We carried out an announced inspection of Healey Lodge Nursing Home on the 19 and 20 December 2016. The first day was unannounced.

Healey Lodge Nursing Home provides accommodation and care and support for up to twenty four people older and younger people including people living with a dementia or learning disability. There were 23 people accommodated in the home at the time of the inspection.

The service was also registered to provide nursing care but at the time of our visit nursing care was not being provided due to difficulties recruiting suitable nursing staff. An application had been forwarded to Care Quality Commission (CQC) to remove this activity and to change the name of the service to reflect this.

Healey Lodge Nursing Home is located on the outskirts of the town of Burnley, Lancashire and is on a main bus route. Accommodation is provided on two floors. Shops, pubs, churches, the library and other amenities are within walking distance. There are surrounding gardens with a patio and seating areas. A car park is available for visitors.

The service did not have a registered manager in post. The previous registered manager left the service in April 2015. A registered manager is a person who has registered with 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. A manager had been in post since May 2016 and an application to register her with the CQC had been forwarded in November 2016.

At the previous inspection on 24 and 25 June 2015 we found the service was not meeting all the standards assessed. We found shortfalls in the management of medicines, maintaining the environment, provision of induction and training for staff, responding to people’s concerns and operating effective quality assurance and auditing systems. We also made recommendations regarding the provision of supervision and support for staff, recruitment processes, infection control practices and obtaining people’s consent. We asked the provider to take action to make improvements and to send us an action plan. The provider complied with our request. During this inspection we found the required improvements had been made.

From December 2015 a number of safeguarding concerns had been raised about the care people were receiving, the management of the home, cleanliness of the home, the lack of suitable nursing staff and the high reliance on agency staff. At that time a decision was made by the provider to cease providing nursing care. The service worked with local commissioners until care reassessments were completed or until alternative suitable placements could be found for people that could meet their needs. The medicines management team, infection control team and local authority commissioners have worked with management and staff to support them to make improvements. In October 2016 we were told they were satisfied sufficient improvements had been made.

During this inspection people told us they did not have any concerns about the way they or their relatives were cared for. They were happy with the care and support provided and told us they felt safe and well cared for.

Staff could describe the action they would take if they witnessed or suspected any abusive or neglectful practice and had received training on the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). This meant they had knowledge of the principles associated with the legislation and people’s rights.

People considered there were enough suitably skilled staff to support them when they needed any help and they received support in a timely and unhurried way. The manager followed a robust recruitment procedure to ensure new staff were suitable to care for vulnerable people. Arrangements were in place to make sure staff were trained and supervised at

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

During this inspection we spoke with four people using the service and with one visitor. We spoke with three care staff, a cook, a housekeeper and the manager. We also spoke with the local authority and a visiting health professional. We viewed records which included, three care plans and daily care records, maintenance and servicing records, recruitment and induction records, menus and records of meals served, customer surveys and quality monitoring records

We considered the evidence we had gathered under the outcomes. This is a summary of what we found:

Is the service safe?

Staff had undertaken training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). This should help staff to understand their responsibilities with supporting people to make their own decisions. Policies and procedures were also available for staff to refer to if needed. There had been no applications made under DoLS since our last inspection visit.

Assessments of any risks were recorded, managed and kept under review. This would help to keep people safe from harm.

Updated recruitment policies and procedures had recently been introduced. We saw pre-employment checks had been sought to verify new staff were of good character. However record keeping in this area needed to be improved. Staff had undertaken training that gave them the skills and knowledge to meet peoples' needs.

We found all areas of the home to be bright, clean, safe and comfortable. People had commented that the décor in some areas of the home needed improving. We found improvements were ongoing although there was no formal plan to support this. People had access to a range of appropriate, well maintained equipment to safely meet their needs and to promote their independence and comfort. Staff had received training to ensure they were competent to use the equipment safely and properly.

People were supported to eat and drink sufficient amounts to meet their needs. People told us they enjoyed the food. Comments included, "The food is very nice; I get a choice", "We get plenty to eat and drink and it is all very good". The meal time was not rushed and people were able to eat at their own pace.

Is the service effective?

Regular reviews were carried out to respond to any changes in people's needs and to ensure the level of care was appropriate. People who we spoke with told us they were involved in discussions about their care and said they were kept up to date with any changes. However, records did not clearly show people's involvement which meant they may not receive the care and support they wanted.

People's health and well-being was monitored and appropriate advice and support had been sought in response to changes in their condition. We found the service had good links with other health care professionals to make sure people received prompt, co-ordinated and effective care.

