Jasmine House Nursing Home is a service providing personal and nursing care for up to 79 people with needs arising from old age. The service included a unit for people living with dementia. Care was provided over three floors, each served by a lift. People had their own bedrooms and had the choice of various communal areas.

At the last inspection, in June 2015, the service was rated Good. At this inspection we found the service remained Good in each area, with good progress having been made, particularly in activities, external liaison and in-house governance.

The service was required to have a registered manager and one was 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.

Further development of the dementia environment had taken place with plans in place for additional improvements, to provide the best environment for people living with dementia. Improvements had also been made to other aspects of the environment, furnishings and equipment.

The service continued to operate a robust recruitment process to try to ensure staff had the necessary skills, attitude and ability to care for vulnerable people. Staff received a thorough induction and a good programme of core and specialist training, which was periodically updated. Staff received ongoing support through regular supervision meetings, annual performance appraisals and observations of their practice to confirm competence. The plan to provide staff with a separate area to take their breaks still needed to be followed through, so it was clear that staff who could be seen were on duty.

People and relatives felt people were safe and well cared for by trained staff who had the skills they needed. They said staff provided effective and responsive care and sought their views and wishes about care. People and relatives felt they had opportunities to raise issues and their opinions of the service were sought and acted upon.

People’s nutritional and healthcare needs were met and monitored and the advice of external healthcare professionals was sought when necessary. People’s cultural and spiritual needs were provided for to some degree, although there was room for further development. People’s dignity was managed well with the exception of hairdressing, which was still being carried out in the Jasmine unit dining area.

People’s rights and freedom were protected by staff. Where they had capacity, people were consulted about their care. The views of relatives and other representatives were sought where appropriate. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People enjoyed a good range of activities, entertainment and some outings. The appointment of a new team of activity staff had led to improvements in this area. Activities and other staff engaged regularly and effectively with people in lounge areas, which helped them to feel valued. There was a need for additional staff support for people in the dementia unit who chose to spend time away from the main lounge.

Within the service, the management team exercised effective governance and monitored required aspects of the service. There was limited evidence of governance activity by or on behalf of the registered provider. The registered manager thought the recently appointed ‘responsible individual’ planned to begin a monitoring regime soon, following their initial visit.

Two adult social care inspectors carried out this inspection. The focus of the inspection was to follow up two warning notices issued on the home following the previous inspection on 15 July 2014. We did not undertake a full inspection of all aspects of the service on this occasion.

As part of this inspection we spoke with three people who use the service, one relative, three members of the management team and three staff. We also reviewed records relating to the management of the home which included care plans, risk assessments and other relevant records.

Below is a summary of what we found. The summary described what people using the

service, their relatives and the staff told us, records we looked at and what we found with regard to the home’s compliance with the warning notices issued following the July inspection.

Is the service safe?

We saw that improvements had been made in terms of keeping people safe. Previous incidents of concern had been investigated and changes to the care plan made to minimise the risk of recurrence. However, the records of an incident of aggression between two people were ambiguous and contained insufficient information. The incident had not been investigated or notified to either the Care Quality Commission or the local authority.

We found that injury and wound monitoring and follow up care had improved. However, these recording systems were confusing to follow. It was not clear if there was a system in place to ensure that any relevant learning from incidents and injuries took place.

Staff had been provided with additional training around aspects of dementia care and more training had been booked. The health authority in-reach team had already provided training support to staff and this was ongoing.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home had liaised with the relevant local authorities DoLS team and had made DoLS applications where they felt these were necessary. There had been an improvement to the process and documentation for approving covert medication. However there was insufficient detail within the new protocol to describe the circumstances under which such administration might be appropriate.

The people we spoke with told us they were happy with their care and felt safe in the home.

Is the service caring?

We found that there were improvements in care plans. The level of detail of people’s needs had been improved, although some gaps remained. The manager told us they were bringing together all the elements of the care planning process into one location to improve staff access. A new cabinet had been ordered to enable this. The new deputy manager was in the process of revising everyone else’s care plans. However, the care plans continued to be held within more than one format and we saw inconsistencies between these records. In some cases the legibility of hand written records was an issue. The quality of daily recording had improved and a new format was being trialled to enable care staff to record details about people’s emotional well-being and how they spent their day. Staff told us and showed they were enthusiastic about these changes. We noted that support was being provided for staff for whom English was not their first language.

We found improvements in head injury monitoring systems although the process of identifying any learning from such incidents was not clear. More information about people’s life history was being incorporated into care plans to make them more person-centred, although this was still a work in progress. The process of seeking relevant background history from family members had provided information which had clearly enhanced people’s care.

Records of fluid/nutritional monitoring had been clarified and were more detailed. Where thickeners were used for fluids the quantities recommended by the Speech and language team (SALT) were now included and available to staff providing drinks. Where swallowing difficulties had been identified, referrals had been made to the SALT team.

Staff communication and accountability had been improved and for the most part, staff were now working in a more person-centred, caring and respectful way while supporting people. We did see some examples of negative interactions but noted that more experienced staff were advising a new staff member about how to interact with people. We saw improvements in how staff addressed people’s dignity but the ongoing use of one of the dining rooms by the hairdresser during meals, conflicted with this principle.

