This inspection was carried out on 10 July 2018 and was unannounced. At our last inspection on 6 and 13 December 2017 the service was rated as Inadequate overall and was placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the provider demonstrated to us that improvements have been made and was no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At the previous inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two of the breaches were repeated on the service’s previous inspections.

At this inspection we found the provider had made overall improvements and met the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We however found concerns around people’s pressure relieving equipment and found the provider’s quality assurance processes needed embedding to demonstrate the improvements can be sustained. The service therefore was rated as Requires Improvements in Safe and Well-led domains and improved to Good in Effective, Caring and Responsive. The overall rating of the service is Requires Improvement.

Ramping Cat Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide care for up to 39 older people. On the day of the inspection there were 17 people living at the service.

There was no registered manager running 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. Following the departure of the registered manager earlier this year, the former service’s deputy manager stepped up to become the new manager. They told us they were applying to CQC to become the registered manager.

People told us they were safe and the management of medicines had improved. Risks to people’s well-being were managed. However, risks in relation to pressure areas were not always managed well. We have made a recommendation for the provider to refer to a national good practice guidance when formulating people’s care plans around pressure relieving equipment. There was sufficient staffing in place to keep people safe and people experienced prompt assistance. There was evidence where things went wrong this was now used as an opportunity to improve the service for people.

People were supported to maintain a good nutrition and were offered food that met their dietary preferences. Staff worked with external professionals to ensure people’s healthcare needs were met. We received positive feedback from professionals that commented positively on improvements made by the new manager.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People’s rights to make own decisions were respected.

People were cared for by the staff that respected people’s individual needs, including equality and diversity. People’s dignity, privacy and confidentiality were maintained.

People's care plans provided guidance to staff on how people needed to be supported. People and their relatives knew how to complain and told us concerns were d

We inspected this service on 6 and 13 December 2017. Ramping Cat Nursing Home provides personal and nursing care and accommodation for up to 39 older people. On the day of our inspection there were 34 people using the service. That included six people staying in Hub beds. Hub beds are placements following a hospital stay when people await a care package to be put in place for when they go back to their own homes.

The service has not been fully compliant with all regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations and has been rated as not well-led since December 2014. The provider had been previously issued warning notices around their poor governance following our inspections in September 2015 and March 2016. Systems and processes to monitor and improve the quality of the service have remained ineffective. The consistency of the quality of the governance systems operated by the provider has been a repeated concern. Sufficient improvements have not been made and sustained to ensure the provider was able to meet the requirements of the regulations.

As a result of this people have not always been protected from a risk of harm. The provider was issued a warning notice around poor medicines management in June 2015. This was followed by subsequent requirement notices in relation to other aspects of medicine management and safety. Ramping Cat Nursing Home was rated Requires Improvement in the Safe domain in all of the last five consecutive inspections. The service has been repeatedly rated as not always safe since December 2014.

At the last inspection on 22 November 2016, we found a repeated breach of Regulation 17 in respect of good governance and quality assurance systems. We asked the provider to take action to make sure their quality assurance systems became effective. At this inspection we found the provider had again failed to make and sustain sufficient improvements to the service to ensure their governance systems remained effective.

People were still not always protected from the risk of harm such as a risk of choking and malnutrition. The provider did not ensure people were protected from the risk of harm in case of an emergency such as a fire. People's medicines were still not always managed in line with the good practice guidance. The provider did not ensure the necessary improvements were made, sustained and lessons learned where necessary.

We also identified further concerns such as staff did not always have a good understanding of equality and diversity and did not always provide a meaningful approach to people.

There was a registered manager in post. 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 2008 and associated Regulations about how the service is run.

People were supported to have control of their daily lives and we observed staff giving people choice. We however found some best interest decisions were not always made in line with good practice guidance. We identified when complaints could not be successfully resolved at the service’s level there was a lack of provider’s involvement to ensure the complainant’s satisfaction.

There were sufficient staff and staff received ongoing training and supervision however this was not always fully effective. Staff were encouraged to attend team meetings and they complimented the team work. The provider followed safe recruitment practices.

People complimented the food and the observed meal service was positive. People were supported to access external health professionals when required. We received positive feedback from external professionals that worked with the team at the service.

