This inspection took place over two days on 09 May and 14 May 2018. The first day was unannounced, which meant the service did not know in advance we were coming. The second day was by arrangement.

Norlands Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Norlands Nursing Home is registered with CQC to accommodate a maximum of 21 older people, including those living with dementia. At the time of this inspection the home was full.

At this inspection we found two breaches of regulations concerning safe care and treatment and good governance. We have also made three recommendations relating to the mental capacity act, person-centred care, and equality, diversity and human rights. You can see what action we have asked the service to take at the back of the full report.

We looked at how medicines were managed and found a variety of issues. For example, on the front of each Medication Administration Record (MAR), there was no place to record if a person had any allergies. This placed people at an increased risk of receiving a medicine that they were allergic to. We also found arrangements for administering ‘as and when required’ medicines was ineffective and not response to people’s needs.

We looked at how the service assessed and mitigated risks. We found that not all people who used the service had individual risk assessments completed and that where a risk assessment had been completed, information was recorded in a variety of different places. For example, some risks were noted and addressed in care plans under the heading of ‘safety’ however these were not easily identifiable or clearly presented, others on a separate risk assessment page.

We looked at the use of thickeners in people’s drinks and how special diets were managed for those deemed a high risk of choking. We found the information recorded in people’s care plans was contradictory and did not reflect the most recent swallowing assessment completed by a Speech and Language Therapist (SaLT). As a result of this, we asked the service to complete an immediate review of each person deemed to be at risk of choking. We also raised safeguarding alerts with the local authority.

Norlands Nursing Home benefited from a low staff turnover and all members of staff were on permanent contracts. The service did not use an external staffing agency and short falls in shifts were covered by existing permanent staff. Recruitment procedures remained safe and effective.

Care staff understood how to help people make choices on a day to day basis and how to support them in making decisions. However, information recorded in care plans relating to the mental capacity was not decision specific and we found a blanket approach had been taken in respect of recording if a person was deemed to lack capacity.

We asked the registered provider to provide us with overarching records relating to the management of Deprivation of Liberty Safeguards (DOLS) made to the local authority and found these were not sufficiently robust to ensure oversight was maintained. For example, there was no DOLS matrix or tracker in place that would help the service to record key dates relating to the DOLS process.

People received care and support from staff who knew them well and who had the skills and training to meet their needs. Staff told us they continued to receive lots of opportunities for training and professional development.

We observed the mealtime experience and saw that people benefited from freshly prepared, home cooked food and were offered choice from a varied menu. At breakfast people could choose from a cooked option, cereal, toast or fresh fruit. At lunch time people were offered a choice of two options for both the main and desert. At tea time a selection o

We inspected Norlands nursing home on 10 March 2016. The inspection was unannounced. The service was last inspected in May 2014 when the home was found to be meeting all legal requirements.

Norlands nursing home provides accommodation and nursing care and is registered for 21 older people including those living with dementia. The accommodation is over two floors. On the day of the inspection 20 people were receiving care services from the provider. The home had an experienced registered manager who had been in post for several 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.

At this inspection we found that people who used this service were not always safe. The care staff knew how to identify if a person may be at risk of harm and the action to take if they had concerns about a person’s safety. However issues regarding the recording of medication could place people at risk.

The care staff knew the people they were supporting and the choices they had made about their care and their lives. People who used the service, and those who were important to them, were included in planning and agreeing to the care provided.

The decisions people made were respected. People were supported to maintain their independence and control over their lives. People received care from a team of staff who they knew and who knew them.

People were treated with kindness and respect. One person who used the service told us, "It's such a homely place, the owner and staff are lovely."

The registered manager used safe recruitment systems to ensure that new staff were only employed if they were suitable to work with vulnerable people The staff employed by the service were aware of their responsibility to protect people from harm or abuse. They told us they would be confident reporting any concerns to a senior person in the service or to the local authority or CQC.

There were sufficient staff, with appropriate experience, training and skills to meet people’s needs. Staff were well supported through a system of induction, training, supervision, appraisal and professional development.

There was a positive culture within the service. This was demonstrated by the attitudes of staff when we spoke with them and their approach to supporting people to maintain their independence.

The service was well-led. There was a formal quality assurance process in place. This meant that aspects of the service were formally monitored to ensure good care was provided and planned improvements were implemented in a timely manner. We found that the audits carried out did not always identify discrepancies and areas for improvement in relation to records. There were good systems in place for care staff or others to raise any concerns with the registered manager.

This inspection was carried out by one inspector. At the time of the inspection there were 16 people who lived at the home. We spoke with seven people who used the service and observed their experiences of care to support our inspection. Some people who lived at the home found it difficult to share their experiences due to their health condition. We spoke with the registered manager, seven care staff and three relatives.

