The inspection took place on 10 and 22 May 2018 and was unannounced. This meant the provider and staff did not know we would be visiting. We last inspected the service in September 2017 and found the provider had breached four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. These related to equipment not being safe for use or used in a safe way, infection control management and unsafe management of medicines. The provider had failed to ensure there were suitably qualified, competent and skilled staff deployed to provide care, support and treatment. We found the provider had not ensured systems and processes were used effectively to assess, monitor and improve the safety of the services provided.

Following the last inspection, we met with the provider to ask them to provide an action plan to show what they would do and by when to improve the key questions of safe, effective, caring, responsive and well led to at least a good rating. At this inspection we found the provider had made improvements and was no longer in breach of regulations.

Craigielea 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 care home accommodates 60 people across four separate units, each of which have separate adapted facilities. Two units specialised in providing care to people living with dementia. One, having been recently redesigned to accommodate people living with dementia who required nursing care. No people were residing on this unit at the time of the inspection. Another unit provided general nursing care. At the time of the inspection 41 people were being supporting in the home, 18 of which required nursing care.

Since the last inspection the provider had employed a new manager who is now 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 provider had policies and procedures in place to keep people safe. The provider had effective systems in place to manage medicines. Risks to people and the environment had been assessed and control measures were in place to reduce risk. Staffing levels were appropriate to meet the needs of the people using the service. The provider had system and process in place to report and manage safeguarding issues. Staff understood safeguarding and knew how to report their concerns. Accidents and incidents were recorded and analysed for trends and patterns. The recruitment process used by the provider was robust. Health and safety checks were completed on a regular basis. Fire safety procedures were in place. The environment was clean and tidy. Infection control procedures were in place. Staff had access to personal protective equipment (PPE) when needed.

Care and support was provided using best practice, such as following health and safety guidance. Training plans were in place, along with supervision and appraisal planners. Staff felt supported in their roles. People and relatives felt staff were well trained and knew how to support them well. People were supported with their nutritional needs where necessary. Staff contacted health care professionals when appropriate. Staff understood the Mental Capacity Act and gained consent prior to any care being delivered. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People and relatives felt the staff were kind and caring. Staff showed r

The first day of this inspection took place on 25 September 2017 and was unannounced. This meant the provider did not know we were coming. We also visited the home on 29 September and 4 October to finalise our inspection.

In December 2016 we carried out an inspection of this home and found three breaches of regulation. These related to equipment not being safe for use or used in a safe way, infection control management and unsafe management of medicines. The provider had failed to ensure there were suitably qualified, competent and skilled staff deployed to provide care, support and treatment. We found the provider had not ensured systems and processes were used effectively to assess, monitor and improve the safety of the services provided.

This inspection was also prompted in part following concerns raised by the local authority commissioners regarding care and support, record keeping, lack of consistent nursing staff and ineffective leadership within the service.

Craigielea Nursing Home provides accommodation, nursing and personal care for up to 64 people including those living with dementia. The service was supporting 46 people at the time of this inspection.

The service does not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 service had a manager who commenced employment in March 2017 and was still in their probationary period. The provider told us the manager intended to submit an application for registration with the Commission. Following the inspection the provider informed us that the manager had left the service. The operations manager was supporting the service until a new manager was employed.

On the first two days of the inspection the manager was on planned annual leave, we were supported by two interim managers from the provider’s neighbouring locations and the operations manager. The operations manager was also available on the second and third day of the inspection. The manager had returned to work on the third day of the inspection. Following our inspection the operations manager sent us information to confirm that the manager had left the service. The operations manager told us they were overseeing the service until a new manager was recruited.

At this inspection we found that there were breaches of four of the Fundamental Standards of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, safeguarding, staffing recruitment and the overall oversight of the home.

Medicines were not always managed safely. We found gaps in the recording on the medicine administration records (MAR). Where people were prescribed ‘as and when medicines’ protocols for such administration were not readily available for staff when administering medicines. The provider did not have topical MARs in place for staff guidance and support when administering topical medicines. Topical medicines are creams or ointments applied to the skin.

One treatment room which contained medical dressings and other equipment used to care for people requiring nursing care was unlocked. We found sharps (such as needles) stored in cupboards which were also unlocked.

The provider had not identified some incidents as potential safeguarding concerns and had not acted appropriately to ensure people were safe.

Risks to people had been assessed, however some assessments contained conflicting information.

The provider had failed to ensure staff were suitably competent and skilled to provide care support and treatment. The provider had a relian

We carried out an inspection of Craigielea Nursing Home on 23 November, 7 and 13 December 2016. The first day of the inspection was unannounced. We last inspected Craigielea Nursing Home in September 2015 and found the service was not meeting some of the relevant regulations in force at that time. We identified breaches related to cleanliness and staffing levels.

