This inspection took place on 19 and 20 April 2018. The first day was unannounced. We told the provider we would be visiting on day two. At our last inspection on 15 March 2017 we rated Nightingale Hall as Requires Improvement. We found the provider had breached one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to medicines administration. Risks to people arising from their health and support needs were not always assessed and plans were not always in place to minimise them. The service was not involving night staff in fire drills.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question of safe to at least Good.

At this inspection, we found medicines were administered safely. Risk assessments were in place, which gave staff the guidance needed to meet people’s needs safely and plans were in place to minimise risks. Fire drills included all staff at the service.

This service is now rated as Good.

Nightingale Hall is a ‘care home’. 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.

Nightingale Hall is a large adapted property and accommodates up to 42 older people, some of who may be living with dementia.

A registered manager was in post. 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.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of the action they should take if abuse was suspected. They were confident the registered manager would address any concerns.

Medicines were stored and administered safely and the premises were well maintained to keep people safe.

Risk assessments were completed to reduce the risk of harm. Accidents and incidents were analysed to reduce the risk of reoccurrence.

There were safe recruitment and selection procedures in place and appropriate checks had been undertaken before staff began work. Staff received the support and training they needed to give them the necessary skills and knowledge to meet people's assessed needs. Staffing levels were sufficient to meet those needs.

People were provided with sufficient food and drink to maintain their health and wellbeing and staff supported people to access healthcare professionals and services.

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.

Staff knew people well and promoted their independence. Care was person centred and people were provided with choice. Staff were kind and treated people with dignity and respect. People told us they felt safe and well cared for. End of life care was provided sensitively.

Care records contained information about people's needs, preferences, likes and dislikes. Staff understood people were individuals and would inform managers if they thought people were being discriminated against.

Complaints or concerns were taken seriously and action was taken to address them. Feedback about the quality of the service was sought from people, relatives and staff.

The registered manager and the provider regularly monitored the quality of service to ensure that people received a safe and effective service which met their needs.

This inspection took place on 15 March 2017. This was an unannounced inspection which meant the staff and registered provider did not know we would be visiting.

The service was last inspected in August 2014 and at that time required improvement in the effective domain as the environment was not suitable for people living with dementia.

Following our last inspection the registered provider sent us information, in the form of an action plan, which detailed the action they would take to make improvements at the home.

At this inspection we found that the environment had started to improve and was more dementia friendly. The new registered manager had plans to further enhance this.

Nightingale Hall provides residential and nursing care for up to 42 people. The home is owned by Wellburn Care Homes Limited and is located in the 'Garden Village' residential area of Richmond. Nightingale Hall offers recently refurbished accommodation, including bedrooms with en-suite facilities and pleasant outside spaces.

There was a registered manager in place who had been registered with the Care Quality Commission (CQC) since March 2017. 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.

Risks to people arising from their health and support needs were not always assessed, and plans were not always in place to minimise them. Risk assessments that were in place were regularly reviewed to ensure they met people’s current needs. However care plans were not updated in a timely manner.

Medicines were not always administered in line with the person’s prescription and some people went without medicines.

Risks to people arising from the environment were assessed and plans in place to minimise them. A number of checks were carried out around the service to ensure that the premises and equipment were safe to use. Although fire drills were taking place there was no evidence that night staff had completed a fire drill.

People could be assured that sufficient numbers of staff would be working within the service to provide their care and support in the way in which they wished to receive it. Staff had been safely recruited and understood the need to protect people from harm and abuse and knew what action they should take if they had any concerns. Staff received effective supervision and a yearly appraisal.

Staff received training to ensure that they could appropriately support people, and the service used the Care Certificate as the framework for its training. Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) training and understood the requirements of the Act. This meant they were working within the law to support people who may have lacked capacity to make their own decisions. The registered manager understood their responsibilities in relation to DoLS.

People were supported to maintain a healthy diet, and people’s dietary needs and preferences were catered for. People told us they had a choice of food at the service, and that they enjoyed it.

The service worked with external professionals to support and maintain people’s health. Staff knew how to make referrals to external professionals where additional support was needed. Care plans contained evidence of the involvement of GPs, district nurses and other professionals.

We found the interactions between people and staff were cheerful and supportive. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity. People and their relatives spoke highly of the care they received. People had access to a wide range of activities, which they enjoyed.

Procedures were in place to support people to access advocacy services should the need arise. The

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This inspection was carried out on 12 August 2014 and was unannounced. The previous inspection was carried out on 21 October 2013 and CQC had no concerns at that inspection.

