We carried out an unannounced comprehensive inspection of Freelands Croft Nursing Home on 13 and 14 March 2017.

Freelands Croft Nursing Home provides accommodation and personal and nursing care for up to 64 older people who are frail or are living with dementia. Accommodation is provided over two floors with the first floor providing nursing care. At the time of our inspection 54 people were using the service.

The service had a registered manager in place. 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 service is required by a condition of its registration to have a registered manager.

The provider operated effective quality assurance systems. Regular checks and audits were completed which enabled the registered manager and staff to continually evaluate the quality and risks in the service. We found these systems had been effective in driving improvements for example, in relation to staff supervisions and daily activities in the service for people. Clinical governance systems enabled nursing decisions to be reviewed and monitored to ensure care was being provided in accordance with best practice standards.

The provider implemented safe recruitment practices and we found all the required staff pre-employment checks had been completed to ensure staff would be suitable to work at the service.

People received their prescribed medicines safely and had access to healthcare services when they needed them. People liked the food and told us their preferences were catered for. People received the support they needed to eat and drink enough.

Staff had a good knowledge of their responsibilities for keeping people safe from abuse. Staff sought people's consent before they provided their care and support. Where people were unable to make certain decisions about their care the legal requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) were followed.

Care plans were based around the individual preferences of people as well as their medical needs. They gave a good level of detail for staff to know what support people required. Staff received training and supervision to support them to meet the individual needs of people effectively.

Staff knew people well and supported people living with dementia to manage their anxiety and agitation. People were treated with kindness, compassion and respect and staff promoted people's independence and right to privacy. The staff were committed to enhancing people's lives and provided people with positive care experiences.

People knew how to make a complaint. People told us the manager and staff would do their best to put things right if they ever needed to complain.

Freelands Croft Nursing Home provides accommodation and personal and nursing care for up to 64 older people who are frail or are living with dementia. Accommodation is provided over two floors with the first floor providing nursing care. At the time of our inspection 37 people were using the service.

This inspection took place on 25, 26 and 28 January 2016. It was carried out to check on the provider’s progress in meeting the requirements made as a result of our inspection on 9, 10, 12 and 16 June 2015 which resulted in the service being rated Inadequate. As a consequence of this judgement the service was placed in special measures and we have taken enforcement action in response to this failure to meet required standards. We have placed a condition on the provider’s registration that they must not admit any new people to Freelands Croft Nursing Home without the prior written consent of the Care Quality Commission. At the time of this inspection the provider had not requested any new admissions be made to the service.

The previous inspection report in June 2015 identified some serious concerns. Risks to people had not always been managed to ensure their safety, staff had not been supported to understand people’s needs, care plans and records did not reflect the care people needed and received and the provider had not adequately monitored the quality of the service and make improvements when required to keep people safe.

The provider took action to address the concerns we found at the last inspection and submitted their service improvement plan telling us how they were addressing the areas in need of improvement. At this inspection we found the provider had made improvements to address the five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 found at the last inspection. Following this inspection the service has not been rated as inadequate for any of the five key questions and has therefore been taken out of special measures. The Interim Area Manager acknowledged that more time was needed to ensure these improvements became part of the routine practice at the service and were maintained over time before people could always be confident that they would receive good care.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered person’. 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 had recruited a new Home Manager in the past month and they had started the application process to be registered with the Care Quality Commission (CQC) to ensure the provider met their registration requirements. The provider was working at inducting the new Home Manager and supporting them to sustain these improvements.

The service had improved the operation of their quality and risk monitoring systems and routine monitoring checks and audits had been completed in the past six months. These had supported the Relief Home Manager to identify areas of risk or quality concerns. Prompt action had been taken to address issues identified. Action plans had been monitored and were effective in driving service improvements for people. The provider was aware of areas that required further improvements and had plans in place to address these.