People that were supported by the team at the service told us they felt safe. People told us they received service that met their needs and

We inspected this service on 22 November 2016. This inspection was unannounced. Ramping Cat is a care home with nursing providing care and accommodation up to 39 older people. On the day of our inspection there were 33 people living at the home. That included six people staying in ‘hub’ beds. These were short term placements developed as an assessments stage following a hospital discharge.

At our last inspection on 30 and 31 March 2016 we found the systems and processes the provider had in place to assess, monitor and improve the quality and safety of services provided were not effective and did not identify issues we found. Additionally the provider had not ensured people were prevented from receiving unsafe care and treatment and protected from avoidable harm or a risk of harm. We also found there were no appropriate systems in place to ensure care and treatment was only provided with the consent of the relevant people.

Following our inspection on 30 and 31 March 2016 we issued a warning notice to the registered manager and the provider to tell them they must take action to ensure their audits and governance systems were effective. Additionally we asked the provider to send us an action plan telling us how they would meet the standards relating to the other areas of concern.

At this inspection we found some improvements had been made. For example, we found the medicines were stored securely, locked in the drugs room and people’s topical medicines were managed safely. The registered manager ensured staff received training in moving and handling and staff used safe techniques. The registered manager introduced ‘Mental Capacity care plans’ that outlined people’s ability to consent to day to day support and they were in a process of sourcing a new format to record people’s capacity assessments in relation to specific decisions. Staff were aware of the principles of the Act and how to ensure people’s rights in relation to making their own decisions were respected. We recommended the provider ensures that recording of capacity assessments and best interests decisions is in line with the Mental Capacity Act 2005 code of practice.

We also found the provider and the registered manager met most of the warning notice however we identified some of the quality assurance processes were not always effective and required further embedding. For example, although staff carried out regular medicines audits we found the audits did not consider the areas where we identified further concerns.

There was a registered manager in post. 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 2008 and associated Regulations about how the service is run.

There were enough staff on duty to meet people’s needs. Throughout the day we observed people were assisted promptly and with no unnecessary delay. The registered manager followed safe recruitment systems when employing new staff. Staff received training relevant for their roles and they told us they were well supported by the management.

People were supported by staff that respected their privacy and dignity and promoted their independence. People were involved in making decisions about the support their received.

People were supported to meet their nutritional and hydration needs. People told us they liked the food provided and commented positively on the quality of meals. Staff ensured people were supported to access health professionals when needed.

People’s care documentation provided the details required for the team to enable them to meet people’s individual needs and preferences. People had access to activities of their choice.

The people and the relatives we spoke with knew how to make a complaint if needed and would feel comfortable speaking to staff if they had concerns. The registered

We inspected this service on 30 and 31 March 2016. This inspection was unannounced. Ramping Cat is a care home with nursing providing care and accommodation to 39 older people older people requiring personal care. Some people at the service were living with dementia. On the day of our inspection there were 27 people living at the service. This included six people who were staying on a short term placements as an interim stage between hospital stay and further assessment needs of their care.

At our inspection of 1 September 2015 we found the provider did not always have effective systems to monitor the quality of the service people received and people's care records were not always current and accurate. We also identified there were no 'as required' medicine protocols in place and there was a lack of medication competencies for the staff. We also found not all allergies were recorded, there were issues noted around records found on Medicines Administration Records (MAR) that related to use of incorrect codes and people's medicines were not always stored appropriately. We also identified staff did not always receive the training required to meet people’s needs and the medication competency observations had not been carried out to ensure their practices were safe. Additionally, we found the environment was not always safe and people were at the risk of undue harm.

Following our inspection on 1 September 2015 we issued a warning notice to the registered manager. We told them they must take action to ensure their audits and governance systems were effective and records were accurate. Additionally we asked the provider to send us an action plan telling us how they would meet the standards relating to the other areas of concern.

At this inspection we found some improvements had been made. We found the issues around environment had been addressed and the staff training was ongoing. The provider improved their systems to manage people's medicines however we identified a lack of control of people’s topical medications.

The service was not always safe. We identified provider did not ensure people were prevented from receiving unsafe care and treatment and from avoidable harm or a risk of harm.

We identified the provider’s systems to monitor the quality of the service were not effective. The concerns we found on our inspection in March 2016 had not been identified by the provider through their own quality assurance processes. Additionally, we identified where the issues had been identified by the provider these were not addressed.

