We carried out an unannounced inspection at Nelson Manor on 4 and 5 September 2018.

Nelson Manor 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. Accommodation is provided on three floors. The ground floor known as Haven suite, provides personal care for older people, the middle floor known as the Jubilee suite provides personal and nursing care for people with mental health needs and the top floor known as the Great Marsden suite provides people with nursing care. All the bedrooms have an ensuite with a shower facility. At the time of the inspection, there were 64 people accommodated in the home.

The service was managed by a registered manager. 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 carried out the last comprehensive inspection on 11 and 12 May 2017 and assessed the service as overall ‘requires improvement’. This was because we found shortfalls in the management of medicines. We carried out a focussed inspection on 18 September 2017, to check the provider had made improvements to way they managed medicines. Whilst we found the necessary improvements had been made, we retained the rating of ‘requires improvement’ in the safe section, because we needed to ensure the improvements were sustained over time. During this inspection, we found the service was compliant with the current regulations and the improvements had been sustained. The overall rating has been assessed as ‘Good’.

People living in the home told us they felt safe and staff treated them well. People were supported by enough skilled staff so their care and support could be provided at a time and pace convenient for them. Appropriate recruitment procedures were followed to ensure prospective staff were suitable to work in the home. Records confirmed that staff had received safeguarding training and they knew how to recognise abuse and report any concerns. Staff conducted risk assessments and devised care plans which guided staff on how to manage the risks identified. People's medicines were managed appropriately and records seen were complete and up to date.

The home remained clean and free of unpleasant odours. People were protected from the risk and spread of infection. Equipment used to support people was clean, in a good state of repair and was regularly serviced.

Staff had the knowledge and skills required to meet people's individual needs effectively. They completed an induction programme when they started work and they were up to date with the provider's mandatory training. 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. There were appropriate arrangements in place to support people to have a varied and healthy diet. People had access to a GP and other health care professionals when they needed them.

Staff were kind and caring and treated people with dignity and respect. We observed people were happy, comfortable and relaxed with staff. Care plans and risk assessments were person centred and provided guidance for staff on how to meet people’s needs and preferences. There were established arrangements in place to ensure the care plans were reviewed and updated regularly.

People had access to a complaints procedure and records were made of complaints received in the home. Any issue raised had been investigated and steps taken to resolve the situation to people's satisfaction. People were provided with a range of

We carried out an unannounced comprehensive inspection of this service on 11 and 12 May 2017. A breach legal requirements was found in respect to the management of medicines and as a result we issued the provider with a warning notice. We undertook this focused inspection on 18 September 2017 to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Nelson Manor on our website at www.cqc.org.uk

During the inspection, we found improvements had been made to the management of medicines and have revised the rating of the well led section and the overall rating to good. However, the rating remains requires improvement for the safe section. This is because we need to be confident the improvements are sustained over time. We will therefore review all ratings at the next comprehensive inspection.

Nelson Manor Care Home is registered to provide personal and nursing care for up to 70 people. There were 60 people accommodated at the time of the inspection. Accommodation is provided in 70 single bedrooms on three floors. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people with mental health needs and the top floor provides people with nursing care. All the bedrooms have an ensuite with a shower facility. The home is located in a residential area approximately one mile from Nelson town centre.

The service was managed by a registered manager. 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 noted appropriate action had been taken to improve the management of medicines. Whilst we found one medicine error during the inspection, this had been identified on a routine audit and the registered manager was due to commence an investigation. Following the inspection, the registered manager sent us details of her action plan, which set out the measures, put in place to prevent a reoccurrence.

The registered manager was well-respected and provided strong, supportive leadership to her team. Systems were in place to monitor the quality of the service provided and ensure people received safe and effective care. There were established arrangements for gathering people’s views about the service, which included regular meetings and satisfaction questionnaires. All people spoken with were very satisfied with the service and felt the management team and staff were approachable, helpful and supportive.

We carried out an inspection of Nelson Manor Care Home on 11 and 12 May 2017. The first day was unannounced.

Nelson Manor Care Home is registered to provide personal and nursing care for up to 70 people. There were 60 people accommodated at the time of the inspection. Accommodation is provided in 70 single bedrooms on three floors. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people with mental health needs and the top floor provides people with nursing care. All the bedrooms have an ensuite with a shower facility. The home is located in a residential area approximately one mile from Nelson town centre.

The service was managed by a registered manager. 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.

