This comprehensive inspection of Hart Care Nursing Home took place on 10 and 14 December 2018. The inspection was unannounced. This meant that the provider and staff did not know we were coming. The second day of the inspection was announced.

Hart Care Nursing and Residential home is registered to provide nursing and personal care for up to 54 people. Most people using the service have multiple health care needs. There were 40 people living at the home on the first day of our inspection; 20 people had nursing care needs supported by the registered nurses at Hart Care Nursing Home and 20 had their nursing needs met by the local community nurses. Two people were staying at the service for a period of respite (planned or emergency temporary care provided to people who require short term support). There were four further admissions by the second day of our inspection.

Hart Care Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection. The home is a large detached home set within Dartmoor National Park located outside the large village of Yelverton on the south-western edge of Dartmoor. People have access to a well-maintained garden.

At our last inspection we rated the service Good. At this inspection we found the service remained Good overall. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated Good.

Since the last inspection in July 2016 the provider had appointed a new registered manager at the service. They registered with the Care Quality Commission (CQC) in July 2017. The registered manager had worked with the local authority quality assurance team (QAIT). They had put in place processes and developed a service improvement plan (SIP) which set out the actions required, by whom and the time scales. The registered manager and staff had prioritised the actions in the SIP and had made great progress working through these. This was an evolving effective tool which the registered manager regularly reviewed and added further actions to, when identified.

The service was well led by the registered manager. The culture was open and promoted person centred values. People, relatives and staff views were sought and taken into account in how the service was run. There were effective systems in place to monitor the quality of care provided. The registered manager made continuous changes and improvements in response to their findings.

People remained safe at the service. People said they felt safe and cared for in the home. People were protected because staff knew how to recognise signs of potential abuse and how to report suspected abuse. People’s care needs were assessed before admission to the home and these were reviewed on a regular basis. Risk assessments were undertaken for all people to ensure their individual health needs were identified and met.

There were sufficient and suitable staff to keep people safe and meet their needs. Thorough recruitment checks were carried out. New staff received an induction that gave them the skills and confidence to carry out their role and responsibilities effectively. The registered manager was working with staff to ensure they had completed all the provider’s mandatory training and update training.

People had a varied and nutritious diet. There was a designated activity staff member to support people to engage in activities they were interested in, on an individual and group basis.

People knew how to make a complaint if necessary. They said if they had a concern or complaint they would feel happy to raise it with the management team.

People were supported t

This inspection took place on 3 and 4 May 2016. The first day of our visit was unannounced Our second visit was announced so that arrangements could be made for us to spend time with the provider and acting manager.

Hart Care Nursing and Residential home is registered to provide nursing and personal care for up to 54 people. Most people using the service have multiple health care needs. There were 43 people living at the home on the first day of our inspection; 26 people had nursing care needs.

At the last inspection on February 2015, four breaches of regulation were found. These were because:

• People who use services were not protected against the risks associated with unsafe recruitment processes.

• People who use services were not protected against the risks associated with a poorly managed complaints system.

• People who use services were not protected against the risks associated with a poor quality assurance system.

• People who use services were not protected against the risks associated with poor supervision and appraisal systems.

The provider wrote to us with an action plan to say what they would do to meet the breaches of regulation by July 2015. At this inspection, we found they had followed their action plan and met the legal requirements.

The service is required to have 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. The registered manager had resigned their position as registered manager at the home. They had applied to CQC to remove their registration. They continued to work at the home as a registered nurse for two days a week. The provider was actively recruiting a new registered manager at the time of our visit. In order to ensure the safe running of the service they had employed an acting manager for two days a week, supported by a deputy manager to keep people safe. The provider also visited the home on alternate weeks to monitor the service and support the staff.

There were adequate staffing levels to meet people’s needs. Improvements had been made to the scheduling of staff on duty. People felt there were adequate staff levels but said sometimes staff response times to bells was slow. The acting manager was taking action to monitor the response times to people’s call bells.

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 had 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.

Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were safely managed and procedures were in place to ensure people received their medicines as prescribed. The acting manager was taking action to address any concerns highlighted.

Care plans were personalised and recognised people’s health, social and psychological needs. 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. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA. Improvements were being made to the provider’s computer system to ensure staff were aware of people’s legal positions and best interest decisions were recorded.

People were supported to eat and d

We had received information from an anonymous source that there were not enough staff working at Hart Care and people were not receiving an acceptable level of care.

We did an unannounced visit to the home. We spoke to 11 people who used the service, one person's family, four staff, the acting manager and the provider.

