This inspection took place on 20 November 2018 and was unannounced.

At our last inspection the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because medicines were not managed safely. At this inspection we found that the management of medicines still required improvement and the home continued to be in breach of regulation 12. Improvements were needed for the reporting of medicine errors and the subsequent actions, the recording of topical medicine application and the storage of medicines.

We found that people who lived at the service were not always risk assessed in relation to their specific needs. We found an example were a person who required one to one support did not have a risk assessment in place to show why they needed this level of increased supervision. People who lived at the service were not always assessed for the risk of choking where it was required. This was also a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that people were assessed against the risk of malnutrition and de-hydration however, people did not always have access to quality food and the dining experience for people living with dementia was poor. Therefore, we found the provider to be in breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that people were not always engaged with in a dignified and person-centred way. We observed care and support on both units and found very little stimulating activity. People’s representatives told us that social activities and stimulation at the service was poor. We found that the service had collated person-centred information about people they supported. However, information was not always included in care plans or risk assessments. We found that care plans and observations of care were task focused. This meant that people did not always receive care and support in a person-centred way. The provider was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at audits undertaken by the registered manager and compliance team and found quality monitoring systems were in place however were not always effective. The provider was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, responsive and well led to at least good. We found that improvements had been made in relation to environment safety, however medicines management still required improvement.

Douglas Bank Nursing Home (Douglas Bank) 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.

Douglas Bank is situated on the outskirts of Wigan. The service accommodates up to 40 adults, who need support with personal or nursing care, including people living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities.

Since our last inspection the legal directors for Douglas Bank had changed. However, the registered provider ‘Tudor Bank Limited’ had not changed. A legal director is a head of an organisation generally with certain powers and duties relating to management and administration. A registered provider is an individual person, partnership or organisation registered with CQC to carry on one or more regulated activities.

The service had a registered manager in post at the time of our inspec

Douglas Bank Nursing Home is situated on the outskirts of Wigan, in a semi-rural setting. The home enjoys panoramic views of scenic countryside and overlooks the picturesque village of Appley Bridge. The home accommodates up to 40 adults, who need help with personal or nursing care needs, including those who are living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities. At the time of this inspection there were 24 people who lived at Douglas Bank Nursing home.

At the time of our inspection the registered manager was on duty. She was cooperative and helpful throughout the inspection process. 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.

This comprehensive inspection was conducted on 26 September 2017 and was unannounced. Our last comprehensive inspection of this service was conducted over two days on 23 January and 1 February 2017, where breaches of the regulations were found in respect of person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and notifications of other incidents. The service was rated inadequate overall and was placed into special measures. We took steps to ensure people were safe and the provider also submitted an action plan detailing the improvements they planned to make. Comments contained in the action plan were considered during this inspection. Since that inspection the directors of the registered provider’s limited company had changed.

During this inspection we found that Douglas Bank Nursing home had demonstrated improvements had been made and therefore as the overall rating for Douglas Bank Nursing Home is now Requires Improvement this service is no longer in special measures.

We did however find when we looked at the management of medicines that although some improvements had been made in this area, further improvements were required. Therefore, this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that risks to people’s health care had been appropriately managed and safety of the environment had significantly improved. However, we noted a small number of minor improvements, which could enhance the premises further. These were discussed with the registered manager of the home and a Director of the company, who assured us these areas would be addressed. We made a recommendation about this.

We looked at the quality assurance systems and saw a range of effective audits and surveys had been introduced and any issues identified had been addressed or were in the process of being rectified. However, the medicines audit could have been more thorough, so that any shortfalls could be identified and addressed in a timely manner. We made a recommendation about this.

People’s care had significantly improved. The plans of care we saw were, in general well written, person centred documents, providing staff with clear guidance about people’s assessed needs and how these needs were to be best met. We found that people’s privacy and dignity was respected throughout the day.

