This inspection took place on 8 May 2018 and was unannounced.

High View Oast is a ‘care home’. 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. High View Oast accommodates up to 33 people in one adapted building. At the time of the inspection 24 people were living at the service.

The service had a registered manager in post, the registered manager had started working at the service after the previous inspection. A registered manager is a person who is registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a 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 High View Oast in March 2017 when one continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. We issued a requirement notice relating to safe care and treatment: the unsafe management of medicines.

At our last inspection, the service was rated ‘Requires Improvement’. We asked the provider to complete an action plan to show how they would meet the regulatory requirements. At this inspection, the continued breach of regulation had been met, medicines were now managed safely. However, two new breaches of regulations were identified. This is therefore the third time the service has been rated ‘Requires Improvement.’ There had been lots of different managers over the past three years. The service was now more stable with a registered manager, some of the issues we identified had already been identified and were being addressed. Staff morale had improved but there was still a way to go which the registered manager recognised.

The service had been rated inadequate or requires improvement at the previous three inspections. The provider had not ensured that any improvements made had been embedded into the culture of the service. The day to day management of the service had been inconsistent over the past three years and the provider had not ensured consistent oversight of the service to meet the regulations.

Potential risks to people’s health and welfare had been identified but had not been consistently assessed. Staff did not have detailed guidance to mitigate risks in respect of people that displayed behaviours that may challenge. When people had displayed behaviours that may be challenging, staff completed behaviour charts and incident reports. This information had not been analysed to identify any patterns, trends or triggers to people’s behaviour and to develop a behaviour support plan. The registered manager told us they had discussed with the local safeguarding team, incidents where other people were at risk from people’s behaviour but this had not been recorded. Staff understood their responsibility to report any safeguarding concerns they may have.

Each person had a care plan that covered all aspects of their care including cultural needs, mental and physical health. These plans varied in detail about people’s choices and preferences, and how they liked their support to be provided. Some care plans did not reflect the care that was being provided. Staff knew people well and described how they supported people and their choices and preferences.

Checks and audits were completed on the quality of the service by the provider and the registered manager. The provider had identified some shortfalls in the care plans and risk assessments and detailed what action needed to be taken. However, there were no action plans detailing who was responsible for the action and when the action had to be completed by. There was no record that checks had been completed to confirm the action had been taken. The registered manager had not identifi

The inspection visit was carried out on 23 and 24 March 2017 and was unannounced. The previous inspection was carried out in September 2016, when areas requiring improvement were noted.

High View Oast Nursing Home is a converted Oast house, and is nursing home for up to 33 people. The bedrooms are situated on both ground floor and first floor, and consist of a mixture of single and double rooms. There is a lift providing access between floors. The communal accommodation is situated on the ground floor and consists of two interlinking lounge areas, a dining room, a small quiet lounge, and a porch area. On the day of the inspection there were 16 people living at the service.

There was no registered manager in post. The service had an interim manager who had been managing the service since September 2016. A new manager had been appointed but was not due to start at the service until April 2017. 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 and associated Regulations about how the service is run. We were supported by the interim manager, the regional manager, and the quality manager.

We last inspected this service in September 2016. We found significant shortfalls in the service. The provider did not have sufficient guidance for staff to follow to show how risks were mitigated when moving people, supporting people with their behaviour and health care needs. Staff had not ensured the proper and safe management of medicines. Safeguarding alerts had not been raised with the local safeguarding team. Staff were not deployed in sufficient numbers. Staff were not suitably qualified, competent, skilled and experienced to meet people's needs. Authorisations to deprive people of their liberty in line with the Mental Capacity Act had not been made. Care plans were not person centred or regularly updated when people's needs changed. The registered provider had failed to take appropriate action to mitigate risks and improve the quality and safety of services. They had failed to seek and act on feedback from relevant people, on the service provided to continually evaluate and improve the service. Records could not be found, were not clear and completed accurately.

We took enforcement action and required the provider to make improvements. This service had been placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. The provider sent us information and records about actions taken to make improvements following our previous inspection.

At this inspection we found that significant improvements had been made. There was, however, one continued breach in the regulations in the safe management of medicines and further improvements were needed in moving and handling risks assessments, details in care plans of what people could do for themselves and to eliminate an odour on the second floor of the premises.

People’s medicines were not well managed, stored and recorded accurately. Some people had not received the medicines they needed.

Although staff were observed moving people safely, some risk assessments to support people with their mobility did not have sufficient information to guide staff how to move people consistently and safely.

Checks had been carried out on the service, to ensure the premises was safe and environmental risk assessments were in place. However, on the second floor, improvements were needed to ensure that the service was free from offensive odours.

