About the service: Midland Care Home is a nursing home that was providing personal and nursing care for up to 66 older people, some of whom were living with dementia. There were 55 people living at the service at the time of the inspection; 10 people were residing at the home whilst waiting for assessment for discharge from the local hospital.

People’s experience of using this service:

• People were not protected from the risks of abuse as not all staff had received training in safeguarding and staff had failed or report incidents to the manager. The manager did not recognise when to report allegations of abuse or the significance of unexplained injuries and poor moving and handling; they had not alerted the relevant authorities.

• There were not enough staff employed to provide people’s care; there was a high use of agency nursing and care staff. Staff were not deployed to ensure people received all of their planned care, and ensure that people had appropriate supervision. People’s dignity was not always maintained as their personal care was not always carried out regularly or at the planned intervals.

• The provider relied on agency staff, but did not ensure they had a suitable induction to the service, employment checks, training and competencies required to carry out their roles. Both agency and permanent staff had not always received the training and supervision they required to provide safe care.

• Staff did not always have information about people’s needs as people’s risk assessments and care plans did not always reflected their current needs. Staff did not always receive all the information they required to meet people’s care safely.

• People did not always receive their prescribed medicines as they were not in stock. People’s medicine records did not have all the information required to enable agency staff to give medicines safely.

• Staff did not consistently ensure people were offered and supported to eat their meals. People were at risk of losing weight and dehydration.

• People living with dementia had access to other people’s rooms; there were no safeguards in place to prevent them accessing maintenance materials or substances that are hazardous to health. People were at risk of acquiring infections as cleanliness in the home was poor, particularly on the first floor where people lived with advanced dementia.

• People were not supported to express their views about their care or be involved in creating their care plans. People and their relatives had not been asked for their feedback. People did not have any involvement in the running of the home.

• People’s verbal complaints were not recorded or responded to. The manager did not always follow the provider’s complaints procedure; complaints were not always reviewed or concluded in writing.

• People had not always had the opportunity to express their preferences or wishes for their end of life care. People’s care plans did not record people’s wishes.

• • The provider failed to have sufficient oversight of the home as there were failings in the quality and safety of the care. The provider has no previous experience of nursing homes.

• There had been failings in recognising when people were unwell and seeking prompt medical attention. A clinical lead had recently been employed to improve the clinical safety, however, the provider had not given them all the resources they required to implement all safety measures. There was insufficient management or a clinical oversight at night, evenings and weekends.

• The provider did not have systems to assess, monitor, evaluate and make changes to improve the service. The provider failed to have systems in place to evaluate the quality and effectiveness of deployment of staff.

• The provider was working within the principles of the MCA, they identified people who required a Deprivation of Liberty Safeguards (DoLS) assessment and made the appropriate applications.

Rating at last inspection: Requires Improvement published

This inspection took place on 18 and 19 September 2018. The visit on the 18 September was unannounced and the visit on the 19 September was announced. This was the first inspection of the service since the provider registered with the Care Quality Commission (CQC) in October 2017.

Midland Care Home is a ‘care home’ with nursing. 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.

Midland Care Home can accommodate up to 66 people in one purpose built building. It provides a service to older people, some of whom have nursing or dementia related care needs. At the time of this inspection 59 people were living in the service.

The registered manager left the service in July 2018. A new manager had taken up post in July 2018 and at the time of the inspection were undergoing the necessary checks to register with the Commission. A registered manager is a person who has registered with the 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.

People felt safe and protected from harm and able to raise any concerns regarding their safety. Staff understood how to keep people safe. The service safely supported people with the administration of medicines. However, the safeguarding and whistleblowing policy required the contact details of the local safeguarding authority included, to support staff to raise any abuse concerns with external agencies.

Safe recruitment procedures were carried out by the service. There was sufficient staff available, but there was the high reliance on using external agency staff. The manager was working towards recruiting more permanent staff to reduce the need to use external agency staff.

Risk assessments addressed the potential risks present for each person. Monitoring records were used to evidence when staff provided care for people at risk of developing pressure sores and at risk of poor nutrition and hydration. However, they lacked sufficient detail to evidence the actual care being provided.

People could not be assured personal information about them was treated confidentially. As files containing personal information were not securely stored away.

People were provided with nutritious meals, but the quality and variety of meals raised some areas of dissatisfaction. In addition, staff did not always ensure meals were presented appropriately.

Relatives raised concerns that staff had not always respected people’s personal clothing. Following the inspection, the provider confirmed the laundry process had recently been reviewed in August and a new laundry system had been put in place. They felt that the concerns raised at the time of the inspection may have been in relation to historic practice. We have made a recommendation that the provider further reviews the laundry processes to ensure people have their own clothing returned to them and their clothing is appropriately cared for.

Arrangements were in place to make sure the premises were kept clean and hygienic so that people were protected from infections that could affect both staff and people using services. Regular checks to the safety of the environment took place.

Systems were in place to question accidents and incidents to learn from them and mitigate the risk of any repeat incidents. The manager took timely action to address areas identified for improvement.

People had their needs assessed before moving into the service. The service worked and communicated with other agencies and staff to enable effective care and support was provided when moving between different services.

People's consent was gained before any care was provided and the requirements of the