We saw that people were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service supported this practice and were in accordance with the principles of the Mental Capacity Act 2005 (MCA). However we have made one recommendation in respect of recording consent where the relevant person is unable to do so.

The system of required notifications had improv

Douglas Bank Nursing Home is situated on the outskirts of Wigan, in a semi-rural setting. The home enjoys panoramic views of scenic countryside and overlooks the picturesque village of Appley Bridge. The home accommodates up to 40 adults, who need help with personal or nursing care needs, including those who are living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities.

At the time of our inspection the manager of the home had been in post for a very short period of time. Therefore, she had not submitted an application to the Care Quality Commission to become the registered manager of Douglas Bank Nursing Home. 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.

This comprehensive inspection was conducted over two days. The first day was unannounced. This was conducted on 23 January 2017. The provider was given short notice of the second day of our inspection, which took place on 1 February 2017.

The last comprehensive inspection of this service was conducted on 22 March 2016, when shortfalls were identified in relation to person centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, receiving and acting on complaints, good governance and staffing. The provider submitted an action plan, as requested. Comments contained in the action plan were considered during this inspection.

At our last inspection on 22 March 2016 we found the provider had not always ensured that the plans of care had been designed to reflect individual needs. Therefore, this area was in need of improvement to ensure that the health and social care needs of people were being appropriately met.

This was a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions would be completed by 1 January 2017.

At this inspection we found that the care plans were not always person centred and did not accurately reflect people’s needs. This constituted a continued breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that some risk assessments were not person-centred; as they did not accurately reflect people’s current needs.

At our last inspection on 22 March 2016 we found that the provider had not always ensured that people were treated with dignity and respect. Therefore, this area was in need of improvement to ensure that people who lived at Douglas Bank were treated in a proper manner. This was a breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a requirement about this. The provider sent us their action plan, which showed that actions in this area had been completed.

At this inspection we observed two staff members preparing one person to be transferred in the hoist. This process did not promote dignity and respect for the person involved. Therefore, this was a continued breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection on 22 March 2016 we found the provider had not always ensured that consent had been obtained from the relevant person before care and treatment was provided. Therefore, this area was in need of improvement to ensure that people who lived at Douglas Bank were in agreement with the care and support delivered to them. This was a breach of regulation 11 of the Health and Social Care Act 2008 (Re

This comprehensive inspection was unannounced, which meant the provider did not know we were going to visit the home. It was conducted on 22 March 2016.

Douglas Bank is situated on the outskirts of Wigan, in a semi-rural setting. The home enjoys panoramic views of scenic countryside and overlooks the picturesque village of Appley Bridge. The home accommodates up to 40 adults, who need help with personal or nursing care needs, including those who are living with dementia. The majority of bedrooms have en-suite facilities and are of single occupancy, although a few double rooms are available for those wishing to share facilities.

At the time of our inspection the manager of the home had been in post for a very short period of time. She was in the process of applying for registration 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 last full scheduled inspection of this service was conducted on 04 August 2014, when some shortfalls were identified in relation to cleanliness and infection control protocols. A follow up inspection was conducted on 04 November 2014, when we found that action had been sufficiently taken to improve the cleanliness of the environment and therefore promote good infection control practices.

At this inspection we identified some areas where improvements needed to be made, which are detailed within each relevant section of the report.

People who lived at Douglas Bank told us they felt safe being there and we found that the recruitment practices were robust, which helped to protect people from harm. There seemed to be sufficient staff on duty on the day of our inspection and it was observed that staff were always present in the communal areas of the home. However, people told us that there were sometimes shortfalls in the staffing levels, particularly at night and records showed there was an excessive number of agency staff used over a short period of time.

The staff team had received training in safeguarding adults and whistle-blowing procedures. However, people’s Personal Emergency Evacuations Plans (PEEPs) were out of date and therefore did not provide current guidance. We made a recommendation about this.

The management of medicines was poor and there were areas of the environment and external grounds, where improvements to safety were needed.

