The inspection took place on 28 November and 4 December 2017. The first day of the inspection was unannounced. This meant that the provider and staff did not know we were visiting.

We last inspected the service in January 2017 and at that time identified breaches in four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were related to person centred care, need for consent, staff training and good governance.

We took action by serving warning notices in relation to two of the breaches and requiring the provider to send us an action plan stating how they would achieve compliance in respect of the others. During this inspection we found there had been improvements made in line with the terms of the warning notices and the provider’s action plan. As a consequence of these improvements the service was no longer in breach of the regulations detailed above.

Chestnut Lodge 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.

Chestnut Lodge Nursing Home accommodates up to 17 people in one adapted building. At the time of this inspection there were 15 people using the service.

The service has a large communal lounge a separate dining area and a small conservatory on the ground floor and a smaller lounge area on the first floor with a table and space to dine in. There is a stair lift connecting the ground and first floor.

The service had a registered manager 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.

Improvements had been made to medicine records. There was guidance in place for the use of ‘as required’ medicines and there were no unexplained gaps in people’s medicine administration records (MAR). Medicines, including controlled drugs, were stored safely, administered appropriately and disposed of correctly.

Staff who administered medicines had a competency assessment every 12 months to ensure they were correctly following procedure. Nurses had their PIN number checked to ensure their registration was current. The PIN is a unique identifier enabling employers to check the registration status of nurses with the Nursing and Midwifery Council (NMC).

Safe recruitment procedures were in place and appropriate pre-employment checks were undertaken.

Some people felt there was not always enough staff on duty and some of the staff agreed this was the case. People’s dependency levels were calculated but not used to determine the number of staff. We have made a recommendation about this.

Care records contained detailed risk assessments. People had individual personal emergency evacuation plans in place. Accidents and incidents were recorded and analysed to look for patterns or trends. Regular maintenance checks and repairs were carried out and all areas of the service were clean and tidy.

Improvements had been made in respect of staff training. The majority of staff were up to date with training and additional training courses linked to the needs of the people using the service had been completed by staff. Some training was still not included on the matrix.

Requests for DoLS authorisations were being submitted appropriately and improvements had been made in the recording of best interest decisions. However, we identified that further improvements were needed in relation to recording of mental capacity assessments.

Staff felt well supported and received regular supervision sessions and annual appraisals.

People were supported to maintain their health and wellbeing and had access to heal

This inspection took place on 9, 12 and 24 January 2017. The first day of the inspection was unannounced. This meant that the registered provider and staff did not know we would be visiting. The other two days of inspection were announced.

Chestnut Lodge Nursing Home offers accommodation for up to 17 people with a physical or learning disability. There are two communal lounges and a dining area as well as a small conservatory on the ground floor and a small lounge on the first floor. There are sixteen bedrooms one of which is to be shared by two people. The home is situated in Norton and is close to local amenities with good local transportation links.

The service had a registered manager 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 service was previously inspected in November 2015 and was not meeting two of the regulations we inspected. These related to staff training and good governance. We took action by requiring the registered provider to send us action plans telling us how they would improve this. When we returned for this inspection we found the issues identified had not been addressed.

The majority of staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). They demonstrated an understanding of how to support people who may lack capacity to make their own decisions.

Eight people living at the service had a DoLS in place. These were monitored by the registered manager to ensure they remained up to date. There was no evidence of best interest decisions being undertaken or documented. The registered manager did not undertake capacity assessments but applied for DoLS authorisations for those people they believed may lack capacity.

There were systems and processes in place to protect people from the risk of harm. Staff had received safeguarding training and were aware of the action they should take if they suspected abuse was taking place. Staff were aware of whistle blowing procedures and all said they felt confident to report any concerns.

People’s medicine records were not always complete or accurate making it difficult to check people were receiving their medicines as prescribed. Staff had received medicines training but had not had their competency checked in line with the registered provider’s policy.

There were not sufficient numbers of staff on duty taking into consideration the complex needs of people and the layout of the service. Although people’s care needs were being met there was not time to engage people in activities or ensure accurate records were kept. We have made a recommendation about this.

Recruitment and selection procedures included some appropriate checks prior to staff starting work. These checks included obtaining references from previous employers and disclosure and barring service checks to ensure that staff were safe to work with vulnerable people. However we saw that nurse’s registration to practice was not always checked prior to employment.

We saw that environmental risk assessments had been carried out. Safety checks and certificates were in place for items that had been serviced and checked such as fire equipment, gas and electrical safety. There was a contingency plan in place but it did not contain up to date information or cover a variety of emergency situations.

Not all staff had received mandatory training and the registered manager was unable to provide sufficient evidence that all staff had the skills and knowledge to provide support to the people they cared for.

Staff received supervision but staff meetings were not held on a regular basis.

The records we viewed showed us that people had appropriate acces

We inspected Chestnut Lodge Nursing Home on 5 November 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

Chestnut Lodge Nursing Home provides personal and nursing care and accommodation for up to 17 adults and / or older people. The service is situated in Norton and is close to local amenities with good local transportation links.

The home had a registered manager 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 registered manager was on annual leave on the day of the inspection; however the registered provider, deputy manager and nursing staff were able to help us with the inspection process.

We looked at the arrangements in place for quality assurance and governance. Quality assurance and governance processes are systems that help providers to assess the safety and quality of their services, ensuring they provide people with a good service and meet appropriate quality standards and legal obligations. Infection prevention and control and health and safety audits were not carried out regularly. Care plan audits were just a tick box and did not inform of the actual checks that had been undertaken.

The registered provider visited the service on a regular basis but did not keep a record of such visits, the people they had spoken with or the checks they had completed.

