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 care home accommodates 30 people over two floors in an older style adapted building. There is a passenger lift to provide access to people who have mobility issues and the garden is also accessible. 27 people were living in the service at the time of this inspection.

This inspection was unannounced and completed by one inspector on 7 and 8 March 2018.

At our last inspection in November 2016 we rated the service Requires Improvement. Following that inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Responsive and Well led to at least Good. At this inspection, we found that they had made the required improvements and the service was rated as Good.

Improvements had been made to people's care plans. There was a new care planning system in place and each person had a care plan. People's individual care needs were recorded and reviewed monthly to ensure they were safe and well. People had better opportunities for social activities and interaction. The registered manager’s understanding of the standards and requirements they were inspected against had improved. An experienced deputy manager had been recruited who provided extra support to the registered manager. Records were more organised and the registered manager had sent us notifications as required to tell us about important events in the service.

Improvements had been made to premises and facilities. New furniture and carpets had been provided in some areas enhancing the safety and quality of the environment for people living there. New equipment was available in the laundry and the changes to the working surfaces in this room supported better infection management.

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.

People were supported in a safe way and staff knew how to recognise and report any risks to people's safety. Medicines were administered in accordance with the prescriber's instructions. Staff recruitment procedures protected people and there were enough staff to meet people’s needs safely. Arrangements were in place for learning and making improvements when things go wrong.

Staff were provided with suitable training and support to enable them to meet people's needs effectively. Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and associated guidance. People were satisfied with the food and drinks available which reflected their lifestyle preferences and nutritional needs. Access to healthcare professionals was well supported. The service worked with other organisations to ensure people received coordinated care and support.

Staff knew what people valued and how they liked to be supported in line with their assessed needs. People’s dignity and privacy was respected and they were supported by friendly and caring staff. Visitors felt welcomed in the service. People told us that they received the care they needed.

People had opportunity to say how they felt about the service and the care it provided. Their views were listened to and actions were taken in response. The provider and registered manager had improving systems in place to check on the quality and safety of the service provided and to put actions plans in place where needed.

This inspection took place on 15 November 2016.

Nightingale House is registered to provide accommodation with personal care for 30 older people. People living in the service may have care needs associated with dementia. There were 27 people living at the service on the day of our inspection.

Improvements were noted to the systems to manage the safety and quality of the service since our last inspection. A manager had been appointed and had recently been registered with the commission as required. 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.

Further improvements were needed to the manager’s knowledge of the requirements of their role and to the content and organisation of required records; including care records. Enhancement of the environment and people’s social opportunities were areas for development.

Staff were knowledgeable about identifying abuse and how to report it to safeguard people. Recruitment procedures were suitable. Risk management plans were in place to support people and to limit risks to their safety. Medicines were safely stored and administered in line with current guidance to ensure people received their prescribed medicines.

People were supported by staff who knew them well and were available in sufficient numbers to meet people's needs effectively. Staff were trained and supported in their role. The manager understood and complied with the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS).

People had choices of food and drinks that supported their nutritional or health care needs and their personal preferences. Arrangements were in place to support people to gain access to health professionals and services.

Staff were friendly, kind and caring towards the people they supported and care provided met people’s care and support needs overall. People’s dignity, privacy and independence was respected and they found the staff to be friendly and caring. Visitors were welcomed and relationships were supported.

People knew the manager and found them to be approachable and available in the home. People living and working in the service had the opportunity to say how they felt about the home and the service it provided. Their views were listened to and actions were taken in response.

This inspection took place on 15 and 16 February 2016.

Nightingale House is registered to provide accommodation for 30 older people who require personal care. People may also have needs associated with dementia. There were 30 people living at the service on the day of our inspection.

A registered manager was not in post. The registered provider had informed us in December 2015 that they had appointed a deputy manager who they planned to put forward for registration as manager for the service. 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.

Risks to people’s health and well-being were not always assessed or were not sufficiently detailed to ensure people’s safety. The provider’s systems to check on the quality and safety of the service provided were limited and not always effective in identifying and acting on areas that required improvement.

Records were not well organised to support the effective management of the service. Staff training and support systems were not demonstrated as being consistently implemented. Care records did always have up to date information on all aspects of people’s care needs to guide staff on how to meet people's assessed needs although staff knew people well and management had made changes to improve this.

Staff had attended training on safeguarding people and were knowledgeable about identifying abuse and how to report it. Recruitment procedures were thorough. Staff understood and complied with the requirements of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards.

People medicines were safely managed and they had regular access to healthcare professionals. A choice of food and drinks was available to people that reflected people’s nutritional needs and took into account their personal preferences.

People were supported by staff who knew them well. People’s dignity and privacy was respected and staff were kind and caring. Visitors were welcomed and people were supported to maintain positive relationships with others.

