About the service: Nightingale House is a residential care home that was providing personal care and accommodation to 22 people at the time of the inspection. The home is in the seaside town of Teignmouth in Devon, and primarily provides support to people with a diagnosis of Korsakoff’s syndrome and/or a mental health diagnosis.

People’s experience of using this service:

• People were supported by caring staff that knew them well. Their needs were captured in person centred care plans and the care they received was aligned with preferences in care plans.

• People’s needs were regularly reviewed and a thorough assessment process undertaken when new people moved in. The service had just re-written all its care planning documents to better capture how people’s needs affected their day to day living.

• Staff knew how to spot and report any safeguarding concerns and risks were fully assessed and positively managed.

• People were given choice and control in their lives, and this looked different for different people.

• Staff had a good insight into Korsakoff’s syndrome and how this might affect people’s behaviours and changing preferences and opinions.

• People’s health needs were actively monitored and supported, and timely referrals made to relevant health care services.

• Medicines were managed safely and staff were trained and competency tested before administering medicines.

• Staff had a basic understanding of the Mental Capacity Act 2005 and asked people for consent.

• People said they felt safe and relatives told us people were happy and well looked after.

• Quality assurance systems had improved and were now more robust.

Rating at last inspection: At the last inspection in February 2018 the service was rated requires improvement. The report was published in April 2018.

Why we inspected: This was a planned inspection based on our schedule. We did not have any concerns prior to inspecting this service.

Follow up: We will continue to monitor the service through notifications and maintaining contact with the service. We will inspect the service according to our planned schedule, or sooner if we are made aware of concerns.

This inspection took place on 26 and 27 February 2018 and the first day was unannounced.

Nightingale House has been rated requires improvement at two previous inspections. The registered manager and staff are working hard to better understand and implement the improvements required. In January 2016 improvements were required in all five key questions; in November 2016 improvements were required in four key questions. At this inspection improvements were required in two key questions.

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. The home is registered to provide care and accommodation for up to 27 people who have an alcohol related brain damage such as Korsakoff's and/or mental health needs. The home is registered to provide care for 24 people in the main house and three people in a house adjacent to the home known as The Porch House. At the time of the inspection 21 people were living at the main house and no one was living in The Porch House. Nightingale House provides accommodation on the lower-ground, ground and first floors. The home can accommodate people with limited mobility on the ground floor, but people unable to use the stairs would not be able to use the dining room situated on the lower ground floor.

The home has a registered manager who has managed the home for many years. 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 told us they were safe living at Nightingale House. They described the staff as “pleasant”, “nice” and “very accommodating”. One person said, “On the whole they [staff] are really very good.” Staff were observed to be caring in their interactions with people and they spoke positively about their relationship with people. No-one we spoke with had any complaints about the home.

Staff had been provided with safeguarding training in January and December 2017 and were aware of people’s vulnerability due to their circumstances. People’s care plans had been rewritten in an easier to access format and these plans included information about risks to people’s health, safety and well-being. However, some further detail about how living with Korsakoff’s Syndrome and other mental health conditions affected people’s day to day lives was required. Staff had received training in supporting people with these specific care needs and knew people well. Where people were unable to consent to receive care and support, best interest decisions had been made on their behalf. Due to people’s vulnerability and to ensure their safety, people were restricted from leaving the home without the support of staff or a family member. Authorisation for these restrictions had been applied for. Some people told us they no longer wished to live at Nightingale House. Records showed people’s continued residence at the home had been reviewed annually by each person’s commissioning authority to ensure it remained in their best interest to do so.

The home continued to support people with managing their money. Records of money received and spent were recorded for each person. Staff said people had access to their money whenever they needed it but most people required support to budget effectively.

Some people told us they would like more to do during the day. Staff said they encouraged people to be involved in day to day activities, as well as planned events both in and out of the home. Since the home had created the games room, staff said people were engaging more with each other. We asked the home to seek guidance about h

The inspection took place on 14 and 29 November 2016 and the first day was unannounced.

Nightingale House is registered to provide care and accommodation for up to 27 people who have an alcohol related brain damage such as Korsakoff's and/or mental health needs. The home is registered to provide care for 24 people in the main house and 3 people in a house adjacent to the home known as The Porch House. At the time of the inspection 21 people were living at the main house and two of these people were living in The Porch House.

The home had 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.

The home was previously inspected in January 2016 and was rated requires improvement in all five key questions. We identified the home was in breach of a number of regulations of the Health and Social Care Act 2008 Regulated Activity Regulations 2014. Improvements were necessary in a number of areas: how the home documented and managed people’s care needs and risks to their health and safety; gaining people’s consent to their care and not depriving people of their liberty without proper authorisation, as well as maintaining the cleanliness of the home and reducing the risk of cross infection. We issued the home with two warning notices relating to the improvements required.

Following that inspection, the registered manager sent us information about how the home was going to make improvements. They have also been working closely with Devon County Council’s quality assessment and improvement team (QAIT) and had consulted with another provider of a similar service to discuss and share good practice.

At this inspection we found improvements had been made to meet the requirements of the warning notices. However, some further improvements in documentation relating to risk assessment and care planning; staff training as well as supporting people’s independence and involvement with their hobbies and interests were still required. We made a number of recommendations in relation to these issues.

The home had been working with QAIT to review how risks to people’s health and well-being were assessed and how people’s care and support needs were recorded. However, this process had not yet been completed and not everyone’s assessments, management plans and care plans had been rewritten to better reflect their individual needs. Care plans required further information about how staff supported people at times when they became distressed and anxious as well as how to encourage and support people with their independence and personal goals. We found documentation to be lengthy and cumbersome to use. The registered manager agreed staff would benefit from more easily accessible information and confirmed the assessments and care plan documents would be further reviewed and simplified.

