This inspection took place on 15 October 2018 and was unannounced. We returned on 16 October 2018 announced.

The overall rating for the service awarded at the previous inspection which took place on 12 September 2017 was ‘Requires Improvement’. The provider was not meeting one of the regulations that we checked and was in breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014. Following the last inspection, we asked the provider to take action to make improvements to promote people's safety and to improve systems and processes to monitor the quality of the service. The provider submitted an action plan outlining their plan for improvements.

At this inspection we found further improvements were still required. This is the second consecutive time the service has been rated ‘Requires Improvement’. Providers should be aiming to achieve and sustain a rating of ‘Good’ or ‘Outstanding’. Good care is the minimum that people receiving services should expect and deserve to receive.

Nightingale House 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 House accommodates up to 12. The service specialises in caring for children and young adults with complex health needs and acquired brain injury, including learning disabilities or autistic spectrum disorder and sensory impairment. Nightingale House provides eight long term beds and 4 short term beds. At the time of our visit three people were living at Nightingale House. In addition to this one person was at the service for respite. People using the service at the time of the inspection were 19 years of age and above.

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.

We found that safeguarding concerns were not always being reported to the local authority safeguarding team. This did not ensure people were protected from the risk of abuse and avoidable harm. Staff did not always seek medical support where there had been an incident involving a person using the service.

The providers quality monitoring systems required further improvements as they had not identified issues that were found at this inspection. Personal information was not stored securely. Risk assessments were not always updated following incidents.

People were supported in a safe way to take their prescribed medicine. At the time of the inspection visit there were sufficient staff on shift. However staffing levels needed to be kept under review as the number of people using the service increased including both long term and short stays.

Relatives felt their family members were safe with the support provided by staff.

Recruitment procedures ensured prospective staff were suitable to support people who were using the service.

Staff had received training in infection control and were provided with personal protective equipment to use when carrying out care and support tasks.

People’s representatives were involved in their care to enable them to make decisions about how they wanted to receive support in their preferred way.

People were supported to receive a balanced diet that met their preferences and assessed needs. People accessed healthcare services received coordinated support to ensure their preferences needs were met.

Relatives told us that staff treated their family members in a caring way and respected their privacy and supported them to maintain their dignity. The delivery of care was tailored to meet people's individual needs and preferences.

The inspection focused on two different service types which operate from the same premises. The first being a residential care home and the second being a service offering support to people living in their own homes.

This inspection took place on 14 September 2017 and was announced. The provider was given 24 hours' notice, as when we had previously attempted to inspect the service, everyone was out. This meant the provider and staff knew we would be visiting the service’s office before we arrived. This was the first inspection since the provider's registration on 26 February 2016.

Nightingale House is situated close to Derby city centre and provides a care home service for up to 12 people. The service specialises in caring for children and young adults with complex health needs and acquired brain injury, including learning disabilities or autistic spectrum disorder and sensory impairment. Nightingale House provides eight long term beds and 4 short term beds. At the time of our visit four people were living at Nightingale House and four people were being supported in their own homes with personal care. In addition to this one person was at the service for respite. The young people using the service at the time of the inspection were 14 years of age and above.

There was a registered manager 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.’

We found that the provider's systems had not picked up the issues we identified at this inspection visit. This demonstrated that the management systems were not always effective in recognising areas which required improvements.

Two staff told us that they had not received training and induction to carry out their roles safely and effectively. Relatives were not confident that staff could meet people’s needs safely as they felt they were not suitably trained or experienced.

People who were supported with their medicines were not always protected against the risks associated with poor medicines management as their medicines were not always stored safely. For example we found that the stock balance of people’s medicines was not always correct.

People's care records showed risk assessments were completed. Assessments related to people’s assessed needs such as moving and handling. However we saw that staff did not always support people adequately to ensure any difficulty to manage behaviours were not exacerbated.

We received concerns that people were not always supported to pursue their hobbies and interests. On the day of the inspection visit we did not see people involved in daily living tasks.

The provider understood their responsibility to comply with the requirements of the Mental Capacity Act (MCA) 2005. Some people were subject to restrictions and the provider had identified where their support needed to be reviewed. This provided assurance the principles of the MCA 2005 were followed.

People were supported to maintain their health and well-being and had access to a range of healthcare professionals such as GP's when required. We observed staff treated people kindly and in a way which respected people's privacy and dignity.

The provider’s complaints policy and procedure were accessible to people who used the service and their representatives. People’s relatives knew how to make a complaint.

People’s relatives did not feel that the service was well managed. Staff felt supported by the management team and enjoyed working for the provider.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.