We carried out this unannounced comprehensive inspection on 01 and 02 October 2018.

Freshfields Nursing Home provides care for people who may require nursing care and for people who are living with dementia. The service provides care and accommodation for up to 38 people. On the day of the inspection 32 people lived in the home.

There was a manager in place, who was registered with the Care Quality Commission. 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 registered manager was due to retire at the end of 2018, therefore the provider had been pro-active and already employed a new manager, who had been working alongside the current registered manager for the past four months, to help ensure a smooth transition. The new manager would be applying to be registered with the Commission shortly.

At our last inspection in October 2017 the overall rating for the service was Requires Improvement because the recruitment of staff was not always carried out safely, and records relating to people’s medicines were not always accurate. In addition, people’s records did not clearly detail how their human rights were being protected in line with the Mental Capacity Act (2005); and the providers systems, to monitor the quality of care people received were not robust, in identifying when improvements were needed. Whist some improvements had been made, we found additional areas requiring action. Therefore, the rating of Requires Improvement remained.

People were not always protected from risks associated with their care. People had risk assessments in place to help guide staff to deliver safe care in line with people’s individual needs. However, people’s risks assessments, relating to their nutrition were not always accurate to help ensure people received safe support. We asked the registered manager to take immediate action to ensure one person received the correct meals, that records were updated to ensure their accuracy and staff knowledge and awareness improved.

People were not always supported by suitable numbers of staff who knew how to meet their needs safely and effectively. The registered manager told us, that whilst they had good numbers of nursing staff, they had experienced a difficult time, with large numbers of care staff recently leaving. They explained, recruitment was ongoing and that three new members of staff had recently been appointed.

People’s medicines were not always managed safety. People’s medicine administration records (MARs) were completed, but not always accurate. People received topical medicines (creams, pastes or lotions). However, these were not always dated upon opening, which meant staff could have applied topical medicines, which were out of date. There was no system in place to help determine if people needed their pain relief and/or whether it was successfully working; this is good practice especially with people living with dementia and/or who find communication difficult.

Overall, people were protected from abuse. However, whilst staff received safeguarding training and had access to safeguarding polices, some staff were not fully aware of the local authorities’ involvement in the investigation of allegations of abuse. The registered manager told us they would speak to staff to refresh their knowledge.

Overall, people were kept safe from environmental risks. All equipment was serviced in line with manufactures guidelines, the fire system was checked on a weekly basis and underwent an annual review to ensure its continued safety. However, on both days of our inspection we found two doors propped open, because batteries in fire release door guards were not working. We also found a large number of wh

The inspection took place on 20 and 23 June 2017 and was unannounced. Freshfields Nursing Home provides care for people who may require nursing care and for people who are living with dementia. The home provides care and accommodation for up to 38 people. On the day of the inspection 34 people lived in the home.

A manager was employed to manage the service who was registered with the Care Quality Commission. 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 on time from staff members who were trained to manage medicines safely. However, actions for improvement, identified in a medicines audit, had not all been implemented.

People’s healthcare needs were met but the care required to meet these needs was not always recorded consistently across people’s records and the care provided not always recorded.

Staff had a good understanding of how to support people who lacked the capacity to make their own decisions. However, records were not in place detailing how people’s capacity had been assessed. Following the inspection, the registered manager confirmed these records had been put in place.

Recruitment practices were in place but the career history of new staff members had not always been recorded in full, to help ensure they had the correct characteristics to work with vulnerable adults.

New members of staff completed an induction programme but records did not show how this had been tailored to ensure they received all the support they required at this time. Not all staff training was up to date. A senior manager told us they were working with the registered manager to ensure all required staff training was up to date.

Staff had not received as many formal supervisions as required by the provider’s policy. The registered manager explained they had now put systems in place to reduce the risk of this happening again.

Quality assurance systems were in place to monitor the quality of the service being delivered. However they had not identified all the gaps in quality identified during the inspection. Recent checks had not identified some windows and a gate did not have locks or restrictors on them. The registered manager told us learning and improvements had taken place as a result of this and they had reviewed security measures.

Relatives were positive about the service their family members received. Comments included, “I’m so pleased we chose for […] to live here. The atmosphere in the home is so positive and she tells me she’s very happy here”, “There’s nothing they can do better” and “I felt I was coming to a special place, which I was.”

