Cranford Residential 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 Cranford Residential Home can accommodate up to 26 people in a detached property situated in the seaside town of Exmouth. The home consists of two floors with a passenger lift providing level access to each floor. There is a main communal lounge, dining area and seating in the large entrance where people could spend their time as they chose. The home has a large landscaped garden which people could use if they chose.

This comprehensive inspection took place on 11, 17 and 19th July 2018. The first and second day of the inspection was unannounced. This meant that the provider and staff did not know we were coming. At the time of this inspection there were 24 people using the service. Three of these people were staying at the service for a period of respite (planned or emergency temporary care provided to people who require short term support).

We had previously carried out a comprehensive inspection in May 2017. At that inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to there not being effective and consistent systems to check some of the safety equipment at the home. The recording of how some risks to people's health were managed was inconsistent. Improvements were needed in how activities were provided, recruitment procedures and how staff were supported. Following the inspection we were sent an action plan which set out the actions the provider was going to take. At this inspection we found the provider had made the improvements and were no longer in breach of these regulations.

There was a new registered manager who registered with CQC in May 2018 (at the last inspection they were working as the acting manager). A registered manager is a person who has registered with 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. Everyone praised the registered manager and the improvements they had made at the home. People said they were happy to approach the registered manager, staff and the provider if they had a concern, and were confident that actions would be taken if required.

The registered manager had put in place a comprehensive quality monitoring system at the service. There were regular audits and checks of the premises and equipment to keep people safe.

Safe recruitment procedures were in place and appropriate pre-employment checks were undertaken. The provider used a new computerised care system where staff completed risk assessments which could be audited by the management team to ensure appropriate action had been taken. Staff were also able to record the support and monitoring checks undertaken on this system.

Staff were well supported. They received regular supervision sessions which gave them the opportunity to discuss their concerns and future development. Staff said they felt involved with the development of the service with regular staff meetings.

A staff member was responsible for co-ordinating activities and there was a varied timetable of events. They were new to their role and with the registered manager’s support had plans to develop activities further. The registered manager had ensured people and their families had been kept informed about changes at the service and asked for their views regarding future developments.

People and their relatives were happy with the way care was delivered and happy with the staff approach. Staff interacted positively with people and had a good knowledge of their care needs. People were cared for without discr

The service was last inspected on 7, 15 and 18 April 2016 by the Care Quality Commission and was rated as ‘Requires Improvement’; there were no breaches of regulations.

The first two days of the inspection were unannounced and took place on 22 and 24 May 2017. We returned on 6 June 2017 to provide feedback to the providers and this was announced to ensure they were available. On this inspection, we judged there were two breaches of regulation relating to recruitment and the management of health and environmental risks. We have made two recommendations relating to supporting people’s social interests and achieving good governance.

The previous registered manager had been in post for approximately a year and resigned in April 2017. The providers had made CQC aware of this change and the action they had taken to address these changes. They had arranged for their training consultant to become an acting manager until their newly recruited manager started. The provider advised us that a new manager had been appointed and was due to start in July 2017. 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.

Cranford Residential Home provides accommodation for 26 people, including people living with dementia, a mental health need and a learning disability plus sensory loss. On the first and second days of the inspection there were 20 people living at the home. This had increased to 21 on the third day as a person had returned from hospital.

Since the last inspection, the registered manager had resigned. A new manager had been appointed and their induction planned. In the meantime, the training consultant had recently stepped into the role of acting manager. The provider and the acting manager told us after an induction period, the aim was for the new manager to register with the Care Quality Commission (CQC). 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 said they felt safe and secure living at the home. They were positive about their relationships with staff, for example in a survey one person said, ‘Good atmosphere with caring staff and I can always talk to someone. I do feel you care and that is important.’ People were protected from potential abuse and avoidable harm. Staff had undertaken safeguarding adults training and understood their responsibility to reports concerns immediately. There were sufficient numbers of suitable staff available at all times to meet people's individual needs.

