This inspection took place on 28 and 29 September 2017 and was unannounced.

Doves Nest Nursing Home provides accommodation and nursing care to up to 40 older and younger age adults. The service provides care to people with complex needs in relation to physical disabilities. Accommodation is located across three floors, with a passenger lift available between floors.

We last inspected Doves Nest Nursing Home on 08 and 09 March 2016 when we rated the service good overall. At that inspection we identified one breach of the regulations, which was in relation to the safe management of medicines. Following the inspection the provider sent us an action plan to tell us about the changes they would make to ensure they were meeting the requirements of the regulation. Whilst there was scope for further improvements to be made in relation to the safe management of medicines, we found the provider was now meeting the requirements of this regulation.

At this inspection we also identified additional breaches regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to providing safe care and treatment, good governance and requirements to display the service’s performance rating. You can see what action we have told the provider to take at the back of the full version of this report.

We have also made two recommendations, which were in relation to the provider reviewing good practice guidance in relation to the implementation of the Mental Capacity Act 2005, and reviewing guidance and risk assessing the safety of the premises in relation to the needs of people living there.

People living at the home told us staff were kind and treated them with respect. We saw people were comfortable requesting support from staff, which was provided promptly. Staff knew the people they provided care and support to, including any preferences, likes and dislikes they had.

The chef was proactive in meeting people’s preferences for meals. People provided us with positive feedback about the food on offer and we found their dietary requirements were met.

The home had made improvements to the way they managed medicines. We found protocols were now in place to inform staff when to administer when required medicines, and body maps were being used to help ensure the safe application of topical medicines such as creams. However, we found further improvements could be made. For example, quantities of medicines carried forward from previous months were not always recorded, which meant we were not able to work out if people had received their medicines as prescribed. One person was prescribed a ‘when required’ medicine and there was no plan or protocol in place to inform staff why and when to administer this medicine.

We found the provider had not fully considered potential risks to people’s health safety and wellbeing arising from the management of the premises. For example, we found some people living at the home lacked capacity and were subject to authorised restrictive practices. There was no restriction on people leaving the home without staff being aware. Whilst the registered manager felt no one at the home was at risk, there was no documented risk assessment. Not all windows had restrictors that met current guidance about their required standards. The registered manager did not feel these potential hazards posed a risk to anyone living at the home. However, this was not as a result of any formal risk assessment.

We found risk assessments were not consistently completed for all people living at the home. For example, we found one person did not have a bed-rail risk assessment, and none of the risk assessment tools had been completed for another person who had moved into the home over two months previously. This meant staff may not be fully aware of potential risks posed to these people’s health and wellbeing or how to reduce such risks.

The environment at the home was clean, bright and spacious. The ho

This was an unannounced inspection which took place on 8 and 9 March 2016. We had previously carried out an inspection in February 2015. At the inspection in 2015 we found there was a breach in regulations in relation to the delivery of person centred care and improvement was needed in relation to the quality and quantity of activities within the home. At this inspection we found improvements had been made in both these areas.

Doves Nest is a nursing home registered to provide accommodation, nursing and personal care for up to forty people with wide variety of complex care needs. On the day of our inspection there were thirty three people living at the home.

The provider had a registered manager in place as required by the conditions of their registration with the Care Quality Commission (CQC). 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 responsible for all the services delivered by the provider.

People who used the service told us they felt safe with staff who supported them. They told us staff were available to support them in the activities they wished to do. People were encouraged to make their own decisions and told us staff always promoted their independence. During the inspection we observed staff were caring and respectful in their interactions with people who used the service.

Recruitment processes were robust and should help protect people who used the service from the risk of staff who were unsuitable to work with vulnerable adults.

Systems were in place to help ensure the safety and cleanliness of the environment.

Staff told us they received the training and support they needed to carry out their role effectively. There were systems in place to track the training staff had completed and to plan the training required. All the staff we spoke with told us they enjoyed working in the service and felt valued by both the registered manager and the rest of the team. Staff felt able to raise any issues of concern in supervisions and in staff meetings.