Staff we spoke with all knew what the concerns were and what action was required from them to improve the service. The provider was developing a culture of learning, development and problem-solving with staff empowered to find solutions to ensure people remained healthy and safe. Staff told us that they felt valued and felt able to put good care and people’s experience at the heart of their work.

Improvements had been made in how risks to people’s health and safety were i

We had previously inspected Freelands Croft Nursing Home on 1 and 2 July 2014 to follow up on areas of non-compliance with essential standards of quality and safety. During that 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?

We found the service was caring, but evidence showed that the service was not always safe, effective, responsive or well led. We served warning notices in relation to medicines management, care and welfare and staffing and required the provider to achieve compliance with these essential standards by 11 August 2014. We also issued compliance actions in relation to supporting workers, assessing and monitoring the quality of service and records management. The provider sent us their action plan showing how they would address the issues we found.

On 16 September 2014 we re-inspected Freelands Croft Nursing Home to assess whether compliance with the three warning notices and three compliance actions had been achieved. We spoke with the new manager, 14 staff members, 12 residents or their relatives and two visiting healthcare professionals. 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?

Systems for learning from accidents and incidents were in place and had been effective in reducing falls.

Staffing levels and staff skills were appropriate for the needs of people using the service. New staff had been recruited since our last inspection and the use of agency staff had reduced. The staff we spoke with understood people needs and how to keep them safe.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards were being applied for in line with legislation.

Some unsafe aspects of medicine management, that we had reported in the warning notice, had not been addressed. We also found other areas of medicine management that were not safe and we advised the service of our concerns. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to safe management of medicines.

Is the service effective?

People’s individual health and care needs were assessed and care planning included clear guidance for staff. Care was reviewed when people’s needs changed. Care and treatment was coordinated effectively and staff understood their roles. External health professionals were involved in people’s care appropriately and their advice was followed.

Best interest decisions had been carried out when people were not capable of making their own decisions.

Staff support was in place, with training and professional development. The delivery of care was clearly documented

Is the service caring?

People using the service and relatives told us that staff were kind and caring. We observed that staff treated people with respect.

Staff provided emotional support to people using the service and their relatives. Carers had been invited to meetings at the service, including a dementia support discussion. We observed that staff spent time talking with people and were patient, friendly and interested in people's views.

Staff encouraged people to be independent and make their own choices.

Is the service responsive?

The service responded to people’s emotional needs by developing the environment to provide different areas of sensory stimulation and diversion. For example since our last visit the service had installed an indoor ‘woodland’ area, a fish tank and there was a cage of two budgerigars on the dementia floor. These had helped give people pleasure and interest.

The service responded to changes in people’s health needs and sought advice from health professionals promptly. Health professionals were positive about the care people received and the way staff worked well together to provide the care people needed.

Opportunities had been provided for people using the service, their relatives and friends to meet with the manager or raise concerns. These were dealt with promptly.

Is the service well led?

The new manager of the service had been in post eight weeks when we inspected and staff, relatives and visitors told us that the leadership, and staff morale, was much improved. Staff understood their roles and responsibilities and there was effective team working. Staff demonstrated a commitment to improving the quality of service provided.

Systems for monitoring quality had not identified that the issues raised in the warning notice in relation to medicine management had not been addressed. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to monitoring the quality of service provision.

Staff said they received good support and training, and enjoyed their work. They said their views were listened to, including their ideas for improving the service.

All of the people who used this service had a diagnosis of dementia and many were not able to communicate with us in a meaningful way. Therefore we used our Short Observational Framework for Inspection (SOFI) to enable us to observe people's experiences of the care provided. We spoke with six people’s relatives about the care provided, they told us that overall they were pleased with the care provided. One told us “Generally, it is very good” and another said “I cannot fault it.” We observed that staff were caring and responsive to people.

We found that people were at increased risk of experiencing falls and urinary tract infections.

Not all staff had received appropriate dementia care training to enable them to meet people’s increasingly complex needs.

The arrangements for the administration of medicines were not sufficiently robust.

