This unannounced comprehensive inspection took place on 3 April 2018.

Honiton Manor Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Honiton Manor provides accommodation with nursing care and support for up to 22 older people. There were 17 people using the service at the beginning of our inspection. The service is located in the town of Honiton and is a detached period property. The home consists of two floors with a passenger lift providing access to each floor. There is a main communal lounge and dining area where people could spend their time as they chose.

At our last comprehensive inspection in February 2017 the service was rated requires improvement overall. We issued the provider with two requirements. These were because the provider had not ensured all staff had received appropriate supervision and appraisal to enable them to carry out the duties they were employed to perform. They had not supported registered nurses employed at the service to demonstrate to their regulator that they continued to meet professional standards required in order to practice.

The provider did not also have systems and processes which were effective to ensure the safety of the service provided. At the last inspection, we asked the provider to take action to make improvements and this action had been completed. For example the registered manager had taken action to put in place systems to ensure all the registered nurses had received regular supervisions and appraisals. They had ensured nurses had training in the management of medicines and completed competency assessments on the nurses. The provider had decided during the last inspection to have thermostatic mixing valves (TMVs) on all hot water outlets accessible to vulnerable people. We received confirmation after the inspection from the registered manager that TMV’s had been fitted. Hot water temperatures were checked weekly to ensure people were not at risk of scalding and actions taken if concerns were found. Relevant information from people’s archived care plans had been added to the new system and reflected people’s needs.

The service had a registered manager. 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. They led by example and was supported by a deputy manager. They both had a high level of expectation of the staff to deliver good quality care.

People said they felt safe and cared for in the home. There were sufficient, suitably qualified staff to meet people’s needs. The registered manager had been addressing staff sickness which had improved staff attendance. There were robust recruitment checks in place.

People were protected from the risks of abuse as staff understood and carried out what they needed to do when they identified a concern.

There was a safe system to ensure the safe management of medicines at the service. Medicines were administered by registered nurses who had been trained regarding medicine management and had their competency checked.

People’s needs and risks were assessed before they were first admitted to the home and these were reviewed on a regular basis and when a change in their needs was identified. There were environmental risk assessments which ensured the premises were safe.

Staff had the skills and knowledge to support people appropriately. They received regular supervision and appraisals to support them with their performance and future development. New staff undertook a thorough induction when they started working at the service. The registe

Honiton Manor Nursing Home offers accommodation with nursing care and support for up to 22 older people. There were 19 people using the service at the beginning of our inspection.

This inspection took place on 18, 27 and 28 February 2017. The first two days were unannounced and we arranged to go back on the third day to spend time with the registered manager and partners. We initially carried out a focussed inspection on 18 February 2017 to follow up on the findings of the previous inspection in August 2016 where we had found a breach of legal requirement. However because of concerns found at this inspection we changed the inspection to a comprehensive inspection.

The breach found at the August 2016 inspection related to people not being protected from unsafe and unsuitable premises. In particular, we highlighted scald risks from the hot water supply and windows on the first floor which were not restricted to prevent vulnerable people from the risk of falling out. Following the inspection we were sent an action plan which set out the actions the provider was going to take.

At this inspection we found the actions set out in the action plan had been taken regarding the concerns. However, the water temperature was still higher than the recommended temperature. The provider had followed their action plan by completing monthly room audits and fitting a temperature restrictor at the boiler. This had not been successful at keeping the water temperature at the recommended temperature. The registered manger was monitoring the water temperature each week and had found at times temperatures were above the recommended. The provider decided during the inspection to order thermostatic mixing valves (TMVs) and had arranged for a plumber to fit on all water outlets accessible to vulnerable people. We received confirmation after the inspection from the registered manager that TMV’s had been fitted to all hot water taps accessible to vulnerable people.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had taken on additional responsibilities since our last inspection. They were now the area manager for the provider and were supporting the manager at the provider’s other service. This had meant they had delegated some of their responsibilities to the deputy manager. The provider was planning for the deputy manager to apply to the Care Quality Commission (CQC) to be registered as joint registered manager of Honiton Manor. We discussed the delegated time allocated to the deputy manager to undertake these responsibilities.

Medicines were not always safely managed. On the first day of our visits we found the medicines room was not locked which meant medicines were not safely stored. We also observed poor administration techniques not in line with the provider’s medicine policy by one registered nurse. The medicine fridge was unlocked, advance recording of the temperature of the medicine trolley had been documented and a discrepancy in the recorded amount of one medicine. When we returned the medicine record was accurate. We were made aware of how the inaccuracy had occurred. We observed that on these days medicines were being safely administered and stored. The registered manager and partners were taking action in relation to the concerns we identified.

There were adequate staffing levels to meet people’s needs. People felt there were enough numbers of staff on duty and that staff responded to bells promptly. Care staff received regular training, supervision and appraisals. However the registered nurses at the service had not received formal supervisions and appraisals since 201

We carried out an unannounced comprehensive inspection on 30 and 31 August 2016. We last visited the service in October 2013 and found the service was compliant with the standards inspected.

Honiton Manor Nursing Home offers accommodation with nursing care and support for up to 22 older people. There were 19 people using the service during our inspection.

There was 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. People said they were happy to approach the registered manager if they had a concern and were confident that actions would be taken if required.

People were not protected from unsafe and unsuitable premises. In particular, we highlighted scald risks from the hot water supply and windows on the first floor which were not restricted to prevent people from the risk of falling out. During the inspection, the registered manager and provider took immediate steps to mitigate the risks of both the concerns regarding the hot water supply and the windows safety.