Is the service caring?

People told us they were happy with the care and support they received. Comments included, "I have my own routine and staff are ok with that; they ask if I need any help" and "Staff are here to help me; I am very well looked after”. Comments from visitors included, “Care has been first class” and “It appears to be a very caring and compassionate home”.

We observed staff interacting with people in a pleasant and friendly manner and being respectful of people's choices and opinions. One person said, “The staff are great; I can have a laugh with them”.

Is the service responsive?

We found people's needs were assessed by suitably experienced staff, prior to admission to the home. Care, treatment and support was planned and delivered in line with people’s individual care plan.

The care plans contained information about people's preferred routines and likes and dislikes. This information would help staff to look after people properly and ensure they received the care and support they needed and wanted. We found the quality of information in people’s care plans varied and was not always reflective of the care people received. We were told a new care plan system was being introduced with clear timescales for completion.

There were opportunities for involvement in suitable activities. People told us they were involved in discussions and decisions about the activities they would prefer and activities were arranged for small groups of people or on a one to one basis.

People told us they were happy with the service they received. They said they could raise their concerns with the staff or managers.

Is the service well-led?

A manager was responsible for the day to day management of the service. The manager had forwarded an application to register with the Care Quality Commission (CQC). The manager was supported by the owner and by managers from the other homes within the organisation.

People had been encouraged to express their views and opinions of the service through meetings, customer satisfaction surveys and during day to day discussions with staff and management. People told us they were kept up to date about how the service was run.

There were systems in place to monitor the quality of the service with evidence that shortfalls had been identified and improvements made. This should help protect people from poor care standards and to identify any areas of non-compliance.

Any incidents and/or safeguarding concerns had been reported to the appropriate agencies. Staff were aware of the procedures for reporting any concerns about poor practice.

We spoke with four people living in the home who told us they were happy with the care and support they received. Comments included, "The staff are great; they know what I need and what I like" and “It’s not home but it’s as good as it can be”. People's health and well-being was monitored and appropriate advice and support had been sought in response to changes in their condition.

We found people's medicines were managed safely. Records were clear and accurate and medicines were stored safely and appropriately.

People told us about the different activities they had participated in. One person said, "I've had so much fun doing different things; it helps to pass the day". A visitor said, "There are plenty of interesting things going on".

During this visit, people told us they were happy with the staff team. Comments included, "They are very accommodating" and "The staff are very good; very kind". However, they also told us that 'at times' they had to wait until staff were available. We reviewed the staffing rotas and found there were times when some people may be left unsupervised for short periods of time. Following our visit adjustments were made to the rotas to ensure people were not left unsupervised.

Systems were in place to encourage people to express their views of the service and involved with any decisions about how the service was run.

We visited the service in response to concerns raised about changes to the staff team and about the lack of support for staff. We looked at a number of records, talked to three staff, three people living in the home and two visitors. We also spoke with the business manager and the provider. We found the service was appropriately staffed with sufficient numbers of staff to meet the needs of the current residents. We found there had been a number of changes to the staff team and the reasons for this were explained to us. We were told the service was trying to recruit additional staff but the use of agency staff had been necessary to cover current shortfalls and to ensure the required skill mix of staff was in place.

We found staff had been updated and involved in discussions about any planned changes. There was a plan of training, support and supervision for staff. This would provide them with the skills and knowledge they needed to look after people properly and help to identify any shortfalls in staff practice. Most of the care staff had achieved a recognised qualification in care, which would help them to look after people properly. Staff were observed interacting with people in a pleasant and friendly manner and being respectful of people's choices.

We were told a new manager was due to start work this month. We were confident this would provide some continuity for people who lived at the home, their relatives and for staff.

At our last inspection visit on 6 October 2011 we were concerned that some of the regulations were not being met. Following the visit we met with the provider and asked for a report that explained what action they intended to take to respond to our concerns. The provider recently sent us an up to date report or 'improvement plan' which showed improvements had been made.

During this visit we found people understood the care and treatment choices available to them. One person said, "I'm not sure that I have seen my care plan but the staff talk to me about what care I need". People told us they were happy with the care and support they received. Comments included, "I can't fault the care", "I'm treated well", "I like it here", "Staff go out of their way to look after you" and "I'm looked after properly".

The home was safe, clean and bright and we found improvements had been made since our last visit. People told us about the work underway to improve the garden and patio areas. We were told, "We can see out of the windows now; it will be lovely when the grass grows" and "The outside looks so much better; what a difference it has made".

