Our inspection of Middlesex Manor Nursing Centre took place on 27 and 30 September 2016. This was an unannounced inspection.

At our previous inspection of Middlesex Manor in September 2015 we found that the service was not meeting the requirements of the law in relation to the assessment and management of risk for people who lived there. During this inspection we found that the provider had made improvements in order to meet the requirements identified at the previous inspection.

Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with ensuite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 67 people living at the service. Most were older people, some were living with dementia or with other conditions associated with ageing. Other people had significant physical disabilities.

At the time of our inspection there was no 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. However, a new manager had been appointed and had started full time working during the week of our inspection. They had commenced the application process to become registered with CQC.

People who lived at Middlesex Manor told us that they felt safe. Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.

We observed that people’s medicines were stored, managed and given to them appropriately. However we found that the number of stored medicine to be administered as required did not always match the service’s records.

People had up to date risk assessments to ensure that they were kept safe from avoidable harm. Risk assessments contained detailed guidance for staff on how to manage identified risk to people. Care plans were also detailed and up to date and included information about how people wished to be supported. We saw that care plans and risk assessments were reviewed regularly and amended where there were any changes in people’s needs.

There were enough staff members on duty to meet the physical and other needs of people living at the home. Staff supported people in a caring and respectful way, and responded promptly to needs and requests. People who remained in their rooms for some or part of the day were regularly checked on. People told us that they were happy with the support that they received from staff.

Staff who worked at the service received regular relevant training and were knowledgeable about their roles and responsibilities. Appropriate checks took place as part of the recruitment process to ensure that staff were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.

The service was generally meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made to the relevant local authority. Staff had received training undertaken training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions. However records of best interest’s decisions did not always meet MCA guidance.

Meals that were provided to people were varied and met individual health and cultural requirements. Alternatives were offered where people did not want what was on the menu. People appeared to

This inspection took place on 2 October 2014 and was unannounced.

At our last scheduled inspection in July 2013 the service was not meeting the requirements of the law in relation to nutritional needs. We carried out a follow up inspection in September 2013 and found that the service was meeting the regulation and there were no concerns.

Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with ensuite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 72 people living in the home, most people were older people, some people had dementia and other people had physical disabilities.

There was 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.

During our inspection feedback from people, observation and most records we looked at demonstrated there were many positive aspects to the service including kind, well trained staff and skilled, experienced leadership. However, it was evident that the registered manager had a significant number of management duties to carry out in this large service. There was not a deputy manager in post to assist her with some of the day-to-day duties such as record keeping, supervision of medicines, checking staffing levels and auditing. The registered manager had received some support from senior management but some failings in these areas had not been identified which effected the quality of the service. So we have asked that action be taken to address these matters.

People’s safety was compromised in the way some medicines were managed and administered. We found shortfalls in the recording and auditing of medicines.

People told us that they were happy with the service, felt safe and had their privacy and dignity respected. Our observations and discussion with relatives supported this. Conversations with people’s relatives indicated that there was general satisfaction with the service provided. However, we found that most people did not have much to do and we saw little evidence of people taking part in meaningful activities individually or as a group.

Staff were familiar with people’s needs and their key risks. However, it was not evident at the time of the inspection how the staffing numbers and skill mix had been determined to ensure people’s varied and at times complex needs were met at all times. We found that there was a lack of sufficient staff to ensure that people received their meals without delay.

Staff received regular relevant training, were knowledgeable about their roles and responsibilities and received support from the registered manager and other senior staff. Staff had the skills to provide people with the care and support that they needed. Appropriate checks were carried out when staff were recruited.

Staff had received training about the Mental Capacity Act 2005 (MCA). However, we found staff were not always following the MCA for people who lacked capacity to make a decision. For example, an application under the MCA/ Deprivation of Liberty Safeguards (DoLS) for a person using the service had not been made, even though their liberty may have been restricted.

We found most people’s health and care needs were assessed and regularly reviewed. Staff liaised with health and social care professionals to obtain specialist advice so people received the care and treatment they needed.

There was a clear management structure in the home. The registered manager was accessible and approachable. People who used the service, staff and people’s relatives felt able to speak to the registered manager and nursing staff when they had any concerns or other feedback about the service.

There were systems in place to monitor the quality of the service and make improvements when needed. Checks of some equipment and call bells had not been carried out at the time of the inspection. However, promptly following the inspection the registered manager ensured these checks were carried out.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced inspection to check if the provider had complied with a compliance action that we had made at the time of our previous inspection that had taken place on the 2nd July 2013. The compliance action was in response to us having found that the provider had not demonstrated that people were always protected from the risks of inadequate nutrition and dehydration.

