This inspection took place on 14 and 19 June 2017 and was unannounced.

Ledbury Nursing Home provides accommodation with nursing and personal care to a maximum of 36 older people. There were 28 people living at the home when we visited.

A registered manager was in post and present during our inspection. 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 our last inspection on 3 and 4 May 2016, we found a breach of Regulation 9 of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. We gave the service an overall rating of requires improvement. This breach related to the provider’s failure to ensure people received personalised care and treatment to meet their needs. The provider sent us an action plan setting out the improvements they intended to make.

At this inspection, we found the provider had made improvements to the service, and was now meeting the requirements of Regulation 9.

The information recorded on people’s repositioning charts about the support they required and received with this important aspect of their pressure care was not always accurate or complete.

Staff had received training in, and understood, how to recognise and report abuse. The risks associated with people’s individual care and support needs had been assessed, reviewed and plans put in place to manage these. The registered manager assessed and organised their staffing requirements, based upon current dependency levels. Prospective staff underwent pre-employment checks to confirm they were suitable to work with the people living at the home. Systems and procedures were in place to ensure people received their medicines safely and as prescribed.

Staff received effective induction, training and ongoing support to enable them to fulfil their duties and responsibilities. People’s rights under the Mental Capacity Act 2005 were understood and promoted. People had the supported they needed to eat and drink, and their nutritional needs were assessed and managed. People were supported to access healthcare services as required.

Staff adopted a caring approach towards their work, and showed concern for people’s comfort and wellbeing. People were encouraged and supported to share their views and be involved in decisions that affected them. Staff understood and promoted people’s rights to privacy and dignity. People could receive visitors at the home without unnecessary restrictions.

People’s care plans included information about their individual needs and preferences, and staff followed these. The involvement of people and their relatives in care planning was encouraged. People were supported to spend time doing things they found interesting and enjoyable. People and their relatives knew how to complain about the care and support provided.

The management team promoted an open and inclusive culture within the service. People’s relatives had confidence the management team would deal with any issues or concerns fairly. Staff felt well-supported by an approachable management team. The provider’s quality assurance activities had resulted in improvements to the service people received.

The inspection took place on the 3 and 4 May 2016 and was unannounced.

Ledbury Nursing Home provides accommodation for older people who need nursing or personal care. This service provides nursing and personal care for up to 36 people. On the day of our inspection there were 33 people living at the home.

There was manager at this home who was in the process of registering with us. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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 did not always receive care that was personal to them and responsive to their needs. For example, people were not supported with enough specialist equipment to ensure they could get up in the morning as they wanted to. People we spoke with that needed this equipment told us they had to wait for their turn with the equipment. Also specialist equipment identified in their risk assessments was not always available for staff to provide the support they needed in the most comfortable way.

On many occasions staff were seen to be kind and caring, and thoughtful towards people. However: people we spoke with said their needs were not met in a consistent way. Relatives said that sometimes staff were excellent and were caring and promoted people’s independence, however at other times there was a lack of consistency in how people’s needs were met. Staff we spoke with said that there were changes depending on how the shift was lead. The manager recognised this and was taking steps to include staff in how they could improve care delivery. The manager told us they were actively recruiting new staff to improve continuity.

People told us they felt safe and there were enough staff available to support them. We saw the manager provided information to staff and agency staff to support people safely. People said call bells were answered quickly and there were sufficient staff on duty to meet people’s needs. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage them.

Staff we spoke with were aware of how to recognise signs of abuse, and systems were in place to guide them in reporting these. Staff knew people well, and took people’s preferences into account and respected them. Staff had the knowledge and training to support people they provided care for. Staff ensured people agreed to the support they received. The manager explained they were in the process of reviewing people’s ability to make decisions and the support they needed to do this. People had access to health professionals as they needed them. We saw people had food and drink they enjoyed and had choices available to them, to maintain a healthy diet.

People said they were able to maintain important relationships with family and friends. They were included in meetings to ensure they had a say in the choices available to them. We saw staff treated people with dignity and respect whilst supporting their needs. We saw people’s personal records we not always kept securely. We spoke with the manager and they said they would take action straight away.

People and their relatives knew how to raise complaints. There was a new management team with the manager and the deputy new to the service. People and their relatives said they were approachable and they would raise concerns if they needed to. We saw there was a process in place to ensure complaints were investigated and action taken to resolve them.

People and their relatives were encouraged to be involved in regular meetings to share their views. The management team were reviewing how they sought feedback to improve the service provided and encourage relatives to be involved in their meetings.

We found the provider had no

An adult social care inspector carried out this inspection. As part of the inspection we spoke with six people who used the service. We also spoke with the registered manager and five members of staff. We reviewed the records relating to the management of the home which included six care records, six staff personnel records, policies and procedures, and minutes of meetings. Ledbury Nursing Home is registered to provide accommodation for 36 people who need nursing or personal care. On the day of our visit there were 32 people using the service.

Below is a summary of what we found. The summary describes what people using the service and staff told us, what we observed and the records we looked at.

Is the service safe?