People were happy with the staff team and described them as "Very nice" and "A good bunch". However people also said, "There are not always enough staff, usually in the afternoon or evening" and "I worry that there aren't always enough staff". Following the visit we discussed this in detail with the provider and were told the staffing shortfalls had been covered.

We observed staff responding to people in a kind, patient and friendly manner. People told us they were treated with respect. Comments included, "Staff are polite and friendly" and "They are so kind and patient".

People who use the service, their representatives and staff were asked for their views about their care and treatment. This meant they could influence how the home was run. One person said, "I am listened to" and "If things aren't right they would sort them out".

We re-visited Healey Lodge to review their progress as at the last inspection on 22 February 2011 we identified major concerns and told them improvements were needed.

People who we spoke with told us they were generally happy with the meals and confirmed that staff asked them each day what they wanted to eat. They told us they were offered a choice of meals and alternatives to the menu.

We spoke with staff who told us how they would respond if they suspected abuse or neglect. However, we were concerned that an allegation of abuse had not been reported appropriately in line with local procedures.

People who we spoke with told us that "most of the time" they were looked after and that "most" staff treated them well. One person told us they did not always get their medicines at the right time.

People were generally happy with the staff team and described them as "excellent" and "good staff". Following concerns about insufficient staff at the last inspection, the service had increased staffing levels to make sure people's needs were met. However, we found that levels had been reduced again. Comments from people who used the service included, "I am sometimes kept waiting as there are not always staff around to help", "I always go to bed early, not because I want to but because I know there are not enough staff to help me later on" and "There are not enough staff during the day, sometimes you can't find anyone".

There was a condition in place to register a manager with the Care Quality Commission (CQC). We were concerned that managers had been recruited but failed to reach a point where they were in a position to register with us. Since our last visit there had been two different managers.

We found that the staff team was unsettled and we were concerned how this would affect the care and support that people were receiving.

People said they were happy to discuss any of their concerns with staff and told us 'resident' meetings were no longer held. Comments included, "It's unfair as staff get to have meetings and we don't, we have things to say too", "They don't want to know" and "Nothing gets done".

Residents told us they were looked after and that staff treated them well. One resident told us they were happy with the care and said “I’m glad I am here”.

All the residents we spoke to told us they were given choices about how they spend their day and that their preferences were respected. Residents told us that meetings were not held but the manager regularly spoke to them; this allowed them to raise concerns and to make decisions about their care and about how the home was run.

One visitor told us their relative was “well looked after”; they said they were kept up to date with any changes.

Residents’ were happy with the meals and told us they were offered a choice of meals and alternatives to the menu and could choose where and what time to eat. Residents comments included “you can have what you want and eat where you want”, “the meals are alright, there are choices” and ‘the cook knows what I like”. Residents also told us that they sometimes had to remind staff about their suppers.

Residents told us they were happy with the cleanliness of the home but were worried that it took a long time to get things repaired; one visitor was concerned about the “lack of maintenance”. Examples of how this impacted on residents’ safety and well being were discussed in detail.

Residents were happy with the staff team but were concerned about the numbers and availability of staff as there were times when residents’ needs and wishes were not being met in a timely and effective way.

People were aware that there was a complaints procedure and were happy to discuss any concerns with the manager. They said they were listened to and their concerns acted upon.

We carried out an unannounced inspection of Healey Lodge Nursing Home on 24 and 25 June 2015. Healey Lodge Nursing Home provides accommodation and personal care for up to 24 people. The service provides nursing care. At the time of the inspection there were 24 people accommodated in the home.

The service is located on the outskirts of Burnley town centre and is on a main bus route. Shops, pubs, churches, the library and other amenities are within walking distances. Accommodation is provided on two floors. On the ground floor there is a lounge and a dining area with a lounge on the first floor. The majority of bedrooms do not have en-suite facilities although suitably equipped bathroom and toilet facilities are available on both floors. There are gardens, including a patio area, with two car parks for visitors and staff.

The registration requirements for the provider stated the home should have a registered manager in place. There was no registered manager in post on the day of our inspection as the previous registered manager had left in May 2015. 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.

A new manager had been in post for one week and was undertaking training to support her with this role.

At the previous inspection on 15 July 2014 we found the service was meeting all the regulations we looked at. Prior to this inspection visit there had been anonymous concerns raised regarding staffing levels, training and the delivery of people’s care. We brought our planned inspection forward.