We considered our inspection findings to answer questions we always ask:-

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We saw that people had received an assessment of their need before moving into the home to ensure that staff were able to safely meet the person’s care and treatment requirements.

People were cared for in an environment that was clean and hygienic and met their needs. The home had additional security measures in place to protect people.

At the time of the inspection, there was no person who lived at the home subject to Deprivation of Liberty Safeguards. Staff had received training, so they knew how to safeguard people at risk of abuse and we saw best interest decisions had been made to protect people from harm.

One relative told us that they thought their relative was safe living at the home. They said, “I can go on holiday with no worries and know they are being looked after properly.”

The provider had emergency procedures in place to keep people safe from harm, including fire evacuation procedures. We also found that the building was in good order and safe for people to live in.

The provider had effective recruitment procedures in place, including appropriate checks on staff before they began working at the home.

Is the service effective?

People who lived at the home had a named key worker which meant that there was better coordination of the person’s needs.

People living at the home and their relatives, told us that they were happy with the care that was delivered and their needs were met. Staff had received adequate training to meet the needs of the people who lived at the home.

When we spoke to one relative, they told us that the service was very good and had helped to improve their relative’s health issues since they came to live there. This showed evidence of an effective service.

Is the service caring?

We asked two relatives if they had any concerns about the care provided by the home and they told us that were happy with the care provided.

Observations during the visit showed staff being attentive to the people they were supporting. We found good interactions taking place and people were comfortable and relaxed with the staff supporting them.

The home held regular meetings for the people who lived at the home to share their views. Yearly surveys were also completed to further collect the views of the people living at the home.

People who lived at the home were escorted to hospital if the need arose, which meant that people were supported by a familiar face.

Is the service responsive?

We could see from care records, that when a person’s needs changed appropriate actions were taken to ensure that needs were met, including for example; arranging for people to see a GP.

Activities were organised around what people liked to do, for example; going on holiday when they wanted to.

We saw staff quickly responding to requests from people who wanted help with personal care and other activities.

Relatives told us staff contacted them to update them on any changes to the health of their relative or any other information that they may need to know about.

Is the service well-led?

There was a registered manager in post at the home. The home also had regular visits from the owner who provided additional assistance to people who lived at the home.

We found a good staff team in place; staff had very good knowledge of the home and what care the service provided to people living there.

Three relatives told us that they were kept regularly updated by the staff team if any changes occurred. One relative told us, “It’s always got a homely atmosphere when you visit and staff go out of their way to make you welcome”.

All of the people who lived at the home and their relatives that we spoke with, knew who to contact if they had a problem.

One relative said: “What I notice when I visit here is that the staff always involve the residents, they include them in whatever conversation is taking place. They never talk over people’s heads. I really like that.”

People’s care needs were assessed before they decided to move to the home.

Care plans were detailed and person centred. People had a range of risk assessments in relation to their care needs and identified risks. This enabled people to remain as independent as possible within the limitations of their care needs.

People received their medication as prescribed.

Staff were trained and supported to do their job.

There were good quality assurance arrangements in place which ensured good outcomes in terms of the care and treatment people received.

We spoke with people who lived at Norlands Nursing Home; however some people were unable to comment in detail about the care they received due to memory impairment. In light of this we spoke to nursing and care staff and spent a lot of time observing routines at the home and staff interaction with people. We spoke with two relatives of a person who lived and the home.

People told us they were happy with the care they received. One person who lived at the home told us “This is the best care home I’ve ever lived in and it’s the cleanest”.

Another person told us “Food is good, there’s always plenty to eat and you get a good variety”.

We found the home was sufficiently staffed and that nursing and care staff enjoyed their work and were committed to ensuring the best possible outcomes for people living at the home. One member of staff said “we [care staff and nursing staff] have the pleasure of looking after these people [people living at the home]’.

One person living at the home said “My health isn’t good and I need my medication and they [staff] are good I always get my medication’.

We spoke with relatives of a person living at the home. They told us ‘staff are very attentive, they are always coming around offering drinks and food to the residents. It’s really good, the care is good”.

People told us that they enjoyed good and supportive relationships with the staff. People who use the service told us that they felt their care was "very good". One person living at the home told us that the staff were "very kind.” Another person living at home said, "It took a while to get used to living here but I like it and the staff, without question, always do their best for you."

People told us that activities were available both within and outside of the home and that they were happy with the choices available. One person living at the home said “They know me really well and I feel safe here. If I ever needed to say or report anything there’d be no problem doing that here.”

People told us that they had completed quality assurance surveys and felt that their views were taken into account.