This inspection took place on 21 and 22 May 2018 and was unannounced. At our last inspection we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The management of medicines was not always safe and the stock of controlled medicines indicated medicines were missing. Records relating to people’s care were not always up to date and accurate. The provider sent an action plan telling us how they would address these concerns. At this inspection we found improvements had been made and there was no longer a breach.

Cams Ridge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Cams Ridge provides nursing care to older persons. Cams Ridge can accommodate up to 51 people in one adapted building. The home has two floors accessed via stairs or a lift, three communal areas and a large garden where people could choose to spend their time. At the time of the inspection the registered manager told us they had changed some of the bedrooms to make more space for people and Cams Ridge was now able to provide accommodation to 43 people. At the time of the inspection 29 people lived in the home.

A registered manager was 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.

People were protected against abuse because staff had received training and understood their responsibility to safeguard people. Concerns were reported and investigated.

Prior to people moving into the home, assessments were undertaken to ensure the home and staff could meet the person’s needs. Staff were aware of the need to treat people as individuals and ensure care reflected their individual needs. Risks associated with people’s needs were assessed and action was taken to reduce these risks. We identified that some of these assessments could be done more promptly when a person first moved into the home and action was taken to address this during the inspection. People were supported to ensure they received adequate nutrition and hydration. Staff worked well as a team and people were supported to maintain good health and had access to appropriate healthcare services. People told us they were always asked for their consent before personal care was provided. Where needed, people’s ability to make decisions was assessed in line with the Mental Capacity Act, 2005 (MCA).

People and their relatives provided positive feedback about staff. Observations reflected people were comfortable and relaxed in staff’s company. People were cared for with kindness and compassion. People’s privacy and dignity was respected and they were encouraged to be involved in making decisions about their care. Staff responded to people’s changing needs and ensured a person centred service.

The provider’s recruitment process ensured appropriate checks were undertaken to ensure staff suitability to work in the home. People told us they felt staff had the skills and knowledge to care for them. Staff received supervisions and training to help them in their role.

People and their relatives said the home was always clean and well maintained. Equipment was managed in a way that supported people to stay safe and people were supported to maintain good health and had access to appropriate healthcare services.

There was a process in place to deal with any complaints or concerns if they were raised. People told us they knew how to complain and we saw complaints were investigated and outcomes shared with people and staff.

Communication was open and staff felt supported by the

This inspection took place on 17 and 18 January 2017 and was unannounced.

Cams Ridge is registered to provided accommodation, support and nursing care for up to 51 people. The people living at the home have complex nursing needs and some live with dementia or other cognitive impairments. There were 27 people living in the home on the first day of our inspection and 26 people on the second day. The home is built on two levels and there is a lift between the floors. There are three communal areas where people can socialise and eat their meals if they wish.

Prior to this inspection we had received some information which caused us concern. The last inspection took place in July 2016 when we rated this service as inadequate and placed it into special measures. Following this inspection we served three warning notices for failing to ensure; safe care and treatment, suitable numbers of appropriately trained and supported staff and good governance systems. We also referred our concerns to the local authority responsible for safeguarding and the provider voluntarily agreed not to admit any other person to the home. In addition to these actions, requirement notices were issued for failure to ensure safeguarding of people, ensuring appropriate consent was sought and person centred care was developed and delivered. . 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 service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At this inspection a registered manager was not in place. 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. A manager had been appointed and was working in the home day to day. They had begun the process of applying to become the registered manager. Throughout this report we refer to this person as the manager.

Some aspects of medicines management had improved although further improvements were needed. The recording of the administration of homely remedies did not always promote safe medicine management. One observation did not reflect safe administration and stock records were not always accurate.

Staff knowledge of people’s health conditions had improved and the assessment and management of risks associated with these had improved.

The manager was reporting safeguarding concerns appropriately and staff understood what constituted abuse and what to do should they suspect this was occurring. All appropriate recruitment checks were completed before staff commenced work and there were enough staff to meet people’s needs.

The support provided to staff had improved. Individual supervisions sessions had improved and more training had been provided to ensure staff understood people’s needs. The manager had a plan in place to develop the skills of staff further.