The Craigielea Nursing Home provides accommodation, nursing and personal care for up to 64 people, including people living with dementia. There were 38 people living there on the day of our inspection.

The service had 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 told us they felt safe. Staff took steps to safeguard vulnerable adults and were trained and guided on safe care practices.

Those areas of the home subject to recent refurbishment were pleasantly decorated, with well-furnished lounges and seating areas. A new ‘café’ area had seating less suitable for people with physical support needs. Most areas of the building were safe and well maintained. There was excess storage in some bathrooms. The property was adapted from an older building with a later purpose built extension. Adaptations had been made and additional signage provided to improve safety and highlight potential hazards. Other risks associated with the building and working practices were assessed and steps taken to reduce the likelihood of harm occurring. On the whole, the home was clean.

We observed staff acted in a courteous, professional and safe manner when supporting people. We heard mixed views about the adequacy of staffing levels. These were subject to ongoing review and shortfalls in nursing were covered by the use of agency staff. The provider had a robust system to ensure new staff were subject to thorough recruitment checks.

Medicines, including topical medicines (creams applied to the skin) were, in most cases, safely managed, although the stock rotation and disposal of sharps required attention.

As Craigielea Nursing Home is registered as a care home, CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found appropriate policies and procedures were in place and the registered manager was familiar with the processes involved in the application for a DoLS. Arrangements were in place to assess people’s mental capacity and to identify if decisions needed to be taken on behalf of a person in their best interests. People’s mental capacity was considered through relevant areas of care, such as with medicines and distressed behaviour. Where necessary, DoLS had been applied for. Staff routinely obtained people’s consent before providing care.

Staff had completed safety and care related training relevant to their role and the needs of people using the service. Further training was planned to ensure their skills and knowledge were up to date. Staff were well supported by their managers and other senior staff. Staff performance was assessed annually and objectives set for the year ahead.

People’s nutritional and hydration (eating and drinking) status was assessed and plans of care put in place where support was needed. People’s health needs were identified and external professionals involved if necessary. This ensured people’s general medical needs were met promptly. People were provided with assistance to access healthcare services.

Staff displayed an attentive, caring and supportive attitude. We observed staff interacted positively with people. We saw that staff treated people with respect and explained clearly to us how people’s privacy, dignity and confidentiality were maintained.

A limited range of activit

We found action had been taken to improve the support people living at the home received at mealtimes. The current arrangements ensured that people were adequately supported to meet their individual needs.

At the time of the inspection there were 50 people living at the home. Due to their health conditions and complex needs not all people were able to share their views about the service that they received, but we did speak with twelve people. We observed their experiences to support our inspection. We spoke with the registered manager, deputy manager, two nurses, five care staff, six relatives, two district nurses and two specialist nurses.

During the inspection five key questions were answered; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service, their relatives and the staff told us.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

All the people we spoke with told us that they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. One person told us, “The staff are first class. I definitely feel safe here.” Another person told us, “I feel I can approach the staff when I want about anything. I know how to make a complaint or raise a concern.” All the relatives we spoke to told us they felt their relatives were safe at the home, one of them told us, “It’s a good service. I have no concerns of abuse; I feel my relative is safe.”

We spoke with staff about Deprivation of Liberty Safeguards (DoLS). The registered manager told us that there had been one application in the last year and showed us the policy and procedures they followed. They told us that some staff had received relevant training and had access to the policy and procedures. Those staff told us that they had received this training.

Is the service effective?

One person commented, “I was losing weight at home before I came here. I have put on a stone and the staff have really encouraged me.” A relative told us, “We have seen real progress here, the staff are very good.”

People explained how their care and welfare needs were met. All people told us that they had support with health appointments and felt that the service was flexible. One person told us, “It’s smashing here. If you want anything the staff will do it for you.” All the people we spoke with told us that they were always asked by staff if they needed help or assistance by staff. The staff told us that they always asked people if they were happy and required assistance before providing help.

All the staff told us they felt supported in their work. They told us they received a full training programme. One person told us, “I have received a full induction when I started. I definitely feel well supported.” Another staff member told us, “I feel well supported, and there is so much training on offer. I feel supported by the manager; I can talk to them at any time.”

Is the service caring?

We saw that staff communicated well with people and were able to explain things in a way that could be easily understood. We saw that they did not rush people in the home and we saw that the interactions were caring. All the relatives we spoke with said they felt the care was very good. One relative told us, “It’s a brilliant service; the staff are really good. They always manage to listen. I am very happy with the care.”

