This was an unannounced inspection that took place on 7, 8 and 10 March 2017.

Homefield is a 44 bedded nursing home situated in the London Borough of Bromley.

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 and associated Regulations about how the service is run.

In May 2016, the areas of safe, effective and well-led required improvement, caring and responsive were good and there was an overall rating of requires improvement with one breach under effective. At this inspection we found that the breach of the regulation was rectified.

People and their relatives told us that this was a nice place to live and staff provided very good support and care that was delivered in a respectful way. People were given the opportunity to do what they wanted and joined in the activities provided if they wished.

The home’s atmosphere was warm, welcoming and inclusive. Visitors during the inspection told us that they were always made very welcome. The home provided a safe environment for people to live and work in, was well maintained and clean. The décor was currently acceptable, although looking a little tired and the home had begun a refurbishment programme with flooring being replaced.

There were thorough up to date records kept, although some historic records required archiving. The care plans contained clearly recorded, fully completed, and regularly reviewed information. This enabled staff to perform their duties appropriately.

The staff knew the people they worked with well including their likes, dislikes, routines and preferences. During our visit people received the same attentive service and everyone was treated equally. Staff had appropriate skills, qualifications and were focussed on providing individualised care and support in a professional, friendly and compassionate way. Whilst professional they were also accessible to people using the service and their relatives. Staff said they had access to good training, support and career advancement.

People were protected from nutrition and hydration associated risks with balanced diets that also met their likes, dislikes and preferences. They said the choice of meals and quality of the food provided was very good. People were encouraged to discuss health needs with staff and had access to community based health care professionals, if they required them. Two people were however not prompted in a timely manner to eat their lunch or drink.

The home’s management team were approachable, responsive, encouraged feedback from people and consistently monitored and assessed the quality of the service provided.

This inspection took place on 17 and 18 May 2016 and was unannounced. At our last comprehensive inspection of this service on 22, 23 and 25 September 2015 we found breaches of legal requirements because risks to people had not always been identified or assessed, and action had not always been taken to manage identified risks safely. People had not been protected from the risk of malnutrition and systems in place to monitor risks were ineffective.

We took urgent enforcement action in response to these concerns and imposed a condition on the provider’s registration, requiring them to send us information on a weekly basis to demonstrate that the service was monitoring and reducing the level of risk to people. We also rated the service Inadequate for the key question ‘Is the service safe?’ The provider has since met the conditions of their registration and submitted the information to us demonstrating how risks to people were being safely managed.

We also found further breaches of regulations because staffing levels did not meet the provider’s assessed level of need and an allegation of abuse had not been shared with the local authority safeguarding team.

At this inspection we found that the provider had taken action to address the breaches we had previously identified. However we found a further breach of regulations because whilst staff sought consent when offering support to people and understood the requirements of the MCA, people had not always been lawfully deprived of their liberty in line with legal requirements. You can see the action we have told the provider to take in respect of this breach at the back of our report.

Homefield provides accommodation, nursing and personal care for up to 44 older adults in Bickley, Kent. At the time of our inspection the home was providing support to 38 people. The home did not have a registered manager in post although the current manager was in the process of applying for the role. 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.

We found that risks to people had been assessed and monitored and staff had taken action to manage risks safely. The provider had systems in place to monitor and mitigate risks to people but improvement was required to ensure audits of people’s care plans consistently identified errors. People were supported to maintain a balanced diet and risks associated with malnutrition were safely managed.

There were now sufficient staff to meet people’s needs, although improvement was required to ensure they were effectively deployed at all times within the service. Appropriate recruitment checks were in place to ensure applicants were suitable for the roles they were applying for, although improvement was required to ensure that any gaps in applicants’ employment histories had been considered by the service

Staff received training and supervision in support of their roles and told us this support gave them the skills to meet people’s needs. People were protected from the risk of abuse because staff knew the action to take if they suspected abuse had occurred.

People had access to a range of healthcare professionals in support of their health and well-being when required. Medicines were safely stored and people received their medicines as prescribed. Accurate records were maintained of the administration of people’s medicines but improvement was required to ensure people’s medicines care plans were reflective of their current needs.

