Nelson House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection. Nelson House is a care home without nursing, which can accommodate up to 21 people. At the time of our inspection 14 people were using the service and these were older people requiring personal care. Some people living in the home had conditions such as Dementia.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

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The inspection visit took place on 12 and 13 April 2018 and was unannounced. The inspection took place in response to some concerns raised with us around people’s safety and that people were not receiving appropriate support to keep them safe. During the inspection we found no evidence that people were not being adequately cared for.

There was a registered manager in post and they were present during the 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.

People continued to receive care that made them feel safe and they received medicine as required. Staff understood how to protect people from abuse and harm. Risks to people were assessed and guidance about how to manage these was available for staff to refer to/follow.

People continued to receive effective support from staff with a sufficient level of skills and knowledge to meet their specific needs. 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 support this practice. People were assisted to access appropriate healthcare support and received an adequate diet.

The care people received was provided with compassion and dignity. People were supported to express their views and be involved as much as possible in making decisions about their support needs. Staff supported people to have choices and independence, wherever possible. People’s diverse needs were recognised and staff enabled people to access activities should they so wish.

The provider had effective systems in place to regularly review people’s care provision, with their involvement. People’s care was personalised and care plans contained information about the person, their needs, choices and cultural needs. Care staff knew people’s needs and respected them. People were able to speak openly with staff and tell them if they were unhappy or wanted to make a complaint.

The service continued to be well-led, including making detailed checks and monitoring of the quality of the service. People and staff were positive about the leadership skills of the registered manager. Arrangements were in place to obtain views on the service from people, staff and their relatives.

Nelson House is registered to provide accommodation and personal care for up to 21 older people. People who live there may have a range of needs which include physical disability and dementia. At the time of our inspection 18 people were using the service.

Our inspection was unannounced and took place on 22 September 2015. At our last inspection on 6 and 7 October 2014 the provider was not meeting the regulations around Safe and Well Led, but evidence that we gathered during this, our most recent inspection, showed that improvements had been made.

The manager was registered with us as is required by law. 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 told us they felt confident that the service provided to them was safe and protected them from harm. Staff we spoke with were clear about how they could access and utilise the providers whistle blowing policy.

We observed there were a suitable amount of staff on duty with the skills, experience and training in order to meet people’s needs. People told us that were able to raise any concerns they had and felt confident they would be acted upon.

People’s ability to make important decisions was considered in line with the requirements of the Mental Capacity Act 2005.

People were supported to take food and drinks in sufficient quantities to prevent malnutrition and dehydration. People were supported to access a range of health and social care professionals to ensure their health needs were met.

Staff interacted with people in a positive manner and used a variety of communication methods to establish their consent and/or understanding. Staff maintained people’s privacy and dignity whilst encouraging them to remain as independent as possible.

Staff were aware of how and when to access independent advice and support for people and assisted with this when required.

People were involved in the planning of care and staff delivered care in line with people’s preferences and wishes.

Information and updates about the service were made available to people in meetings and to relatives verbally. The complaints procedure was displayed in a clear and understandable format to maximise people’s knowledge and understanding of how to make a complaint.

People, relatives and staff spoke positively about the approachable nature and leadership skills of the registered manager. Structures for supervision allowing staff to understand their roles and responsibilities were in place.

Systems for updating and reviewing risk assessments and care plans to reflect people’s level of support needs and any potential related risks were effective.

Quality assurance audits were undertaken regularly by the provider. The registered manager had also ensured that checks on staff were undertaken periodically out of normal working hours.

Medicines were given appropriately with audits carried out daily. Medicines that were refused or not given were recorded and disposed of appropriately.

We spoke with eight people using the service, three relatives, three members of staff, a contracts officer from the local authority and an environmental health officer. All made positive comments about the service. A visitor we spoke with told us, "Nelson House provided care for another relative, so we made the decision to place X here. We know the care is good. We can leave knowing it is absolutely fine. I speak on behalf of my family".

We found that people were involved in making decisions about their care treatment and support. We saw that people were supported in their chosen lifestyles and the choices they made.

We saw that people's care records contained detailed information about their needs and that they had access to a range of health and social care professionals to support them. Care and treatment was planned in a way to ensure each person's personal safety and wellbeing.

People using the service did not indicate that they had any concerns about their wellbeing or safety and were able to tell us what action they would take if they had any concerns.

Regular checks were in place to ensure the premises were secure, safe and adequately maintained.

