This comprehensive inspection was completed on 7, 13, 14 March 2018. The first day of the inspection was unannounced. At the last comprehensive inspection completed in June 2017, we rated the service as overall Requires Improvement with inadequate in Safe. This was because medicines were not always well managed and this resulted in people receiving their medicines much later than prescribed. We also found the deployment of staff did not always ensure people’s safety. Further training was needed to ensure staff could fully action people’s healthcare needs, including those who required specialist support to ensure adequate nutrition. Quality assurance systems and audits were failing to pick up on the various aspects of improvement the inspection highlighted. As a result we issued two warning notices. One in respect of safe care and treatment and the other in respect of good governance. Warning notices set out what the service have failed to do and gives them a date by which improvements need to be made. We also asked the provider to complete an improvement action plan following the last inspection. We met with the provider on 23 February 2018 where they shared their service improvement plan and actions taken to meet regulations. We found improvements had been made and the service had met the warning notices.

Deer Park 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.

Deer Park is a purpose built service on two floors which accommodates up to 56 people. Most people living at the service are older people with conditions associated with frailty and/or dementia. Some younger people live at the service that has complex nursing conditions.

Since the last inspection the registered manager had resigned but continued to work as part of the clinical team. The service’s development manager had taken over the role as an interim arrangement, but has now agreed to register and was in the process of applying during this inspection. 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.

When we met with the manager and provider in February 2018 to review their service improvement plan, they gave us further assurances that the risks we had identified in June 2017 had been improved upon. This had been achieved by ensuring care plans and risk assessments had been updated with more detail and direction for staff. Training had been completed by nursing and care staff in core areas of ensuring people’s healthcare needs were being met. The service had been supported by a senior community nurse from NHS who had been seconded for a three month period to assist them with making the right clinical improvements. They had also been supported by the Devon County Council Quality improvement team. They had also employed a clinical lead who had experience and knowledge of key nursing needs.

Improvements had been made to the way medicines were administered to ensure they were done in a timely way. However we found some areas of improvement were still needed in respect of the record keeping of some medicines. The provider gave assurances this would be actioned by the following day of inspection we saw what improvements had been put in place in respect of topical creams.

We made a recommendation in respect of ensuring staff had the right training in the electronic record keeping so accurate records could be maintain of when people had been checked and what actions staff had taken. For example if they had assisted them to move position to help with the prevention of pressure damage. We did not

This inspection was a comprehensive inspection and took place on 20 and 21 June and 5 July 2017. At the last comprehensive inspection, completed in April 2016, we rated the service as overall requires improvement. We issued two requirements in relation to regulation 11, the need to consent and regulation 18 - staff did not receive appropriate supervision and support to be able to identify and plan of future professional development. The service sent us an action plan to show how they intended to meet these requirements by June 2016 or earlier.

At this inspection completed in June 2017 we found that although some improvements had been made in respect of supervision and support to staff, further improvements were still needed in relation to how consent to care was recorded. This related to the lack of records in relation to best interest decisions where restrictive practices had been used to keep people safe. This included the use of bedrails and pressure mats which alerted staff when people might be at risk of falls. We also found other areas where the service was not meeting the regulations.

Before this inspection we received some information of concern about staffing levels from an anonymous source. We also received some information from visiting professionals about the lack of a proactive approach in meeting people’s needs and in particular about end of life care. At this inspection we found there were adequate staff but their deployment was not always ensuring people’s safety and comfort. For example no staff presence in lounge areas for periods of up to half an hour. We also found some of the care planning around end of life care and the skills of some nursing staff in ensuring effective and safe pain relief, required some improvements.

The local authority quality assurance team (QAIT) had been offering support and guidance to this service in developing an improvement plan and reviewing the care plans to ensure they were more personalised. This work had been halted at the services’ request as they had decided they needed to remodel their service and were working with Devon County Councils business relationship manager to implement this. The remodelling involved reducing the nursing staff by one per shift and skilling senior care staff to take on some of the medicines and care planning processes. At the time of our inspection this had not been implemented.

Deer Park nursing home is registered to provide personal and nursing care for up to 56 people. They provide care and support for frail older people and those people living with dementia. On the day of the inspection there were 46 people living at the home, including one person who was having a short break there.