The number of staff had been recently increased, however this required further review. The provider had taken steps to recruit permanent staff; however we found that there was a high usage of agency staff.

Incidents had been investigated and trends within the home had been monitored.

We spoke with seven people and three people’s relatives. We found that their feedback about the service was positive. People commented “I am happy here and the service is fine” and “The care can’t be faulted.”

People had been consulted about their care and preferences. Where people lacked the capacity to consent to decisions about their care, the correct processes had been followed.

Staff were observed to be caring and demonstrated that they had an understanding of people’s individual needs. People had care plans to meet their identified needs. Risk assessments had been completed and there were plans in place to manage risks to people.

People had been provided with sufficient choice in relation to their food and drink. They had been provided with appropriate support to ensure that their nutritional needs had been met.

We found that staff had worked with other agencies to ensure that people’s needs had been met.

The home was clean and well cared for. We found that some staff needed to update their infection control training. The registered manager had already identified this need and had made appropriate arrangements to meet this need.

We last inspected this service on the 17 September 2012 and found the provider was not meeting a number of the essential standards. The provider sent us their action plan which addressed how and by when they would become compliant with the required standards.

This inspection on the 10 January 2013 was for the purpose of following up on whether the provider had achieved compliance with these standards.

We spoke with people who use the service and their relatives. People told us that they were ‘very happy with the care’ and ‘I like it’.

We found that the use of agency staff had significantly reduced and that there was more consistency with the agency staff that had been employed. This meant that the staff team were aware of people’s individual needs when providing them with care. People told us that the staff treated them well.

When agency staff were used, checks were made to ensure that they had undergone the required training. They were also provided with enough information to provide people with safe care.

During the inspection we found that medicines were being managed safely and that nurses had received further training.

Staff were up to date with their safeguarding training and were able to apply their knowledge. People's relatives told us that they felt the care provided was safe.

We also found that the manager had ensured that the pre-employment checks for staff were thoroughly completed.

We spoke to people who used the service and their relatives. Most people who used the service appeared satisfied, one said ‘Caring is excellent.’ One person told us that some of the staff lacked respect.

A relative told us that the care was very good, whilst another told us ‘it has changed a little bit.’ Concern was expressed regarding the high use of agency staff. Another told us that the staff seemed under pressure and didn’t know people.

People were provided with information about the service; however there was a lack of written evidence to demonstrate that they had been involved in their care plans or had been offered a copy. People’s needs were assessed and risk assessments were completed. Not all staff however particularly agency staff were sufficiently familiar with the care plans.

Not all staff had received safeguarding training, in particular some agency staff.

There were insufficient permanent staff; therefore there was a heavy reliance on agency staff who received an inadequate induction.

The provider had systems to monitor the quality of the service provided, but they were not fully effective.

There were concerns around medicines. The records showed that medicines had not been administered as prescribed by the doctor.

People we spoke to, such as people who used the service and relatives, told us they were very happy with the care provided at Freelands Croft

Freelands Croft Nursing Home provides accommodation and personal and nursing care for up to 64 older people who are frail or are living with dementia. Accommodation is provided over two floors. At the time of our inspection 56 people were using the service.

We received concerns about people’s safety and undertook an unannounced inspection on 9, 10, 12 and 16 June 2015 to look into these concerns.

During the inspection, we identified a number of serious concerns about the care, safety and welfare of people who received care from the provider. We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have taken enforcement action in relation to the regulatory breaches identified. We imposed a condition on the provider’s registration in respect of the regulated activity, Accommodation for persons who require nursing or personal care, they carry on at Freelands Croft Nursing Home. The provider must not admit any new service users to Freelands Croft Nursing Home for the purposes of this regulated activity without the prior written consent of the Care Quality Commission.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'.