Although some statutory training had been undertaken, the provider was not able to demonstrate that all staff had access to appropriate training or that they were supervised regularly to monitor their progress and performance. This meant that staff were not supported in their responsibilities to deliver care and treatment to an appropriate standard.

There were 17 people living at the home at the time of our inspection. We spoke with five people, two staff, the cook, care manager and owner. One person told us, "The staff here are considerate and caring, and we have a good chat and a laugh”.

We saw people who use the service are supported to make choices about the care and support that they receive. Relatives are involved in this where people are not able to express their desires. This ensures people’s needs as well as choices are considered and planned.

People had care plans in place which reflected both their care and their specific health needs. Plans detailed risks to people, and how these are met. For example we saw people who had specific health needs such as fragile skin and risk of weight loss had the support they needed to keep healthy.

We found that staff had training so that they could give people their medications safely.

There is enough skilled staff to look after people’s needs. We saw people did not have to wait for care or support.

Systems are in place to monitor the quality of service provided, and people who live there are involved in this process.

We spoke to five people who live at the home and one relative. People told us that they were happy with the care they received and that they felt safe living at Nelson House. They said, "I was frightened on my own at home after my husband's death. I can relax here".

We found that the home is a comfortable and pleasant place to live. The home will be further improved when the new extension is completed and the remainder of the home will be refurbished. The home has both double and single rooms and people have the choice if they wish to share a bedroom. People are able to personalise their bedrooms as they choose to reflect their taste and interest.

People told us how they spend their day. They said that they get up and go to bed when they choose and are able to have their meals in either the main lounge-dining room or their bedrooms if they preferred or were unwell. They told us that activities take place which they join in with but they are also able to spend time reading, doing quizzes or seeing their friends and relatives. They also told us, "I have my friends here".

People told us, "Staff are kind and very caring". They told us that staff assisted them when they needed it. All the people we spoke to said, "We cannot fault them they are all so good".

The inspection was unannounced and was carried out over two days on 6 and 7 October 2014.

The last inspection on 25 October 2013 identified that the provider was not meeting legal requirements in respect of systems to support staff development. At this inspection we saw that improvements had been made.

Nelson House provides personal care to up to 21 people who may have needs due to old age, physical disability and dementia. At the time of our inspection 17 people lived at the home. A registered manager was employed at the service. 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 and their relatives consistently told us they were happy with the service provided and that staff understood their needs and they felt safe. The recognition and reporting of safeguarding issues was not consistent. A recent incident in the home demonstrated the provider had not involved other professionals which they are required to do under safeguarding procedures in order to keep people safe. 

Staff had the training to manage people’s medicines. Staff were aware of the precautions to take where medicines had to be given in a specific way, although written details to support these practices were not always evident. Staff managed the agitation of some people very well without relying on additional medication. Audits of medicine stocks showed that errors were being identified, and repeated. The action taken therefore to  reduce risks to people was not effective as the cause of errors had not been identified.

Safe staffing levels were maintained and people were cared for by staff who knew them well so that they received the right care at the right time to meet their needs and promote their safety.

Improvements were needed to ensure that people were not placed at risk due to the layout of furniture that partially blocked the fire exit door. Obstacles in the hall and lounge could potentially cause accidents.

People’s needs were assessed and care plans were detailed to provide guidance for staff. People’s care was effectively planned because staff supported them to access health care services so that they received care based on their individual needs.

People were supported to follow their individual interests both in the home and out in the community. However opportunities for people with dementia could be strengthened to meet their specific needs. People told us that staff were friendly and that they were supported to maintain relationships that were important to them.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and The Mental Capacity Act 2005 (MCA) and report on what we find. We saw people were given choices about their care and support. The manager was following the requirements of this legislation so that decisions are made in people’s best interests when they are unable to do this for themselves. Staff were aware of those people who needed protection and were taking the least restrictive approach to protect them. This meant that people could be confident that actions and decisions were being made in their best interest and only by people who had suitable authority to do so.

Risks to people’s health and wellbeing were well managed. They were supported to eat and drink well, and arrangements for managing risks to people’s skin were well established so that people were supported to remain healthy.

Staff were provided with the skills and knowledge to provide safe and appropriate care to people, and we saw that systems were in place to support the staff to do this appropriately. There were a range of ways people could raise their concerns or complaints and they told us they were confident they would be listened to and acted upon. The manager was open to managing people’s complaints although the recording of these could be improved.

The views of people that lived there and their relatives were looked at regularly by the manager to look at any areas for improvement.

We saw that there were systems to monitor and check the quality of the service although some risks had not been captured by the systems in place.