About the service:

Nicholas House is a residential care home in south Buckinghamshire. At the time of the inspection 19 older people, some of whom were living with dementia, lived at the home.

People’s experience of using this service:

People and their relatives gave us positive feedback about the care and support they received. Comments included “Neither of us could speak highly enough about the staff we met during our visits,” “Nicholas House is a first class residential home and I would highly recommend it,'' “During this period we always felt she was very well looked after, treated with dignity, and in very safe hands,” “We visit frequently and there is always a very open, calm and friendly welcome for us when the front door is opened at Nicholas House” and “The staff were incredibly sensitive and caring in the last few weeks of her life. Really, we feel so much gratitude for the amazing staff.”

There was a lack of good governance at the home. There was a lack of formal quality assurance processes in place. Records relating to people’s care and treatment lacked details on how to minimise risks to them.

Environmental risks were not always assessed within the timescales recommended by national guidance.

The service did not ensure there was a robust recruitment process in place for new staff. New staff had started to work unsupervised without a full criminal record check by the Disclosure and Barring Service (DBS) being carried out. This placed people at risk of unsuitable staff supporting them.

People were cared for by staff who felt supported. However, records did not demonstrate staff were given appropriate opportunities to discuss their performance. We have made a recommendation about this in the report.

Staff were unsure if they had completed training in supporting people who required end of life care. We found there was mixed understanding from staff about what end of life care was. We have made a recommendation about this in the report.

We found the home to be light, clean and consideration had been given to the environment so people living with dementia were easily able to find their way around the home.

People were supported to receive their prescribed medicines on time.

People were supported by staff who demonstrated compassion and were kind. People’s dignity and privacy was maintained.

People were supported to maintain important relationships with family and friends.

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.

People were supported to engage in meaningful activities both within the home and the local community. The home had forged links with local schools and other care homes.

Rating at last inspection:

The previous inspection was carried out on 9 June 2016 (Published on 7 July 2016). The service was rated Good at the time.

Why we inspected:

The inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Inspections will be carried out to enable us to have an overview of the service, we will use information we receive to inform future inspections.

We identified breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. Details of action we have asked the provider to take can be found at the end of this report.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

This inspection took place on the 9 June 2016 and was unannounced.

At our most recent inspection on 24 February 2014 we found the service was meeting the requirements of the regulations in place at the time.

Nicholas House is registered to provide care for up to thirty older people. Twenty seven people were being cared for at the time of our visit.

The service had two registered managers. 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 received positive feedback on the quality of the service from people who lived in Nicholas House and their relatives. “Staff are superb” and “The whole service is wonderful and caring,” were some typical comments made to us.

There were safeguarding procedures in place and staff received training on safeguarding vulnerable people. This meant staff had the skills and knowledge to recognise and respond to any safeguarding concerns.

Risks to people were identified and managed well at the service so that people could be as independent as possible. A range of detailed risk assessments were in place to reduce the likelihood of injury or harm to people during the provision of their care.

We found staffing levels were adequate to meet people’s needs effectively. The staff team worked well together and were committed to ensure people were kept safe and their needs were met appropriately. The senior management team gave additional support when required. “No issues with staffing numbers” was one relative’s assessment.

Staff had been subject to a robust recruitment process. This made sure people were supported by staff that were suitable to work with them.

Staff received appropriate support through induction and supervision. All the staff we spoke with said they felt able to speak with the senior management team or senior staff at any time they needed to. There were also some team meetings held to discuss issues and to support staff.

We looked at summary records of training for all staff. We found there was an on-going training programme to ensure staff gained and maintained the skills they required to ensure safe ways of working.

Care plans were in place to document people's needs and their preferences for how they wished to be supported. These were subject to review to take account of changes in people's needs over time. We found the format for care plans was very concise, clear and sufficiently comprehensive to ensure people were protected by accurate and up to date records of their care.

Medicines were administered in line with safe practice. Staff who assisted people with their medicines received appropriate training to enable them to do so safely.

The service was managed effectively. The registered managers and provider, together with the service’s management team, regularly checked quality of care at the service through audits and by giving people the opportunity to comment on the service they received and observed.

Nicholas house is a purpose built building offering care without nursing, to up to 30 people. At the time of our visit there were 25 people living at the home. The home was arranged over three floors.

We spoke with six people who lived at Nicholas House and with two visiting relatives. We also spoke with six staff including the registered managers.

We found that people were cared for appropriately and that care plans were specific and detailed to the individuals' needs.

People’s nutritional needs were met. Where necessary, people were supported to eat and drink.

Staffing levels were sufficient and people were supported by appropriately trained and managed staff.

The provider took account of the views and comments made by people and their relatives and produced action plans to provide solutions.

Records were generally kept safely and appropriately. They were comprehensive and informative.

People told us there was high regard for their privacy and dignity at the home. We saw that care plans contained specific preferences. Staff were respectful of people when speaking with them.

Personalised care plans were in place which described specific needs and outlined how these were met, for example, one person liked to rise and breakfast early, and this was denoted in the care plan. Risk assessments were written specifically to the individual for example a falls assessment for a person with reduced mobility. All documentation we looked at was up to date and appropriately reviewed.

People told us they felt well-cared for. We spoke with a visiting healthcare professional who said the care was good, the people who lived there appeared to be happy, and it was a calm environment.

Staff told us they felt supported and spoke positively of the new managers. They felt able to raise concerns, and were sure these would be dealt with quickly and appropriately.

We found there were adequate systems in place to supervise and appraise staff. Training had been provided to ensure staff had the skills and knowledge required to meet people's needs. Further training had been planned in response to staff requests.

There was a complaints policy and procedure, and this was made known to people. We saw the complaints file, and read some compliment cards. People told us they knew how to make a complaint, and were sure it would be "properly addressed".