The providers had a good relationship with staff and the acting manager. Through investment they showed an on-going commitment to improve the experience of people living and working at the home, including refurbishment. They said they were going to be more pro-active in the running of the home in the future as they had not identified some systems were not in place to ensure the environment was safe and some safety checks were not routinely completed. Improvements were also needed to how staff were recruited and trained. Information within the service user guide needed updating, which included the complaints information.

People using the service also fed back that the current arrangements for activities and social interaction did not meet their needs. We have made a recommendation about supporting people to meet their individual interests. Communication about changes within the home still needed to be developed to include people living at the home, although this had improved for the staf

This inspection took place on 7, 15 and 18 April 2016 and was unannounced. Cranford Nursing Home is registered to provide personal care for up to 26 people. They provide care and support for frail older people. On the first day of our visit there were 15 people living at the home.

We brought forward this comprehensive inspection because we received concerns regarding the care provision and the staff levels at the service. We last visited the service in June 2014. The service was compliant with the standards inspected and no breaches of regulations were found.

In April 2015 the provider had made changes to their registration with the Care Quality Commission (CQC) and had removed two regulated activities. This meant they no longer provided a service for people with on-going nursing needs. People living at Cranford Nursing Home were now under a residential service contract and any nursing needs were being met by the community nurse team.

When we visited there was a registered manager in post. However their employment ended with the provider on the last day of our visit. They had applied to CQC to remove their registration. A registered manager is a person who has registered with 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 provider made us aware that the deputy manager and two senior care staff had also submitted their resignation. People and staff expressed concerns regarding the loss of the registered manager and other senior staff. The provider recognised the upset this had caused people and staff and were working to develop a stable workforce. They confirmed they were actively looking to recruit a new manager and senior staff and would keep CQC updated on the situation on a weekly basis.

There were adequate staffing levels to meet people’s needs. Although people concerns were expressed regarding recent staff reductions and a proposed staffing level change. The provider confirmed this would not be something they would be considering in light of the staffing issues. Staff had clear leadership roles at the home with delegated responsibilities.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. The provider used the services of a care consultant to deliver training. Care staff had received training to take over some roles previously completed by nurses. Staff had developed skills and knowledge to meet people’s needs. Staff relationships with people were strong, caring and supportive. Staff delivered care that was kind and compassionate.

Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were safely managed on people’s behalf.

Care plans were personalised and recognised people’s health social and psychological needs. People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People were supported to eat and drink enough and maintained a balanced diet. People were positive about the food at the service.

The premises and equipment were managed to keep people safe. The provider was undertaking repairs and refurbishments.

The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. Where there were concerns or complaints, these were investigated

We considered our inspection findings to answer 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.

This planned inspection was undertaken as part of our on-going monitoring but also to follow up on required improvements which had been made in relation to care and welfare and records management, following our previous inspection in February 2014. Following the inspection the provider sent an action plan to us detailing the improvements being made.

On the day of our inspection there were 20 people living at Cranford nursing home.

We spoke with seven people using the service and six visitors, the providers, registered manager and eight staff supporting them.

Following our visit we contacted the hospice team who regularly visits the home to support people living there to ask their views.

Is the service safe?

The service is safe because the registered manager ensured that recruitment procedures at the home were robust and effective. They ensured staff on duty had the appropriate qualifications, skills and experience required to ensure people’s needs were met.

The registered manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards (DoLs). The registered manager told us there had been no reason to restrict or deprive people using the service of their liberty, in line with Deprivation of Liberty Safeguards legislation.

The home had suitable arrangements in place to reduce the risks of people receiving inadequate nutrition or becoming dehydrated.

Is the service effective?

The service was effective because we found people’s health and care needs were assessed and their care plans and assessments were reviewed monthly. Specialist dietary, mobility and equipment needs had been identified in care plans where required. This showed that people were having care delivered effectively or in accordance with their assessed needs.