People were treated with kindness and compassion in their day-to-day care. Staff were exceedingly caring and openly affectionate towards the people they were supporting. One staff member explained, “We aim to give the clients 100% dignity and respect, to be person centred and ensure they’re safe.”

Staff knew people well and used this knowledge to ensure people’s needs were met. One staff member told us, “People come first. People are our number one priority and giving each one person centred care. They’re like my grannies and grandads. That’s how I treat them.”

The registered manager and staff were keen to make people feel a part of the home. People were supported to make decisions and have as much control over their daily lives as possible. People and their relatives were involved in planning their own care and making decisions about how their needs were met. Care plans were in place that explained people’s needs and were reviewed regularly.

People’s friends and relatives were made to feel welcome at the service, consulted about their loved one’s care and preference

During our previous visit on 12 September 2013 we found that there was not a robust system in place to monitor the quality of service provision, particularly in relation to record keeping which could have put people at risk. During this visit we found significant improvements had been made.

We spoke with the registered manager and reviewed five care records in people's rooms. All care records we reviewed were accurately completed and reflected the care people were receiving.

We found the home had good systems in place to assess and monitor the quality of the service provided. These included reviewing any complaints made, a six monthly questionnaire which was sent to people and reviewing accidents and incidents on a monthly basis. The home acted promptly where action had been identified to improve the care people were receiving.

People told us "Yes, they respect my privacy and dignity, the little I have left anyway"; "I'm very well looked after"; "I have a nice clean room every single day."

We found that people at Freshfields Nursing home had their views listened too and they were able to contribute to the home during the regular coffee mornings which were held and they were able to complete questionnaires about the service.

We found care was assessed according to people's individual needs. Risk assessments were completed and regularly reviewed and external health professionals were consulted about people's care where necessary. A quiet room was being created for people and improvements to the home had occurred to meet the needs of people with sensory difficulties. People had the opportunity to engage in activities with the activities co-ordinator or could choose to spend time in their room.

We found the home was clean and there were regular checks and audits completed about all aspects of the home and equipment. The staff we spoke with were well trained and felt supported in their roles. Staff were encouraged to develop their skills through further training and staff had recently completed training in end of life care.

The home had a complaints policy and people felt able to raise any concerns they might have.

The people residing at Freshfields had dementia so not everyone was able to tell us about their experience of the home. We spent time observing what was going on in the home. This was to see what support people received from the staff and if this was treating people as individuals.

We saw calm and sensitive interactions by the staff with the people using the service. We saw staff encouraging and prompting people to make decisions to enable them to maintain their independence. When people needed assistance we found staff worked alongside at a pace suited to the person.

We found one area of the home had bedrooms overlooked by neighbouring properties. These rooms had no screening protection in place to ensure people's dignity and privacy were maintained.

We found staff knew what to do if they were concerned someone was at risk and if they were concerned about anything in the home. They were confident they would take appropriate action if they felt it was needed.

We found appropriate arrangements were in place to ensure the safe use and management of medicines.

We found people were cared for and supported by suitably qualified, skilled and experienced staff. There were not however effective management systems to monitor volunteers working in the home.

We found the Care Quality Commission was not notified about incidents that affected the heath, welfare and safety of people using this service so that where needed action could be taken.

The people that used the service at Freshfields had dementia and therefore not everyone was able to tell us about their experiences. We spent time watching what was going on in the home, looking at what support people got and whether they had positive experiences. Three people using the service were able to tell us about their experiences and we also spoke with visitors to the service and other social care professionals. There was friendly and sensitive interaction between staff and people using the service. Several people were seen to smile and respond positively when the staff engaged with them.

One person told us that they were able to have privacy when they wanted it and that staff listened to what they had to say. This person chose to spend time in their own room and staff respected this decision. Another person told us “They look after us very well here”.

Activities were provided during the morning and we saw that people were able to take part or decline depending on their preference.

We heard people being offered choices during coffee time and the lunch time meal. People were given visual prompts which enabled them to choose lunchtime meals, puddings and drinks. When staff assisted people with procedures such as helping them to move, staff clearly explained what they were doing and obtained consent where possible.

