This inspection took place on 22 and 30 May 2018 and was unannounced on the first day.

At our last inspection in June 2017 we rated this service as good. However, we found at this inspection that there was a deterioration in the standards of record keeping which meant the service has been rated as requires improvement.

Rambla Nursing Home provides care and support for up to 30 people who may have nursing needs. The service is registered to provide care for older people and younger adults as well as people who may be living with a physical disability or dementia. At the time of this inspection there were 29 people who used the service and all required nursing care and support.

Rambla 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.

The service had a registered manager who registered with CQC in December 2017. 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 quality of the record keeping varied and some care records we looked at were not personalised and were inconsistent or incomplete. This meant staff did not have an up to date record of people’s care and treatment.

Although we found there was a good level of day to day monitoring and overview of risks and quality of the service by the registered manager, there were few up to date audits to record their observations and demonstrate that they acted on shortfalls in a timely way. The frequency of staff supervisions and staff meetings had dropped below the provider’s expected standards. Action was taken during and following the inspection by the registered manager to rectify this.

People told us they felt safe and were well cared for. The provider followed robust recruitment checks, to employ suitable people. There were sufficient staff employed and on duty that they were able to assist people in a timely way. Medicines were given safely and as prescribed by people’s GPs.

Staff had completed an induction and attended relevant training to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were able to talk to health care professionals about their care and treatment. People could see a GP when they needed to and they received care and treatment when necessary from external health care professionals such as the district nursing team and speech and language therapists (SALT).

People were treated with respect and dignity by the staff. People said staff were caring and they were happy with the care they received. They or their relative (where appropriate) had been included in planning and agreeing the care provided.

People had access to community facilities and a range of activities provided in the service. People and relatives knew how to make a complaint and six out of the seven relatives who spoke with us were happy with the way any issues they had raised had been dealt with.

People told us that the registered manager was approachable, open and honest. People and staff were asked for their views and their suggestions were used to continuously improve the service.

At this inspection we identified a breach of regulation 17 with regard to poor record keeping.

You can see what action we told the provider to take at the back of the full version of this report.

Rambla Nursing Home provides care and support for up to 30 people who may have nursing needs. The service is registered to provide care for older people and younger adults as well as people who may be living with a physical disability or dementia.

On the day of the inspection, there were 29 older people using the service, all of whom had nursing needs.

We carried out an unannounced comprehensive inspection of this service on 5 April 2017. We found the service required improvement to become safe, responsive and well-led.

This focused inspection took place on 22 June 2017 and was announced. We gave 24 hours’ notice of our visit, because the manager was on leave, and we wanted to ensure the provider’s nominated individual would be at the service when we inspected.

This focused inspection was in part prompted by concerns shared with us regarding the care and support provided at the service. This included concerns about the support provided around mealtimes and whether people had enough food and drink to ensure they were not dehydrated or at risk of malnutrition. We used this information to plan our inspection and have reported our findings in relation to these concerns in the body of our report.

We also took the opportunity to review the provider’s progress following our last inspection and looked to see whether the service was safe at this inspection. This report only covers our findings in relation to the ‘Safe’, ‘Responsive’ and ‘Well-led’ domains. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Rambla Nursing Home on our website at www.cqc.org.uk.

During our inspection, we found action had been taken to improve the safety and responsiveness of the service. We have changed the rating of the safe and responsive domains to ‘good’ and, because of this, the service is now rated ‘good’ overall.

We observed consistently positive and effective interactions between staff and people who used the service. Staff were observed to be kind, caring and attentive to people’s individual needs. People presented as comfortable, clean and exceptionally well cared for.

Although we noted a number of improvements had been made, we found further work was still needed to ensure the service was well-led. The provider is required to have a registered manager as a condition of their registration for this service. On the day of the inspection, the service did not have a registered manager. However, the nominated individual was taking action to become registered until a suitable candidate could be found. 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 records were not yet consistently well maintained and work was on-going to improve the provider’s quality monitoring systems, to ensure issues and concerns would be effectively identified and robustly addressed.