On our last inspection on 4 and 5 January 2017, we found significant shortfalls in the management of complaints, the maintenance of records and quality assurance systems. We therefore issued warning notices, which required the provider to be compliant with the relevant regulations by 28 February 2017.

We also found shortfalls in a number of other regulations including the management of medicines, the need for consent, the support provided to people during meal times, person centred care, the assessment and mitigation of risks and the recruitment of new staff. Following the inspection, the provider sent us detailed action plans which set out the action they were taking to meet the regulations. We also received regular updates on the progress of the action plan.

During this inspection, we found there continued to be an upward trend towards improvement in most aspects of the service. However, we also found significant shortfalls in the management of medicines. You can see what action we told the provider to take at the back of the full version of the report. (Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded).

People living in the home said they felt safe and staff treated them with respect. There were sufficient staff deployed in the home to meet people's care and support needs. Whilst appropriate checks were carried out when new staff were recruited, we found minor shortfalls in two staff member’s employment histories. These issues were rectified during the inspection. Safeguarding adults’ procedures were in place and staff understood their responsibilities to safeguard people from abuse. Risks associated with people’s care were identified and assessed. There was a whistleblowing procedure available and staff said they would use it if they needed to.

Medicines were not always managed and administered safely. We found medicines were not consistently given in line with the prescriber’s instructions and records were not always clear and accurate.

Staff had completed an induction programme when they started work and were provided with ongoing refresher training. The registered manager and staff understood the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and acted according to this legislation. There were appropriate arrangements in place to support people to have a varied and healthy diet. People had access to a GP and other health care professionals when they needed them.

Staff treated people in a respectful and dignified manner and people's privacy was respected. Wherever possible, people living in the home had been consulted about their care needs and had been involved in the care planning process. We observed people were happy, comfortable and relaxed with staff. Care plans and risk assessmen

We carried out an inspection of Nelson Manor Care Home on 4 and 5 January 2017. The first day was unannounced.

Nelson Manor Care Home is registered to provide personal and nursing care for up to 70 people. There were 60 people accommodated at the time of the inspection. Accommodation is provided in 70 single bedrooms on three floors. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people with mental health needs and the top floor provides people with nursing care. All the bedrooms have an ensuite with a shower facility. The home is located in a residential area approximately one mile from Nelson town centre.

The service was managed by a registered manager. 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 comprehensive inspection on 3, 4 and 5 November and 9 and 10 December 2015, we found the provider was not meeting a number of regulations. We therefore asked the provider to take action in relation to the management of medicines, staff training and support, the need for consent, the unlawful deprivation of people’s liberty, person centred care and good governance. We also made recommendations in respect to improving people’s experiences at mealtimes, making appropriate adaptations to the environment to support people living with dementia and developing suitable and meaningful activities. We issued a warning notice in respect to the management of medicines and checked compliance with this notice on 9 March 2016. We found the provider was compliant with the notice; however, we identified minor shortfalls and made a recommendation about future practice.

Following the inspection, the provider sent us an action plan which set out the action they were taking to meet the regulations. The manager in post at the time of the inspection, left employment at the home shortly afterwards and a new manager was appointed in June 2016.

During this inspection, we found there were continuing shortfalls in respect to the need for consent, person centred care and good governance. We also noted limited progress had been made to improve people’s experiences of meal times on the Jubilee unit and the development of activities. We found further shortfalls in the management of medicines, the assessment and mitigation of risks, the recruitment of new staff, the maintenance of records and the management of complaints. You can see what action we told the provider to take at the back of the full version of the report.

People told us they felt safe and staff were kind and caring. Safeguarding adults’ procedures were in place and staff understood how to safeguard people from abuse. We were aware safeguarding investigations were ongoing at the time of our visit. A representative from the safeguarding team told us the registered manager was fully cooperating with the investigation of the issues.

Whilst some risks had been assessed and documented, we found the assessments had not always been updated in line with changing needs. Similarly, we found people’s care plans and other associated records had not been kept up to date. This is important to ensure staff have accurate information about people’s current needs. Although all people had a care plan, including people new to the home we noted that people were not routinely involved in the development and review of their plans.

There were shortfalls in the management of medicines and we noted medicines were not always given as prescribed by the doctor and one person had not received a medicine for nine days. Further to this, a relative raised concerns about the way staff were handling their family member’s medicine

This focussed inspection was carried out on the 9th March 2016. This was an unannounced inspection which meant the staff and provider did not know we would be visiting.