Where people lacked capacity to make specific decisions about their care staff, relatives and healthcare professionals, where appropriate had been involved in making the decisions in people’s best interests.

People told us that staff were kind and

During this inspection we spoke with six families, and with eight people who use the service regarding their experience of the care provided. We also observed care being given, as many people who use this service were unable to communicate with us. We spoke with staff, the manager and the clinical lead nurse regarding people’s involvement in decisions about their care, staff recruitment and staffing levels.

We found the provider had made improvements to ensure that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Families we spoke with told us that they were consulted about plans for relatives, including plans for end of life care and a some said they visited every day and were fully involved in caring for their relative, and in decisions about such issues as medication.

The provider carried out appropriate checks to ensure that staff were of good character, and had skills and experience in providing care for people before they started employment. Staff records we saw were well maintained, and contained all relevant recruitment and employment information.

We found that there were enough staff who were skilled and experienced to provide safe and responsive care for people who lived at the home. One person said: “there are always enough staff around when we need them, they are caring and helpful”. Another person said: “the manager is around most days, and comes in at weekends sometimes to meet relatives for care reviews or when we feel we need to talk”. This was reflective of comments we received from all of the people we spoke with.

When we inspected the home we found that people were treated with dignity and respect. A person visiting their family member told us "staff are very kind and caring here". People's care was planned and delivered in accordance with their assessed needs and people told us the care they received was good. We found that staff had acted on advice and guidance from other professionals and that generally the number of staff on duty met the level identified as required by the provider. At our July 2012 inspection we raised concerns regarding the ineffective measures in place to monitor risks to people’s health, safety and welfare. At our April 2013 inspection we found the provider had taken action to address this issue.

However, on our recent visit we also found that the provider had not always correctly assessed people's capacity to make decisions.

People or their relatives told us that they received good care at the home. People told us they were happy at the home and that the staff treated them well.

This unannounced inspection took place on 22, 23 and 25 September 2015. At our previous inspection in March 2014 we found the provider was meeting the regulations in relation to the outcomes we inspected.

Homefield provides accommodation, nursing and personal care for up to 44 older adults in Bickley, Kent. At the time of our inspection the home was providing support to 41 people. The home had a registered manager in post. 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 this inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risks to people had not always been identified or properly assessed, and action had not always been taken to manage risks safely. People were not always protected from the risk of malnutrition because staff were not always aware of who required fortified diets, and the monitoring by staff of risk areas did not always meet the requirements stated in people’s care plans and risk assessments. We also found breaches which relate to good governance of the service as the quality assurance processes used within the home had not identified these issues and the provider was unable to demonstrate that appropriate action had been taken in response to an audit of the service’s electrical system. CQC has taken urgent enforcement action in response to these concerns. We are closely monitoring the service and require the provider to submit information on a regular basis to assure us of the safe running of the service.

There were procedures in place to protect people from the risk of abuse. Staff had received safeguarding training and were aware of the action to be taken if they suspected abuse had occurred. However the provider had not consistently followed their procedures when an allegation of abuse had been raised. You can see the action in respect of safeguarding adults that we have asked the provider to take at the back of the full version of this report.

Appropriate recruitment checks were in place and staff received support through regular training and supervision. People and relatives told us that staff were kind and considerate, and treated them with compassion. However, there were not always enough staff to meet people’s needs. You can see the action in respect of staffing that we have asked the provider to take at the back of the full version of this report.

Medicines were safely managed and administered, but some medicines had been stored in an area where temperatures were not regularly checked, and one staff member responsible for administering medicines had not received training in that area from the provider. Arrangements were in place to ensure people consented to their care and treatment, or that decisions about their care were made in their best interest, in line with the requirements of the Mental Capacity Act 2005, although we found some examples of mental capacity assessments having been recorded that were not decision specific. The provider took action to address these issues during our inspection.

People and relatives told us that they were involved in their care and that their privacy and dignity were respected. There were arrangements in place to comply with the Deprivation of Liberty Safeguards and people were aware of the procedure for raising a complaint. Staff were aware of people’s individual needs and preferences, and we observed staff supporting people in a caring and considerate manner. People and staff told us that the registered manager listened to them and took action to address their concerns, and we observed example of people receiving good quality care.