The health authority in-reach team were supporting the home to develop their recording, staff competencies and the dementia care environment and we saw good progress in these areas as a result. We could not judge whether the improvements made would be sustained and development continued.

The People we spoke with thought the service was caring and were happy with the care and support provided. One told us that: “Staff are very kind to me and are very nice people. They are very helpful and they come if I press my bell or want anything at all”.

Two adult social care inspectors carried out this inspection supported by a specialist advisor on dementia care. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led? As part of this inspection we spoke with people who use the service, their relatives, the manager, deputy managers and staff We also reviewed records relating to the management of the home which included care plans, risk assessments and other records. Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us and the evidence collected from the records we looked at.

Is the service safe?

We found that people’s care plans often contained insufficient detail and were sometimes contradictory. This meant that we could not be assured their full range of needs would be met. Risk assessments had not always been carried out when necessary. The home had sought the advice of external healthcare specialists to maintain people’s wellbeing. However, recording in some cases was inadequate to ensure staff were fully aware of their guidance. We saw that staff relied on the verbal handover of information between shifts. This was not effective as we saw examples where key information had not been passed on or recorded.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager was aware of a recent Supreme Court judgement relating to ‘deprivation of liberty’ but it was not clear that DoLS applications had been made in all relevant cases.

Staff members said they believed that people who lived in the home were safe from any form of abuse. However, we had concerns about potential inappropriate restraint in terms of the use of side tables, bed rails and from the records of one personal care event. There was insufficient evidence of proper assessments of mental capacity, consent; and of ‘best interests’ discussions, to assure us that these had taken place. Therefore some care decisions had been taken without such safeguards in place. We also found that some injuries to people had not been adequately recorded, investigated or reported to ensure that any possibility of abuse or neglect had been followed up and their recurrence minimised. We found examples of covert medication which were not in line with good practice guidelines which protected people from inappropriate use of medication.

A number of safeguarding issues had been raised regarding the quality and safety of care in the home since the last full inspection. The local authority required various actions by the home to remedy some of these concerns.

We found some parts of the environment which were potentially hazardous to people in the home. In one case despite a risk assessment and a serious fall, no steps had been taken to address the hazard.

The people and relatives we spoke with told us they felt the service was safe and no one had seen anything that concerned them.

Is the service effective?

People’s needs were not always effectively met. This was for a number of reasons including the lack of interaction from some staff, the inadequacy of the environment, particularly within the dementia unit, poor communication systems and care plans, inadequate management monitoring and analysis of events and information.

We found that care plans did not clearly demonstrate how people’s changing needs in relation to dementia/nursing care, were being actively managed. Many of the care plan entries and daily record sheets were difficult to interpret, due to the language used and unclear handwriting. Many records were very brief and task driven. They did not always demonstrate people’s needs had been met or that they enjoyed a fulfilling lifestyle.

Care practice in the dementia unit did not reflect current research and guidance on dementia care in terms of the environment, activities provision or the limited interaction with and engagement of people living there. Dementia training for some staff had not been updated since 2009.

The people and relatives we spoke with told us that the home met people’s needs.

Is the service caring?

We saw some staff working in a caring and respectful way while supporting people. Others were uncommunicative and failed to engage the person they were supporting in the task at hand. People were sometimes left for extended periods without receiving the support they needed. The care plans lacked detail about how individual needs should be met. This meant that care was not sufficiently person centred. A separate form developed by the Alzheimer Society, to help homes gather information about people’s social history and interests had not always been completed. Where the information was present it was not included in the care plan and therefore not available to staff. The staff were often unaware of it when asked.

We saw examples where basic personal care issues had not been identified by staff. Some of the terminology used by staff within records was unprofessional and did not reflect a caring and individualised approach.

The people and relatives we spoke with thought the service was caring. People said they had been treated with dignity and respect.

Is the service responsive?

Care plans were not always reviewed in accordance with the provider’s policy. The lack of detail in care plans meant that care may not be provided based on people’s known and indicated wishes and preferences. People had limited access to meaningful activities. Where a person’s interests were known, this did not necessarily mean they were respected. Where people needed additional monitoring of food and fluid intake this was not always consistently recorded and did not always evidence that the required care had been maintained.

We were told that the night staff helped all the residents who were awake to get up before they went off duty. This suggested a task based approach to personal care which was not responsive to people’s individual wishes and preferences.

The people and relatives we spoke with said the home generally met their or their relative’s changing needs. However, some issues raised by people in the relatives/residents survey had not been addressed and others not followed up to identify the issue more specifically.

Is the service well-led?

There were clear lines of managerial responsibility and monitoring systems were used by the management team. However, these were not always used to maintain an effective overview of the home’s operation. There had been inadequate analysis of events to ensure effective learning from them. It was evident that the provider and management team were not fully aware of the shortfalls within the home.

The management team had reacted to the action plan provided by the local authority in response to a series of safeguarding referrals. They had also taken action to address the issues raised in our January 2013 inspection. However, in the main, the management team’s response had been reactive in addressing issues, rather than proactively identifying and addressing them for themselves. Several of the issues and concerns identified at this inspection had been identified previously.

