs and ways are known to the manager and care workers who work with external professionals where they feel advice is required. A consistent staff and management provides people and their families with confidence.

People are safeguarded from abuse through the culture of the home, staff training and information.

Care workers are well supported both formally and in their everyday work. All required safety training is provided and care workers are encouraged to undertake qualifications in care. However, all care and nursing should be based on current research and best practice guidelines and the extent of the current training at Blackdown does not ensure this will be the case.

There are systems in place to monitor the quality of the service at Blackdown and people regularly have the opportunity to meet and have discussion with the provider and manager. There has been upgrading of the environment, some at people's request and some which helps people remain independent and safe. However, there remains many ways in which the environment could be further adapted to promote independence, one example being pictures for description.

This inspection took place on 6, 9 and 12 November 2015.

Blackdown Nursing Home is a registered home for a maximum of 33 people. The home offers nursing care for people with a variety of physical and mental health needs including advanced dementia. There were 33 people living at Blackdown at the time of this inspection.

Our inspection in May 2015 found five breaches of the regulations. People’s legal rights were not upheld, care and treatment was not designed around people’s needs and preferences, records were not always clear or complete and risks were not always assessed and managed. The provider sent us an action plan following that inspection. We felt the action plan was not sufficiently detailed but the registered manager was not available to discuss the plan at the time. This inspection found there was improvement at the home but one breach remained.

The service had a registered 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 of Health and Social Care Act and associated Regulations about how the service is run.

Staff did not comply with the Mental Capacity Act 2005 (MCA). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. This was not being done and had led to staff making unlawful decisions on other people’s behalf.

Deprivation of Liberty Safeguards (DoLS) provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. The required steps to gain the legal authority to subject people to continuous supervision and control, including preventing them from leaving, were being taken.

Staff had good knowledge of people’s backgrounds, behaviours and day to day needs. More information about each person, as an individual, was recorded in people’s care files. However, people had very little to stimulate their interest which might bring back important memories and give them feelings of well-being and contentment. This might include objects which remind them of important times in their past life. We recommend that this service explore and follow the relevant guidance on how to make environments, and activities used by people with dementia more ‘dementia friendly’.

The home appeared clean but there was odour of urine in some areas of the home.

The provider had frequent contact with the home and provided resources as necessary. People and their families expressed a lot of confidence in the registered manager (Matron). However, Matron not having enough time to fulfil her management duties adversely affected the running of the home and her responsibility to meet legal requirements.

The staff and management at Blackdown Nursing Home were kind and caring. People told us, “Without exception staff are lovely; kind and caring” and “Always friendly and helpful.” The standard of nursing and personal care promoted people’s health because there were enough staff and they were trained and supervised to ensure standards were met.

Assessment and management of risk and servicing and maintenance of the premises provided a safe environment for people.

People were protected from abuse. Recruitment practice meant new staff were checked before starting work at the home and there were enough staff to keep people safe. The management of individual risks to people’s health and welfare helped keep people safe and healthy.

New care files were helping staff to find information more easily and a computerised record system was about to be introduced which the registered provider felt would improve recording.

People liked the food and they were supported to maintain a healthy and varied diet. Concerns were followed up and specialist dietary needs were met.

Medicines were managed so people received their prescribed medicines in a safe way and when needed.

Complaints the service had received had been investigated and where it was felt necessary an apology or compensation was given. People felt confident they could take any concern to the registered managers, provider or staff members and it would be followed up.

People and staff’s views about the service were sought and plans to improve the service took their views into account. Plans for improvement, such as monitoring the service were started but were not yet embedded.

We found one repeat breach of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.