This inspection took place on 16 May 2018 and 22 May 2018. The first day of our inspection visit was unannounced. We returned to meet the provider and speak in more detail to the registered manager. Haven Nursing Home is a large nursing home, which is registered to provide care for 70 people, of which 10 beds are part of the ‘Discharge to assess’ (D2A) scheme (funded by Clinical Commissioning Groups and North Warwickshire Foundation Trust). The D2A scheme aims to ensure people are moved out of hospital (when medically stable) to receive a period of rehabilitation/re-ablement in a community setting, prior to assessment of their long term care needs. At the time of our inspection visit there were 55 people living at the home, 7 of whom were on the D2A scheme.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home had a ‘registered manager’ in post appointed by the provider. 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.

At our last inspection in June 2017, there was one breach of the legal requirements and Regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relation to the management of medicines. At this inspection we found there were no breaches in the Regulations, however, we have rated the service as ‘Requires Improvement’ as the registered manager and provider needed to embed and sustain safe procedures, and demonstrate they were consistently mitigating risks to people’s safety.

Improvements were still required to medicines management procedures to ensure people always received their medicines, and the administration of medicines was always recorded. Medical equipment was not always stored in line with safety guidelines.

People felt safe, and personal risks to people had been assessed to inform staff how people should be supported safely. However, risks were not always mitigated, for example where people had specialised equipment to protect their skin, we found this was not always used properly.

The environment at the home required improvement, to ensure it was always safe for people. Equipment needed to be more closely monitored to ensure it was always safe to use.

At this inspection, we found action had been taken to ensure care plans were reviewed and updated regularly so people’s needs had been properly assessed and could be met.

There were enough staff to meet people’s needs safely, however, there were not always enough staff to meet people’s preferences in a timely way. Staff did not always take opportunities to engage with people due to time constraints. Further improvements in the way staff were deployed was being implemented. Staff were recruited safely and were aware of their responsibilities to protect people from harm or abuse.

Staff received essential training to meet people’s individual needs, and effectively used their skills, knowledge and experience to support people and develop trusting relationships. Food and fluid intake was monitored where people were at risk, and action was taken where required.

Staff were clear about their responsibilities under the MCA (Mental Capacity Act 2005) and DoLS (Deprivation of Liberty Safeguards) legislation. People’s capacity to make decisions had been assessed, and DoLS applications made as required. However, it was not always clear which decisions people needed support to make and who was involved in making the decisions.

People told us they were supported with kindness and respect, and staff respected people’s privacy when

This inspection took place on 8 and 9 June 2017. 8 June was unannounced. Haven Nursing Home is a large nursing home, which is registered to provide care for 70 people, of which 12 beds are part of the ‘Discharge to assess’ (D2A) scheme (funded by Clinical Commissioning Groups and North Warwickshire Foundation Trust). The D2A scheme aims to ensure people are moved out of hospital (when medically stable) to receive a period of rehabilitation/re-ablement in a

community setting prior to assessment of their long term care needs. Some people on D2A may have complex health care needs and may not be able to return to their own home. At the time of our inspection visit there were 65 people living at the home, 11 of whom were on the D2A scheme.

The home had 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.

At our last inspection in September 2016, there was one breach of the legal requirements and Regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014. This breach was in relation to the level of staffing at the home which impacted on the support people received. The care and treatment was not focused on, and did not meet the needs of, each person. Service user’s individual needs had not been assessed to ensure they were appropriate, or that their preferences had been taken into account.

At this inspection, we found action had been taken to ensure care plans were reviewed and updated so people’s needs had been properly assessed and could be met. However, people’s care records were not always detailed enough to ensure people received consistent support from staff.

People did no always have their medicines administered as prescribed, and medicines were not always stored safely. Medical equipment was not always stored in line with safety guidelines.

We found this was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

People felt safe, and risks had been assessed so people were supported safely. However, risk assessments were not always followed by staff, for example where people had specialised equipment to protect their skin, we found this was not always used properly.

There were enough staff to meet people’s needs safely, and the provider had reduced the use of agency staff so people had consistent staff supporting them. Staff were recruited safely and were aware of their responsibilities to protect people from harm or abuse.

Staff received essential training to meet people’s individual needs, and effectively used their skills, knowledge and experience to support people and develop trusting relationships. Food and fluid intake was monitored where people were at risk, and action was taken where required.

Staff were clear about their responsibilities under the MCA (Mental Capacity Act 2005) and DoLS (Deprivation of Liberty Safeguards) legislation. People’s capacity to make decisions had been assessed, and DoLS applications made as required. However, it was not always clear which decisions people needed support to make and who was involved in making the decisions.

People told us they were supported with kindness and respect, and staff ensured people’s privacy and dignity was preserved.