Improvements had been made to the gaining of consent and the assessment of people’s capacity to make their own decisions. Staff understood the importance of this although the recording of best interests decisions could improve.

The management of people’s nutrition and hydration needs had improved. Action was taken when concerns presented and clear plans were in place to support people. Where required external health support was accessed.

People were treated with dignity and respect. People told us staff were kind, caring and compassionate.

Care plans required more work to ensure these were personalised and reflected people’s needs, wants and wishes. People and their relatives felt invo

This comprehensive inspection took place on 12 and 14 July 2016 and was unannounced. We bought this inspection forward as we had received some information which caused us concern, including information provided to us by the service. The last inspection took place in February 2015 when we rated this service as requires improvement.

Cams Ridge provides accommodation, support and nursing care for up to 46 people, however it is registered to provide support to 51 people. The people living at the home have complex nursing needs and some live with dementia or other cognitive impairments. There were 35 people living in the home on the first day of our visit and 33 on the second day. The home is built on two levels and there is a lift between the floors. There are four communal areas where people can socialise and eat their meals if they wish.

A registered manager was in place. 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 overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Feedback from people living at the home was mixed, although they said they were happy living there. Some were concerned that there were not always enough staff to meet their needs and some felt not all staff knew them well.

Staff lacked knowledge and understanding of people’s complex health needs and the risks associated with these. Care records lacked information about risks associated with people’s needs and health conditions. Some of these risks could have life threatening consequences so the lack of guidance and knowledge placed people at serious risk of harm. Where people were losing weight action had not been taken to identify the cause of this or plans developed to address this. We referred these concerns to the local authority safeguarding team.

Medicines were not always managed safely. Temperature checks were not consistently undertaken. As required medicines lacked clear guidance and gaps in recording could not be explained.

Staff awareness of safeguarding adults at risk was good and they said they were confident that the manager would respond appropriately to any concerns. However, we found reco

Thirty three people were using the service on the day of our inspection. We looked at five outcomes during our visit and looked at people’s care and welfare, food and nutrition, medication, staffing and quality assurance. We spoke with four people who used the service, three visitors, eight staff and the manager. 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?

This is a summary of what we found-

Is the service safe?

We found that some aspects of the service were not safe because people’s assessments and care plans were not detailed enough to ensure their needs were met and the storage of some medical items could put people at risk. We have set compliance actions for the provider to tell us what they are going to do to improve these areas. However, people were cared for by staff who were knowledgeable about their needs and had the skills to provide the support people required.

People who use services would only be deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards. At the time of the inspection, the safeguards were not needed to protect anyone.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. One person said, “Yes, I don’t mind it here”. Another person said the home was, “great” and explained staff helped them if they wanted help but did not “push themselves” on them, if they could attend to their own needs. Other quotes included, “I cannot fault it…the care is outstanding”, “I am very happy here…the staff are kind”. It was clear from what we saw and from speaking with staff that they understood people's care and support needs, which they knew well.

Is the service caring?

We spoke with one person about whether they felt cared about and they confirmed they did. Visitors told us they were happy with the way their relatives were looked after and cared for. One said it was a, “very nice home” and another one said the home was “brilliant” with “very good care”.

We observed staff as they supported people around the home and saw they responded to people in a caring way. Staff knew people’s needs and cared that they worked in a way which met those needs. Staff spoke about people in a caring way.

Is the service responsive?

People’s needs were assessed before they moved into the home. Records confirmed people's preferences were noted and formed part of the care plan. Staff responded to changes in people’s health in order to meet their needs.

Is the service well-led?

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Each month, the provider sent a survey to people who use the service, their friends and families or visiting professionals.

The provider had a system of audit in place. An external company undertook health and safety and fire audits once a year. The provider’s compliance officer visited once a month to assess the quality of the service and monitor any improvement needed. Action plans were put in place where they were warranted and the manager followed them up. A senior member of the leadership team ensured the actions had been completed.