Emergency procedures were in place and the service had a business continuity plan. There was a ‘grab file’ which was available in case of an emergency such as a fire, and each person had a personal eme

The inspection visit was carried out on 21 and 22 September 2016 and was unannounced. The previous inspection was carried out in September 2015, when areas requiring improvement were noted.

High View Oast Nursing Home is a converted Oast house, and is nursing home for up to 33 people. The bedrooms are situated on both ground floor and first floor, and consist of a mixture of single and double rooms. There is a lift providing access between floors. The communal accommodation is situated on the ground floor and consists of two interlinking lounge areas, a dining room, a small quiet lounge, and a porch area. On the day of the inspection there were 22 people living at the service.

There was no registered manager in post. The service had an interim manager who had left on 16 September 2016. A new interim manager was due to start on 26 September 2016. The regional manager told us they planned to work at the service until a permanent manager had been appointed. 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 and associated Regulations about how the service is run. We were supported by the regional manager, the quality manager and deputy manager.

At our previous inspection on 21 September 2015 the service was rated as ‘requires improvement’. At that time areas for improvement had been identified by the management team and action plans were in place to address the shortfalls. However, at this inspection we found the required improvements had not been made and additional shortfalls in the service were identified, as detailed in this report.

Although people told us they felt safe living at the service, people were not fully protected from harm or abuse. The management team had failed to report incidents of alleged abuse by staff to people to the local safeguarding authority, in line with safeguarding protocols.

Risk assessments to show staff how to support people positively when their behaviour were not detailed enough. There was no information on what may be the trigger to this behaviour and how to reduce the risk of this happening again. Measures were not in place to reduce the risks and keep people as safe as possible. Some risk assessments to support people with their mobility did not have sufficient information to guide staff how to move people consistently and safely.

Accidents and incidents were recorded but lacked detail, and these were not analysed so action could be taken to reduce the risk of further events.

There was not enough staff on duty to ensure people’s needs were fully met. On the day of the inspection the deputy manager confirmed that staffing levels were not up to the preferred levels due to staff sickness. Recruitment procedures had not been followed to ensure staff had been recruited safely.

People were at risk of harm as they were not always receiving their prescribed medicines. The storage room for medicines was not maintained at the correct temperature to ensure the medicines were safe to use.

Checks on the equipment and the environment were carried out, but staff could not find the environmental risk assessments. The service had a ‘grab file’ which was available in case of an emergency such as a fire, and each person had a personal emergency evacuation plan in place. Regular fire drills had been carried out.

The training programme had not ensured that all staff had received the training and training updates they needed to carry out their roles safely.

During the last inspection in September 2015 it was noted that not all staff had received a yearly appraisal to discuss their training and development needs and the programme of staff supervision was not up to date. There was an action plan in place to address these shortfalls, but at that time of this inspection there rem

We spoke with people who used the service, visiting relatives, the deputy manager and staff. Everyone we spoke to said that they were very happy. One person told us “I feel safe here. The staff are all lovely and take their time talking and listening to me”. A relative told us “The staff are very friendly and if we need to know anything they will tell us”.

We looked at the care records of four people who used the service. We saw that each person had a set of care records that were up to date and person centred.

We found that people could choose what they wanted to eat and drink. One person told us “I get to choose what I would like to eat and if I change my mind they always make me something else. They really are very good”. We observed staff assisting people at mealtimes. We saw that staff engaged positively with people.

We looked at the recruitment records and spoke with staff. We found that there were effective recruitment and selection processes in place to ensure that the staff were suitable for the role.

We spoke with people who use the service, the manager and to staff members. Everyone we spoke with said that they were very happy with the service provided at High View Oast. One person said “It is very comfortable and we are looked after well. I am settled here, contented.”

People told us that they felt safe and well looked after. They said that the staff were kind and caring. People said “Oh, they (the staff) are very kind” and “I really enjoy it here. They are all very good” and “I have enjoyed myself here and feel much better for being here.”

People said they could talk about any problems to the manager and to the staff. People said that they would be listened to and any problem would be sorted out. Everyone we spoke with said they had no complaints about the service.

People said that the home was clean and that their bedrooms were kept clean. People said that they were happy with their bedrooms. People told us that the food was good and said “There are two or three choices at lunchtime and there is always a salad. They come round mid morning and tell us what there is and we choose.”

People’s health needs were supported and the service worked closely with health and social care professionals to maintain and improve people’s health and well being.

People were satisfied with their care and support. Some people said told us they were involved in decisions about their care. People felt safe using the service. People told us staff were polite, kind and caring. People were given opportunities to say what they thought about the service and management listened. People told us that they thought staffing levels could be improved as sometimes they had to wait for several minutes before staff responded to their calls. Some of the staff told us that at times there were was not enough staff on duty.

The inspection visit was carried out on 15 and 16 September 2015 and was unannounced. The previous inspection was carried out in February 2014, and there were no concerns.