There was a registered manager in post. A registered manager is a person who is 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 2008 and associated Regulations about how the service is run.

People told us they felt safe living at Ramping Cat Nursing Home. People’s relatives also told us they felt the service was safe. Staff were aware of their responsibilities in keeping people safe from harm and suspected abuse.

There were enough staff to meet people’s needs. People were assisted promptly and with no unnecessary delay, we noted that the call bells were answered in a timely manner. The service had appropriate recruitment system in place that helped the management make safer recruitment decisions when employing new staff. The staff told us they felt supported however the supervision process required embedding to be more effective.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS enable restrictions to be used in a person’s support, where they are in the best interests of a person who lacks capacity to make the certain decision themselves. We identified the registered manager made referrals to the supervisory body. However no evidence was available tha

We inspected The Ramping Cat Nursing Home on the 1 September 2015. The Ramping Cat Nursing Home provides residential and nursing care for older people over the age of 65, a number of the people living at the home were living with dementia. The home offers a service for up to 39 people. At the time of our visit 31 people were using the service. This was an unannounced inspection.

We last inspected in June 2015 when we carried out a focused inspection to see if the provider had taken action following our December 2014 inspection. We found people did not always receive their medicines as prescribed. We issued the provider and registered manager with a warning notice, requiring they address our concerns by 31 July 2015. At this inspection we found improvements had been made, however we still had concerns around how people's medicines were stored and managed. 

There was a registered manager in post on the day of our 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.

The service did not always manage people's medicines safely. Protocols for the administration of ‘as required’ medicines were not available. These protocols provide guidance as to when it is appropriate to administer an ‘as required’ medicine to ensure people receive their medicines in a consistent manner.

The environment was not always safe. Some rooms which posed a danger to people, staff and visitors were not always secured. There was on-going building work and some wires in the building were loose and window restrictors were not always working or in place.

Staff received supervision however no staff were observed or had their competencies assessed. Staff told us they felt supported by the provider and manager. Not all staff had knowledge of the Mental Capacity Act or Deprivation of Liberty Safeguards.

People were cared for by supportive and compassionate staff. People told us they valued the staff and we observed many kind and caring interactions between staff and people.

People spoke positively about the support they received around their healthcare needs. People were supported with their dietary needs and spoke positively about the food they received.

People and their relatives told us they knew how to make complaints. People told us their concerns were acted on, however the registered manager and provider were unable to identify trends in people's complaints or concerns as there were no clear systems for documenting concerns.

People's care plans were not always current and accurate. Two people staying at the home did not have care plans in place. Staff however knew people well, and people spoke positively about the support they received.

People were not always involved in planning their care. People who wished to self administer their own medicines, were not supported to do so. Other people told us they were involved in their care, with one person telling us how they choose how staff assisted them.

The registered Manager had developed systems to monitor the quality of the service, however these were not always effective or consistently being used. People and their relatives views had been sought, however there was no evidence these views had been acted upon.

Some concerns raised following recent safeguarding concerns had not been acted upon or monitored by the registered Manager. Some concerns we reported to the registered manager during our inspection were not addressed. Additionally, staff were not aware of the culture within the home, and not all staff felt involved in making decisions within the service.

Staff protected people from the risks associated with their care. Staff had clear guidance to protect people from pressure area damage.

There were enough staff deployed by the provider to meet people's needs. People told us they felt safe in the home, staff had a good understanding of safeguarding and the service took appropriate action to deal with any concerns or allegations of abuse.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We inspected Ramping Cat Nursing Home on 11 June 2015. Ramping Cat Nursing Home provides nursing care for people over the age of 65. Some people at the home were living with dementia. The home offers a service for up to 39 people. At the time of our visit 28 people were using the service. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 23 December 2014. Three breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to management of medicines, people’s care records and the quality assurance of the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Ramping Cat Nursing Home on our website at www.cqc.org.uk

There was a registered manager at 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.

People were at risk of not always receiving their medicines as prescribed. Nursing staff did not always record when they had given people their medicines. Additionally as nursing staff did not always keep an accurate record of people’s prescribed medicines it meant people could not be reassured they had received their prescribed medicines.

Medicines were not always stored in accordance with manufacturer guidelines. The temperature of the room in which medicines were stored, on a number occasions exceeded the recommended temperature. Following the inspection the provider informed us a cooler unit was being provided.