During this inspection we found people were happy with the home and with the approach taken by staff. People said, “I am looked after really well”, “I am very comfortable here” and “Staff are very kind to me.” Two visitors said, “Staff are pleasant and helpful” and “Staff are very good.” Although one person said, “Staff don’t seem to have much time these days; I feel a bit neglected sometimes.” We observed people were comfortable around staff and seemed happy when staff approached them. Staff responded to people in a caring and considerate manner and we observed good relationships between people.

People told us they were confident to raise any concerns although there were mixed opinions about whether they would be listened to. People said, “There are lots of things that could be made better; they just don’t ask”, “I told them what was wrong and nothing has been done” and “They listen sometimes”. It was clear from our discussions with people living in the home and their visitors and from looking at records that a number of concerns and complaints had been raised but had not been recorded or acted on.

Staff had an understanding of abuse and had received training about the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS). The MCA 2005 and DoLS provide legal safeguards for people who may be unable to make decisions about their care. We noted appropriate DoLS applications had been made to ensure people were safe and their best interests were considered.

We looked around the home and found some areas were well maintained whilst other were in need of improvement. A member of staff said, “This is a lovely home but things have fallen behind recently.”

The number of shortfalls we found indicated quality assurance and auditing processes had been ineffective. Checks on systems and practices had been completed by the previous manager but matters needing attention had not always been addressed. However, there was evidence that monitoring of systems and practices had re-commenced.

We found a number of appropriate checks had been completed before staff began working for the service. However, we found examples that the home’s safe and fair recruitment policy and procedures had not been followed. We also found people’s medicines were not always managed in line with the home’s safe procedures.

We looked at how the service trained and supported their staff. We looked at the records of two recently employed staff. We found neither staff had received a basic induction into the routines and practices of the home and had not received any mandatory safety training. We noted agency nursing staff were used to take charge of the home. However, there were no records to demonstrate they had been given a basic safety induction and introduction to the home. Without appropriate training and induction staff could place themselves and others at risk.

Most of the existing staff had received a range of appropriate training to give them the necessary skills and knowledge to help them look after people properly. However some of this training needed to be updated. We were shown a revised training plan which included attended training and planned updates. There were also gaps in the provision of formal one to one supervision sessions. This meant shortfalls in staff practice and the need for any additional training and support may not be identified. Following discussion with staff we made a recommendation the service obtained support and training for the management team, regarding effective supervision and support for staff.

People told us the home did not have enough staff. They said, “Staff are a bit short on the ground. The worst is after 2pm. If you want to go to the toilet there is no-one around. The nurse is sometimes nearby”, “I have had to wait to go to bed. I have a routine but if they are busy then I have to wait” and “They don’t seem to have time these days.” Another person said, “I do my best to look after myself but staff will come if I need help.” One relative said, “Sometimes there just aren’t enough staff.”

Whilst we did not see any evidence of people’s needs not being met we were concerned people may be left unattended for periods when staff were providing care and support in other areas of the home. We discussed this with the manager, the area manager and the owner. We were told staffing numbers were kept under review and we were shown a recent staffing analysis. Following our inspection we were told staffing levels had been increased in the afternoon.

During our visit we found a number of areas that presented a risk of cross infection. However they had already been noted as part of the recent audit. We made a recommendation that the service followed appropriate advice and guidance regarding infection prevention and control matters.

People told us they enjoyed the meals. During our visit the meals looked appetising and hot and the portions were ample. The atmosphere was relaxed with friendly chatter throughout the meal. We saw people being sensitively supported and encouraged to eat their meals. Care records included information about people’s dietary preferences and any risks associated with their nutritional needs.

Each person had a care plan which included information about the care and support they needed, their likes, dislikes and preferences and their ability to make safe decisions about their care and support. We were told the information in people’s care records was being improved to be more person centred and to reflect more of people’s preferences and routines. Some people had been involved in discussions about their care plan and the care and support they needed and wanted.

People were involved in a number of activities although the records were not reflective of the activities taking place. We observed people sitting outside enjoying the sunshine, some group discussions and people being accompanied on a walk to the park. One person said, “There hasn’t been much going on until recently; I prefer to read my paper or watch TV so it doesn’t affect me.” People told us they were able to keep in contact with families and friends.

People’s views and opinions were sought through day to day conversations, during reviews of care plans and from the annual customer satisfaction surveys. Resident and relative meetings had not routinely taken place for some time although some people told us they had been kept up to date and involved informally.

During this inspection visit we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to ineffective quality assurance and auditing systems, provision of training and induction, management of people’s medicines, management of people’s concerns and complaints and failure to maintain a safe and suitable environment. You can see what action we told the registered provider to take at the back of the full version of the report.