The manager was informed at the follow up inspection in July 2013 that we would be looking at the fitness of the environment for dementia care at the next full inspection. However, we saw few developments to enhance the suitability of this environment, at this inspection.

The views of people’s relatives and some people in the home had been sought but analysis of their feedback had focussed on the positives and not really addressed or followed up on the potential shortfalls. Complaints about the service had not always been managed in an effective way and a defensive or challenging attitude by managers had at times made their resolution less satisfactory to the complainant.

We found that since the last inspection staff had received additional training in dignity, manual handling and in other key areas. We saw improved care practice, consultation with and involvement of people in their care, since the last inspection.

The people we spoke with and their relatives were generally happy with the home and the care provided and felt they were involved in planning care.

We found that care plans and other records had been reviewed and contained more person-centred care information than previously. Staff were seen to respond more promptly to people’s needs and to engage more effectively with them. The ‘In-reach team’ was providing observation, care practice modelling and advice which was helping to develop practice. Support had been sought from external healthcare agencies where necessary. Involvement in activities had improved and people now had a choice of two main meals on the menu.

Improvements had been made in the safety monitoring of manual handling aids and staff training and competency monitoring had been provided on manual handling. A range of other training had been provided to enhance staff skills and knowledge.

We saw that some improvements had been made to management monitoring systems to better enable the management team to maintain an overview. A survey had been carried out to obtain the views of people in the home and their relatives. People had other opportunities for raising any issues or concerns they might have.

Not all aspects of consent to care were documented for the people supported. We saw that staff sought consent from people in some cases before they administered aspects of care.

The staff we spoke with demonstrated some awareness of people’s needs and support. However, care plans and related records were out of date and no longer reflected people's needs. The home relied heavily on verbal transfer of information and did not keep detailed records of the care given, particularly where enhanced care was provided.

Advice had not always been sought from external healthcare specialists with regard to issues like skin integrity, infection, nutrition, weight loss and managing behaviour. Some choices were offered to people in the home but sometimes they were not asked their wishes or provided promptly with the support they requested. A choice of menu was not actively offered to people.

The home had obtained some new equipment to support manual handling. However, an effective system to monitor its age, condition and hygiene had yet to be established. Monitoring systems for staff manual handling practice had begun to be implemented. Core training had been provided to all staff, but training on specialist aspects of care had not always been provided.

The home had an appropriate complaints system in place and had investigated some concerns that had been raised. However, they were not always able to achieve outcomes which were satisfactory to complainants.

We spoke to five of the people living in Jasmine House about their experience there. We also spoke to the next of kin for four people living in the home and of two residents who had recently died, to obtain their views.

The people we spoke to were generally very positive about the home and the staff who looked after them. They felt that the staff were mostly very good at meeting their needs and that the home itself was a warm and pleasant place.

The family members of the five current residents were all regular visitors to the home. They were very positive about the management and staff. The staff were described as helpful, friendly, positive and enthusiastic. The relatives also said that the staff worked well together and supported each other. They felt that the staff knew the people in the home well and kept them informed about their relative’s wellbeing. The home was described as homely and clean and the relatives said that activities were provided for people using the service.

This inspection took place on 3 and 4 June 2015 and was unannounced. This was a comprehensive inspection which included follow-up of progress on the non-compliance identified in the reports of the previous inspection on 15 July 2014 and at the ‘Warning Notice’ follow-up inspection on 16 October 2014. At these previous inspections we identified non-compliance against Regulations 9 (care and welfare of service users), 10 (assessing and monitoring the quality of service provision), 11(safeguarding from abuse), 15 (safety and suitability of premises), 16 (safety, availability and suitability of equipment) and 24 (co-operating with other providers) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

From April 2015, the 2010 Regulations were superseded by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection on 3 and 4 June 2015 we found that the provider was meeting the requirements of the comparable current regulations. Regulations 9 (Person centred care), 12 (Safe care and treatment), 13 (Safeguarding service users from abuse and improper treatment), 15 (Premises and equipment) and 17 (Good governance).

Jasmine House Nursing Home is a care home service with nursing. The home is located in a residential area of Reading and can accommodate up to 79 people. The Home is divided into two units, one supporting people living with dementia and the other catering for those with nursing or other care needs.

A registered manager was in place as required. 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 significant improvements had been made across all areas of the service.

Staff worked to keep people safe and where concerns had arisen, management had followed them up effectively. People were supported to have their medicines safely and appropriately.

Staff awareness of people’s needs and health conditions had improved and they had clear instructions from the new care plans on how to meet them. Staff engaged well with people and responded promptly to their needs, whilst maintaining their dignity. The quality of recording was much improved since the previous inspection.

Staff training and support had improved and communication throughout the team was good. The views of staff at all levels were listened to and valued.

The consent of people or their representatives was sought appropriately and where limitations on people’s freedom were necessary these were properly discussed and authorised. The least restrictive suitable options were used.

The views of people, relatives and staff had been sought and acted upon and people had been consulted about planned changes in the service. Complaints had been responded to and action taken to address issues identified through monitoring and audit processes.