We spoke with six people who lived at Cams Ridge during the visit and spoke with the six staff who were on duty. People we spoke with described the home as a nice place in which to live. One person told us: "The carers are very kind, I've nothing to complain about." We spoke with a relative who told us: "This home is first class. If I raise any concerns it gets sorted. We also reviewed six care plans and found that the care was person centred and people were listened to by the staff. We saw the care plans had been drawn up with the person so that the home could be sure they were meeting the person's needs and wishes.

A person we spoke with said, "The home is very clean, spotless." We found the rooms to be clean.

The recruitment records showed the provider had effective recruitment policies and procedures in place to ensure staff were both fit and able to meet people's needs.

Cams Ridge had systems in place that ensured all aspects of the running of the home, and meeting people's needs had been regularly audited. People had been invited to comment on how the home was meeting their needs.

People told us what it was like to live at Cams Ridge Nursing Home and described how they were treated by members of staff and their involvement in making choices about their care. People we spoke with felt that their personal care was carried out in a manner that promoted their privacy and dignity.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. People told us they liked living at the nursing home because members of staff were kind and caring. People said that they liked the garden and they were able to sit outside in the patio area when the weather was good. They told us that the staff always asked how they were and told them what they were going to do to assist them.

Relatives told us the care was "Good" and spoke highly about the care provided by members of staff. They told us people were spoken to in "A calm and respectful way which respected their dignity." We saw that members of staff were polite and courteous to people and offered them choices about their day to day routines.

The inspection took place on 4 and 12 February 2015 and was unannounced. Our last inspection on 10 July 2014 found breaches of the Regulations related to care planning and the management of medicines. We set two compliance actions for the provider to ensure each person had an individual and up to date care plan and to improve medication audit systems. During this inspection we found people did have individual care plans and action had been taken to improve the administration of medicines. However, we found some medicines were not stored securely.

There was a registered manager for the home but they had not been in day to day charge of the home since April 2014. 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 home had been managed by the deputy manager whilst the registered manager had been seconded to manage other homes run by the provider.

The home provides accommodation and nursing care for up to 46 people, some of whom were living with dementia. This number included four beds which were used by local hospitals to support people leaving hospital until they moved into permanent accommodation. There were 40 people living at the home when we visited. There are bedrooms over two floors and a passenger lift. There is a range of communal sitting areas as well as a dining room where people can eat together if they choose to.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the home was currently subject to a DoLS, the manager had made an application for one person and was reviewing each person with regard to whether they should be referred to the local authority and was beginning the process. The manager was aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. People’s consent was sought before staff supported them to make choices.

People received their medicines as prescribed, both routinely and when they were in pain. People felt safe living in the home and staff had been trained in safeguarding adults. Risk assessments were in place to identify and minimise risks.

People told us they did not wait long for staff to respond when they pressed their call bell. The manager was able to ask for, and get, more staff when needed. Staff started work after satisfactory recruitment checks had been completed.

People felt the staff understood their needs and that they were knowledgeable. Relevant training was provided for staff which reflected the needs of people living in the home. There was a system in place which ensured staff received supervision with a more senior staff member.

People enjoyed the food and said the food was always good. There was a programme of organised activities and entertainment which some people chose to take part in.

Staff treated people with kindness and compassion in their day to day care and involved them in decision making. Some people living at the home had very individual and specific requirements for their personal care. Staff were consistent in their knowledge and understanding about why people preferred certain ways of being supported, and respected their privacy and dignity.

People and their relatives, where appropriate, were involved in their needs being assessed before they moved into the home. New care plans had been created for people, which covered their health and social care needs as well as their preferences in how they liked to be supported. The format was also new and used a narrative to tell staff how to support people, rather than a tick box sheet seen previously. Some people’s needs were more complex and there was a good level of detail which reflected them as people, rather than a list of tasks to be completed.

People were complimentary about the attitude of the staff team and the way they all worked together. There was an open culture within the home which ensured people were at the centre of how the home was managed.

The registered manager had not been in day to day control of the home since April 2014. In their absence, the home was being managed by the deputy manager. The provider did not return the Provider Information Return when we asked for it. We took this into account when we made the judgements in this report. There was a system of audit in place which meant the quality of the service was regularly monitored. However, the medication audit did not identify the concerns we found.