Staff did not always take opportunities to engage with people, or to ensure the environment was as responsive as possible.

A range of activities were on offer, and people could maintain any hobbies or interests they had.

The provider ensured they received, handled and learnt from complaints and concerns raised by people.

People, relatives and staff were

This inspection took place on 9 August 2016 and 5 September 2016 and was unannounced. Haven Nursing Home is a large nursing home which provides nursing care for up to 70 people, across three units. People who need more staff input are mainly supported in Birch Unit. Older people and people with more complex nursing needs are mainly supported in Oak and Elm units. At the time of our visit there were 49 people living in the home.

At our last inspection in March 2016, there were three breaches in the legal requirements and Regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

These breaches were in relation to the support people received. Care was ‘task focused’, not focused on the needs of each person. Staff did not have the time to support people with interests or activities. People in the Birch unit experienced very little engagement to meet their social care needs. The provider did not ensure the proper and safe use of medicines. Risks were not always recorded and responded to appropriately; there was not an effective and accessible system for complaints; the provider did not have effective systems and processes to make sure they assessed and monitored their service.

Following the September inspection, we issued the provider with a Warning Notice in relation to the lack of effective oversight and the home was put into ‘special measures’. When we inspected in March 2016 we found the requirements of the warning notice had not been met and the home remained in special measures.

The provider sent us an action plan which detailed the actions they were taking to improve the service. At this inspection we found that there was enough improvement to take the provider out of special measures however further improvements were still required.

A new manager was appointed in May 2016. The manager has submitted an application to us so they can be ‘registered’. 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.

Since the March inspection, there had been some improvement in the management of medicines, and the provider had taken steps to ensure people received their medicines safely and as prescribed. However, guidelines which were now in place for staff to administer medicines to people on as ‘as required’ basis, continued to require improvement.

The provider now ensured they received, handled and learnt from complaints and concerns raised by people.

People continued to be supported in ways that were task focussed and were not person centred. Care plans did not support staff to provide personalised care consistently as they had not always been reviewed and information in them was not always accurate. This meant assessments intended to identify and address risks to people’s health and safety had not always been updated.

There were enough staff were on duty to meet people’s needs. However, people sometimes had to wait longer than they should for needs to be met, and staff said they sometimes struggled to meet people’s needs. The provider used agency staff, but recruitment for permanent staff was underway.

Staff were clear about their responsibilities under the MCA (Mental Capacity Act 2005) and DoLS (Deprivation of Liberty Safeguards) legislation. The manager understood their responsibilities and had ensured applications had been made to the appropriate body. However, these had not always been followed up with the local authority where delays in assessing restrictions were experienced.

People living with dementia were properly supported. People’s needs had been reassessed and those living with dementia had now begun to be integrated into the rest of the home, and the unit where people living with

This inspection took place on 1 March 2016 and was unannounced. Haven Nursing Home is a large nursing home which provides nursing care for up to 70 people, across three units. People whose primary care need is dementia, are mainly supported in Birch Unit. Older people and

people with more complex nursing needs are mainly supported in Oak and Elm units. At the time of our visit there were 38 people living in the home.

At our last inspection on 8 and 10 September 2015, we found there were six breaches in the legal requirements and Regulations associated with the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014.

These breaches were in relation to the support people received. Care was task focused, not focused on the needs of each person which meant individual needs had either not been identified or acted on. People’s social care needs were not met because staff did not have the time to provide interests or activities for all. People in the Birch unit (a specialist unit for people living with dementia) experienced very little engagement to meet their social care needs; staff did not act in accordance with the requirements of the Mental Capacity Act 2005 to ensure that decisions to restrain people were in their best interest; the provider did not ensure the proper and safe use of medicines, or ensure there was always sufficient stock, to meet people’s needs. The provider did not ensure risks were recorded and responded to appropriately; there was not an effective and accessible system for identifying, receiving, recording, handling and responding to complaints; the provider did not have effective systems and process to make sure they assessed and monitored their service to ensure compliance with the requirements of the Health and Social Care Act 2008. People were not receiving the personal care they required to be safe, because there were insufficient staff to meet their needs; staff had had not received training to enable them to support people living with dementia.

We issued the provider with a Warning Notice in relation to the lack of effective oversight.

As a result of the September 2015 comprehensive inspection, the provider was put into special measures. We asked the provider to take action to improve the areas we had identified as being of concern. The provider sent us an action plan which detailed the actions they were taking to improve the service. This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

Following our September 2015 inspection, a new manager was appointed but had since left so that at this inspection visit, the home did not have 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.

Since the September inspection, whilst there had been some improvement in the management of medicines, the provider had not done enough to ensure people received their medicines safely and as prescribed.

