Halwil Manor Nursing Home provides personal and nursing care to a maximum of 25 older people. Most live with the condition of dementia. There were 24 people using the service at the time of the inspection.

At the last inspection April 2015, we gave the service an overall rating of ‘Good’. However we rated the ‘safe’ domain as requires improvement because we found a breach of regulations. This was because the provider had not ensured medicines were safely managed at the service. At this inspection we checked that they had followed their action plan and to confirm that they now met legal requirements. We found improvements had been made and medicines were being safely managed. At this inspection we found the service remained good.

Why the service is rated good.

Medicines were safely managed and procedures were in place to ensure people received their medicines as prescribed. Improvements were being made regarding the monitoring that topical creams had been administered as prescribed.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. Staff had received training and developed skills and knowledge to meet people’s needs. Staff relationships with people were caring and supportive. They delivered care that was kind and compassionate.

Individual risks to people’s safety had been assessed and care plans written to show how these were being addressed. The home had a contingency plan and had also developed individual personal evacuation plans to support each person.

There were adequate staffing levels to meet people’s needs. People received person centred care. Staff knew people well, understood their needs and cared for them as individuals. People were relaxed and comfortable with staff that supported them. Staff were discreet when supporting people with personal care, respected people’s choices and acted in accordance with the person’s wishes. People where possible and appropriate family members were involved in developing and reviewing their care plans.

People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported to eat and drink enough and maintain a balanced diet. People were positive about the food at the service.

The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. There had been no complaints received at the service since our last inspection. Where there were niggles or concerns action was taken to resolve them.

The premises and equipment were managed to keep people safe.

Further information is in the detailed findings below.

There were many positive comments about the home from people and their families, in particular what a homely atmosphere it was; "a home from home". Staff provided gentle, kind and unrushed care to people, many of whom had complex physical and mental health needs. A health care professional said that the home went "the extra mile". We found that the home understood about consent to treatment and how to ensure decisions were made in people's best interest if they could not make them for themselves. However, this was not always documented.

We saw the standards of care ensured people's dignity and that health care needs were met. People had equipment available to ensure their safety and comfort and this was well maintained. Staff had good strategies where people had challenging behaviour. Care was planned and reviewed.

Recruitment procedure would ensure people's safety but was not followed through in each case. People thought the staff were very good but one said "some of the young staff don't think." We found that staff were formally supervised and new staff received a comprehensive induction but update training did not always happen and some training was very out of date.

People had been given the opportunity to voice their opinion about the home. Actions had been taken based on the comments. Another review was due. A comment in the 2012 feedback survey said, "We will never forget the love and care she was given."

We conducted an unannounced visit to Halwill Manor Nursing Home on 11 June 2012 to check that the home was complying with the regulation relating to the safety and suitability of the premises. The provider was required to be compliant no later than 31 May 2012. We also looked at the essential standards relating to respecting and involving service users and quality monitoring systems at the home.

We saw that the provider had taken steps to ensure the environment was much safer for people. Hazards had been identified and made safe, examples being fire safety, trip hazards and hot water. One person told us that the home was comfortable and warm enough, adding, "If people are cold staff give them a blanket".

We saw that people's property was now handled in a respectful way as individual wardrobes had been provided. There had been a lot of investment in the building and furnishings, providing a more pleasant and safe environment. These included a new fire safety system, carpeting, handrails and toilet seat raise.

We met and observed six people sitting in a lounge. Staff offered them choice; they were friendly and respectful and care was provided appropriately. Staff were discreet when they assisted a person to the toilet and gave reassurance when moving a person with a hoist. A GP with knowledge of the home had said that he was always impressed by the compassion that the care staff showed.

We saw that the management (unregistered manager, provider and provider administrator) roles were now better defined and from this better systems of working were in use. These included auditing of the environment, accidents and the handling of medicines. These checks had led to positive changes, including new equipment and the prioritising of work.

We (the Care Quality Commission) conducted an unannounced visit on 11 April 2012 to Halwill Manor Nursing Home to review improvements made following the planned inspection in October 2011. During that inspection we found that the home was not meeting all the essential outcomes, as was required, and this was negatively affecting the outcomes for people.

Following that inspection we were provided with a satisfactory report on how the home intended to improve outcomes for people. At that time we also received information that a person was being restrained in their chair. That concern was investigated by the local authority safeguarding team, and followed up at the time, but we reviewed the situation during this visit. We found that the person was now safe and their legal rights upheld.

During this visit we were assisted by an expert by experience. This is a person who, through their own experiences, work with us to find out what it is like for people using the service. The expert's findings are included within this report. During the visit the expert spoke with seven people and two visitors. Most of the people were living with some form of dementia and conversation was limited. Three people were constantly on the move throughout the ground floor and did not communicate verbally.

We looked closely at the care of one person, meeting them, visiting their room and looking at records of their care. We also toured the building with the manager to see if previous safety concerns had been dealt with.

We looked in detail, with the manager, at the action plan which had been supplied following the last inspection. We also asked the provider how they monitored the quality of the service they provided, especially regarding health and safety.

Without exception people and their families told us that they were happy with the service being received and they liked the staff and had confidence in them. Comments included “I get on very well with all the staff”. We found that people were being addressed in a more respectful way and their preferred name had been recorded so that staff were fully aware.