High View Oast Nursing Home is a converted Oast house, which is registered for 33 nursing beds. The bedrooms are situated on both ground floor and first floor, and consist of a mixture of single and double rooms. There is a lift providing access between floors. The communal accommodation is situated on the ground floor and consists of two interlinking lounge areas, a dining room, a small quiet lounge, and a porch area. On the day of the inspection there were 29 people living at the service

There was a registered manager in post who was not available at the time of the inspection. We were supported by the deputy 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 and associated Regulations about how the service is run.

People told us they felt safe living at the service. Staff had been trained in safeguarding adults, and understood how to keep people safe and were aware of the service’s whistle-blowing policy. They were confident they could raise any concerns with the manager, or with outside agencies if required.

There were individual risk assessments for each person, which included the risk of falls, nutrition, the use of bed rails and the risk of developing pressure sores. Appropriate actions were identified and put in place to reduce the risks and moving and handling risk assessments were being reviewed to include further information. Nursing staff ensured that medicines were stored and administered to people safely.

Checks on the equipment and the environment were carried out and emergency plans were in place in the event of an emergency such as fire. People had a personal emergency evacuation plan (PEEP) which were not detailed enough to show how people should be supported with their mobility, to ensure that they could be safely evacuated from the service in the event of an emergency. Regular fire drills had not been carried out since December 2014. After the inspection the service notified us that a fire drill was carried out on 18 September 2015. There had been no analysis of the accidents/incidents since April 2015 to identify any patterns or trends to reduce the risk of re-occurrence.

People were being supported by sufficient staff who had the right skill mix, knowledge and experience to meet their needs. Recruitment procedures were in place to check that staff were of good character and suitable for their job roles. There was a training programme in place and further training had been arranged to address the shortfalls identified in the training matrix. Staff received additional training relevant to their job roles. New staff were given a detailed induction, and were supported through their probationary period.

Not all staff had received a yearly appraisal to discuss their training and development needs. The programme of staff supervision was not up to date; therefore staff were not regularly meeting with their line manager on an individual basis to discuss their role. Meetings were held with the nursing staff, care staff and catering staff to encourage staff to voice their opinions of the service and discuss any issues.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The registered manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Applications had been made to the DoLS department and authorisations had been processed so that people remained safe. When people were unable to make important decisions for themselves, relatives, doctors and other specialists were involved in the decision making process regarding their care and treatment and decisions were made in people’s best interest.

People told us there was always choices on the menu and records showed that people were assessed to make sure they received a healthy diet to ensure their nutritional needs were met. People’s physical and mental health was monitored and people were supported to see healthcare professionals and visit the hospital when required.

People and relatives told us the staff were kind and respected their privacy and dignity. Staff were familiar with people’s likes and dislikes, and supported people with their daily routines.

People’s care plans were personalised and contained clear information about people’s care needs. Separate care plans were written for each aspect of care, and monthly reviews were carried out. Records about people’s end of life care were not always completed and in some cases there was a lack of people’s personal histories to ensure that staff would know what was important to them. People or relatives had signed the plans to confirm they had agreed with the care to be provided.

The service was in the process of developing the activities programme in line with individual’s choices and preferences. Many people had high nursing needs and were confined to bed or preferred to stay in their own rooms. The activities co-ordinator held group activities as well as spending time with people individually in their rooms. Staff greeted people as they went about their duties and people were asked if they preferred to have their doors open to prevent feelings of social isolation.

The complaints procedure was on display to show people the process of how to complain and there was a suggestions box at the entrance to the service. People, their relatives and staff felt confident that if they did make a complaint they would be listened to and action would be taken.

People had opportunities to provide feedback about the service provided. Quality assurance surveys were sent out annually and the recent survey showed that people were satisfied with the service being provided. However, feedback had not been sought from a wide range of stakeholders such as staff, visiting professionals and professional bodies, to ensure continuous improvement of the service was based on everyone’s views. Although resident meeting had been arranged, people had not attended although they did join in with other events such as coffee mornings.

There were systems in place to review the quality of all aspects of the service. The service had received a ‘mock inspection’ from a quality assurance provider and completing an ongoing action plan to address any identified shortfalls. Audits had been completed in medicine management, infection control, wound care and call bell monitoring. The evaluation forms had not always been completed to show what issues had been raised, what action had been taken, and if checks had been made to confirm the identified improvements had been made.

Staff said that the service was well led and they were supported well by the management team. They were clear about their roles and responsibilities and felt confident to approach senior staff if they needed advice or guidance. They told us told us they were listened to and their opinions were taken into consideration.

Records were stored safely and securely. Some records such as the evaluation on the audit process, life histories in care plans and end of life documentation were not always completed appropriately.