Nightingale Hall provides residential and nursing care for up to 42 older people. The home is owned by Wellburn Care Homes Limited and is located in a residential area of Richmond.

There was a registered manager at this service. 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; as does the provider.

We found that this service was safe and people told us that they felt safe living in this service. Staff were recruited safely and checks were made before staff were employed to ensure that they were considered suitable people to work with people who used the service.

There was sufficient staff with appropriate skills and knowledge on duty to meet the needs of the people who used the service. Staff received supervision from more senior staff which enabled them to discuss any matters pertinent to their work and develop personally.

The staff spoke kindly to people and treated them with respect which was reflected in the good relationships between staff and people who used the service that we observed during our inspection. There was a mutual respect and kindliness evident when people spoke to each other.

Staff were able to explain how they would safeguard people and if necessary how they would report any incidents that may have caused people harm. We saw that staff had received training in safeguarding vulnerable adults. This meant that staff awareness around safeguarding was good and therefore if any situation arose where someone was at risk of harm staff would know what to do. We found medicines were managed appropriately ensuring that people received their medication safely.

The registered manager was following the principles of the Mental Capacity Act 2005 but had not made any applications in respect of people being deprived of their liberty.

The environment was exceptionally well maintained and decorated but was not suitable for people living with dementia. There was a lack of directional signage, contrast and colour in specific areas to help the person know where they were within the service .Activities had not been designed to provide meaningful occupation and were not person specific. Bedrooms were personalised and people had brought personal items and photographs to decorate the rooms but there was no colour and contrast to support people living with dementia to use fixtures and fittings. “Good practice in the design of homes and living spaces”, a publication by the University of Stirling, says that, “colour and contrast can be used to enable people with sight loss and dementia to identify different rooms and key features inside and outside of their homes”.

This was a breach of the Health and Social Care Act 2008 (Regulations) 2010 Regulation 15.  You can see what action we told the provider to take at the back of the full version of the report

There was an effective quality assurance system in place which helped in the development of the service and the making of changes and improvements.

During our visit we spoke with six people who used the service and three relatives. We also spoke with the area manager, home manager, a nurse and member of care staff and spent time observing the support people received.

People were able to express their views and were involved in making decisions about their care and treatment. Systems were in place to assess, plan and review people’s care needs. The people we spoke with were positive about their service, telling us that they were well cared for and that staff were helpful and kind. Comments made to us included “I’m more than happy”, “staff respond well and give help when needed” and “I get very good care.”

Safe systems were in place for the management and administration of medication, with regular checks carried out to ensure that people had received the medication they needed. However, the provider should consider improvements to some aspects of medication storage.

Staff were provided with the training and support they needed to do their jobs. Staff told us they felt well supported and were provided with appropriate training and opportunities for professional development.

We found that people who used the service and their representatives were asked for their views about their care and checks were carried out to monitor the quality of service provided.

People told us that they were happy with the care they received. Comments included ‘everything is fine, I’m quite content’, ‘I think they do very well’, ‘if I rang that bell now and asked for a cup of tea I’d have it’ and ‘oh yes things are good’. We saw staff acting in kind and attentive ways, talking to people, asking if people wanted to do things and explaining what was happening when they assisted people. People looked clean, appropriately dressed and well cared for. Staff were able to tell us about people’s individual needs and preferences. They could also describe the systems that were in place to make sure that people received regular baths or showers, could get up and go to bed at times that suited them, could take part in activities and spend time in their preferred part of the home.

People told us that they were happy with the home’s staff, who were described as pleasant and polite. Comments made to us included ‘they do their best’, ‘they help when I need them’, ‘very polite’ and ‘they tease, but in a nice way’. Our observations showed that staff acted professionally and appeared to be competent in the work they were doing. Records showed that staff were recruited carefully and thoroughly, with the appropriate checks being completed before staff started to work in the home. Staff told us that they felt there was a good staff team at the home, with people working well together. One staff member told us ‘I’ve worked all over and this is the best’.

People we spoke with told us that they were happy at Nightingale Hall and that staff supported them well. One person said "they look after me very well".

People told us they are asked about their views and choices and that these are respected.

People told us that they were very happy with the staff at Nightingale Hall and the care that they provided. People also told us that their needs were being met. If they were unhappy with anything they would tell the staff, who would then act upon this. Everyone that we spoke with said they didn't have any complaints or concerns about the home.

We also spoke with people's relatives who were visiting the home. They were positive about the staff and their competence in looking after their relatives.