We found improvements had been made to the safety of the service. Care plans and risk assessments were in place to support staff to provide safe care. Improvements had been made to how topical medicines were managed and administered. The provider had introduced a new system to record important information staff would need to know when administering medicines that were prescribed to be taken only when needed. Sufficient staff were deployed to meet people’s needs and staff were observed to be proactive and attentive in managing risks.

Staff supported people in a person-centred way to ensure they ate and drank enough. People were supported to spend their time how and where they wished. The provider employed an activities coordinator and staff were observed to regularly engage and provide meaningful stimulation for people who used the servic

The inspection took place on 5 April 2017 and was unannounced. We carried out the last inspection in October 2016, where we found the registered provider was not meeting all the regulations we inspected. We found at that inspection the provider had failed to provide safe care and treatment, person centred care and the overall governance of the service was not effective in identifying issues that needed to be addressed. There was also a lack of understanding by staff around the safeguarding of people from abuse and improper treatment, adequate training and recruitment processes. We told the provider they needed to take action and we used our regulatory powers to address the shortfalls. We also asked for and received an action plan telling us what they were going to do to ensure they were meeting the regulations.

At this inspection we found efforts had been taken to address the shortfalls identified at the October 2016 inspection. We saw what improvements had been made and that a structured plan was in place to move the service forward.

Rambla Nursing Home provides personal care for up to 30 older people who may have nursing needs. The service is also registered to care for younger adults, people who are living with dementia and people whose needs are predominantly associated with physical disability. On the day of the inspection there were 25 people living in the home, 23 of whom required nursing care.

Since the last inspection the registered manager had left the service. The registered provider had recruited a new manager who told us they were intending to apply to be registered with the Care Quality Commission. The service has to have a manager 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.

Overall people told us they felt safe. Staff understand how to safeguard people from abuse. People and staff we spoke with expressed mixed views regarding staffing levels. We saw from the rotas staffing levels were based on the provider’s assessment of people’s needs and occupancy levels. The recruitment process was robust and staff completed an induction when they started work.

We found the amount of information in care plans had improved and contained more relevant information and noted that further staff training was in progress. This meant people were protected against the risks of receiving care that was inappropriate or unsafe. Care staff had access to people’s care plans. On the whole individual risks were updated regularly and contained sufficient information. However, some further work was needed in some cases to make sure staff fully understood the actions they should be taking to minimise any potential risks identified. It was clear, however, that staff were receiving additional supervision to allow them to understand the importance of accurate record keeping. This stance had been adopted so that staff knew the principles of record keeping rather than a senior member of staff rewriting all the care records. We have made a recommendation regarding the completion of risk assessments.

We found people had access to healthcare services to make sure their health care needs were met. People lived in a clean, comfortable and well maintained environment. People were mostly protected against the risks associated with the administration, use and management of medicines. We have made a recommendation regarding the use of ‘as required’ medication and the completion of records relating to prescribed topical creams.

Staff had completed a range of training and additional training had been planned for the remainder of the year. We saw from the 2017 supervision schedule that staff had received supervision and a programme of regular updates was in place.

The care plans we looked at cont

Rambla Nursing Home provides personal care for up to 30 older people who may have nursing needs. The service is also registered to care for younger adults, people who are living with dementia and people whose needs are predominantly associated with physical disability. On the day of the inspection there were 29 people living in the home, 27 of whom required nursing care.

This inspection took place on 21 October 2016 and was a re-rating inspection carried out to provide a new rating for the service under the Care Act 2014 and to see if the registered provider and registered manager had made the improvements we required during our last inspection.

This inspection was also prompted in part by a continuing investigation into alleged serious shortfalls in care delivery to one person living at the service. This has involved the police, North Yorkshire County Council, Scarborough and Ryedale Clinical Commissioning Group and the Care Quality Commission (CQC). This matter is subject to an on-going investigation and as a result this inspection did not examine the specific circumstances of the allegations.

However, the information shared with CQC and other stakeholders, indicated potential concerns about the management of people using the service in relation to moving and handling and the risk of choking. This inspection examined those risks.