Staff kept a current and accurate record of the care people received. Care plans accurately reflected people's needs and were written using an assessment carried out by nursing and care staff.

The provider and registered manager had developed systems to monitor the quality of service; this enabled them to identify any areas of concern and make improvements. The registered manager and provider were planning to implement more systems to improve the monitoring of the quality of care. People and their relative’s views were sought to help inform improvements to the service.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

We visited Ramping Cat Nursing Home on 23 December 2014. Ramping Cat Nursing Home provides nursing care for people over the age of 65. Some people at the home were living with dementia. The home offers a service for up to 39 people. At the time of our visit 23 people were using the service. This was an unannounced inspection.

We last inspected in January 2014 when we followed up on actions we had asked the provider to take in relation to care and welfare and supporting workers. We found action had been taken.

In December 2014, there was a registered manager in post at 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.

People had not always received their prescribed medicines on time and people’s medicine administration records were not always accurate. There were no medicine audits and the registered manager had not identified issues with people not receiving their medicines as prescribed.

Peoples’ care plans did not always provide clear details for staff to follow. The registered manager had identified risk, but no clear guidance was documented to protect people from these risks. However, despite records being poor, staff we spoke with had a good understanding of people’s needs.

The registered manager and provider did not always have effective systems in place to monitor the quality of the service they provided. Both the provider and registered manager had a plan in place to ensure systems would be introduced. This included the recruitment of a deputy manager and more nursing staff. Neither the registered manager nor the provider had informed us of all deaths that had occurred at the home as they are required to do.

People benefited from positive relationships with care staff and nurses. People were treated with kindness and compassion. Staff clearly knew the people they cared for, their needs and preferences.

Staff had good knowledge of safeguarding and there were enough staff in the home to meet the needs of people. Staff had access to training such as Mental Capacity Act 2005 (MCA 2005 provides the legal framework to assess people’s capacity to make certain decisions, at a certain time) training, dementia and moving and handling. However not all staff had awareness of the Deprivation of Liberty Safeguards. Deprivation of liberty safeguards is where a person can be deprived of their liberty where it is deemed to be in their best interests or for their own safety.

One person was being deprived of their liberty in order to keep them safe. The registered manager had made an application to the regulatory body to deprive them of their liberty.

People had access to activities and food, which they enjoyed. People and their relatives felt their views were respected and were happy they could raise concerns to the registered manager or provider.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We carried out this visit because when we last visited in September 2013 we identified some concerns. We noted that people were not protected from the risk of unsafe moving and handling techniques. We noted that staff did not always receive appropriate supervision. We found that care worker and nurse’s employment records were not kept securely. The provider sent us an action plan in response to our visit. We found that the provider had taken appropriate action.

People told us they were happy with the service they received. One person told us, "I'm happy here. Wouldn't change it, they know exactly what I need". Another person told us, "I'm looked after. I feel safe".

Care workers and nurses received appropriate professional development. We spoke with two care workers, the chef and a nurse. We asked staff if they had access to training. One staff member told us, “there is lots of training. We’ve had a lot of training recently on health and safety and moving and handling”.

We noted that records relating to staff and people who used the service were safely secured. People’s care files were secured in the home’s clinic room. Staff recruitment, supervision and training records were secured in a locked cabinet. We saw that when records were not needed this cabinet was locked.

We spoke with five people who used the service, four care workers and one nurse. At the time of our visit 13 people lived at the home. We looked at six people’s care files. We reviewed other documents made available to us by the registered manager, such as staff files and training records.

People were complimentary of the staff and how they were respected and involved. One person told us, “Staff are lovely, they have a lot of respect for me and what I need”. Another person told us, “Staff are very friendly and I get lots of choice.”

People were not always protected against the risks associated with their physical well-being. We observed poor moving and handling practice by some staff.

Staff we spoke with felt supported. One care worker told us, “I like working here. I feel supported, we are very well managed”. Another care worker told us, “If we have any worries we can talk to the manager anytime”.

People and staff we spoke with told us they felt able to raise concerns. One relative commented in their survey, “any concerns we have are addressed straight away and we are kept informed of what is happening”. We also observed where a person had raised their concerns about two male workers being on at night and the registered manager made changes accordingly.

People’s records were not always kept securely and night staff did not all receive appropriate supervision and appraisal.