People were receiving the care that they needed. Their comments included "They are very good"; "Staff are very good"; "The standard of care is pretty good" and "I think it is alright." People looked comfortable and, with the exception of staining following people's lunch, the standard of personal care appeared to be satisfactory. Staff explained how they ensured that people's needs were met, including regular visits to the most frail to change their position or offer them a drink. They said "We never miss those visits." We saw that people had drinks and a call bell within their reach. We saw staff assisting some people with their lunch time meal. This showed that people’s needs were understood and being met.

Call bells rang throughout our visit and the provider showed how the response times could be checked. The majority of people felt that staff responded quickly enough when they needed assistance; there were some negative comments.

Staff felt that the majority of the time there were enough staff. They said that the acting manager and provider always tried to meet staffing shortfalls, using agency staff if necessary.

In this report the name of the registered manager who appears was not in post and not managing the regulated activites at this location at the time of the inspection. Their names appear because they were still a registered manager on our register at this time.

People we met told us, "It's very, very nice here" and "The staff are all wonderful, they all interact so well together and they have a lot of patience." We met many people and everyone felt well cared for. One person told us, "...there are enough staff, you don't have to wait long when you ring your call bell." Another person told us, "I have been in some horrible ones but this is clean and friendly and it's nice to see the garden, it's good here." We were told, "The new Matron is ever so nice."

We found that the staff knew people well and were able to meet their varied needs because they were skilled and experienced. People told us their choices were respected and they felt treated like individuals.

The environment at the home was clean and people told us it felt, "Homely." We saw people enjoying the two lounges, conservatory and gardens. People told us they liked being able to, "..choose to do their own thing."

There was a complaints policy and process in place. People at the home and staff all felt confident to raise any issues they may have and felt these would be managed appropriately.

We conducted an unannounced visit to Hart Care Nursing and Residential Home on 8 June 2012 a part of our programme of planned inspections. We met 11 of the 27 people who used the service. We spoke with two staff, the manager and provider. We also spoke with a health care professional who visits the home.

People who used the service spoke very highly of the manager, known as Matron, saying she "goes the extra mile". They told us that they were satisfied with the care they received, were regularly consulted about their wishes and had no current complaints about the home. They said they were enjoying the improved activities available to them.

People told us that any problem would be dealt with properly. We found that the manager had good systems in place to identify where improvements to the home could be made. These included residents meetings, surveys, auditing systems, such as medicines, and the supervision of staff work.

There had been a lot of investment in the property, which met with positive comment from people. An example was the newly refurbished dining room, which one person described as "sophisticated".

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The inspection visits took place on 10, 13 February and 25 March 2015. The first two visits were unannounced and the third visit was announced so that arrangements could be made for us to spend inspection time with the registered manager and/or the provider.

Hart Care Nursing and Residential home is registered to provide nursing and personal care to a maximum of 54 people. Most people using the service have multiple health care needs. There were 45 people living at the home on the first day of our inspection; 27 people had nursing care needs.

The home is required to have a registered manager. This is a person 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. The current manager employed at Hart Care applied to register with the CQC and that registration was completed during the inspection. They are therefore referred to as the registered manager throughout this report.

At the last inspection on 2 September 2014 we found staffing arrangements were not based on the changing needs of people using the service. People were not fully protected from the potential of risks because assessment and quality monitoring of the service was not part of routine practice. Following the last inspection, the provider sent us a comprehensive action plan.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for vulnerable people who are, or may become, deprived of their liberty. One person living at the home was subject to a DoLS; some staff were unaware of this application, which could potentially mean they did not support them appropriately. Some staff had a better understanding of the Mental Capacity Act and the Deprivation of Liberties Safeguards than others. Not all staff had received this training. The registered manager understood when an application should be made and how to submit one.

Improvements were needed to ensure that the home was well-run so that environmental safety checks and actions were monitored effectively and the management of complaints were consistent and well-managed. Recruitment was not managed in a safe way and potentially put people at risk of being cared for staff who not suitable to work in a care setting. The new registered manager and the provider had begun to identify where improvements were needed in staff training, supervisions, and record keeping. They had already started to instigate some new ways of working by the creation of a new role for a senior staff member. They also recognised further training was also needed to support a broader range of training being made available to staff.

Most people living at the home were positive about their care and the support they received from staff. Most people felt there were enough staff on duty to meet their social and care needs. People were satisfied with the quality of the food. The overall view of visitors to the home was that people were supported by caring staff. Staff were positive about the appointment of the new registered manager and told us the provider was approachable.

Staffing arrangements were now based on people’s changing needs. Quality monitoring of the service still required further improvement, which was also identified during our last inspection in 2014. We found other breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 linked to the management of complaints and supporting staff through supervision and monitoring staff disciplinary matters.

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