Some areas of the home could have been cleaner and more hygienic. Infection control practices could have been better.

Care plans did not always reflect people’s assessed needs and some care records provided conflicting information. This did not give the staff team clear guidance about how people’s individual needs were to be best met.

Social care profiles were in place in each person's care file, which reflected people’s preferences and what they liked to do and needs assessments had been conducted before people moved into the home.

Deprivation of Liberty Safeguard (DoLS) applications had not always been submitted, in line with the requirements of the Mental Capacity Act. Records showed that people’s mental capacity had not always been considered when developing their plans of care and formal consent had not always been obtained from the relevant people before care and support was provided.

We observed that confidential records were sometimes left unattended on the nurses’ station, although there was always a member of staff in the vicinity. We have made a recommendation about this.

The provision of meals could have been better, although we saw people being supported with their meals in a sensitive manner. We have made a recommendation about this.

The majority of staff we spoke with had a good understanding of people in their

This inspection was carried out to focus on previous non-compliance in the domain of cleanliness and infection control. During the course of this visit we gathered evidence against this specific outcome area.

The summary below is based on our observations during the inspection, speaking with people who lived at the home, the manager and staff members. We also toured the premises, viewing a random selection of private accommodation, as well as all communal areas and we looked at a variety of relevant records.

During our visit to Douglas Bank the manager of the home told us about the systems she had implemented to improve the area of non- compliance. We gathered evidence from a variety of sources and found improvements had been made since our last visit to this location, which enhanced the environment for the people who lived at Douglas Bank. Those we spoke with said they were satisfied with the overall standard of cleanliness of the home.

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

During the course of this inspection 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?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with those who used the service, their relatives, support staff and the manager and from looking at records. We were able to speak with five people who lived at the home, who gave us positive responses to the questions we asked. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People we spoke with told us they felt safe living at Douglas Bank and their dignity was always respected. Safeguarding procedures had been implemented and staff understood how to safeguard people they supported. Systems were in place to help managers and the staff to learn from untoward incidents, such as safeguarding concerns. This helped the service to continually improve.

The home had proper policies and procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Applications were made, as was needed. This helped to ensure people were not being unnecessarily deprived of their liberty. People who lived at the home (or their relative) were involved in making decisions about the care and support they received.

At the time of our visit to this location, we toured the premises and found the home to be warm and friendly. However, the standard of cleanliness and attention to detail needed to be improved, so that people were provided with a hygienic and clutter free environment, in which to live. Equipment was well maintained and serviced regularly. This helped to protect people from unnecessary risk.

Is the service effective?

People were able to access an independent advocate for additional support, should they wish to do so. The health and personal care needs of those who used the service had been thoroughly assessed, with a range of people involved in their care and support. Records were maintained in an effective way, so that data protection guidelines were followed and personal information was appropriately protected.

Systems were in place to ensure the service was effectively assessed, so the quality of service provided could be consistently monitored. A broad range of training modules were provided for staff, with regular mandatory updates. This helped to ensure the staff team delivered effective care and support for those who lived at the home.

Is the service caring?

We asked those who lived at the home about the staff team. Feedback from them was very positive. They said staff were kind and caring towards them and helped them to meet their needs. When speaking with staff it was clear they genuinely cared for those they supported and were observed speaking with people in a respectful and friendly manner. People's preferences, choices and leisure interests had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

A wide range of daily activities were available both inside and outside the home on a regular basis. This supported people to maintain contact with their local community and encouraged people from outside to become involved with activities provided at Douglas Bank.

Staff were seen to be responding to people well by anticipating their needs appropriately. The service worked well with other agencies and services to make sure people received care and support in a consistent way. Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

Is the service well-led?

The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the manager of the service. One member of staff told us, "Coming to work at Douglas Bank is the best move I have ever made. I love it."

People who lived at Douglas Bank and their relatives completed annual satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately.