It was clear from our observations and from speaking to people and staff, they had a good understanding of people’s care and support needs and they knew them well.

A nurse from the hospice team told us the people they support were well cared for and that the home contacted them promptly for advice if they had any issues.

Is the service caring?

The service was caring because people were supported by staff who were understanding and sensitive to their needs. We saw that staff showed patience and gave reassurance and encouragement when supporting people.

People at the home told us they were happy at the home. Comments included, “I have never been in such a nice place, I could not wish for better” and “the food is classic English food, very nice” and “I cannot fault the home at all”.

Is the service responsive?

The service was responsive because the home had appropriate systems in place for gathering, recording and evaluating information about the quality and safety of the overall service. Systems were in place to make sure the registered manager and provider learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

People told us they knew how to make a complaint if they were unhappy. A complaint was received during our inspection we saw it was acted upon promptly and in line with the homes complaints policy and procedure. People can therefore be assured that the home acts upon complaints, they are investigated and action is taken as necessary.

We saw the provider acted promptly to put in place locks to ensure archived records were stored safely at the home.

Is the service well-led?

The service is well lead because we saw the registered manager who does not have a health qualification and as a requirement of CQC is supported by a registered nurse as the clinical lead. The hospice nurse told us “The manager is approachable and very enthusiastic to get it right”. People we spoke with were positive about the registered manager comments included “I can always tell X” and “She (the registered manager) always listens”. This showed that the registered manager was demonstrating effective leadership at the home.

The providers are based at the home. We found they worked with the registered manager and the staff to ensure the standards people expected at the home were maintained. For example we saw the providers working with the manager to implement training and new documentation at the home.

In response to some concerning information received by the Care Quality Commission we conducted a responsive inspection.

The information we received related to people who used the service, not being supported to take adequate fluids and diet. Information also referred to poor documentation and a decline in the care provided at the service.

At the time of our visit there were 23 people living at the home, we spoke with six people and two visitors. We also spoke with the manager,director, two nurses, five care workers and two ancillary workers.

People who required anticipatory care and support were not consistently having their care needs met. Care was not consistently monitored. Care workers did not have clear guidance to provide consistent care.

People who were able to express their wishes were prioritised. People who were unable to ask for assistance were not always made a priority.

People told us that the carer workers were very kind and nothing was too much trouble.

There was a variety of healthy and nutritious food and drink available.

Not all records were reviewed or updated regularly. Some care records had not been reviewed for four months and some records had not been completed accurately.

Visitors told us they had been kept involved and informed. One commented, “It is absolutely brilliant, I can’t fault it”.

At the last inspection in April 2013 we identified concerns with certain aspects of the records kept by the home. Care plans were not complete and did not contain up to date information. At this inspection we found significant improvements had been made.

We (the Care Quality Commission) visited the Cranford Nursing Home as part of the scheduled inspection plan and also to follow up on one area of non compliance identified at the last inspection.

Care workers demonstrated a good knowledge of how each person was affected by their condition and of the principles of person centred care.

People enjoyed living at the home. One person said “they are all very nice here”. Another person said “I get everything I need”.

We saw that people’s privacy, dignity and independence were respected. For example, personal care needs were attended to in private. People were supported to maintain their abilities for example being supported to feed themselves and to remain continent.

People were helped to remain healthy because their health care, health promotion and social and psychological needs had been assessed and actions had been taken to address these needs.

People said they felt safe and were very complimentary about care workers. They said “they are very kind”. We saw there were enough care workers and staff on duty with the right skills, to meet people’s needs.

Records were kept securely. However, care plans were inconsistent and poorly organised with gaps in information. This could result in a risk of unsafe or inappropriate care.

We visited The Cranford Nursing Home to look at concerns we had been made aware of by an anonymous correspondent. These included how people that were unable to move themselves were supported to do so by staff, what time people went to bed, the meals provided at tea time and patients that had not been referred to healthcare professionals as necessary.