People told us that they felt safe. Risk assessments were well completed and actions to minimise the risks identified were reflected in care plans. Risk assessments balanced risk with the rights of people to choice and independence. Service wide risk assessments together with the actions to reduce those risks were reviewed regularly.

The provider had appropriate systems and processes in place with regard implementing the Mental Capacity Act 2005. Staff had received training in relation to this and were clear about their role and responsibilities.

People told us that the home was always clean and tidy. We saw that people were being cared for in clean, hygienic premises. Staff had received infection prevention and control training and were clear about their role and responsibilities. There were effective systems in place to reduce the risk and spread of infection.

There were registered nurses on duty at all times. All staff had received training on dealing with emergencies and sudden illness.

Is the service effective?

People had their needs assessed at the service. Care plans reflected both the needs and preferences of people. Staff had a good knowledge of people’s care needs.

Staff had access to a range of relevant training to meet the needs of the people they cared for. Policies and procedures were appropriate, up to date, and reflected current research and guidance. Registered nurses had undertaken training and had been assessed in a range of clinical skills including medication, skin care and catheterisation.

Is the service caring?

People told us that the staff were kind and compassionate. We observed staff treating people in a friendly and caring way. One person told us, “They (the staff) are all very kind.” Another person told us, “All the staff look after me very well.” We saw staff talking to people in a friendly and respectful way. People who were unable to communicate fully had communication care plans. We saw staff responding to non-verbal communication effectively.

Is the service responsive?

People's needs were assessed and care plans developed. People told us that they had been involved in developing their care plan. Care plans reflected both the needs and wishes of people. One person told us, "The staff are very responsive to what I ask for.”

The provider had systems in place to ensure the views of people who received the service were sought and acted upon. People were invited to resident and relative meetings where they were encouraged to make suggestions about improvements to the home.

People had access to a wide range of activities. A member of staff was employed to coordinate activities for residents.

Is the service well-led?

Staff we spoke with told us they felt well supported by the registered manager and senior staff. Staff said they were able to raise issues with their manager at any time and were confident they would be acted upon. Staff had opportunities to raise and discuss issues at staff meetings and at supervision sessions.

The provider had a well-established quality monitoring system which consisted of regular audits and quality reviews.

People who used the service and staff were clear about the complaints process. People told us they were confident that any issue raised, or complaint made, would be thoroughly investigated and acted upon. Complaints that had been received by the provider had been investigated and responded to appropriately. Lessons learnt from incidents, feedback, and complaints and any subsequent actions were discussed at regular staff meetings and supervision sessions.

We spent time at the home watching to see how staff supported people, and talked with people about life at Ledbury Nursing Home. We spoke with four people who lived at the home. We also looked at records, and spoke with five staff which included the manager.

We found people who lived at the home were safe because the staff were given clear instructions, support and guidance. People told us they were treated with care and compassion and the staff responded well to their needs. One person told us: “Care is quite fantastic day and night.” Another person said that the staff: “Go out of their way to be helpful” and “Are very nice.”

We saw positive interactions between staff and people during the day, with staff helping people to make simple everyday decisions. There were arrangements in place where required, to help people with bigger decisions so that their best interests were upheld.

We saw that people who lived at the home had their medicines as prescribed at the right time and in the right way. This made sure people’s health needs were effectively met.

There were enough staff to meet people’s needs. People who lived at the home told us that care was provided by staff who knew them well and their needs.

We found that the service was well led. The manager had responsive systems in place to monitor and review people’s experiences and complaints. This meant that positive outcomes for people were continually developed, reviewed and improved upon when needed.

We found that the management of medicines by the service had improved. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We used a number of different methods to help us understand the experiences of people using the service. We did this through observing people's care records and speaking to the nursing staff who were responsible for their care

We found that the management of medicines by the service needed to improve in order to ensure that people using the service received their medicines safely.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an “expert by experience” (people who have experience of using services and who can provide that perspective).

Thirty six people were living in the home when we visited. We talked with eight of them, one relative about their experience of living there and six staff. We also looked at the care plans for three people who lived in the home to see how their needs should be met.

Many of the people who lived in the home that we spoke with were happy with the quality of the care provided. One person told us, staff are ‘’very good’’ and ''always friendly’’ and ‘’never have to wait a long time when I need something.’’ Another person said, ‘’I am happy with my care and have no complaints.’’

People who lived in the home that we spoke with told us that staff treated them with respect and helped them to be as independent as possible. Throughout the day we observed staff supporting people with words of encouragement where needed whilst completing tasks. We also saw that time was taken to pass the time of day through general chat between people who lived in the home and staff. It was evident that staff had a good rapport with people and it became evident that the manager and staff knew people’s likes and dislikes.

We observed lunch being served to people during our visit. Staff were seen to offer people choices of where they would like to eat their meal and assistance was provided at people’s own pace. Many of the people who lived in the home who we spoke with told us that they were happy with the meals provided at Ledbury Nursing Home. They said, ‘’I like the food most of the time, I’m a vegetarian, the choice is alright I suppose, it’s always hot,’’ ‘’The food is very good; we get a really good choice’’ and ‘’On the whole the food is good, I find the choice ok, it’s always hot.’’