Nelson Manor is a purpose built care home registered to provide personal and nursing care for up to 70 people. There were 47 people accommodated on the day of the focussed inspection. The home is located approximately one mile from Nelson town centre in a residential area. Accommodation is provided on three floors and each floor has a unit manager. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people living with a dementia and the third floor provides nursing care.

There was no registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law. 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 previously visited this home for an unannounced comprehensive inspection on 3, 4 and 5 November and 9 and 10 December 2015. During that visit, we found people were not protected against the risk associated with the unsafe management of medicines and issued the provider with a warning notice.

As part of this focussed inspection, we checked to see that improvements had been implemented by the service in order to meet the requirements of the warning notice. This report only covers our findings in relation to those requirements. Reports from our last comprehensive inspections are available on our website by selecting the “all reports” link for Nelson Manor at www.cqc.org.uk.

At this inspection on 9 March 2016 we looked at arrangements for the management of medicines and found that improvements had been made. We reviewed the providers action plan and saw evidence of the actions they had taken on our visit.

A pharmacist specialist carried out the inspection and we looked at the management of medicines. There had been concerns on a previous inspection that there were delays in obtaining medicines. This meant people using the service sometimes went without prescribed medicines because they were not available in the home. We saw improvements had been made to the ordering process for repeat medicines to ensure people got their medicines on time and that regular stock checks were being carried out. We found no incidences on this inspection where people had not received their medicines as prescribed because they were not available. This was an improvement in comparison with our previous visit.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

We carried out this inspection to follow up on actions set at our previous inspection on 4 February 2014. During this visit we found the actions had been completed and the necessary improvements had been made.

We considered the evidence we had gathered under the outcomes we inspected. We spoke with seven people living on Jubilee unit, looked at three people’s care records in detail and a selection of other records. We also spoke with one relative, four staff on duty, the deputy manager and registered manager.

This a summary of what we found:

Is the service safe?

Since our last inspection, staff had received training and had discussed the methods used to help people to move. We found people requiring assistance were transferred safely using the hoist.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found there was a plan of care and appropriate documentation relating to a deprivation of liberty safeguard authorised for one person living on the Jubilee unit. (The Deprivation of Liberty Safeguards provide a legal framework to protect people who need to be deprived of their liberty for their own safety).

Individual risks had been assessed and identified as part of the care planning process. Control measures had been put in place to manage any risks in a safe and consistent manner. This meant people were supported to take appropriate risks.

Is it effective?

Each person had an individual care plan, which provided staff with information about their needs and preferences. The plans were detailed and had been reviewed on a monthly basis. This ensured staff were provided with up to date information.

Since our last inspection, the arrangements around meal times on Jubilee unit had been reviewed and revised. We observed people had their meals at the same time and staff were attentive and sensitive to people’s needs. People were offered a choice of food the day before and there was sufficient food for them to change their choice on the day. The meal served looked appetising and was well presented.

Is it caring?

People spoken with were satisfied with the care provided. Staff were observed throughout the inspection to treat people with kindness and respect.

Is it responsive?

People’s needs had been assessed before they moved into the home. This meant the manager had ensured people could be cared for properly. Records seen confirmed people’s preferences, interests and past experiences had been recorded and care was delivered in accordance with people’s wishes.

There were sufficient staff on duty and people told us the staff responded in a timely way when they required assistance.

Is it well led?

The service had an established manager, who had been registered with the commission since November 2012. Staff spoken with told us the home was well managed and organised. We found there were systems in place to ensure staff received appropriate training and supervision.

We carried out this unannounced inspection in response to concerning information about the care provided to people living on the Jubilee unit. We therefore focussed our activities on this unit and all findings relate to this area of the home. Further to this staff interviewed during the visit consistently told us the service provided on the top and ground floor was “well organised” and “very good”.

Whilst all people on the Jubilee unit had a detailed care plan, which provided clear instructions for staff on how to meet people’s needs, we found staff were not always using the hoist to assist people who required help to move. By not using the hoist on every occasion people’s health, safety and welfare was placed at risk of harm.

People were provided with varied, wholesome and nutritious food, which was well presented and appetising. All people spoken with confirmed they enjoyed the meals. However, people living on the Jubilee unit were not always asked for their choice of meal. This is important so people can express their preferences and be involved in making decisions about their lives.

