Green Gables is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Green Gables accommodates up to 38 people in one adapted building. There were 31 people at the service at the time of inspection. The accommodation is over three floors, each floor is accessible via stairs or a passenger lift.

The service was rated Requires Improvement at its last inspection in September 2016 and had a breached one regulation in relation to staffing. Following the last inspection, we asked the provider to complete an action plan to show what they would do to meet the breach and improve the key question of Safe to at least Good. At this inspection, we found that the provider had made sustained improvements by increasing staffing levels. There were sufficient staff available to monitor people’s wellbeing and attend to people’s needs without appearing rushed. The service is now rated Good overall.

The registered manager had increased the number of staff on shift during daytime hours. This meant that there was always a member of staff present in communal areas of the home to attend to people’s needs. The deputy manager was prominent in organising and supporting staff to ensure they were effectively meeting people’s needs. People and their relatives told us that improvements had been made to both the level and standard of staffing. This meant that staff were able to quickly respond to people’s requests and spend quality time during the day with them. The provider had systems in place when recruiting new staff to check their character and experience to help ensure they were suitable to work with people.

There was 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.

People were supported to maintain good health. The provider had participated in programmes in conjunction with health professionals to promote people’s nutrition and hydration. People told us they were happy with the meals available to them and they received the appropriate support from staff if they required or assistance whilst eating. People had access to healthcare services as required and recommendations from health professionals were incorporated into people’s care plans.

Risks to individual’s health and wellbeing were assessed and monitored. The provider had made improvements after feedback from incidents. In one example, the provider had made changes to how they managed people’s wound care after feedback from professionals highlighted where improvements were needed.

People’s needs were assessed using assessment tools which helped the registered manager determine appropriate care and treatment plans. Care plans were developed in partnership with people, families, social workers and health professionals. Where people required additional healthcare support, the registered manager made the relevant referrals in good time, to ensure that people received effective care.

People’s care plans detailed their preferences around their daily routines and personal care arrangements. Staff were sensitive to these needs and treated people with dignity and respect. People were positive about staff and told us they were caring, humorous and attentive to their needs.

The provider had made considerations about how to provide dignified and empathetic support to people at the end of their lives. People’s wishes about their final care arrangements had been explored, which helped to ensure that the care provided was in line with their preferences.

People were supporte

This unannounced inspection took place on 1 and 2 September 2016. Green Gables Nursing Home provides accommodation and nursing care for up to 38 people who have nursing needs. At the time of our inspection there were 35 people living at the service. The home consisted of three floors, with en-suite bedrooms on each floor, and a communal lounge, dining room and conservatory on the ground floor. Access between the floors was provided by stairs and a lift.

The home had a registered manager. 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 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.

We identified concerns relating to staffing that may compromise people’s safety. There were insufficient staff deployed to ensure people remained safe at busy times when staff were mainly task driven. Staff often took too long to respond because they were providing support to other people. This meant that there was an increased risk that people’s needs may not be met safely.

Staff were always under pressure and did not have time to sit and talk with people, which left some people feeling lonely and socially isolated. The home did not employ a full time activities coordinator which meant that people were not always supported to follow their interests and take part in stimulating social activities which enhanced their well-being.

Staff generally felt supported by the registered manager and deputy manager but some had become disillusioned in relation to the management response regarding their concerns about staffing levels. Staff did not always feel their views were listened to by the management team.

Most people told us they felt safe because they were supported by staff whom they knew and trusted. People were protected from abuse because staff were trained in safeguarding and understood the actions required to keep people safe.

Potential risks to people's safety had been identified and managed appropriately to mitigate the risk of harm to them. Risk assessments gave staff clear guidance to follow in order to provide the required support to keep people safe and promote their independence.

The provider followed safe recruitment practices. All staff underwent pre- employment checks as part of their recruitment, which were documented in their records. People were safe as they were cared for by staff whose suitability for their role had been assessed by the provider.

People were protected as processes were in place to manage emergencies to ensure people were safe, for example; evacuation plans in the event of a fire or flood and contingency plans to deal with the failure of utilities.

People’s medicines were administered safely by nursing staff who had completed safe management of medicines training and had their competency assessed by the registered manager. People had medicines risk assessments to manage the risks associated with the use of their medicines, including any known allergies or side effects.

Most people and their relatives told us the registered manager and staff provided effective care and support. People told us staff knew their needs and how they wished to be supported. Staff received effective supervision, training and support to enable them to carry out their roles and responsibilities effectively. Staff completed an induction course based on nationally recognised standards and spent time working alongside experienced colleagues. New staff had their competency assessed by the registered manager and nurses before they were allowed to support people unsupervised. Staff had completed the provider’s required training which ensured they understood how to meet people’s support and care needs. The provider had enabled further staff training to meet the specific needs of the people they sup

We spoke to five people who used the service, seven relatives and three members of staff. We found that people were involved in their care and had choices about what they wanted to do and when. People told us that staff were “Good” and spoke to them in a “Kind” manner. Staff treated people with dignity and respect.

All the people and relatives we spoke with told us that the care was good and that staff look after people “Very well”. One relative told us that their family member looked “Really well” since they moved in.

People said that they felt “Safe” and relatives we spoke with confirmed this. Staff were able to describe to us what to do if they had concerns about safeguarding.