We saw that people were treated with respect and dignity by the staff. We saw that people were given choices in their care and all the relatives we spoke to told us they were very happy with the care. All the people we spoke with told us that they were happy with the care and support they received.

Is the service responsive?

All the people we spoke to told us that staff would respond to any of their requests for support. One person told us, “They give people opportunities to stay independent. But if you need help the staff will help.” Another told us, “It’s a good service. If I am not well they will call a doctor.”

All the relatives told us that they were very happy with the service. One told us, “We are very much involved in the care of our relative. When there are any changes the staff always let us know.”

We saw that staff responded to people's requests for help in a timely way.

Some of the people we spoke with told us they were involved in decisions about their care. They told us that the staff were flexible and responded to their requests promptly. One person told us, “I can get up in the morning when I want. I just need to ask for help.”

We saw that there was a complaints policy at the home. People told us they found the manager very approachable and would not hesitate to raise any issues or complaint.

People’s care needs had been reviewed at least every six months. We saw that when people's requirements had changed the provider had responded and reviewed their care needs so that they could meet their changed support and care needs.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service well-led?

We spoke with the registered manager. They showed us that there was an effective system to regularly assess the quality of service that people received. We found that the views and opinions of people, relatives and staff had been regularly recorded and responded to. The manager showed us that they had just recruited a new activities co-ordinator in response to the views and opinions they had received.

We saw the home had systems in place that made sure managers and staff learnt from any accidents, complaints, whistleblowing reports or investigations. This helped reduce the risks to people and helped the service to continually improve.

Staff told us they understood their roles and responsibilities. Staff had a good understanding of the ethos of the service and quality assurance processes were in place. This helped to ensure that people received a good quality care service at all times.

The inspection took place on 16, 17 and 28 September and 5 October 2015 and was unannounced. This means the provider did not know we were coming. We last inspected Craigielea Nursing Home in March 2015. At that inspection we found the service was not meeting the legal requirements in force at that time and issued two warning notices relating to staff training and the management of quality in the service.

Craigielea Nursing Home provides personal care for older people for up to 64 people, including people living with dementia. Nursing care is also provided at the home. At the time of our inspection there were 39 people living at the home.

The service had a registered manager who had been in post for fifteen years. 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 said they felt safe at Craigielea. Staff were trained in and understood the importance of their duty of care to safeguard people against the risk of abuse.

People expressed mixed views about staffing levels and there was no formal mechanism to help calculate staffing levels based on people’s needs. New staff were suitably checked and vetted before they were employed.

The home was undergoing extensive refurbishment, and those areas where work was completed were decorated and equipped to a high standard. Some areas were clean, others areas, along with pieces of medical equipment, were not. Safety checks were conducted to ensure people received care in a safe environment.

On the whole, medicines were managed safely to promote people’s health and well-being. One person did not receive their medicines in line with their care plan and this was addressed during the inspection.

Staff were supported in their roles to meet people’s needs. Extensive training had been carried out since we last inspected and further training was being undertaken.

People’s nutritional needs and risks were monitored and people were supported with eating and drinking where necessary. People were supported to meet their health needs and access health care professionals, including specialist support.

People were consulted about and were able to direct their care and support. Formal processes were followed to uphold the rights of those people unable to make important decisions about their care, or who needed to be deprived of their liberty to receive the care they required.

Staff knew people well and the ways they preferred their care to be given. People and their relatives told us the staff were kind, caring and respectful in their approach. On the whole our observations confirmed this, however the delay in responding to a person’s requests for support did not promote their dignity. Response times to call alarms were varied, but at times were excessively delayed.

A range of methods were used that enabled people and their families to express their views about their care and the service they received. Concerns or complaints were clearly documented, investigated and the outcome reported to the individual concerned. Where necessary practice was changed or other measures taken in response to the concern raised.

Staff assessed people’s needs and risks before they moved in and periodically thereafter. Staff ensured care plans were in place and regularly reviewed. A variety of activities were made available to encourage stimulation and help people meet their social needs.

The management arrangements ensured clear lines of accountability. Systems to monitor and develop the quality of the service had improved since we last inspected, but required further refinement to ensure standards of hygiene and safety were more consistently assured. Quality monitoring arrangements included seeking and acting on feedback from the people using the service and their relatives.

We made a recommendation for the provider to assess staffing levels in relation to people’s levels of need.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to the cleanliness and security of the premises and equipment and to the deployment of staff. You can see what action we told the provider to take at the back of the full version of this report.