We found that people were being treated in a more individual way, for example, a book recording every person's bowel actions had been discontinued and those records were now kept in their individual file. The 'bath list' was still in use but no longer on display. However, some people sharing a wardrobe still had their clothes piled high together showing no respect for their valuables or individuality. Some had signed consent to sharing a room and wardrobe but some had not and one person was having their movements monitored without this being part of their plan of care or having agreed to it.

We found that people were better safeguarded against abuse and the risk of abuse because the manager was fully aware how to respond to any concerns. However, people did not know who the manager was and so might not take those concerns to them. We found that three people were involved in the quality monitoring and management of the home; roles and responsibilities were confused and conflicting and this affected the service provided in that things did not always get done.

We found that the home had achieved their action plan in some areas, but not in others. The date that had been provided for completion of the improvement plan was 15 March 2012 and we had not been informed that this deadline could not be met.

We saw that some people liked to walk around the home and we found several hazards, which might cause an injury. These included fire doors held open with a wedge or furniture, poorly taped floor carpet posing a trip hazard, hanging wiring, steep stairs with no hand rails and a hot water outlet where the water could scald and the thermometer in use was defective. We contacted the Health and Safety Executive and Devon and Somerset Fire and Rescue with our concerns.

We (the Care Quality Commission) conducted two unannounced visits to Halwill Manor Nursing Home as part of a planned inspection of the home. We spent a total of seven hours there. We met all of the people using the service but none were able to tell us what it was like to live there due to communication difficulties. However, we spent a lot of time observing, had conversation with three people and met three people's family. We spoke with five care workers, two nurses, the registered manager and the office manager, who represented the provider.

People's family said they were very happy with the service provided. One said: "I would come here myself". Another said: "He gets all the care he needs and the nurses are very friendly". We found that the standards of personal and health care promoted people's health and welfare, family were kept well informed on people's behalf and involved in some care decisions.

Some of the guidelines relating to the safe handling of medicines were not being followed and this could impact on people's well being.

There was some friendly and sensitive interaction between care workers and people using the service and one person was seen to smile when the manager engaged with them. However, people's dignity, privacy and independence was not properly promoted. Care workers were heard to say: "Hello darling, it's lunch time" and "Good girl". We saw examples of people being treated as a group rather than individuals. This included the use of a ‘bath list’ openly displayed in a corridor where any person passing would see it – lacking confidentiality. We saw examples of conditions which had not been agreed upon, including the shared use of a wardrobe. We found examples of some dirty equipment and equipment storage impinging on people's living space.

People were being safeguarded from abuse in that staff know how to respond should they see incidents which concerned them. However, it was not realised that should a person using the service assault another person the appropriate agency (local authority safeguarding team or the police) must be informed, as would be the case for any other person.

People had their needs met by a sufficient number of staff, including domestic and office support.

People were given the opportunity to comment on the service and where changes were requested action plans had been produced and changes were being progressed. There had been much investment in the building. However, much remains to be done to ensure a safe, pleasant and suitable environment for people with dementia.

The inspection visits took place on 14 and 17 April 2015 and were unannounced. The home was last inspected on 14 October 2013 and was meeting all the required standards we checked at that time.

Halwill Manor Nursing Home provides personal and nursing care to a maximum of 25 people. Most live with the condition of dementia. There were 25 people using the service at the time of the inspection.

The home has 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.

Medicine management was not robust. Although medicine management had been reviewed a discrepancy was found in the number of tablets recorded to what was actually in stock. Staff were also putting medicines into pots and carrying them on a tray and so increasing the potential for mistakes. Some medicines had been recorded into the home, not needed, but were still in stock over three months later. Changes to people’s medicine records had not been dated or signed which increased the risk of medicine errors.

Staff numbers and deployment met people’s needs in a safe way and were under regular review, taking into account people’s needs and staff opinion.

People were protected by the arrangement for prevention of abuse. This included staff training, robust recruitment and an openness to notify external agencies of any concern.

The home environment and equipment was well maintained and kept in a safe state. Improvements to the environment were planned and in progress.

There was a strong emphasis on staff training. Staff were encouraged and supported to undertake qualifications in care and they benefitted from a broad range of training opportunities. Staff received supervision and support to succeed in their role.

The provider had acted in accordance the Mental Capacity Act (2005) and Deprivation of Liberty safeguards to promote decision making and protect people's rights.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). People at the home were not being deprived of their liberty unlawfully.

People received a diet which promoted their health and welfare. Dietary concerns were identified and action taken as necessary. There was on-going nutritional assessment and management.

One staff member said, “People are loved here not just cared for.” People, their families and health care professionals reported staff to be kind, friendly and caring. Staff understood how to engage with people as individuals and in a person centred way. People’s dignity and privacy were promoted.

End of life care was provided in accordance with people’s wishes and with regard to their dignity and comfort.

People’s needs were assessed and their care was planned with them or with people who knew them best on their behalf. People’s hygiene and personal care needs were well met and their health was promoted. Staff could describe people’s needs and how to meet them, in detail.

People said they had no reason to complain but felt any complaint would be dealt with effectively.

The service was well led by a registered manager and provider working together to manage any risks and looking at how to continually improving the service.

We found one breach of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.