We found that the service was clean and tidy in all the areas we looked at and staff followed procedures to keep people safe and well. Relatives told us that the service was always “Spotless.”

We found that there were sufficient staff to meet people’s needs. People told us that staff were always available and that they did not have to wait for them if they needed something.

We found that some records were not always easy to read and that there were gaps in recording in respect of some people's food monitoring charts.

We spoke with ten people and one relative to find out their opinions of the care and treatment provided at the home. People were complimentary about the home. Comments included, “You wouldn’t be able to find any better place” and “The care is very good.” Following our visit we contacted two local authority care managers. They told us that they did not have any concerns about people’s care and welfare.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

We concluded that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

The home was undergoing major refurbishment. The provider was in the process of adding a further 12 bedrooms; four on each floor. We found that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We concluded that staff were able, from time to time, to obtain further relevant qualifications. However we found that there were not enough qualified, skilled and experienced staff to meet people’s needs.

We concluded that people’s complaints were fully investigated and resolved, where possible, to their satisfaction.

A number of the residents who lived at Green Gables Nursing Home had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences of people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

Residents who could express a view told us they were very happy at the home. They said that the staff were lovely, caring and very helpful.

They told us the food was good and they looked forward to mealtimes.

Relatives told us that the home was lovely, the staff were very good and issues were dealt with promptly. They told us that they believed their relatives were safe living at Green Gables Nursing Home.

This unannounced inspection took place on 3 and 4 June 2015. Green Gables provides accommodation and nursing care for up to 38 people who have nursing needs. At the time of our inspection there were 34 people living at the service. The home consisted of three floors, with bedrooms and bathrooms on each floor, and a communal lounge on the ground floor. Stairs and a lift provided access between floors.

The home had a registered manager. 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 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.

We last inspected Green Gables Care Home on 20 and 21 August 2014 and judged the provider to be in breach of regulations relating to staffing levels, assessing and monitoring the service and records. The provider sent us an action plan detailing how they would make improvements to address these concerns. At this inspection we found the provider had made the necessary improvements in all areas where there had previously been breaches in legal requirements.

Since our last inspection in August 2014 the provider had embedded their recruitment process, had increased night time staffing levels and employed contract cleaners on the week end, which allowed care staff more time to deliver person centred care. Care staff told us people were safe but felt they were often stretched, which did not allow them to stop and talk with people as much as they would like.

Robust recruitment procedures ensured people were supported by care staff with appropriate experience and suitable character. Care staff had undergone relevant recruitment checks as part of their application and these were documented.

The provider had implemented effective systems for identifying and recording incidents and accidents. The registered manager had analysed learning from individual incidents to reduce the risk of recurrence but had not always analysed them as a whole to identify trends that may affect other people. We reviewed the incidents since our last inspection and found no trends were apparent.

People told us they trusted the care staff who made them feel safe. Care staff had completed safeguarding training and had access to relevant guidance. They were able to recognise if people were at risk of abuse and knew what action they should take if required. Since the last inspection the provider had reported one safeguarding incident which had been investigated by the registered manager. We noted that the required learning and appropriate care staff supervision had been implemented as a result of this incident.

We observed medicines administered safely in a way people preferred, by trained care staff who had their competencies assessed by the registered manager.

People’s needs had been appropriately assessed and reviewed regularly. Their safety was promoted through individualised risk assessments. Where risks to people had been identified there were plans in place to manage them effectively. These plans were responsive to people’s specific needs and tailored the care delivered for each individual. Care staff understood the risks to people and followed guidance to safely manage these risks.

People’s health needs were looked after and any concerns were promptly escalated to health care professionals for advice and guidance, which was then followed by care staff. Care staff were trained to deliver effective care, and where required, followed advice from specialists. This included training in caring for people with specific health conditions.

Care staff had completed training on the Mental Capacity Act (MCA) 2005 and understood their responsibilities to protect people’s rights. The MCA 2005 legislation provides a legal framework that sets out how to support people who do not have capacity to make a specific decision. Where people lacked the capacity to consent to their care, legal requirements had been followed by care staff when decisions were made on their behalf.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide a lawful way to deprive someone of their liberty, where it is in their best interests or is necessary to protect them from harm. They were aware of a Supreme Court judgement which clarified the definition of a deprivation of liberty. The registered manager had taken the necessary action to ensure care staff recognised and maintained people’s rights.

People’s needs in relation to nutrition and hydration were documented in their support plans. People were supported appropriately by care staff to ensure they received sufficient to eat and drink. Meals reflected people’s dietary needs and preferences. When necessary people had been referred to appropriate health professionals for dietary advice, which was then implemented by care staff.

The provider aimed to enable people to maintain their independence and socialise as much as possible. People’s dignity and privacy were respected and supported by care staff who were skilled in using individual’s unique communication methods.

When complaints were made they were investigated and action was taken by the provider in response. Complaints were analysed by the provider for themes and where these had been identified action had been taken.

The registered manager was highly visible, and promoted a culture of openness where people and staff were encouraged to provide feedback. During our inspection care staff demonstrated the values of the provider through their behaviours. Care staff were observed to treat people as individuals, with kindness and respect.

The registered manager had not always demonstrated good leadership. For example, care staff raised concerns during supervisions regarding staffing levels, particularly in the afternoon. The registered manager investigated the issues raised and conducted a staffing needs analysis to ensure staffing levels were sufficient, but had not communicated the outcome to care staff.