The inspection took place on the 7 and 12 November 2018 and was unannounced.

Northbrooke House Nursing Home is registered to provide accommodation for up to 67 older people. There were 58 people living at the home at the time of the inspection. The home is a large extended property and accommodation is arranged over two floors and within two buildings. All bedrooms were for single occupancy and many had ensuite facilities. Bathrooms and toilets were provided on both floors. There was a lift and stairs available to access all the first-floor areas. There was a flat patio area adjacent to the home and lawned garden areas including a paddock housing two donkeys.

Northbrooke House Nursing Home is a ‘care home’. People in care homes receive accommodation, nursing and 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. We found the home to be clean and well maintained throughout the inspection.

There were two registered managers, each responsible for different parts of the home and both had an overarching responsibility for the whole of Northbooke House. 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 in place to monitor the quality and safety of the service provided and to manage the maintenance of the buildings and equipment. However, these systems were not always effective. They had not identified the areas of concern we found during this inspection in relation to: the inappropriate use of restrictive practices, the safe management of medicines, individual risk management systems, wound care and inconsistencies in care plans and record keeping.

Not all aspects of medicines management were safe. This included the administration of some medicines and ensuring safe storage temperatures.

Individual risks to people were not always managed effectively and the provider’s physical intervention policies and procedures were not always being followed.

Staff usually protected people’s rights by following the Mental Capacity Act, 2005 (MCA) and were aware of which people were subject to restrictions of their freedom.

Staff demonstrated a good awareness of the individual support needs of people living at the home.

However, people's care plans did not always support staff to deliver care in a personalised way and ensure some specific healthcare needs were met in a timely manner.

Staff supported people at the end of their lives to ensure their comfort and their dignity.

People's nutrition and hydration needs were met and people were satisfied with the quality of their meals. Where necessary people received the support they required with eating and drinking.

People were treated in a kind, considerate and compassionate way by staff. Privacy and dignity was maintained and staff used appropriate techniques to communicate effectively with people.

People's individual cultural, sexuality and diversity needs were identified and staff respected these and supported people to meet these and to follow their faith.

Staff encouraged people to be as independent as possible. Relationships with family and friends were encouraged and staff ensured family members were kept up to date with events that had occurred for their relative.

Staff supported people to access a range of activities suited to their individual interests. Positive links with the local community had been developed.

Appropriate recruitment procedures were in place and there were sufficient staff available to meet people’s needs. Staff were competent and understood people's needs and were appropriately supported in their role by senior staff and managers.

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Northbrooke House is registered to accommodate up to 62 people. The home provides services to a range of people in three distinct units. Services include rehabilitation and nursing care in Hazel Lodge, nursing care for older people in Mercury Suite and care for people living with dementia in Rylands Suite. At the time of the inspection the home accommodated a total of 59 people.

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.

The inspection was unannounced and was carried out on the 17 March 2016.

The people, their families and health professionals told us they felt people were safe. People experienced care in a safe environment because the registered manager and staff had the knowledge necessary to enable them to respond appropriately to concerns about people’s safety.

People were protected from individual risks in a way that supported them and respected their independence. The risks relating to people’s health and welfare were assessed and these were recorded along with actions identified to reduce those risks in the least restrictive way. They were personalised and provided enough information to allow staff to protect people whilst promoting their independence.

People were supported by staff who had received the appropriate training, professional development and supervision to enable them to meet their individual needs. There were enough staff to meet people’s needs and to enable them to engage with people in a relaxed and unhurried manner.

People received their medicines safely. There were suitable systems in place to ensure the safe storage and administration of medicines. Medicines were administered by staff who had received appropriate training and their competency to administer medicines had been assessed. Healthcare professionals such as GPs, chiropodists, opticians and dentists were involved in people’s care where necessary.

People and their families told us that staff asked for their consent when they were supporting them. Staff followed legislation designed to protect people’s rights and ensure decisions were the least restrictive and made in their best interests.

Staff developed caring and positive relationships with people and were sensitive to their individual choices and treated them with dignity, respecting their choices and privacy. People were encouraged to maintain their family relationships.

People were supported to have enough to eat and drink. Mealtimes were a social event and staff supported people in a patient and friendly manner.

Staff were responsive to people’s communication styles and gave people information and choices in ways that they could understand. They were patient when speaking with people and gave them time to respond to what was being said.