There was a registered manager who has been in post for just under 12 months. 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 not fully protected against the risks of unsafe medicine management. Medicines were not given on time and nurse practices and competencies had not been checked. The treatment room was disorganised and this made it difficult for nurses to have enough space to prepare medicines and to find the right equipment. By the third day of our inspection the medicines and treatment room had been de-cluttered and the registered manager had checked nursing staff competencies. They had also changed the start of the daily routine so that nursing staff received a short written handover report which freed their time to start the medicines for the morning at an earlier time. It was reported this was working to good effect and that the morning medicines were completed in a more timely way than when we had inspected.

Risks had not always been fully asses

This unannounced inspection took place on 12 April 2016. We returned on 19 and 21 April 2016 as arranged with the unregistered manager to complete the inspection. At our last inspection in April 2014 we found the service was meeting the regulations of the Health and Social Care Act (2008) we inspected.

Deer Park Nursing Home is registered to provide accommodation for 56 people over the age of 18 years old who require nursing and personal care. At the time of our inspection there were 46 people living at the home.

There was no registered manager in place. However the new manager was currently in the process of registering. 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.

Staff did not always comply with the Mental Capacity Act (MCA). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. This was not being done and had led to relatives making unlawful decisions on other people’s behalf. For example, consent to care plans.

Staff received a range of training to keep their skills up to date in order to support people appropriately. However, staff had not been receiving on-going supervision and appraisals in order for them to feel supported in their roles and to identify any future professional development opportunities. There were effective staff recruitment and selection processes in place. Staffing arrangements were flexible in order to meet people’s individual needs.

We heard staff referring to people who required their food prepared in a manner that supported them to not choke being referred to as ‘feeds’ as if this was their surname or name. This was not respectful. We raised our observations with the manager and provider. They told us they would raise this with staff and monitor the situation to ensure other unacceptable language had not become the norm. However, staff relationships with people were caring and supportive. Staff were motivated and inspired to offer care that was kind and compassionate. People said there were plenty and varied activities which they could engage with or not as they chose. The organisation’s visions and values centred around the people they supported.

A number of methods were used to assess the quality and safety of the service people received. However, these methods had not picked up on the issues we identified as part of our inspection. For example, the correct application of the Mental Capacity Act (2005). We were assured by the manager their quality assurance processes would look more closely at the areas we identified for improvement.

People were safe and staff demonstrated a good understanding of what constituted abuse and how to report if concerns were raised. Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were safely managed on people’s behalf.

Care files were not personalised to reflect people’s personal preferences. However, their views and suggestions were taken into account to improve the service. They were supported to maintain a balanced diet, which they enjoyed. 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.

End of life care was undertaken with compassion for the person and their family and with regard to the person’s dignity.

Staff spoke positively about communication and how the manager worked well with them.

There were two breaches in regulation. You can see what action we took at the end of the report.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them and observing care practices.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

People told us they felt safe. Systems were in place to help the manager and staff team learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. Staff showed a good understanding of the care needs of the people they supported.

Deer Park alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service. Deer Park had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). This helped to ensure that people’s needs were met.

Is the service effective?

People’s health and care needs were assessed with them and in some cases with the input from relatives. During our inspection it was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people’s needs.

Specialist dietary needs had been identified where required. Care plans were up-to-date.

We saw there was good liaison and communication with other professionals and agencies to ensure people’s care needs were met.

The quality of recording seen was of a good standard enabling nurses and care staff to use the information correctly.

Is the service caring?

We spoke with five people and asked them for their opinions about the staff that supported them. Feedback from people was positive, for example, “wonderful” and “Staff are very friendly” and “Very considerate carers”. When speaking with staff it was clear that they genuinely cared for the people they supported.

People’s preferences and interests had been recorded and basic life histories were evident.

Deer Park had regular support from the GPs from the local GP practices and other visiting health professionals. This ensured people received appropriate care in a timely way.

Is the service responsive? Many people who lived at Deer Park had complex health and care needs and were either not able, or chose not to join in group activities. The care records showed evidence of the lifestyle of these people and we observed that staff spent one-to-one time with people throughout the day.

The home employed activity co-ordinators and during our inspection we observed people being taken out for a ride in the company's vehicle during the morning and in the afternoon a group of bell ringers entertained a large group of the people who lived at Deer Park.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

We saw minutes of regular meetings held with the staff. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

The service had a quality assurance system, and staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.