We last inspected this service on 7 and 11 April 2016 where we identified breaches relating to:

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to medicine audits which were not formally recorded; clinical monitoring charts which were not always completed accurately with no gaps to ensure people received the care they required; and, risk assessments which were not always clearly linked with care plans to provide a consistent plan for staff to follow when offering care.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 where one aspect of medicines handling was unsafe.

After that inspection the provider sent us an action plan telling us about the actions to be taken. During this inspection we found that some of the previous assurances from the provider had been implemented with some improvements made in relation to medicines audit.

However, at this inspection we also found breaches of five of the Fundamental Standards of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safe delivery of care and treatment, person centred care, safeguarding people from abuse and improper treatment, staff induction, training and recruitment processes and the overall governance of the service. For example, unsafe manual handling and feeding techniques which had placed at least one person at serious risk were seen. Risk assessments were not sufficiently detailed to mitigate identified risks. Staff recruitment was not robust and although systems were in place to assess and monitor the service, these had not been completed consistently.

Prior to the inspection a relative had provided us, the local authority and the provider with video footage showing round the clock care delivery to one person using the service. After the inspection visit and as part of our inspection CQC inspectors viewed this footage. They also considered the verbal accounts and views of what was seen on the footage from the local authority and police. We saw care practices by several staff members which raised serious concerns over staff supervision. Also, a clear need for registered nurses to lead other staff designations by example of best practice at all times. This also raised significant concerns about the registered manager’s leadership and lack of action where care practices were unsafe and unacceptable.

As a consequence of this CQC has instigated their enforcement powers against the registered provider and registered manager. Full information about CQC's regulatory response to any c

This inspection took place on 7 and 11 April 2016 and was unannounced. The provider of this service changed. This is the first inspection of the service with the new provider. This has been a change in provider name only in order to rationalise the registration across the provider group. The professional relationships remain with the same individuals as under the previous registration.

Rambla Nursing Home provides personal care for up to 30 older people who may have nursing needs. The service is also registered to care for younger adults, people who are living with dementia and people whose needs are predominantly associated with physical disability. On the two days of the inspection there were 30 people living in the home. The home is located in the town of Scarborough.

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.

Medicines were generally safely handled; however, we noted one aspect of medicines handling which was unsafe. This was a breach of Regulation 12(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the end of this report.

Risks were generally well assessed to protect people, however falls risk assessments did not always clearly outline the current risk to people. Risk assessment guidelines were occasionally not acted upon to protect people. We made a recommendation about this.

Staff were able to tell us what they would do to ensure people were safe and people told us they felt safe at the home. The home had sufficient suitably recruited and trained staff to care for people safely. The environment of the home was safe for people and safety checks were regularly carried out. People were protected by the infection control procedures in the home.

Staff had received up to date training in Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). They understood that people should be consulted about their care and the principles of the MCA and DoLs. People were protected around their mental capacity.

People’s nutrition and hydration needs were met. People enjoyed the meals and they were of a good quality. Risks were generally well assessed and specialist advice was usually followed. However, we made a recommendation about the way in which risk was assessed in relation to monitoring weight and a further recommendation about one instance of following specialist advice in relation to eating and drinking.

People were treated with kindness and compassion. We saw staff had a good rapport with people whilst treating them with dignity and respect. Staff had knowledge and understanding of people’s needs and worked together well as a team. Care plans provided detailed information about people’s individual needs and preferences. Records and observations provided evidence that people were treated in a way which encouraged them to feel valued and cared about.

People were supported to engage in daily activities they enjoyed, which were in line with their preferences and interests. Staff were responsive to people’s wishes and understood people’s personal histories and social networks so that they could support them in the way they preferred. Care plans were kept up to date when needs changed, and people were encouraged to take part in their reviews and to give their views which were acted upon.

People told us their complaints were responded to and the results of complaint investigations were clearly recorded. Most people we spoke with told us that if they had concerns they were always addressed directly with the registered manager who responded quickly and with courtesy.

The service ha