People were not protected by an effective system to assess and monitor the health and safety risks at the home. The provider had identified through their assessment process temperatures of hot taps in sinks in all rooms exceeded the Health and Safety Executive (HSE) recommended temperatures. However no action had been taken to ensure these posed no risk to people at the service. Since the inspection an electrician and heating engineer have visited and are providing quotes for the necessary work to be completed.

There were sufficient and suitable staff to keep people safe and meet their needs. The staff and registered manager undertook additional shifts when necessary to ensure staffing levels were maintained. However this meant the registered manager had undertaken a lot of additional shifts which had meant they had to prioritise their managerial duties.

People’s needs were assessed before admission to the home and these were reviewed on a regular basis. Risk assessments were undertaken for people to ensure their health needs were identified. Care plans reflected people’s needs. They were personalised and people had been involved in their development. People were involved in making decisions and planning their own care on a day to day basis. They were referred promptly to health care services when required and received on-going healthcare support.

People received their medicines in a safe way because they were administered appropriately by suitably qualified staff and there were effective monitoring systems in place.

People could choose from a menu which was regularly reviewed and updated and took into account people’s choices and preferences. People were very positive about the food provided at the home. Staff were polite and respectful when supporting people who used the service. Staff supported people to maintain their dignity and were respectful of their privacy. People’s relatives and friends were able to visit without being unnecessarily restricted.

The registered manager and staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People had access to activities at the service and were encouraged to take part. Arrangements were in place for people who stayed in their rooms to have support to avoid social isolation.

Recruitment checks were carried out. New staff received a thorough induction that gave them the skills and confidence to carry out their role and responsibilities effectively. Staff received regular training and updates when required and several st

At the time of the inspection there were 21 people living at the service; we met with or saw the majority of people. We spoke in depth with five people to hear about their experiences. People told us they were happy with the level of care and attention they received and that they felt safe at Honiton Manor. Comments included, "The owners are brilliant, nothing is too much trouble and we see the same staff”, “The staff chat with us all the time, it’s a lively home” and “I like all the activities, today we are playing bingo with prizes!”.

We also spoke with three providers, the supporting manager, cook, activities co-ordinator, domestic, deputy manager and two care workers. People were cared for and had their needs assessed and reviewed so that they could be met in a personalised way. This included one to one meetings with people to ensure that they were happy with their care. The home was clean and odour free. There was on-going maintenance which was outlined in a maintenance programme to ensure that actions were completed in a timely way.

We found that Honiton Manor was meeting all five of the outcomes we inspected.

There were 18 people living at the service at the time of the inspection. We spoke with eight people living there, the registered manager and three care workers and spent time observing life in the communal areas and during lunch.

We saw that care and support was delivered in a kind and respectful way. People told us that their views were respected with comments like, “It’s nice, I’m having a lie-in today” and about the activities “I’m not very good at sketching but I’ll have a go. The staff are very supportive”.

When care was being planned, we saw that people were involved in making decisions about their care and treatment and activities of daily living. We saw that people were encouraged to be engaged in various activities or offered one to one time with staff and that people were able to make choices about how they spent their day.

Everyone we spoke with made positive comments about the running of the home and opportunities available to them. Records showed that the home regularly monitored the quality of the service including people’s views, risks, care plans and audits. For example the recent quality assurance survey included comments such as ”The manager is one of the best” and “It’s a lovely, happy home”.

We carried out this review to follow up on concerns that we had identified during a visit in February 2011.

We spoke to people living at the home about their care and about staffing numbers and whether they felt that their needs were met. We found that everyone using the service was well cared for and having their needs met. There was a calm atmosphere at the home and a good staff presence. There has been a change in how staff are used to ensure that people using the service have their needs met in an unhurried way. There are extra care staff hours to ensure that people have one to one time with staff who are taking appropriate break times that do not compromise care quality.

We spoke to people living at the home about the meals and about staffing numbers and whether they felt that their needs were met. People said that the staff were ‘lovely’ but they were ‘rushed off their feet’. Two relatives were concerned that often ‘staff were not around when help was needed’. One relative felt that they had to be at the home as much as possible to ensure that their relative’s needs were met.

We saw that staff were very busy, call bells were ringing and being answered as soon as staff could but staff were not available on the ground floor for long periods.

One relative said that they had to go and find staff to get help if someone needed assistance to mobilise. The cook said that it was not unusual for them to have to leave the kitchen to try and find staff. The activity co-ordinator also works as a carer and said that they sometimes have to stop activities to assist people in the lounge as other staff are not around. People living at the home said that they were disappointed when a quiz had to stop when the activity co-ordinator had to go and assist people who required help.

We heard that staff were very caring and felt to be ‘trying their best’. Relatives said that staff were not able to sit and talk to people living at the home and staff said that this was the case because they were busy upstairs. We heard that seven people living at the home need two staff to mobilise on a regular basis and some people also need help to eat and drink. This means that two staff can be occupied for longer periods with one person.

We asked people about the food and provision of special diets at the home. We heard that the food was excellent, home made and ‘very nice’. Staff showed us how they managed special diets for people. There is an excellent system in place to ensure that people living at the home are identified as needing a special diet and that this is given safely. We heard how specialist advice is sought and that this is followed with good records to back this up.

Relatives said that they thought that the food was good. One relative said that they did worry when the tea trolley was in the lounge because some people who need assistance to walk sometimes try to move by themselves. They said that this was because there was no way for people to call for help in the lounge other than a relative going to find staff. Relatives said that they worried about leaving boiling water unattended on the trolley.