This comprehensive inspection took place on 13 and 14 December 2018 and the first day of the inspection was unannounced. We informed the registered manager we would be returning the following day.

Following the last inspection on 18 and 19 May 2016, we rated the service Good in the key questions, is the service effective, caring, responsive and well-led?. We rated the service requires improvement in the key question, is the service safe?. This was because the provider continued to fail to ensure staff member’s full employment history was documented. Staffing levels were not always sufficient to keep people safe and people were not always protected by robust infection control measures.

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

Jansondean is a large residential house set over two floors in the London Borough of Bromley. The service is registered to provide care and support to a maximum of 28 people. At the time of the inspection there were 28 people using the service.

The service had a registered manager in place. 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 provider continued to fail to obtain employees’ full service history in health and social care as required by law.

People did not always receive support from staff that had adequate rest between shifts. One staff member had been deployed to work excessive hours over a six-day period with only one day off.

The provider did not deploy sufficient numbers of staff during the lunch period to ensure people received effective care and support with their meals in a timely manner.

The service did not have robust cleaning schedules in place to ensure the service was free from dust and that the kitchen floor was adequately cleaned to minimise the risk of cross contamination.

People did not always receive activities that were stimulating and met their social needs. During the inspection we observed people were left without interaction which meant they were at risk of social isolation. We have made a recommendation in relation to the provision of activities.

Auditing systems in place did not always identify issues in a timely manner, to ensure issues were acted on appropriately.

People continued to be protected against the risk of harm and abuse as staff received on-going safeguarding training, knew how to identify, report and escalate suspected abuse. Risk management plans in place gave staff clear guidance to mitigate identified risks. Accidents and incidents were reviewed and audited to ensure patterns and trends were identified and action could be taken to minimise repeat occurrences. Staff continued to be provided with sufficient personal protective equipment to minimise the risk of infection.

People’s medicines were managed in line with good practice. Registered nursing staff ensured people received their medicines as intended by the prescribing pharmacist. Medicines were stored, administered, documented and disposed of safely.

People were supported to access healthcare professional services as and when needed; care plans were updated to ensure guidance given by healthcare professionals was included in the service delivery. People were supported to access sufficient amounts of food and drink that met their dietary needs and requirements. People with specific dietary needs were catered for.

Staff received on-going training to enhance their skills, and put these into the delivery of care. Staff confirmed training provided enabled them to improve t

This inspection took place on 18 and 19 May 2016 and was unannounced. At the last inspection on 21 and 22 May 2015 we had found two breaches of regulations in respect of the arrangements for consent where people lacked capacity to make certain decisions, and an absence of an effective system to monitor the quality of the service. We carried out a focused inspection on the 29 September 2015 and found improvements have been made to meet the legal requirements. However, the quality monitoring system which had been implemented required some improvement to be effective as it was not always consistently carried out.

Jansondean is currently registered to provide personal and nursing care for up to 28 people who may have dementia. At this inspection there were 26 people using the service. There was a registered manager in post who was appointed in April 2015 and had experience in nursing and as a previously 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 this inspection on 18 and 19 May 2016 we found some improvement was needed to the fire risk and detection systems. Work was in progress to address issues that had been identified during a recent London Fire and Emergency Planning Authority inspection at the time of our inspection, but had yet to be completed. We will monitor the progress of the work and report on this at our next inspection.

We found improvements had been made to the quality monitoring system at the home and when issues were identified action was taken to address them. People and their relatives told us they knew the registered manager. They found her to be effective and told us she was visible in the home. At our previous inspections in November 2014 and February 2015 we had identified concerns about the monitoring of people’s needs and a lack of staff presence on the top floor of the service. The top floor had been out of use at our last inspection in May 2015. At this inspection we found there was an electronic system to monitor the care of people who were nursed in bed and we saw this was checked effectively. Additionally, we found noticeable improvements in staff communication and team work at the home.

People told us they felt safe and secure at the home. Staff knew how to raise any concerns about the people they cared for. Individualised risks to people were identified, assessed and monitored, and staff had guidance to reduce these risks. The premises and equipment were routinely checked for possible risks. Medicines were managed and administered safely. There was a high level of agency staff use but we found the manager tried to use the same agency and the same staff to ensure consistency wherever possible. The provider and registered manager also told us they had made efforts to recruit more permanent staff. People and their relatives told us they would like more permanent staff but there were enough staff to meet people’s needs.

Staff received training so that they could support people effectively. Staff told us they received regular supervision including a lot of informal supervision. The registered manager had identified supervision records were not up to date and had an action plan in place to address this by the end of the month. People told us they had enough to eat and drink and we observed this to be the case.

Staff asked people’s consent before they delivered care and there were arrangements to comply with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People were referred to health professionals when this was needed and professionals’ advice was used to form part of people’s care plans.