The provider had a clear complaints procedure in place. People felt able and had opportunity to express their views on the service and to be listened to.

The majority of people we spoke with during our visit were unable to tell us about their experiences of using the service due to their short term memory or other dementia related cognitive or communication impairment. For this reason we used observations to help us make judgements about the standard, quality and safety of care and support that people received. We also spoke with relatives who visited the service during our inspection.

People we spoke with told us that staff were ''kind'' and ''caring'' and that they received the help and care they needed.

We saw that staff had a good understanding of each person's needs in relation to their physical, mental and general health. There were detailed assessments and care plans in place to help staff care and support people appropriately and risks to the health, safety and welfare of people were generally well managed.

Improvements were needed to ensure that the premises were properly cleaned and that risks of infection were assessed and managed. Improvements were also needed to ensure that the quality and safety of the service provided was monitored effectively and improved where needed.

The majority of people in Nightingale House were living with dementia or age related memory loss and were unable to tell us about some aspects of what it was like to live in the home.

People we spoke with told us that they were treated well and that their wishes were taken into consideration. Two people told us that they were regularly asked about the things that were important to them such as choice of meals and activities and how they spent their days.

People said that they were well cared for. One person told us: ‘’I cannot fault the care I get here.’’ Another person said: ‘’We are all looked after very well. I have no complaints about anything.’’ Relatives we spoke with told us that they were happy with the care and treatment people received. People we spoke with told us that staff treated them well and that they felt safe living at Nightingale House.

People told us that they were happy with the choice of meals provided at Nightingale House. People told us that the food was good and that they enjoyed their meals. One person told us ‘’ the food here is as good as I expect. There is plenty to eat and the menu is changed regularly so there are new meals to try.’’

People we spoke with told us that they felt that improvements had been made to the home in recent months. One person told us ‘’we are asked how things can be improved and I think this had made a difference.’’

All of the people we spoke with told us that they were happy with the way that complaints were dealt with and they felt confident that their concerns were taken seriously.

Nightingale House is a service that provides care and support to older people, many of whom have dementia. It was not possible to obtain the views from many people who were using the service. Information was therefore obtained mostly from relatives and through observations made during our visit.

People we spoke with told us that they were unaware of choices available to them, for example choice from menus at mealtimes and choice of activities available to them. Three people we spoke with told us that they did not know what choices or meals were planned for the day’s lunchtime meal. One person told us ‘’We never know, we just eat what we get.’’ Three people told us that there was ‘’little’’ or ‘’nothing’’ to do during the day. A number of people told us that they would like to go out more but that there were no opportunities to do so.

Relatives we spoke with told us that they had little information about the home and the services provided prior to their family member being assessed and moving into Nightingale House. One relative told us that a leaflet had been given, together with a good explanation of the care and facilities provided, whereas another relative felt that little information had been given. Relatives told us that they or their family members had not been involved in planning individual’s care or support.

Relatives on the whole said that they felt that resident’s privacy and dignity was respected. One person told us that staff had acted supported their family member when they were behaving inappropriately and had helped to change their behaviour in order to maintain their dignity.

Most people we spoke with were unable to tell us about the care and treatment they received. One person told us ‘’It’s ok , we get our meals and its fairly comfortable here. What more could we ask for?’’ Another person said ‘’ We have nothing to do, we just sit here all day and wait for something to happen.’’

Relatives we spoke with told us that overall they felt that their family members were safe. One relative commented that people were ‘’kept clean, warm and fed.’’ They told us that they felt that with more support and encouragement people would benefit from exercise and activities.

People we spoke with told us that they felt safe living in Nightingale House. Two people told us that staff treated them well and that most staff were caring. Two people told us that some staff had an ‘’attitude’’ and were ‘’not as nice as others.’’

Most of the people who use this service have difficulty understanding and responding to verbal communication. During our visit we were able to hold a conversation with four people. A few others were able to make comments about specific issues, such as the meals, however; most of the information about people's experiences of Nightingale House was gathered through our observations.

One person with whom we spoke said, "I can do pretty much what I want during the day, I enjoy spending time in the garden.’’ Two other people told us that there was little to do during the day. One person said, ‘’ It’s the same old, same old every day nobody asks us if we would like to go out or do something different.’’

Staff understood people's communication difficulties but did not always try to find ways to help people make choices and decisions about their everyday lives. For example, staff did not offer people the opportunity to make choices about where they took their lunch time meal, offer choices for drinks or condiments.

People using the service said they liked the food. One person told us, "The food is good. It’s like a hotel." Four people told us that they did not know what menu choice was available and one person told us that they had not seen a menu card. People were given time to eat their meals in an unrushed way.

People with whom we spoke told us that they were treated well by staff and that they felt safe. One person said, ‘’I feel safe here, staff are caring and kind.’’