The provider had taken action to ensure enough staff were on duty to meet people’s needs. They were no longer in breach of the Regulations of the Health and Social Care Act 2008. However, staff said they felt under pressure at times and struggled to meet people’s needs. The provider also continued to use agency staff to provide care to people, but recruitment for more permanent staff was underway.

Staff were clearer about their responsibilities under the MCA and DoLS legislation and were no longer in breach of the Regulations of the Health and Social Care Act 2008. Plans were in place for people who lacked capacity to ensure they were not restrained unlawf

This inspection took place on 18 March 2015. It was unannounced.

Haven Nursing Home provides nursing care for up to 70 older people and people living with dementia. At the time of our inspection there were 61 people living at the home.

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.

The registered manager and staff had limited understanding of the Mental Capacity Act and Deprivation of Liberty safeguards. They had undertaken recent training in this, but they acknowledged they needed further advice and support. The manager had not sent applications to the supervisory body (the local authority) for some people who lived in the home whose freedom had been restricted.

Most medicines were managed safely. However information to support staff with the administration of ‘as required’ medicines was very limited and some of the recording did not meet good practice guidance.

People and their relatives told us people were safe. They were supported by a staff team who had undergone recruitment checks by the registered manager to check staff’s suitability to work in the home. Staff understood safeguarding policies and procedures, and worked with people’s individual risk assessments to ensure they minimised the identified risks.

Staff had received, or were booked on training considered essential to meet people’s health and safety needs. Staff had received dementia awareness training and training to help them understand and work with people with behaviours that challenged others. But the provider did not have links with specialist dementia organisations to provide more specialist advice and knowledge.

People were supported to have enough to eat and drink and enjoyed the food provided. The provider ensured people’s dietary needs were catered for. People who were not drinking or eating sufficiently to stay healthy, were referred to the right health care professionals for further guidance.

People had access to other health and social care professionals when required. These included their GP, dentist, social workers and dieticians.

Staff were caring to people who lived at Haven Nursing Home. They had a good understanding of people’s past histories, likes, dislikes and preferences. People told us staff treated them with dignity and respect.

Visitors were welcome at any time during the day and evening at the home, and were encouraged to be involved in the care of their relations. We saw some activities were available to people who lived at Haven, but a lot of the time there was little to sustain people’s interests. The manager told us they were recruiting another activity worker which would mean the home had 40 hours of activity work each week.

The registered manager had worked at the home for six months. During their time as manager they had recruited new staff and instigated changes to make it easier for people and their relatives to discuss issues or concerns on an individual or group basis. Not all quality checks had been carried out and this had resulted in some issues not being addressed.

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

At our last inspection on 28 October 2013 we identified a number of shortfalls within the service. We found that people who used the service were not always protected against the risks of receiving care or treatment that was inappropriate or unsafe. There were not enough staff on duty to meet people’s needs and the home’s quality assurance system was inadequate to identify shortfalls.

At this inspection, we saw significant improvements had been made.

We found that people’s needs were assessed and regularly reviewed and that their care records were sufficiently detailed to reflect the care and support they required from staff.

We saw that there were sufficient qualified and experienced staff on duty to meet people’s needs in a timely manner.

We found that people were asked for their views about the home and people were listened to. The provider had an effective system in place to ensure the quality of service provision was monitored so that any necessary improvements could be made.

We spoke with two people who used the service and three visiting family members. Some people were unable to communicate with us so we spent a period of time observing how people were being cared for within the home.

We saw that not all people's care plans were regularly reviewed. Staff knew and understood the changes in people’s needs, but changes were not clearly recorded in their care plans.

The manager and staff understood their responsibilities for reporting any concerns regarding potential abuse of people who used the service.

We found that staffing levels were inadequate to meet the care needs of people in a timely and effective way. As a result, some people did not have their preferences and choices respected and were at risk of not having their health and wellbeing met.

Quality monitoring systems were in place but were not fully effective in ensuring people received the care and services they should expect.

During our last visit on 19 December 2012 we identified a number of concerns which we had asked the provider to address. This Inspection was to check whether the actions the provider told us they were taking in response to these concerns had been addressed.

We found that suitable and sufficient improvements had been made in the areas where we had identified concerns. We saw the provider had put right what was required.

During our inspection we spoke with two people who used the service and with one relative who was visiting the home. People told us that they were well cared for. One person said, "It's very nice indeed, it couldn't be better."

A visiting relative told us, “My relative is well looked after, I couldn’t ask for better care for them.”

We looked at the care records for three people to check how well their needs were assessed and planned for. We saw that care was based on the individual needs of people and, where appropriate, specialist advice was sought.

We observed the lunch time meal in the dining room and saw there was a pleasant eating environment without interruptions.