During this follow up inspection we spoke to five people who used the service, but the main focus was on talking to staff and checking records to make a judgement as to whether the provider was compliant with Regulation 14 (HSCA 2008 Regulated Activities) Outcome 5 Meeting nutritional needs.

At this inspection we found that the provider had taken proper steps to ensure that people were protected from the risks of inadequate nutrition and dehydration.

During this inspection we spoke with a significant number of people who used the service, visitors, nursing staff, care staff, a kitchen assistant, receptionist, activities co-ordinator, housekeeping staff, and the deputy manager. People who used the service told us that they were generally very happy living in the home, felt safe and received the care that they needed and wanted. They told us that they were supported to make decisions about their care and treatment. Some people who used the service told us that they felt there was not enough to do.

People’s health, safety and welfare were protected as they received the advice and treatment that they needed from a range of health and social care professionals. Staff knew about their roles and responsibilities in meeting the needs of people who used the service and they supported people in a friendly and respectful manner. People who used the service told us that they found that staff were very approachable and they felt able to talk to them and to management staff if they had any concerns.

Each person had a plan of care that had been regularly reviewed and included information about the individual support and care that people using the service needed. However, there was not evidence that people' nutrition and hydration needs were always monitored closely.

People told us what it was like to live in 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 Care Quality Commission (CQC) inspector joined by an Expert by Experience, (people who have experience of using services and who can provide that perspective) and a practising professional.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

On the day of the inspection the home was warm, and had a relaxed and friendly atmosphere. We spoke to people using the service living in two of the three units in the home. We also spoke to visitors.

People who use the service told us that staff understood their needs and provided them with the care and support they needed in the way that they wanted. They confirmed that staff were kind, respected their privacy and promoted their independence. They told us their religious and cultural needs were met by the home.

People’s comments about their experience of living in Middlesex Manor Nursing Centre included, “it’s very comfortable”, “it’s like home”, “i did not expect it to be so lovely”, and “having my own space is a dignified way of spending my later life”.

People told us that they had sufficient and suitable food and drink which met their dietary needs and preferences. We observed staff supporting people in a sensitive manner. We saw people using the service were offered choices of food and drink.

As part of this review, we spent time on each unit of the home, talking with people using the service to gain their views about living in Middlesex Manor Nursing Centre. A number of people had some difficulties in conversing with us due to their individual communication, and health needs. Some people understood English but had difficulty speaking it. People that couldn’t answer our questions in detail answered ‘yes’ and ‘no’, other people signed, gestured, nodded or shook their head in response to our questions. Throughout our visit we looked for signs of people’s ‘well being’ (happiness, comfort, welfare, safety and health).

People told us; they liked living in the home, they had their health needs met, staff listened to them, and provided them with the care and support they wanted and needed. Comments included; ‘I visited before moving in’, ‘staff help me in the way that I want’, and ‘I get things done the way I want’.

People informed us they had the opportunity to participate in a range of activities, and were positive about the care, and support they received at the home. Comments included; the staff ‘ask me what I want to do’, ‘I like doing puzzles’, ‘I like music’, ‘It’s fine here, staff are really nice, I like doing something’, ‘ I like my TV, it’s very important’, and ‘I do something every day’. A person spoke very positively about the support she received from an activity worker.

People spoke of the staff being ‘kind’, ‘friendly’,’ nice’, and approachable. They told us they felt safe living in Middlesex Manor Nursing Centre, and knew who to talk to if they had any worries or concerns. People confirmed that they felt staff would respond to these in an appropriate manner.

People spoke about being able to make choices about their lives; ‘I visited before moving in’, ‘I can choose to go out’, and ‘I can choose what to do’.

People confirmed that they attended healthcare appointments and saw a doctor when they needed to, and had contact with a variety of other health care and social care professionals.

People were positive about the environment of the home and were happy with their bedrooms. Some people told us they had personalised their rooms. Comments included; ‘I have my room as I like it’, ‘my room is nice’, and the home is ‘clean and very cheerful’.

People’s views varied when they were asked for feedback about the meals. Some people when asked if they had enjoyed their meal said ‘yes’, ‘I liked it, ‘I thoroughly enjoyed it’,’ it’s good’, ‘I have drinks when I want’, and ‘I have enough to eat’. When asked the same question, others commented; ‘not really’, ‘the food is not good, my (relative) brings in food for me’, ‘the food is awful, it’s not fresh’, ‘my (relative) brings me fruit’ and ‘I don’t get choice’.