People who used the service had support plans in place. Records were stored securely and were easily accessible by staff. Records reviewed showed that, where necessary, people were provided with support from staff to attend health appointments. People were also supported by staff to maintain a healthy diet as far as possible.

Care records we looked at showed people who used the service had been involved in developing and reviewing their care and support plans. The support plans we looked at were person centred and focused on the care and support people said they wanted.

All the people we spoke with told us they felt able to raise any concerns with the registered manager and were confident they would be listened to. We noted systems were in place to encourage people who used the service to provide feedback on the care and support they received.

Staff had received training in the safe administration of medicines. The competence of staff to administer medicines safely was regularly assessed. However there were no systems in place to support staff to administer ‘as needed’ (PRN) medicine. Some of the records relating to the administration of medicine had gaps which had not been accounted for. We found this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

The inspection took place on 24 February 2015 and was unannounced. The last inspection of Doves Nest Nursing Home was carried out on 11 August 2014 where we found a breach in legal requirements relating to supporting workers. Part of this inspection was to follow up on the action the provider said they would take to address this issue.

Doves Nest is a nursing home providing accommodation for up to 40 people with complex health care needs. Support is offered to both younger and older people who reside at the home.

The service had a registered manager. 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 ethos of the home was to provide person centred care and support to each person who used the service. We found this did not always happen. (Person centred means care is tailored to meet the needs and aspirations of each individual. Personalised programmes and flexible staffing enable people to be as independent as possible with the right amount of support they need to meet their needs.)

We found people were not always supported in line with their care plan or included in decisions and discussions about their care and treatment. Activities were not offered to people according to their wishes.

It was clear from speaking with people who lived at the home and our observations, that the staff had developed good relationships with people and understood people well. The feedback was generally positive. We saw most people had their dignity and privacy respected in the day to day support they received. We saw one occasion where this did not happen.

The care plans were detailed and contained enough information to help nursing staff support people with their clinical needs. However these were often generic and there was no person centred information contained within the file. Some information was out of date or no longer relevant to the person being supported. This meant that people were placed at risk from inappropriate delivery of care. Care staff we spoke with said they would like more time to spend with people to find out about their lives and capture information which was important to them as individuals.

There were mental capacity assessments in place. The correct procedures had been followed to ensure people were not unlawfully deprived of their liberty and any restrictions had been agreed as in the person’s best interest.

We found the service to be relaxed and friendly and people were supported by appropriately trained staff. We found the skill mix and staffing levels were sufficient to support people safely and effectively.

There were sufficient staff on duty to meet people’s needs. However we noted some staff were not properly co-ordinated at mealtimes, which made the mealtime experience a bit chaotic. Staff received training and support to enable them to carry out their tasks in a skilled and confident way.

People who used the service did not have the opportunity to be involved in activities which they said they enjoyed.

We found the home provided a good level of nursing care but did not explore opportunities for younger people to improve and enhance their quality of their life. We found the aim of the home and the registered manager, to provide good quality person centred care, did not reach all of the people living at the home at the time of our inspection.

During our visit, we spoke with four of the thirty eight people who used the service. They shared some of their experiences at the home. We spoke with two care staff, a registered nurse, the activities co-ordinator, the operational lead, the chef, the registered manager and two people who were visiting their relatives.

One inspector carried out the inspection. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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.

Is the service safe?

We saw people were being cared for in an environment which was clean. Processes for the prevention and control of infection were in place. For health, safety and security reasons, visitors were asked to sign in and out. There were enough staff on duty to meet the needs of the people living at the home at the time of our visit. A qualified member of staff was on duty on each shift.

The people we spoke with who used the service told us they felt safe. One person said “Nothing is done which makes me feel uncomfortable or embarrassed.”

Discussion with staff and examination of records confirmed a programme of training was in place for all members of staff. However, one training system was not available due to technical failure, so staff did not have access to some training, some of which was required to be refreshed periodically. The manager was not able to assure us that this was being addressed.