We observed people's care as a way of understanding their experience. We saw that staff were attentive, kind and respectful. People were supported to make choices, for example in relation to what time they got up and what they ate. We saw records that showed what food people were offered at tea time.

We saw in care records that referrals to health care professionals had been made when required. We saw that where recommendations had been made that staff followed this advice.

We saw staff moving people, including those who were unable to move themselves, correctly with the appropriate equipment. All staff were trained in moving and handling and further training had been booked.

Staff had the knowledge and skills to safeguard people from abuse. They were employed in sufficient numbers.

We last visited the home in September 2012. At that inspection we identified some concerns with regard to people’s care and welfare. We asked the provider to take action which they agreed would be completed by the end of January 2013. We will be revisiting the home again in January 2013 to check on compliance with that issue.

We (The Care Quality Commission) carried out an unannounced inspection at Cranford Nursing Home on 22 November 2011.

We spoke with six people living at the home, met with one visitor and observed interactions between staff and residents. We looked in detail at the care of four people who lived there. We spoke with three care workers, the administrator, the new manager, the audit consultant and the provider.

People told us they liked living at Cranford and felt safe and well cared for. We saw people being treated with respect in a caring way but at times people’s choices were not sought. People who wanted to could partake in a range of activities offered but this tended to focus on a regular group and did not include people in their rooms or people who were less able. People told us they were very happy with the quality and choice of food offered.

There was a risk that people’s needs could not be met due to poor record keeping and dis-organised care planning. Staff were fairly knowledgeable about people's needs in a general sense but care delivery was task orientated rather than personalised and there was a lack of attention to detail and involvement of people and their advocates.

Care workers we spoke to could describe what abuse was, and told us about their roles and responsibilities to ensure people were protected from abuse. They were confident that concerns raised within the home would be dealt with. However, information about local safeguarding arrangements and contact details were not clearly available in the home. This would make it more difficult for staff to report safeguarding concerns to appropriate outside agencies if there were not staff on duty who knew what to do, especially as staff have not had recent training.

We found that care workers were not well trained or appropriately supervised with opportunities for ongoing development. Although people’s views were listened to when issues were raised, there was no robust complaints system to ensure that issues they identified were acted upon quickly or recorded. We found that systems for monitoring the quality of care were lacking.

A recent safeguarding alert identified that there were some short falls in care, such as particular care not delivered and care plans not audited or evaluated. The home had employed an audit consultant over two weeks to help them make progress as a result. A temporary suspension of placements was put in place with monitoring by the community nurse team. This has now been lifted due to improvements since our visit.

During our visit we spoke with the manager, three staff, two relatives and four people who lived at the home.

Not everyone was able to tell us what it was like living at the home as some people had a dementia type illness or were too poorly and were in bed so we observed the care they received.

We looked at the care files for four of the people who lived in the home. We saw that four contained detailed care plans that set out the individuals' needs. The files were clear about the level of support people needed and what they could manage on their own. However two of the four had not been reviewed within the past month to reflect the changes in the persons needs. The same two people were being nursed in bed and had fluid and positioning charts which had not been completed so it was impossible to see if they had been moved or had anything to drink.

There was some information about people's backgrounds which meant that staff was aware of events in people's lives that could impact on the care they provided.

We saw some evidence that people or their representatives had been involved in completing their care plans. This meant that people could contribute and have their say about how they were supported.

We saw positive interactions between staff and individuals. Staff spoke kindly and with warmth to the people living there.

Staff that we spoke with told us that the home had a policy relating to safeguarding people. They were able to tell us about different types of abuse and what they would do if they suspected abuse was occurring.

People that we spoke with praised all the staff who worked at the home. One person told us "Staff are very nice – I'm very lucky to be here". They also said “I am very happy here there is nothing more I need”.

There were satisfactory numbers of staff on duty and all had been suitably trained.

The home was clean, tidy and comfortable.