We inspected the service on 22 and 25 May 2018. The inspection was unannounced. Nettleton manor is a care home providing accommodation, nursing and personal care for people who live at the service. 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. Nettleton Manor accommodates up to 43 people. On the day of our inspection 36 people were using the service which was divided into to two units. The main house which had two levels which were connected by a lift, and the coach house which was on one level.

A registered manager was in post 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection in May 2017, we rated the service as Requires Improvement as we found the principles of the Mental Capacity Act 2005 had not always been followed. Although people had not been deprived of their liberty unlawfully, the assessments undertaken around people’s mental capacity lacked sufficient detail to show correct processes had been followed during the assessments. At this visit we found the provider had made improvements in this area of care and the principles of the Mental Capacity Act had been followed. 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.

At this inspection we found evidence to show the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Our overall rating for the service is Requires Improvement, this is the second consecutive time the service has been rated as Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

People living at the service were protected from the risk of abuse as the provider had responded to and reported safeguarding concerns relating to the people in their care. Staff had a good knowledge of their responsibilities in relation to safeguarding and they had received recent training to support their knowledge base. The registered manager dealt with safeguarding issues openly, and worked with the local authority to deal with any safeguarding issues.

The risks to people were assessed and measures were in place to reduce these risks. However, on the day of our inspection we saw some staff lacked knowledge of particular risks to people’s safety and the measures meant to be in place to reduce the risks. This had resulted in an incident that impacted on one person’s safety. We did see evidence of staff knowledge of how to manage risks to other people who lived at the service.

People received their medicines from suitably trained staff and majority of medicines were managed safely. However, we found one person did not have their protocols in place to guide staff when they were prescribed ‘as required’ medicines. We also found some of the daily medicine checks, undertaken by staff, identified discrepancies that were not followed up, which meant errors may not be addressed.

While we saw the provider and registered manager had made some significant improvements to the environment to protect people from the risks of infection. People were not always protected from the risks of infection as some staff did not follow safe practices in preventing risks associated with cross infection.

Staffing levels met the needs of the people in the service and they were supported by staff who received an induction, were well trained and receive

This inspection took place on 20 and 21 February 2017 and was unannounced. Nettleton Manor provides accommodation, nursing and personal care for up to 43 people. On the day of our inspection 27 people were using the service who had a variety of needs associated with dementia and physical health conditions.

At the time of the inspection the service did not have a registered manager working at the service. The previous registered manager had retired in October 2016 and the new manager had applied to the Care Quality Commission to become registered. Following our inspection their registration was approved. 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 used the service were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The manager shared information with the local authority when needed.

The risks to people’s safety were assessed when they were admitted to the service and measures identified to reduce the risks. Staffing levels were sufficient to support people’s needs and people received care and support when required. Medicines were managed safely and people received their medicines as prescribed at the times they needed them.

People were encouraged to make independent decisions, however staff did not always follow the principles of the Mental Capacity Act (2005). Although people had not been deprived of their liberty unlawfully the assessments undertaken around people’s mental capacity lacked sufficient detail to show the correct processes had been followed during the assessments.

People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when required.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care. People were treated in a caring and respectful manner and staff delivered support in a relaxed and considerate manner.

People felt they could report any concerns to the management team and felt they would be taken seriously.

There were audits and analysis in place to monitor some aspects of the quality of the service. However there was a lack of robust audits around cleaning and this had an impact on the cleanliness of the service.

We inspected Nettleton Manor Nursing Home on 17 November 2015. The last inspection of the home took place on 18 June 2013 and we found the registered provider was compliant with all of the outcomes we inspected.

Nettleton Manor Nursing Home is situated on the outskirts of the village of Nettleton close to the Lincolnshire towns of Caistor and Market Rasen. It is registered to provide nursing and personal care for up to 43 people, some of whom experience memory loss and have needs associated with conditions such as dementia. At the time of our inspection there were 33 people living at the home.

The registered provider had a registered manager in place. 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.

People were involved in making decisions about how they wanted to be supported and how they spent their time. The provider had processes in place which ensured, when needed, they acted in accordance with the Mental Capacity Act 2005 (MCA). CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves.

At the time of this inspection applications had been submitted by the registered manager for 21 people to have their freedom restricted and the provider had acted in accordance with the Mental Capacity Act 2005 (MCA).

Background checks had been completed by the provider before new staff were appointed to ensure they were safe to work at the home.

Staff knew how to recognise and report any concerns they had regarding people’s safety so that people were kept safe from harm.

Staff understood people’s needs, wishes and preferences and they had received training in order to enable them to provide care in a way which met people’s individual needs. Positive working relationships had been developed between staff, people who used the service and their relatives and were being maintained. Staff were caring in their approach and people’s privacy and dignity were respected.

People and their relatives had been consulted about the care they needed and were offered the opportunity to undertake person-centred activities in order to help them to maintain and further develop their interests and hobbies.

Staff provided the care described in care records. In addition people and staff had access to a range of healthcare and social care professionals when they required more specialist help and advice. Clear arrangements were also in place for ordering, storing, administering and disposing of medicines.

People were provided with a good choice of nutritious meals. When necessary, people were given any extra help they needed to make sure that they had enough to eat and drink to keep them healthy.

The home was run in an open and inclusive way. Staff were encouraged to speak out if they had any concerns and there was a process in place for handling and resolving complaints.

The provider and registered manager also had a structured system in place to enable them to continually assess and monitor the quality of the services they provided.

When we visited Nettleton Manor Nursing Home we used a number of different methods to help us understand people’s experiences. We spoke with three people who lived at the service, three relatives who visited the service, seven staff members, a hairdresser who had visited to support people to maintain their appearance and the registered manager.

We looked at records.These included care records and information about how the service operated.

We also observed how people received their care in order to help us understand the needs of people who we were not able to speak directly with.

For example, we observed how staff used their training and experience to interact with, and support people with their care, meals and activity needs.

One person said, “I have complete privacy when I need it.” Another person told us, “They (staff) get me everything I want. When I ask for drinks or help at any time during the night and it’s always given.”

We found the environment was maintained appropriately to support the safety of the people who lived there. A visiting relative told us, “The home always seems clean and tidy.”

We also found the home owner and manager had monitored the service and gained views on the quality of services provided from people and their relatives.