Firtree House 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. Firtree House accommodates 50 people across a large home in a quiet residential area of Royal Tunbridge Wells. There are facilities and lifts for people with restricted mobility. All bedrooms are for single occupancy, and some had en-suite facilities. Firtree House specialises in providing care to older people with nursing needs. At the time of the inspection there were 37 people living at Firtree House.

This inspection site visit took place on 13 and 15 March 2018 and was unannounced.

There was a registered manager in post at the time of the inspection. 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.

At the last inspection on 06 October 2015, the service was rated ‘Good.’ At this inspection we found the service to be ‘Requires Improvement.’

Not all risks had been managed safely. Falls had not been assessed and monitoring tools had not been scored correctly. Other risks around the environment had been managed safely and the possibility of harm reduced through effective risk assessment.

Medicines were not consistently being managed in a safe way. Audits had not been effective in counting correct stocks of medicines and some ‘as required’ medicines were not being recorded correctly.

Not all people had been supported to eat and drink enough to maintain a balanced diet. Some people had lost weight but not received a reassessment of their care plan or alternate strategies such as fortified foods. Other people told us that they liked the food and we observed staff supporting people to drink regularly.

The principles of the Mental Capacity Act 2005 (MCA) were not being adhered to. Three MCA assessments had not been completed correctly and some people who required an application to deprive them of their liberty had not been referred to the local authority.

Care plans were not as person centred as required giving personalised details such as how a person prefers to receive their personal care. Activities were being reviewed and we observed a range of activities being provided to people but there were some gaps in recording. We have made a recommendation about this in our report.

A programme of quality audits were in place but had not been effective in highlighting the issues we found at this inspection. The service had a friendly and homely culture and people told us they liked living at Firtree House.

People and families were engaged in the running of the service. The registered manager was a visible presence in the service and ensured that feedback led to learning and improvement. The service was working effectively with other key partner organisations such as local health teams.

Staff had received training in a range of courses relevant to their role. However, competency checks were not consistently effective. We have made a recommendation about this in our report.

People were protected from the risk of abuse by staff that understood their role in reporting any concerns. There was sufficient staff deployed to keep people safe and meet their needs. The service was clean and the risk of infection was reduced through effective infection control procedures. Lessons had been learned when things went wrong and incidents and accidents were tracked by the registered manager.

People had effective assessments prior to admission. This meant that care outcomes were planned for, and staff understood what support each person required. The service worked with other professionals such as people’s

The inspection was carried out on 06 October 2015 by three inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert-by-experience who took part in the inspection had specific knowledge of caring for older people. It was an unannounced inspection. The service provides nursing, personal care and accommodation for a maximum of 50 older people. There were 37 people living at the service at the time of our inspection.

There was a registered manager in post. 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 supported by a deputy manager and a team of nurses and senior carers to ensure the daily management of the service.

We last inspected the service in July 2014 and found the service was not compliant with the regulations. There were shortfalls in care and welfare, quality monitoring, nutrition, staffing and safeguarding. The provider wrote to us to tell us what action they had taken to improve the service. At this inspection we found that improvements had been made and there were no breaches of regulations.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to report any concerns. People told us that they felt safe using the service.

Risk assessments were centred on the needs of the individual. They included clear measures to reduce identified risks and guidance for staff to follow to make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how risks of recurrence could be reduced.

There were enough qualified, skilled and experienced staff to meet people's needs. Staffing levels were calculated according to people’s changing needs. The registered manager had identified shortfalls in the arrival times for some calls and had taken appropriate action to address this. The registered manager followed safe recruitment practices.

People told us that staff communicated effectively with them, responded to their needs promptly and treated them with kindness and respect. People were satisfied with how their care was delivered. The registered manager had clear person centred values that formed the basis of the service and these were followed by staff in practice.

People were supported to manage their medicines in a safe way. Staff responded quickly to changes in people’s health and worked with health care professionals to meet their needs.

The registered manager kept up to date with relevant best practice guidance in person centred care and encouraged and enabled staff to improve their knowledge and skills on an ongoing basis. Staff had completed the training they needed to care for people in a safe way. They had the opportunity to receive further training and qualifications specific to the needs of the people they supported. All members of staff received regular one to one supervision sessions and an annual appraisal to ensure they were supporting people based on their needs.