While we recognise the manager had made progress to ensure that changes needed were taking place, improvements in the way the home supported people to take risks and promote their independence and choice were not yet fully established and some people still felt overly restricted. This is a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the previous inspection we found people were not being routinely assessed in respect of their mental capacity. Also some people told us they wished to live more independently rather than in a group care home. Following that inspection everyone living at the home had had their capacity to make decisions about their care and support assessed. For those people whose liberty was restricted to maintain their safety, applications for legal authorisation had been submitt

The inspection took place on 2 January 2016 and 8 January 2016 and the first day was unannounced.

Nightingale House is registered to provide care and accommodation for up to 27 people who have an alcohol related brain injury such as Korsakoff’s and / or mental health needs. On the day of the inspection 25 people were living at the care home.

The service had 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.

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People told us staff were kind and caring, and most people told us they were treated with dignity and respect. We found staff did not always have time to talk with people, promote their independence and social activities were limited.

People’s involvement in the community and social life were not promoted, and some people told us they were bored. People felt staff were competent; however, people were not supported by staff that had the knowledge, skills, experience and training to carry out their role and deliver personalised care. People were protected by safe recruitment procedures.

People were supported to eat and drink enough and maintain a balanced diet. Mealtimes were at set times throughout the day and people told us they did not have a choice of meals. Drinks were also at set times throughout the day and served in the dining room.

Some people felt safe living at Nightingale House, some people felt restricted. The registered manager understood their safeguarding responsibilities.

People were protected from risks but to the extent their independence and freedom was affected. Where staff felt there were risks, risk assessments did not identify these. We found blanket rules in place for everyone rather than individual assessments of people’s needs.

People’s mental capacity was not always being assessed and regularly reviewed which meant care being provided by staff may not always be in line with people’s wishes. People who may be subject to Deprivation of Liberty applications (DoLS) had not been assessed. Staff did not understand how the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) protected people to ensure their freedom was supported and respected.

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People did not always have care plans in place which addressed their individual health and social care needs. People were not involved in the creation of their care plan and ongoing reviews of their care. Therefore care plans may not have reflected people’s needs, wishes and preferences about what care they needed and how they wanted staff to provide it.

People’s end of life wishes were not documented and communicated. This meant people’s end of life wishes were not known to staff.

People who were living with short term memory difficulties due to their previous alcohol use were not always appropriately supported in an individual way. People’s care plans did not address people’s cognitive and memory needs or demonstrate how they would like to be supported. People were not always protected by effective infection control procedures.

People knew about the complaints procedure. Staff felt the registered manager was supportive. Staff felt confident about whistleblowing and told us the registered manager would take action to address any concerns.

The registered manager did not have effective systems and processes in place to ensure people received a high quality of care and people’s needs were being met.

People’s medicines were managed safely.

People’s confidential and personal information was stored securely and the registered manager and staff were mindful of the importance of confidentiality when speaking about people’s care and support needs in front of others.

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Because of the complexities of people's illnesses, some people at the home were unable to accurately express their views in detail. For this reason we used observation to ascertain wellbeing and happiness of people. We saw signs of wellbeing and examples which showed that people were relaxed in the company of staff.

We spoke with four people who told us they felt supported by staff and that they were able to be involved in their care. One person said “They don’t ever force anything on me.”

We saw that there were appropriate restrictions and routines placed upon people. Records clearly showed the reasons for these decisions and restrictions.

People had access to health and social care services. People we spoke with said they were happy living at the home. One person said “I’d rather be in my own home but my doctor says I need to put my feet up here and get looked after.”

The home was clean, tidy and free from offensive odours. There were systems in place to ensure that people living at the home, staff and visitors were protected from the risk of infection.

There were suitably skilled staff on duty. The staff we spoke with and people who lived at the home thought there were enough staff on duty. One person said “There is always someone floating around.

The majority of records were well maintained. Care records and maintenance records were clear, easy to use and kept under review.

Because of the complexities of people’s illnesses, some people at the home were unable to accurately express their views. As well as speaking to people who were able to we used direct and indirect observation of interactions between people and the staff providing support. This was to ascertain peoples well being and happiness. We saw signs of positive well being and examples which showed that people were relaxed in the company of staff.

People we spoke with said they were happy living at the home. One person said “I am well cared for.” People explained that staff “Sorted out doctor, dentist and hospital appointments and took them wherever they had to be.”

Staff were knowledgeable about the care and support needs of people in the home. Care records were well written, up to date and clearly reflected the complex needs of people at the home.

Staff felt supported by management and had received training and education to care for vulnerable people. They also knew how to recognise and report any allegations of abuse.

Medications were well managed at the home although the storage of controlled drugs could be improved to meet current storage legislation.

People living at the home, their relatives and staff had opportunities to feedback their views about the service and the provider had systems in place to regularly monitor and assess the quality of the service.

People we spoke with said they felt well treated. We saw signs of well being and many examples where people were being treated with respect by staff. People sitting in the lounge area appeared in a positive mood and were engaged in activities such as watching television, doing puzzles, talking to staff and walking around the home. Conversations were genuine, warm and enabled people to feel included and valued.

Three of the four people we spoke with said they were happy at the home, with the other person giving two different answers.

People told us they liked the staff at the home and felt safe in their company. Laughter and appropriate use of affection was heard and seen throughout the visit.

Questionnaires sent to reviewing officers, care managers and senior practitioners for a council were all complimentary. Quotes included: ‘Korcare have provided a safe and caring environment for our client, maximising his opportunities to lead a full life.’ Another quote read ‘I was impressed by the level of care given to my client. He looked well cared for and content.’

People said the meals at the home were ‘really good’ ‘great’ and ‘lovely.’