One person told us that they always received their medicines on time.

Four people told us that they did not have any complaints but that they were unaware of the procedure for making complaints.

During our inspection we spoke with most of the people who used the service and one of their visiting relatives. We also spoke with six members of staff and the manager. We looked at four people's care files, four staff’s training records, staff duty rotas and kitchen records. We carried out a random check of the service’s medication system, quality assurance and complaints processes.

We thought about what we found and asked the questions that we always ask; is the service safe, effective, caring, responsive and well-led?

This is a summary of what we found:

Is the service safe?

When we arrived at the service we were asked to sign the visitor's book and our identity was checked. This meant that people were protected from unwanted visitors such as others who posed a risk to their safety.

People told us that they felt safe living in Nightingale House. One person said, “I can go out and leave all my things here and I don’t have to worry as they are all here when I get back.” Another person said, “I am happy here but would rather be at home, I do feel safe as the staff are always around when you need them.” Another person said, “The manager is really lovely and always has the time to stop and speak with me, I do feel safe here.”

Staff had received training in safeguarding vulnerable adults from abuse (SOVA). Senior staff had undertaken training in the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). The manager was aware of recent changes to guidance about DoLS. Other staff were due to attend MCA 2005 and DoLS training when it becomes available. This meant that staff had been given the information that they needed to ensure that people were cared for safely. Health and safety checks had been carried out and issues had been dealt with appropriately. This showed that the service was safe.

Is the service effective?

People told us that they felt that the service met their needs. One person who used the service said, “The staff are very quick to come when I call them, I have never had to wait too long for help.” Another person said, “This is a great service, the staff are all so good and they make sure that I get my meals when I want them. They serve a good meal here and they offer me plenty of choice.”

People's care records showed that care and treatment was generally planned and delivered in a way that was intended to ensure their safety and welfare. There were risk assessments together with clear management plans on most of the care files that we looked at. However, on one care file we found that a low risk had been identified but there were no plans on how it was to be managed. The care records were handwritten and provided personalised details such as ‘put toothpaste on the brush and hand to [person’s name]’ and, ‘support to choose appropriate clothing.’

Care records and risk assessments had been reviewed and updated on a three monthly basis. This may not be regular enough to ensure that staff have up to date information on how to meet people’s needs.

Is the service caring?

Staff’s interaction with people who used the service was good. They spoke with people respectfully and supported them in a kind and caring way. Staff had a good knowledge of people’s likes and dislikes. People told us that all of the staff treated them well. One person said, “The staff are ultra-caring, they can’t do enough for you. If I was an employer, I would employ any of the staff who work here as they are all so good and reliable.”

People told us that the staff treated them respectfully. They said that they were always given choice in what to eat and what to do. One person said, “The staff are very respectful, they always knock on the door and ask if it is OK for them to come in. They take the time to listen to what I have to say and they all have time to talk with me when I need it.” One visiting relative said, “This is an excellent service, the manager and staff are so kind and caring. I am very happy with my relative’s care and I now have peace of mind that they are cared for safely.”

We saw ‘thank you’ cards from the relatives of people who had used the service in the last three months. They contained compliments about the care provided and expressed their thanks for making their relative comfortable in a kind and caring environment.”

People’s preferences and diverse needs had been recorded in their care files and care and support had been provided in accordance with their wishes. This showed that people were cared for by kind and caring staff.

Is the service responsive?

People told us that they had plenty to do. One person said, “I go out quite a bit and there is plenty to do in the house if I want it.” Another person said, “We have a dog visit quite regularly and it is lovely.” Another person said, “I have had my nails done today and I really like the colour. I enjoy pampering days.”

People told us that staff were quick to respond if they called them. They said that their call bells were always within easy reach when they were in their rooms. We saw that there was plenty of staff on duty who acted swiftly when people who used the service called for assistance.

People were supported to see other professionals such as general practitioners, psychiatric nurses, chiropodists, opticians, and district nurse. This showed that people’s general health care needs were met and that the service responded to people’s changing needs.

Is the service well-led?

There was a good quality assurance system in place. The service had sought the views of people who used the service, their relatives and visiting professionals. They had analysed the information and carried out any necessary actions.

People told us they were happy with the service they received. One person said, “This is a really good service, the staff are kind and caring and they always take the time to listen to me.” Another person said, “They care, and they listen to what I have to say.” One visiting relative said, “The manager is excellent, they are all good communicators, they keep me informed and my relative is doing well.”

The manager had carried out regular quality and safety checks such as for the building, incidents/accidents, medication and complaints. The complaints procedure was clear and it showed timescales for when complaints would be responded to. People told us that they knew how to complain. There was a range of information, including the complaints procedure, available in the entrance hall. This showed that there was an effective quality assurance system in place and that the service was well-led.