The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered person’. 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 management of the service had changed in the past month following concerns identified by the provider about the quality of the service provided at Freeland’s Croft Nursing Home. A new deputy manager, acting home manager and area manager had been appointed to address these concerns. The provider had started recruiting for a new registered manager. We had not received a notification to cancel the previous manager’s CQC registration and therefore their name still appears on the CQC website as registered manager for the service.

The provider had not effectively implemented their quality and risk systems and routine monitoring processes had not been completed in the past six months. The previous area manager had raised concerns about the management of the service and undertook a Home Review Audit of the service on 10 March 2015. Widespread shortfalls, similar to the ones we found at this inspection, were identified and a basic action plan was developed to address these concerns. Some action had been taken but the provider’s monitoring system had failed to ensure action was taken in line with their action plan. Significant improvements had not been made and people remained at risk of receiving inappropriate or unsafe care

Action had not been taken by the provider to ensure the information in people’s care records were accurate and could effectively be used to evaluate and identify the correct treatment and care required for people. Nurses could not be assured from the records that people had received their medicines as required. The provider had not taken action to improve the quality of record keeping which they had identified as a significant concern during the internal audit on 10 March 2015. People remained at risk of receiving inappropriate or unsafe care through the provider’s failure to maintain accurate, complete and contemporaneous records in respect of their care and treatment.

People’s individual risks were not managed safely. Risks had not been fully assessed and staff had not received sufficient guidance on how to support people to minimise risks where possible. Skin pressure relieving equipment including air mattresses, were not monitored to ensure they were used in a safe appropriate manner.

The provider did not ensure that there was enough suitably competent and experienced staff to meet people’s needs safely. The provider had ensured that agency nursing staff had been engaged to support the staffing levels in the home. However, there were insufficient numbers of nursing staff who understood people’s individual needs and the support they needed to stay safe. The provider had not identified the impact that temporary staff, who did not know people, would have on the deployment of regular staffing levels. The skills and knowledge mix of the staff had not been reviewed continuously and adapted, to keep people safe.

Staff did not receive regular support and supervision to enable them to identify solutions to problems, improve care practices and to increase understanding of work based issues. Agency nurses had not been inducted effectively to ensure they had the necessary knowledge of the provider’s policies, care practices and people’s needs to care for people in the home appropriately.

People’s health needs were not always understood. People who lived with diabetes were not consistently supported in line with nationally recognised guidelines to adequately manage their blood glucose levels so as to protect them against diabetes-related complications. Making appropriate treatment decisions for people were complicated by care plans not providing health professionals with up to date and accurate information about people’s treatment histories and how people’s health had deteriorated or improved over time.

There were shortfalls in the support people received to meet their nutritional and hydration needs. People were at risk of aspiration and/or choking as clear support guidelines, based on Speech and Language Therapy (SALT) recommendations, were not available to staff when supporting people with swallowing difficulties. Where records indicated potential shortfalls in people’s fluid intake, nurses failed to investigate and take appropriate action to ensure people had enough to drink.

Staff understood their responsibility to follow the Mental Capacity Act 2005 (MCA) code of practice to protect people’s human rights. Two people were subject to Deprivation of Liberty Safeguards (DoLS) and the DoLS team was processing a further 12 applications for people living at Freeland’s Croft Nursing Home. The service was reviewing everyone using the service to assess whether further DoLS applications were required. Best interest decisions were being made to agree restrictions in people’s care plans, with input from family who knew people, enabling staff to keep people safe whilst awaiting the outcome of the DoLS applications.

Staff demonstrated kindness and compassion but some did not understand and support people living with dementia appropriately. A lack of a clear consistent approach and understanding on current good practice, at times, resulted in staff acting in an uncaring way. They did not pick up on people’s attempts to make contact or take part in activities resulting in opportunities to engage with people living with dementia being missed.

Staff did not always have the information they needed to meet people’s needs and preferences. Needs assessments had not always been used to plan people’s care in a timely manner following their admission to the service. People’s care plans were not always reviewed monthly in line with the provider’s policy to ensure people’s changing needs were identified and their care adjusted accordingly.

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