This visit to Douglas Bank enabled us to establish if the provider had taken action to address the concerns raised at the previous scheduled inspection. We found significant improvements had been made. At the time of this inspection there were 31 people living at the home. We spoke with five of them, asking them for their views about life at Douglas Bank. We received positive feedback from them all. They were very complimentary about the service provided, the management team and staff attitudes.

Comments received included:

"It is rather nice here. I like how comfortable it is and the staff are so friendly and helpful."

"I do think there are enough staff around, but sometimes they seem to be in a rush when doing things for me. Perhaps it is because they are very busy."

"This is a super place."

During our visit we looked at the management of meals and how people were supported to receive adequate nutrition. We also assessed outcome areas related to medications, staffing levels and quality assurance. We found appropriate action had been taken in each area and therefore we did not find any concerns on this occasion.

During our inspection, we were able to speak with nine people who lived at the home and several relatives, who all provided us with positive comments about the staff team, describing them as, kind, caring and helpful. Those using the service told us that they were able to make decisions and choices about what they wanted to do, whilst living at the home.

Comments received included:

"Pam, the activities organiser is brilliant. She really does some good things with us."

"I am very happy and the staff are smashing. They are considerate and always listen to what we have to say, even though they are always so busy. The young lads are super."

"They (the staff) are always on the go. They never have a minute to spare. There isn't enough of them."

"It's a lovely place here. The food is good and the staff are good and I've got a lovely bedroom. I'd sooner be at home, but I've got to stop here."

During our visit, we assessed standards relating to care and welfare and how people consented to care and treatment provided. We also looked at the management of medications and how people were supported to make complaints. Standards relating to monitoring the quality of service provision were also inspected. We identified concerns in some areas. Therefore, we also assessed areas in relation to nutrition, staffing and suitability of the premises.

During our inspection we were able to speak with five people living at the home, who all provided us with positive comments. They told us that they felt safe living at Douglas Bank, with their privacy and dignity always being respected and their needs being met by a kind and caring staff team. They said independence was promoted and they were able to make decisions and choices about what they wanted to do, whilst living at the home.

We found staff to be well supported and appropriately trained and those living at Douglas Bank looked comfortable in their presence. We also spoke with several relatives who were all very complimentary about the staff team and the managers of the home.

Methods for monitoring the quality of service provided had been established and systems had been developed in order to protect the health and safety of those living at the home.

Comments from those living at the home and some relatives included:

"I cannot fault any of the staff. I am really 'pally' with them. They are so funny. We have a good laugh and I enjoy a bit of banter with them, it keeps me going."

"The young fellows who work here are marvellous. They seem to be really interested in their work. They talk to us all like ladies and gentlemen and don't brush us off because we are old folk."

"The staff are absolutely superb. The meals are excellent. The home is second to none. Everything is first class. I have not one complaint about this place."

We were able to speak with a good number of people during our visit to this location, including those living at the home and their relatives.

In general we received positive feedback from everyone involved in the inspection process.

We were told people's privacy and dignity was consistently protected and that people were encouraged to maintain their independence as far as possible. Those living at the home who we spoke with felt their needs were being met in the way they wanted them to be and that staff were competent to do the jobs expected of them.

Comments received from people living at the home:

"it is absolutely great living here."

"The staff are all really very nice people. They treat us all the same, with respect and kindness."

"You get real value for money living at Douglas Bank."

"When I came to live here I was told, 'This is your home and treat it as such. You can do here whatever you did at home. We (the staff) are visitors to your house."

Comments received from relatives:

"The manager is very helpful. She has set times when we can 'pop' in and see her to discuss any concerns, which is great, although we can speak with her at any time if we want to. We have meetings too, so people can voice their opinions in a group forum if they like."

"My relative receives the care he needs. The staff are lovely. They respect hime and treat him very well."

"The activity lady is fabulous. I think she is on holiday this week, but usually there is always something going on."