People spoken with were satisfied with the service provided. One person told us, “I like living here the carers are very nice” and another person said, “I like everybody, we all get on well”. People told us their rights to privacy, dignity and independence were upheld and respected. Relatives spoken with were also complimentary about the service.

People’s care was planned and delivered in accordance with their needs. People had individual care plans which were supported by a series of risk assessments. People told us they had discussed their needs with staff and had been involved in the reviews of their care. We saw people or their relatives had signed their care plans wherever possible to indicate their participation and agreement.

People were provided with a variety of suitable and nutritious meals. People were given a choice each mealtime and could make special requests in line with their preferences. We noted drinks and snacks were served throughout the day.

We observed staff were attentive and sensitive to people’s needs during the visit. The manager informed us the staffing levels were due to be increased during the day and night and she was actively recruiting new staff.

Suitable arrangements were in place for the on-going maintenance and safe storage of records. All records seen were complete and up to date.

We spoke with several people about their medicines and the way they were handled. Nobody raised any direct concerns about the way their medicines were managed.

Comments included:

‘’I see the doctor regularly’’

‘’Quite content myself’’

‘’Not allowed to keep my own cream even though I apply it’’

‘’My pain is managed, I still occasionally get dizzy, but what can be managed is being managed’’

Overall we found people were given their medicines safely.

People spoken with were satisfied with the service provided, one person told us, “It is a lovely place and the staff are very nice” and another person said, “I’m very happy here, I have no complaints at all”. People told us their rights to privacy, dignity and independence were upheld and respected.

People were aware about how their level of fees was assessed and calculated and they had received appropriate information about the amount and payment of fees.

People’s care was planned and delivered in accordance with their needs. People had individual care plans which were supported by a series of risk assessments. People told us they had discussed their needs with staff and they were familiar with their care plan. This meant people were able to have an input into the delivery of their care.

We found staff had received training on safeguarding vulnerable adults and had access to appropriate policies and procedures. All people spoken with said they felt safe in the home.

Whilst people told us they received appropriate support with their medication, we found the systems to manage medication were not always effective.

There were sufficient numbers of staff on duty to meet people’s needs. People made complimentary comments about the staff team and staff were observed to have a respectful and sensitive approach to meeting people’s needs.

We found there were established systems to monitor the quality and operation of the service. We saw evidence to demonstrate that people and their relatives were asked for their opinion of the service.

People told us they were happy living in the home and able to express their views and opinions about the care they were provided. One person said “The staff are very nice” and a relative commented “This is an excellent home, the care is second to none”. People spoken with felt they were well cared for and the staff respected their rights to privacy and dignity.

Visitors were welcome in the home at any time and people said they were supported to maintain good contact with their family and friends. Relatives spoken with were mostly satisfied with the quality of care provided and felt that their family members were looked after in a caring and sensitive manner. One relative told us, “I am very impressed with the care and the staff’s approach”.

People and their relatives were aware of their level of fees and confirmed the process used to determine the amount they paid had been fully explained and discussed with them before they moved into the home.

Suitable arrangements were in place to maintain and store people’s records in a secure and confidential manner.

People living in the home said they liked the staff, who they described as “kind” and “lovely”, one person said “they do their best”. However, one person felt that she sometimes had to wait a while before staff were able to attend to her needs and another person said they thought the home was “understaffed”. The staff team also expressed concern about the level of staffing and the impact this had on the amount of time they were able to spend with people. The manager who was on leave at the time of the visit, later confirmed that these comments were taken very seriously and as a result of a review of the service provision additional staff were being recruited to supplement the current staff team.

People were very satisfied with the food provided, with everyone describing the food as “excellent” and “very good”. People said they enjoyed all their meals on the day of the visit.

People said they were able to express their views about life in the home and they felt confident they would be listened to.

We carried out the first part of the inspection of Nelson Manor Care Home on 3, 4 and 5 November 2015 and the second part on 9 and 10 December 2015. Our visits on the 3 November and 9 December 2015 were unannounced.

Nelson Manor Care Home is registered to provide personal and nursing care for up to 70 people. There were 52 people accommodated at the time of the first part of the inspection. Accommodation is provided in 70 single bedrooms on three floors. The ground floor provides personal care for older people, the middle floor known as the Jubilee unit provides personal and nursing care for people with mental health needs and the top floor provides people with nursing care. All the bedrooms have an ensuite with a shower facility. The home is located in a residential area approximately one mile from Nelson town centre.