One visitor told us that, because their relative was unable to make decisions for themselves, they were involved in their care on their behalf. They said that they were kept well informed, telling us, “I am totally involved and get regular up-dates…”

A relative told us, “Staff understand Mum; they treat her so well…they listen to me and respond to her preferences and engage her”.

Visiting staff from social services told us about the good working relationship they had with the home and remarked on the good progress made by one person recently admitted to the home. Overall they were very happy with the care provided to people.

The Inspection took place on 6 and 7 October 2015 and was unannounced.

Freshfields Nursing Home (referred to as Freshfields) is registered to provide accommodation, nursing and personal care to 38 people.

The service had a registered manager 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.

During the previous inspection in June 2014 we asked the provider to take action to improve aspects of people’s care, the staffing levels, quality assurance processes and to inform CQC of important events that occurred at the home. The provider sent us an action plan informing us of the improvements that would be made in these areas. We found improvements had been made.

During the inspection people and staff were calm and relaxed; the environment was clean and clutter free. There was a happy, peaceful atmosphere. Comments from people, relatives and health professionals were very positive.

Care records were focused on people’s needs and wishes and encouraged people to maintain their independence. Staff responded quickly to changes in people’s needs. People and those who mattered to them were involved in identifying their needs and how they would like to be supported. People’s preferences were sought and respected. People’s life histories, disabilities and abilities were taken into account, communicated and recorded, so staff provided consistent personalised care, treatment and support.

People told us they felt safe and secure. People who were able to share their views told us they felt the home was safe. Staff described how they kept people safe through regular observation, maintaining their training and equipment checks. We saw staff were visible in the shared areas and responded promptly when people required assistance. Equipment to maintain people’s safety was visible where needed for example grab rails in bathrooms and accessible call bells.

Staff were kind, thoughtful and compassionate. People, relatives and professionals were exceptionally positive about the quality of care and support people received. Supportive, kind and respectful relationships had been built between people, family members, professionals and staff. Staff took pride in their roles and the care provided which made people feel special.

There was an open, transparent culture where learning and reflection was encouraged. People’s risks were monitored and managed well. Accidents and safeguarding concerns were managed promptly. There were quality assurance systems in place in all areas. Incidents related to people’s behaviour or well-being were appropriately recorded and analysed. Audits were conducted in all areas, action points noted and areas improved where needed. Feedback during the inspection was listened to and changes made immediately. Staff received good training and held lead roles in particular areas such as end of life care, infection control and dignity. Research was used to promote best practice in dementia and end of life care.

People were encouraged to live active lives and were supported to participate in community life where possible. Activities were meaningful and reflected people’s interests and individual hobbies for example bingo, dominoes, arts and crafts and group discussions. External activities and visits from school children were enjoyed. People were supported to maintain their spirituality.

People had their medicines managed safely. People received their medicines as prescribed, received them on time and understood what they were for where possible. Improvements to medicine management were made during the inspection to ensure everyone had clear plans in place to monitor all prescribed medicines and the temperature of medicines. People were supported to maintain good health through regular visits with healthcare professionals, such as GPs, dieticians and chiropodists.

People, friends, relatives and staff were encouraged to be involved in meetings held at the home and helped drive continuous improvements. Feedback we reviewed was excellent from families and health professionals. Complaints were investigated and responded to promptly. Listening to feedback helped ensure positive progress was made in the delivery of care and support provided by the home.

People and those who mattered to them told us the management team and staff listened and were approachable. People told us they did not have any current concerns but any previous, minor feedback given to staff had been dealt with promptly and satisfactorily. Staff described the management as open, very supportive and approachable. Staff talked positively about their jobs, understood their roles and felt valued.

Staff understood their role with regards to ensuring people’s human rights and legal rights were respected. For example, the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by staff. All staff had undertaken training in safeguarding adults from abuse; they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated.

Staff received a comprehensive induction programme and the Care Certificate had been implemented within the home. Sufficient staff were available to meet people’s needs. Staff were appropriately trained and had the correct skills to carry out their roles effectively. Training was used to enhance staff skills and the care people received.

People’s end of life wishes were known and specific details sought and recorded about how people wished to be cared for in their final days. Staff had completed the local hospice end of life care programme and acted as “champions” in this area.