People told us staff were kind and considerate. People told

This focused inspection took place on 29 September 2015 and was unannounced. At the previous comprehensive inspection on 21 and 22 May 2015 we had found breaches of legal requirements in the arrangements to obtain and record people’s consent when they lacked capacity for some decisions and in the quality assurance system. The provider sent us an action plan to tell us how they would meet the requirements of the regulations. We carried out this inspection on 29 September 2015 to check action had been taken to address the breaches of legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for (Jansondean) on our website at www.cqc.org.uk

Jansondean is currently registered to provide personal and nursing care for up to 28 people who may have dementia. At this inspection there were 23 people using the service.

There was a registered manager in post at this inspection. They had been appointed in April 2015 and their application for registration as a manager had recently been confirmed. 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 on 29 September 2015 we found that arrangements to obtain and record people’s consent to care and support where they did not always have capacity to make decisions complied with the law. People’s capacity to make decisions was assessed for each specific decision. Where people needed to have their liberty restricted for their own safety relevant authorisations from the local authority were applied for in line with the relevant legislation and code of practice. A visiting social care professional confirmed that the applications made by the service were appropriate. Processes were in place to ensure the authorisations were complied with. In view of the changes made and the fact there were no other breaches or concerns in this key question at our last inspection, we have revised the rating for this key question, improving the rating to ‘Good’.

There were new arrangements to monitor the quality of the service; these were now more detailed and covered all aspects of people’s care. They included a system for checks on the premises and equipment, and accidents and incidents were monitored and analysed. However some improvement was required as some checks on the quality of the service were not always consistently completed. It was not always clear that action taken had successful resolved the problem. The rating for this key question remains ‘Requires Improvement’ and the overall rating remains unchanged from the comprehensive inspection.

We considered our inspection findings to answer questions we always ask; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them, and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

At the inspection on 22nd and 23rd January 2014 we found a breach of regulation 9 of the Health and Social Care Act 2008. There were inadequate arrangements for emergencies. At this inspection we found that there was a business contingency plan. This had contact details and guidance to cover a range of possible emergencies; although we noted it did not always refer to the correct location. There were personal emergency evacuation plans in place.

Most people told us they felt safe at the service. Staff knew how to recognise abuse and how to raise a safeguarding alert. They were also familiar with whistleblowing procedures. There were risk assessments in place where risks to an individual had been identified although these were not all up to date. There were not always enough staff on duty to meet the service required staffing levels.

We found that people may have been deprived of their liberty unlawfully as we observed circumstances where an application for authorisation under the Deprivation of Liberty Safeguards (DoLS) should have been considered and it had not been made.

We also found that some people did not have access to call bells to alert staff if they needed help.

Is the service effective?

People’s consent to care and treatment was not routinely or regularly sought. Mental capacity assessments were not carried out to establish if people had the capacity to make a decision about their care and treatment. Staff told us they had training on the Mental Capacity Act 2005 but we did not see evidence that this was put into practice. Some people’s Do Not Attempt Cardiopulmonary Resuscitation (DNAR) forms had not been completed correctly in accordance with the law.

People using the service had access to health and social care professionals when required.

Is the service caring?

At this inspection we found there were aspects of the service that were not caring. Most people and their relatives we spoke with were happy with the care provided and told us they thought the staff were kind.

However we found people were not always involved in decisions about their care or treatment. We found people were expected to be in their rooms from approximately 5pm onwards, rather than choosing where they wished to be. Some people were also routinely put to bed at this time without consultation. We found that most meals were taken in people’s bedrooms. People were not involved or consulted about their care plans. We observed that people were not always treated with respect and dignity. Staff did not always knock on people’s doors before they entered and did not always explain or ask consent before carrying out personal care.

Is the service responsive?

We carried out this inspection in response to concerning information given to us regarding people’s care. At the inspection on 22nd and 23rd January 2014 we found that there was a breach of regulation 9 of the Health and Social Care Act 2008 in respect of the planning and delivery of people’s care. At this inspection while we saw some improvement in the care planning; people’s care and treatment did not always meet their needs. Some care plans did not always provide information and guidance to staff about how people’s health needs, individual needs and preferences should be met. People’s fluid food and turning charts were not always kept up to date.

Is the service well led?

At our inspection on 22nd and 23rd January 2014 we identified areas of this domain where the provider was not meeting the essential standards of quality and safety. They sent us an action plan to tell us how it would become compliant with the regulations.

At this inspection we found the registered person was failing to notify the Care Quality Commission of incidents that arose while carrying out the regulated activity as it was required to do under the regulations.

Otherwise we did not inspect the service for its compliance with essential standards in this area at this inspection but will consider this question at a later inspection.

You can see the action we have taken in respect of our findings in the full report.

People using the service and staff we spoke with felt the home had made improvements in ensuring that it was clean and a safe place to live and work in. Most people were happy with the quality of care they received and we observed staff providing care in a caring way.