A person told us that he sometimes receives meals that met his preferences and cultural needs. Another person spoke of positively of a relative who regularly brought in food for him to eat that met his cultural dietary needs and preferences.

Visitors told us they had visited the home before their relative moved in and had immediately ‘liked the atmosphere’. Recorded and verbal comments from relatives and significant others included; ‘the staff are very nice’, ‘they are friendly people’, ‘ we are always offered a cup of tea’, my relative ‘has received excellent care from all members of staff’, ‘the care given to (my relative) is second to none’, ‘excellent care’, ‘I am pleased with the care my (relative) is receiving’, staff are ‘friendly’, ‘staff are caring and easy to communicate with’, ‘my (relative) is well looked after’. ‘I am happy with the care’; ‘staff ring me and talk to me about (my relative)’.

Staff spoke of enjoying their job, and told us ‘everyone is friendly’, ‘the manager is approachable’, and ‘we receive regular supervision’.

Our inspection of Middlesex Manor Nursing Centre took place on 28 and 29 September 2015. This was an unannounced inspection.

At our previous inspection of the service in October 2014, we found that the service was not meeting the requirements of the law in relation to the following: management of medicines; staffing; nutritional needs; safeguarding people who use services from abuse; assessing and monitoring the quality of service provision. During this inspection we found that the provider had taken significant steps to improve the service in order to meet the requirements identified at the previous inspection.

Middlesex Manor Nursing Centre is purpose built and consists of three units of single rooms with en suite facilities. The home provides nursing care for up to 83 people. At the time of our visit there were 63 people living at the service. Most were older people, some were living with dementia or with other conditions associated with ageing. Other people had physical disabilities.

There was 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.

People who lived at Middlesex Manor told us that they felt safe, and this was confirmed by family members whom we spoke with.

Staff members had received training in safeguarding, and were able to demonstrate their understanding of what this meant for the people they were supporting. They were also knowledgeable about their role in ensuring that people were safe and that concerns were reported appropriately.

People’s medicines were stored, managed and given to them appropriately. Records of medicines were well maintained.

People had up to date risk assessments to ensure that they were kept safe from avoidable harm. Most risk assessments contained detailed guidance for staff in managing risk to people. However, we were concerned that some risk assessments had not been completed which meant that we could not always be sure that people were safe.

There were enough staff members on duty to meet the physical and other needs of people living at the home. Staff supported people in a caring and respectful way, and responded promptly to needs and requests. People who remained in their rooms for some or part of the day were regularly checked on.

Staff who worked at the service received regular relevant training and were knowledgeable about their roles and responsibilities. Appropriate checks took place as part of the recruitment process to ensure that staff were suitable for the work that they would be undertaking. All staff members received regular supervision from a manager, and those whom we spoke with told us that they felt well supported.

The service was generally meeting the requirements of The Mental Capacity Act 2005 (MCA). Assessments of capacity had been undertaken and applications for Deprivation of Liberty Safeguards (DoLS) had been made to the relevant local authority. The majority of staff had received training undertaken training in MCA and DoLS, and those we spoke with were able to describe their roles and responsibilities in relation to supporting people who lacked capacity to make decisions. However the risk assessments for people regarding use of bedrails did not show that this was the least restrictive option available to meet their needs which is a requirement of the MCA.

Meals that were provided to people were nutritionally balanced and met individual health and cultural requirements. Alternatives were offered where people did not want what was on the menu. People appeared to enjoy their meals. Drinks and snacks were offered to people throughout the day. People’s nutritional needs were recorded in their care plans and risk assessments with guidance for staff. Health professionals were involved where there were concerns about maintenance of weight.

People’s care plans were person centred and provided guidance for staff about how people wished to be supported. The plans were updated regularly to ensure that they addressed people’s current needs.

People told us that staff were caring and we saw some positive interactions between people and their care staff. People told us, and we observed that they were offered choices and that their privacy was respected. However we observed that a small number of staff did not speak with people when they were providing support at mealtimes.

The service provided a range of individual and group activities for people to participate in throughout the week. People’s cultural and religious needs were supported by the service

People and their family members that we spoke with knew how to complain if they had a problem with the service

Care documentation showed that people’s health needs were regularly reviewed. The service liaised with health professionals to ensure that people received the support that they needed.

There were systems in place to review and monitor the quality of the service, and we saw that action plans had been put in place and addressed where there were concerns. Policies and procedures were up to date and staff members were required to sign that they had read and understood any new or amended ones.

People who used the service, their relatives and staff members spoke positively about the management of the service. We were told that the new manager had made a number of positive improvements.

We found two breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.