At the time of the inspection the home was being run by a new manager who had started working in the home on 19 October 2015. There was no registered manager. A registered manager is a person who has registered with the Care Quality Commission (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.

At the last inspection on 10 and 11 February 2015 we found the provider was not meeting a number of regulations in force at the time. We therefore asked the provider to take action to improve the management of medication, make an appropriate response following a safeguarding incident, ensure people were protected from the risks of inadequate nutrition and dehydration, ensure people’s healthcare needs were met in timely manner and improve record keeping. We also recommended the provider seek advice and guidance on improving the level of cleanliness, the implementation of the Mental Capacity Act 2005, the development of person centred care and the development of suitable activities.

Following the inspection, the registered manager sent us an action plan which set out the action they were taking to meet the regulations. However, the registered manager left the home and the action plan was revised and updated by the management team who took over the day to day operation of the service.

During this inspection we identified there were continuing shortfalls in the management of medication. We also found new breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, staffing, need for consent, safeguarding people from abuse, person centred care and good governance. You can see what action we have asked the provider to take at the back of the full version of the report.

We also made recommendations about improving people’s experiences at mealtimes, making appropriate adaptations to the environment to support people living with dementia and we have repeated our recommendation to develop suitable and meaningful activities.

People told us they felt safe and were complimentary about the staff team and the management of the service. However, we found improvements needed to be made to the management of medication.

Individual risks had been assessed and recorded in people’s care plans. In order to help staff have an overview of people’s needs and areas of risk we found, on the second part of the inspection, the manager had developed a live communication board. This was continually updated to ensure staff had access to up to date information.

Since our last inspection the provider had increased the level of staffing. Staff working on the ground floor and Jubilee unit told us they had sufficient time to spend with people and carry out their duties. However, we noted the number of staff available on the top floor meant they prioritised completing care duties rather than meeting individual needs. On our visit on 9 and 10 December 2015 we found the manager had deployed an additional member of staff to the top floor on most days.

On our visit on 3, 4 and 5 November 2015, we found new staff had not completed induction training and established staff had not received refresher training in key aspects of their work. We saw no records of staff supervision and appraisal. This meant staff were not adequately supported in carrying out their roles. On our visit on 9 and 10 December 2015, we noted one member of staff had completed a local induction programme and the staff training matrix had been updated. Whilst some training had been booked for early in 2016, there were still significant gaps in the staff training. We also noted the manager had completed supervision with individual members of staff following issues raised about their performance.

We found a large majority of the staff had not completed training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). This meant they had limited knowledge of the principles associated with the legislation and people’s rights. As a result, appropriate assessments and DoLS applications had not been carried out.

People were served with nutritious food; however, our observations indicated improvements should be made to the way food is served to people. During our inspection on 9 and 10 December 2015, we found the manager had implemented an effective system to record and monitor people’s dietary and fluid intake.

People’s healthcare needs were met and appropriate referrals had been made to specialist services as appropriate.

There were appropriate arrangements in place for the ongoing maintenance and repair of the building. However, there was limited signage and adaptations to support people living with dementia. This meant some people were disorientated within their living environment.

All people had a care plan, which had been reviewed on a monthly basis. However, on the first part of the inspection, three staff spoken with had not read people’s care plans and told us they relied on information shared at handover meetings and in the communication book. This meant the care plans were not used as part of daily practice. On the second part of the inspection, we found staff working on the Jubilee unit were assigned specific people to care for during the day. This meant staff were aware of their responsibilities and this helped to ensure people’s needs were met.

People living on the ground floor had been involved in the care planning process, however, there was no evidence people living on the Jubilee unit had been supported to make or participate in making decisions relating to their care.

There were limited opportunities for people to engage in meaningful activities. There were numerous gaps in the activity records and there was no evidence alternative activities had been offered when people had declined.

People were aware how to make complaints and were confident the manager would listen and take appropriate action. There was an appropriate system in place to ensure complaints were investigated and responded to.

All people, staff and relatives made positive comments about the manager and were optimistic the necessary improvements were being made to the service. The manager had held meetings with staff and relatives and along with the interim governance manager had begun to complete audits to check the quality of the service. Action plans had been devised to address any shortfalls. The manager was supported in her role by the provider and following the inspection we received an internal action plan which set out the resources available to the manager to help her develop and improve the service. However, we found a number of concerns during the inpsections which should have been addressed.