People and when necessary their families were involved in discussions about their care planning, which reflected their assessed needs. Each person had an allocated keyworker and a key nurse, who provided a focal point for that person and maintained contact with the important people in their circle of support.

There was an opportunity for people and their families to become involved in developing the service and they were encouraged to provide feedback on the service provided. They were also supported to raise complaints should they wish to.

People’s families told us they felt the service was well-led and were positive about the registered manager who understood the responsibilities of their role. Staff were aware of the provider’s vision and values, how they related to their work and spoke positively about the culture and management of the service.

There were systems in place to monitor quality and safety

The home provided services to a range of people in three distinct units. Services include rehabilitation and nursing care in Hazel Lodge, nursing care for older people in Mercury Suite and care for people with dementia in Rylands Suite.

Across the three units, we looked at 11 care plans, spoke with nine people and four family members. We also spoke with the provider, 14 members of staff and two external healthcare professionals.

We found care plans were signed by the person, showing they had been consulted about their planned care. People told us staff knew them and they felt involved in the way their care was delivered on a day to day basis. A family member said of the staff, “They really involve me and talk to me. I feel like I’m one of them, they are so supportive”. Several people we spoke with in the Mercury and Rylands suites talked about feeling “loved”. Comments included: “I’d like to stay here forever; I get special love here”.

People in Hazel Lodge had a diverse range of conditions, including degenerative disorders and brain injuries. In addition, seven beds were allocated to people discharged from hospital for short term rehabilitation. We found people received appropriate care and treatment that met their diverse needs.

In the Mercury and Rylands suites, we found care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People’s needs were known and met by staff who showed warmth and kindness. One person said, “I’m comfortable, looked after and I like the carers”.

People were provided with a choice of suitable and nutritious food and drink. Those who required support to eat their meals received it on a one to one basis by staff who sat and engaged with them in a warm and positive way.

People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff had the knowledge required to identify and report abuse and the provider responded appropriately to any allegation of abuse.

People were protected from the risk of infection because appropriate guidance had been followed. Laundry procedures complied with best practice guidance. People were cared for in a clean environment.

New staff received a comprehensive induction in line with the industry standard. Staff told us they received regular supervision and felt well supported. Arrangements were in place to ensure received an annual appraisal.

We spoke with nine of the 58 people who were living at the home. They said that they were happy with the way they were cared for. People also said the “staff knew what care they required” and were “available when I need them”. People told us they were “looked after very well”. We spoke with three relatives. One said they were “very happy with the care their loved one was receiving”. The other relatives expressed similar views. They all said when visiting the home they had never observed or heard anything that caused them any concern.

Not everyone was able to tell us about their experiences. We therefore used the Short Observational Framework for Inspection (SOFI2) to observe care and help us understand the experience of people who could not talk with us. We completed this in the lounge within a part of the home specialising in the care of people with dementia. We found people had positive experiences. We observed that care and support were provided in a warm, friendly and respectful way. Staff were aware of how people should be supported, individual likes and dislikes and the help they required.

We found that medication was correctly managed and appropriate staffing levels were provided. The home was well maintained and suitable for the people living there. Care plans were relevant to people’s needs and records were well maintained and stored securely.

Northbrooke House Nursing Home has a separate area dedicated to the care of people with dementia and therefore these people were not able to tell us about their experiences. To help us to understand the experiences these people have we used our Short Observational Framework for Inspection (SOFI) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. This showed that people are well cared for by staff who had time and the necessary skills to meet their needs.

Other people using the service were able to tell us about their experiences and we also spoke with visitors to the service and other health professionals.

People were very positive about their experiences. They said their health, care and rehabilitation needs were being fully met. People said that staff knew how to look after them, and although staff were busy they were always friendly and polite. People said that if they had any concerns or complaints they would raise these. They had no complaints when speaking with us.

Visitors were also positive about the way the home met the needs of their relatives. Visitors confirmed that they were kept informed about any illness or untoward incidents and this gave them peace of mind when they were not visiting. Visitors felt that health and personal care needs were being met. Visitors were positive about staff and felt they did a good job although they were kept busy. Visitors said that they did not have any concerns or complaints but would raise these with the staff or the manager if they did.

We also spoke with other professionals involved in the care of people. They stated that they had no concerns about how people’s health and care needs were met.