Staff had not received regular updates on their training to enable them to carry out the duties within their role.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Staff we spoke with were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety.

Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed. Risk assessments had been personalised to each individual and covered areas such as choking, falls, nutrition and moving and handling, This enabled staff to have the guidance they needed to help people to remain safe.

We saw that staff had received supervision on a regular basis and an annual appraisal.

Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were working within the law to support people who may lack capacity to make their own decisions.

The service did not have a high turnover of staff. The registered manager and staff that worked at the service had done so for some time. The registered provider talked us through the safe recruitment and selection procedures they followed including checks they would undertake before staff started work.

Appropriate systems were in place for the management of medicines so that people received their medicines safely.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful, patient and interacted well with people. Observation of the staff showed that they knew the people very well and could anticipate their needs. People told us that they were happy and felt very well cared for.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People were weighed on a regular basis and nutritional screening was undertaken to identify those people at risk of malnourishment.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital appointments.

We saw people’s care plans were very person centred and written in a way to describe their care, and support needs. These were regularly evaluated, reviewed and updated.

People’s independence was encouraged and their hobbies and leisure interests were individually encouraged. Activities and outings were planned and the priest from the local Roman Catholic church visited on a weekly basis. Staff encouraged and supported people to access activities within the community.

The registered provider had a system in place for responding to people’s concerns and complaints. People said that they would talk to the registered manager or staff if they were unhappy or had any concerns.

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

The inspection team was made up of one inspector. They answered our five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. We saw that staff had a good knowledge and understanding of the people who lived at the home. One person commented, “Oh they (the staff) are just lovely, really they are”. A relative said, “It makes me happy knowing that he is happy here, honestly I don't think that I could ask for more”.

Is the service responsive to people's needs?

People’s care and treatment needs had been assessed and care plans put in place that detailed the care and treatment that people needed. These records provided guidance to staff on what care and support was needed. People had access to activities that were important to them and had been supported to maintain relationships with their friends and family.

During the inspection we spoke with a district nurse who was visiting the home. They told us that staff were good at responding to people's changing needs and that they were not afraid to approach them for advice where needed.

We saw that following our previous inspection the service had responded to our concerns and had taken appropriate action to ensure that improvements were made in respect of the safety and suitability of the premises.

Is the service safe?

Care plans and risk assessments were in place and were current and up to date. Care records detailed the support people required and encouraged people to be independent where possible. People we spoke with during the inspection told us that they felt safe. One person said, "It is nice living here, knowing that they will help me and that I am safe".

We saw that nutritional screening was carried out for people who used the service. This meant that people received timely and appropriate intervention if they lost weight to help maintain their welfare and safety.

The premises were suitable, safe and clean. The premises were well maintained and integral elements of the premises were serviced regularly to ensure the safety of people who lived at the home and others who worked there or visited.

We saw that there was a consistent group of staff employed and deployed within the service. The registered manager oversaw the staff rota. They took people’s needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were always met safely and effectively.

Is the service effective?

People we spoke with told us that they were very happy with the service. People told us that the staff were, "Lovely" and that, "Nothing seems too much trouble for them". Relatives we spoke with said, "I have complete peace of mind, I know that he is in the best place and getting the best care".

We observed throughout the day that people appeared to be happy. There was a lot of laughter, joking and smiles between staff and the people who lived at the home.

Is the service well led?

The service had a quality assurance system, we found that where they identified shortfalls these were addressed promptly. As a result the quality of the service was continuingly improving.

We saw that the service proactively gathered the views of the people who used the service. We saw that their feedback was acknowledged and that action was taken in response to this feedback. This helped to ensure that people received a good quality service at all times. Relatives we spoke with told us that the management team had an open door policy. They said, "Any concerns, anything at all and I would not hesitate to raise them, they are very approachable".

During the inspection we spoke with three people who used the service and two relatives. We also spoke with the provider, the manager, a nurse and a care assistant. People who used the service told us that they were happy with the care and service received. One person said, “I have been in the home a number of years, so long that I have forgotten when I arrived. Everyone is kind.” Another person said, “Everyone is lovely.” A relative we spoke with said, “I think that the home is very good we made the right choice.”

We were able to observe the experiences of people who used the service. We saw that staff treated people with dignity and respect. We saw that people had their needs assessed and that care plans were in place.

People’s health, safety and welfare were protected when more than one provider was involved in their care and treatment, or when they moved between different services.

We saw that people lived in a homely environment that promoted their wellbeing, however people who used the service, staff and visitors were not protected against the risks of an unsafe premise.

We saw that the service had appropriate equipment. We saw that regular checks and servicing of equipment was undertaken to ensure that it was safe.

We found there was an effective complaints system in place at the home.

Throughout our inspection visit we found that the home was well presented and tidy. We found that people were cared for in a clean and hygienic envirnonment by suitably qualified, skilled and experienced staff.

We found that before people received any care or treatment staff asked for their consent and acted in accordance with their, or their families wishes. We found that people who lived at Chestnut Lodge Nursing Home experienced care, treatment and support that met their individual needs and protected their rights.

We saw that the home retained and maintained accurate and appropriate records which protected people who used the service from the risks of unsafe or inappropriate care and treatment.

One relative we spoke with told us, "The staff are very good, they are all familiar with her needs and she is familiar with each of them and this is really important."

One person who used the service told us, "It is top notch here it really is great, I have stayed in a few homes and this one is just wonderful."

People told us “it’s lovely here”, “The staff are very good”, “I’ve got no complaints.” , “It’s very nice here” and “They’re looking after me.”