All care staff and management were knowledgeable in the principles of the Mental Capacity Act 2005 (MCA) and the requirements of the legislation. Staff sought and obtained people’s consent before they provided support. When people declined, their wishes were respected and staff reported this to the registered manager so that people’s refusals were recorded and monitored.

Clear information about the service, the management, the facilities, and how to complain was provided to people. Information was available in a format that met people’s needs.

People’s privacy was respected and people were supported in a way that respected their dignity and independence. The staff promoted people’s independence and encouraged them to do as much as possible for themselves.

Staff knew each person well and understood how to meet their needs. Each person’s needs and personal preferences had been assessed before care was provided and were regularly reviewed. This ensured that the staff could provide care in a way that met people’s particular needs and wishes.

The registered manager took account of people’s comments and suggestions. People’s views were sought and acted upon. The registered manager sent questionnaires regularly to people to obtain their feedback on the quality of the service. The results were analysed and action was taken in response to people’s views.

Staff told us they felt valued under the registered manager’s leadership. The registered manager notified the Care Quality Commission of any significant events that affected people or the service. Quality assurance audits were carried out to identify how the service could improve and the registered manager had an ongoing and effective improvement plan for the service.

People experienced support that met their personal, social and health care needs and ensured their safety and welfare. A variety of activities and events were organised for people who used the service, although not everyone was aware of the opportunities available to them.

Care plans gave staff guidance about how to support each person with their personal, social and health care needs.

The manager was knowledgeable about how to refer to and work with the safeguarding authority about concerns or allegations of abuse.

People benefitted from safe and comfortable accommodation, which was suitably designed and maintained to meet their needs.

People who used the service were supported by enough skilled staff who knew how to meet people’s needs. People told us “The staff and the care is good.”

People who used the service and their relatives and/or representatives were asked for their views about the service provided. We saw that people were able to communicate their wishes to staff, who listened and took action. People who used the service told us “They’re very nice. I’ve got no complaints.”

The inspection was carried out by three inspectors over a period of eight hours. A pharmacy inspector also visited the home. There were 38 people who lived at the home. They had a range of needs including difficulties with mobility and communication.

We visited to undertake a responsive inspection following receipt of concerning information through our whistleblowing process and other safeguarding concerns reported by the Local Authority. The report is based on our observations during the inspection, talking with people who lived at the home, their relatives and also staff. We also reviewed records.

During this inspection we set out to answer our five 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. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

Although there were systems in place to protect people from the risks associated with infection, these were not always effective in identifying and addressing concerns. Health and safety audits were carried out but did not address issues such as the security of the home. We found that there were insufficient numbers of staff to ensure that people’s needs were met.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While we were told no applications have been submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Is the service caring?

People were supported by kind staff. We saw that staff showed patience and sensitivity when supporting people. Four families we spoke with said that staff were good at keeping them informed when their relative was not well or if it had been necessary to call the doctor out. One said the staff are excellent, and another relative told us "I could not ask for better care, the care workers and nurses are really kind and help me a great deal". However, we spoke with some people who lived at the home and their relatives who were concerned about the care they receive. .

Is the service responsive?

Some people and relatives we spoke with said that they had been involved however we were also told by a person who lived at the home and their relative that they had not been involved in the formation of the care plan. This meant that although most of the people who lived in the home and/or their families had been involved and had agreed the care and the way they wanted care provided, not all people felt that they were not involved in the planning of care for their relatives.

Is the service effective?

In the care files we viewed people’s care needs were assessed with them or their relatives and they were involved in discussions about their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Some people and relatives we spoke with said that they had been involved however we were also told by a person who lived at the home and their relative that they had not been involved in the formation of the care plan. This meant that although most of the people who lived in the home and/or their families had been involved and had agreed the care and the way they wanted care provided, some people felt that they were not involved in the planning of care for their relatives.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service well-led?

Staff told us that the head of care was approachable and they were able to raise any concerns they had with them. We saw that many aspects of the operation of the home were monitored through regular audits and reviewed. However, these were not always effective in identifying and addressing concerns in a timely manner.

Some relatives we spoke with were positive about the support provided by managers at the home. Other relatives were less positive and felt that improvements needed to be made at the home. We saw that appropriate processes were in place for ensuring that people were able to make their views known through surveys sent to people who lived at the home and their representatives. People also had a forum for voicing their opinions through regular service user meetings.