We saw maintenance records for lifting equipment and noted that on inspection in May 2014, some slings had not been available and one hoist had required repairs. The manager was unable to identify these items or confirm whether they were being used.

The gas safety certificate we were shown had expired in May 2014.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). The aim is to make sure people in care homes and hospitals are looked after in a way which does not restrict their freedom inappropriately. Staff had all received training about the Mental Capacity Act and Deprivation of Liberty Safeguards so they understood when an application should be made and how to submit one.

Is the service effective?

People’s health, social and care needs were assessed with them and they were involved in writing and reviewing their care plans. Specialist needs had been identified in care plans, for example, ways to communicate. Care plans were reviewed every month and when people's needs changed.

The people we spoke with told us they were happy with the care they received and said their needs were met. They spoke positively about the staff who supported them. From what we saw and from speaking with staff it was clear they had a good understanding of the care and support needs of the people who used the service.

Is the service caring?

People we spoke with told us they liked living at the home. Comments included “I love it here”, “The staff are good” and “They do everything for me in a way I’m ok with.”

We saw the staff showed patience and gave encouragement when they were supporting people so people were able to do things at their own pace and were not rushed.

In September 2013, the home had been commended for high quality end of life care by the local authority’s “Life is for Living” Gold Standard Framework. This is a standard designed to improve care for people living with a life limiting illness.

Is the service responsive?

The records we saw confirmed people’s preferences and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People had access to activities which were important to them and had been supported to maintain relationships with their friends and relatives.

There was a sensory room and outside there was a sensory garden to help stimulate and enhance the senses. There was an assisted learning area, which provided an interactive, memory enhancing, sensory experience. However, some staff we spoke with were unsure how this should be used and some people we spoke with said they did not know about these facilities and had not been offered them.

Is the service well-led?

We saw documentary evidence which showed the service worked well with other agencies and services to make sure people received their care in a joined up way.

From speaking with staff we found they had a good understanding of the home’s values. They told us about their roles and responsibilities and they were clear about these. We saw quality assurance processes were in place to make sure the provider monitored the care provided and made improvements where necessary. For example, meetings were held with people who used the service so that they had the opportunity to express their opinions.

Three people who lived at Doves Nest nursing home told us staff explained their actions and asked for their agreement before they carried out personal care. Three relatives told us they were informed about their relatives’ treatment. One told us how they had “excellent” communication with the staff and they were “always listened to”.

We spoke with three people living in the home all told us they were satisfied with the care and treatment they received. They said staff were always quick to respond when they asked for help.

During our visit we heard staff speaking with people respectfully and politely. We saw staff supporting and assisting people at a pace that was unhurried and met their needs.Each person who used the service had a care plan in place and this was being reviewed on a monthly basis or sooner should the need arise.

We found everywhere to be clean, tidy and comfortably furnished with no unpleasant smells detectable.

Three people who lived at Doves Nest nursing home told us staff explained their actions and asked for their agreement before they carried out personal care. Three relatives told us they were informed about their relatives’ treatment. One told us how they had “excellent” communication with the staff and they were “always listened to”.

We spoke with three people living in the home all told us they were satisfied with the care and treatment they received. They said staff were always quick to respond when they asked for help.

Three people using the service and three relatives told us the staff always treated them with respect, and were polite. One person told us they felt “safe in the staff hands”. A relative told us the staff were “excellent” and “top notch”.

We talked with three relatives; one told us the service was “smashing”, an “excellent nursing home” and provided a “high level of care”. However one relative told us they had concerns about the nursing care.

We found the care records did not reflect peoples care needs accurately and this had the potential to lead to people not receiving the correct treatment.

We spoke to people who use the service when we visited. They told us that they were treated with dignity and respect. All of the service users and their families were extremely happy with the care they received . Comments included ‘I'm very happy here’; I'd prefer to live at home but I'm safe and cared for here'’, ‘ ‘you get everything you want', 'we are involved in all the decisions about the care provided'.