We looked at medication processes to assess compliance with this outcome. We found that the home had carried out improvements to provide safer storage and administration of medicines.

We visited the service on 11 July 2012. Our inspection was unannounced which meant no one who lived or worked there knew we were coming.

During our visit to the home we watched to see what life was like for people who were living at Haven Nursing Home. We spent time talking to four people who live at the home, three visiting relatives and to five members of staff. We also spoke with the administrator of the home and a director of Regal Health Care Coventry Ltd. We looked at some of the records kept to support staff in providing the correct care to people who use the service.

People that use the service have dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences 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.

We saw that staff knew people at the home well and spoke with them in a friendly, respectful way. Throughout the day we noticed that staff were prompt to come to people who were upset or restless and spoke with them using a calm, reassuring tone of voice. We observed that people sought out the company of members of staff and it was evident from people's body language and facial expression that they were comfortable with them.

The people we spoke with were positive about their experiences of living at the home and the care they received. People told us that they were “very happy here" and “It’s alright.”

The relatives we met told us they were happy with the quality of the care their family members received. They spoke highly of the staff and described them as kind and caring. One person said, “I couldn’t be more pleased with the care my relative receives.” Another person described the staff as “top class.”

Staff were motivated, caring and positive about working in the home They demonstrated a sound understanding of the needs of the people they were supporting. Staff spoken with told us that they received regular supervision to monitor their care practices and had access to training which kept their skills up to date.

We spoke with seven people living at Haven Nursing Home and three visitors. People living at the home told us that staff were friendly and respectful towards them and they were satisfied with the care they were receiving. Comments included: “They change me, wash me everything”. “The girls are really good they would do anything for you”. “They are alright, they are very good, there are some that are exceptional”. “Everything is top”. “It’s not too bad”.

The three visitors that we spoke with raised no concerns about the home. They told us: “The communication has been good”. “X seems happy enough”.

We saw that the lounges were well attended by people living in the home. Some people were too ill to sit in the lounge and were being cared for in bed.

When we asked people if there was anything they would change, most said “no” or they did not know. Two people told us they would like to go somewhere else due to not being able to communicate with people living in the home.

We saw that the results of a quality survey carried by the home were mostly positive. People told us “I am quite happy with everything”. “Happy there abouts”.

This inspection took place on 8 and 10 September 2015, and was in response to concerns raised by staff and relatives about the quality of care provided. The inspection was unannounced.

Haven Nursing Home is a large nursing home which provides nursing care for a maximum of 70 people in three units. People whose primary care need is dementia, are mainly supported in Birch Unit. Older people and people with more complex nursing needs are mainly supported in Oak and Elm units. At the time of our visit there were 64 people living in the home.

The service did not have 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. The registered manager left the service at the end of May 2015. Since then, two other managers had been appointed and left. The last one had worked for the provider for five weeks and left suddenly. We were concerned about the high turn-over of managers at the service, and the lack of leadership from the provider in relation to the monitoring of the quality of service provided. The provider had arranged for an interim manager from a consultancy agency to work at the home to provide management cover.

The provider of the service has a history of non-compliance with regulations and any improvements made in relation to the quality and safety of service people receive have not been sustained.

Staff were not always available at the times people needed them, and gaps in the planned staff rota were being filled with agency staff. The use of agency staff to cover staff vacancies meant people were not provided with continuity of care by staff who knew them well. There was no clear process used by the provider to determine the number of staff required. The provider did not provide sufficient staff to meet the needs of people, or take account of the size and layout of the building.

Staff were kind and tried their best to provide care. However, staff interaction with people was when supporting them with care tasks. We saw little involvement between staff and people at any other time of the day. There were limited opportunities for people to be involved in social activities, particularly for people living with dementia and who had been identified as having behaviours which challenged.

People who were independent received food and fluids which met their nutritional and hydration needs. We were concerned that people who received a pureed diet did not have the choice that other people had.

The personal care provided did not always meet people’s preferences or expectations. Most people only received a shower once a week and records showed that many were not supported to have a wash at night or their teeth cleaned. Care provided was task orientated and not tailored to the needs of each individual (person centred care).

People did not feel their concerns were listened to. We could not see an accessible policy to inform people how to complain about the care provided. The records of complaints investigations did not provide the outcome of the investigations.

Since our last visit, staff at the service had applied to the local authority for some people who required a Deprivation of Liberty Safeguard in order to ensure people’s liberty was being lawfully restricted. However, we could not be certain that applications had been submitted for everyone who had restrictions on their liberty. We were concerned that people had been restrained through the use of ‘as required’ medication and bedrails were used without consideration of whether this was in people’s best interest or the least restrictive option.

Relatives and friends were able to visit the home at any time of the day.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

Services in special measures 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.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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