This inspection was a follow up to enforcement action taken against the provider and to ensure that suitable improvements had been implemented in relation to: cleanliness and infection control and the safety, and suitability of premises. The provider had suitable systems in place to protect people against the risks of acquiring an infection; this included arrangements related to the safe handling and disposal of waste, cleaning within the home and relevant training for staff. We found concerns related to the flooding and dampness within the premise had been addressed. However, we were not able to assess if the provider was meeting the requirements of Regulatory Reform (Fire Safety) Order 2005 as this assessment would need to be undertaken by the London Fire and Emergency Planning Authority.

People and relatives we spoke with told us they were happy with the care received and had no complaints. One person told us staff “responded promptly” to their needs and another person told us the staff were "friendly” and it was “a lovely home”. Two relatives told us that staff kept them up to date with their family member's progress and they were pleased with the care provided. We found that people’s needs were assessed and care was planned in a way that ensured their safety and welfare. Staff were supported in their roles through training and supervision and were aware of the action they would take if they had any concerns.

People using the service told us that they were treated with dignity and respect with comments including '“kind and respectful”, “very nice and treat me well” and 'they treat me respectfully'. Relatives spoken to also told us that staff communicated well with their family members, were excellent and caring. We saw staff being polite and courteous when supporting people.

We found that people were happy at the home and that they felt supported by staff to maintain their independence where possible. However, we also found that care was not always carried out in the way that had been planned and that care plans were not always accurate or reflected the needs of the person living at the home. Staff we spoke with showed a good understanding of the safeguarding of vulnerable adults but had not been supported with recent training. Medication was stored securely and administered correctly according to the prescription.

People told us that they were happy living in the home. People said that they felt safe in the home.

Some people told us that staff were “brilliant”, “very friendly” and “polite.”

People said that staff were responsive to their needs although they appeared to be very busy at times.

Some people told us that they had been involved in the needs assessment process and development of care plans.

People told us that they were generally happy with the services provided at Jansondean Nursing Home. They said that things were ‘pretty good’ and that staff were ‘very good and helpful’.

Family and friends told us that they could turn up at anytime and that ‘care seems reasonably good’. Staff were observed by people using the service to be ‘friendly and kind’.

The home’s 2010 resident customer survey shows that overall people thought the quality of service provided was at a minimum ’quite good’. An action plan had been put in place to address areas identified as needing improvement. From resident meeting minutes, people who used the service acknowledged the improvements that the nursing home had made in relation to areas requiring attention from the survey.

This inspection took place on 21 and 22 May 2015 and was unannounced. At the last inspection on 3, 4 and 6 February 2015 we had found breaches of legal requirements of the Health and Social Care Act (Regulated Activities) Regulations 2010 in respect of people’s care and welfare, medicines management, staffing, recruitment, quality assurance and record keeping. CQC is considering the most appropriate regulatory response to resolve the problems we found.

There were also breaches of regulations for training and processes to seek and record people’s consent from a previous inspection of November 2014 which we had not been able to follow up at the February 2015 inspection because the provider had submitted an action plan they were working through at this time.

We carried out this inspection of 21 and 22 May 2015 to check action had been taken to address all the previous concerns found and to provide a fresh rating for the service.

Jansondean is currently registered to provide personal and nursing care for up to 28 people who may have dementia. At this inspection there were 18 people using the service.

There was no registered manager in post at this inspection. The previous registered manager left in January 2015. The current manager was appointed in April 2015 and had experience in nursing and as 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 new manager and a representative of the provider told us the new manager would be applying to register later in the month.

At this inspection we found improvements had been made in most areas where we had previous concerns. Despite this we found breaches of the regulations in respect of the need for consent where people lack capacity and in relation to good governance of the service. There were no specific decision based mental capacity assessments for people who may lack capacity and there was not an effective system in place to manage and monitor some risks to people in relation to aspects of the premises. You can see the action we have asked the provider to take at the back of the full version of this report.

People told us they felt safe at the service. Staff were aware of how to raise any safeguarding issues. Identified risks to people such as falls or from skin integrity breakdown were now effectively monitored and plans were in place to reduce risk. Records of people’s care such as fluid charts and wound charts were being completed and checked so that people’s welfare was effectively monitored. There were plans in place to manage a range of emergencies. There were safe recruitment procedures in place and there were enough staff to meet people’s needs. Medicines were safely managed and there were adequate systems to reduce the risk of infection.

People said they had enough to eat and drink and we saw nutritional risk was monitored and plans were in place to reduce risk. Staff told us they had received suitable training and support to carry out their work. People had access to a suitable range of health care professionals and staff made appropriate referrals when needed to meet people’s needs.

People told us they were well looked after and we observed staff to be attentive and caring. Staff knew people‘s preferences and respected people’s dignity. People’s care plans provided an accurate record of their care and support needs however people or their relatives had not been involved in planning care and treatment. People’s needs for socialisation were met through a range of suitable activities. There was a complaints system readily available and relatives and residents meetings were held to capture people’s experiences of care and views about the service.

People and staff commented positively about the new manager at the service and said they had confidence in their ability to lead. We found that improvements had been made in a short space of time. The manager had introduced a range of quality checks to monitor the quality of the service although these had not been implemented at the time of inspection. It was therefore not possible to judge their effectiveness.