About the service: Ranvilles Nursing & Residential Home is a residential care home that was providing personal and nursing care to 43 people at the time of the inspection. Care and support was provided to older people living with dementia and mental health needs.

People’s experience of using this service:

• People were at a significant risk of avoidable harm. Risks to people were not fully assessed and measures were not sufficiently put in place to mitigate risks to people.

• The culture of the service was task focused and staff did not always recognise poor practice. For example, incorrect manual handling practice. We observed some poor manual handling practice during the inspection that put people at risk.

• People in the service displayed a significant number of physically aggressive behaviours. There were a high number of unexplained incidents including bruises. Accidents and incidents were not always recorded and notified to the appropriate organisations such as the local authority. Accidents and incidents were not fully investigated and analysed to prevent future occurrences.

• We received mixed feedback about how open and transparent the service was.

• A staff feedback survey demonstrated concerns about a lack of teamwork. Feedback from staff and relatives was not appropriately acted upon. We have made recommendations about this.

• Staff were not consistently caring and people were not always treated with dignity and respect.

• The provider was not person-centred. People’s diverse needs were not always respected and met.

• The provider was not providing care in accordance with the Mental Capacity Act (2005).

• Staff training was out of date and staff did not always have the skills and expertise required to provide safe care and support.

• The service met the characteristics of inadequate in most areas.

Rating at last inspection: The service was last rated Good, published in December 2017.

Why we inspected: This inspection was brought forward due to information of concern.

Enforcement: Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: Following the inspection we took urgent action to ensure the provider improved the safety in the service. We informed the local authority and clinical commissioning group (CCG) of our concerns.

The overall rating for this registered provider is 'Inadequate' and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special

We carried out an unannounced inspection of this home on 16 and 17 November 2017. CQC had been made aware of a complaint the home had received in 2016 following the death of a person. This matter was being further investigated and as such was not reviewed as part of this inspection. However, the information shared with CQC about the incident indicated potential concerns about the management of nutrition and hydration for people who lived in the home and poor record keeping. These identified risks were examined in this inspection.

The home is registered to provide accommodation and nursing and personal care for up to 53 older people who live with advanced dementia or mental health conditions. Accommodation is arranged over two floors with access to all areas by stairs and lift. At the time of our inspection 46 people lived at the home.

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.

Staff had a good understanding of how to protect people from the risk of infection and policies and procedures were in place for the management of infection control. However, some flooring in the home required replacement as it was difficult to maintain this hygienically.

People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse, discrimination and harassment and report these appropriately. Robust processes to check the suitability of staff to work with people were in place. There were sufficient staff deployed to meet the needs of people and they received appropriate training and support to ensure people were cared for in line with their needs and preferences.

Risk assessments in place informed plans of care for people to ensure their safety and welfare, and staff had a good awareness of these. Incidents and accidents were clearly documented and investigated. Actions and learning were identified from these and shared with all staff.

Medicines were administered, stored and ordered in a safe and effective way.

People were encouraged and supported to make decisions about their care and welfare. Where people were not able to consent to their care, staff followed legislation designed to protect people’s rights and freedom.

People received nutritious meals in line with their needs and preferences, in an environment which provided a calm and relaxing dining experience for them. Those who required specific dietary requirements for a health, cultural or religious need were supported to manage these.

Staff were calm, kind and gentle in their interactions with people and supported them to remain independent whilst maintaining their safety and welfare. People’s privacy and dignity was maintained and staff were caring and compassionate as they supported people. Staff knew people in the home very well and involved them and their relatives in the planning of their care.

Care plans were person centred and reflected people’s physical, mental, emotional and social needs. The home worked with a multidisciplinary team of health and social care professionals to ensure people’s individual needs were met.

The registered manager promoted an open and honest culture for working which was fair and supportive to all staff. Staff felt supported in their roles and provided care in a manner that was in keeping with the provider’s philosophy of care. People and their relatives spoke highly of the registered manager and all their staff team.

Effective systems were in place to monitor and evaluate any concerns or complaints received and to ensure learning outcomes or improvements were identified from these. Staff encouraged people and their relatives to share their concerns and experiences with

We carried out an unannounced inspection of this home on 13 and 14 October 2016. The home provides accommodation, nursing and personal care for up to 53 older people who live with dementia or mental health conditions. Accommodation is arranged over two floors with stair and lift access to all areas. A third floor of the home accommodated office space for training and management offices. At the time of our inspection 48 people lived at the home. The home was fully occupied as some rooms designated for two people were occupied by one person to accommodate their individual needs.

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 by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately. Whilst processes to check the suitability of staff to work with people were in place, records were not always fully informed with this information. There were sufficient staff available to meet the needs of people and they received appropriate training and support to ensure people were cared for in line with their needs and preferences.

Medicines were administered, and ordered in a safe and effective way.

Staff had a good awareness of people’s needs and the risks associated with these. Risk assessments were in place to identify the risks associated with people’s individual needs; however sometimes care plans did not reflect these needs clearly.

External health and social care professionals were involved in the care of people and care plans reflected this.

People were encouraged and supported to make decisions about their care and welfare. Where people were unable to consent to their care the provider was guided by the Mental Capacity Act 2005. Where people were legally deprived of their liberty to ensure their safety, appropriate guidance had been followed.

People received nutritious meals in line with their needs and preferences.

People’s privacy and dignity was maintained and staff were caring and considerate as they supported people. Staff involved people and their relatives in the planning of their care.

Care plans in place for people reflected their identified needs and were person centred. Staff were caring and compassionate and knew people in the home very well.

Effective systems were in place to monitor and evaluate any concerns or complaints received and to ensure learning outcomes or improvements were identified from these. Staff encouraged people and their relatives to share their concerns and experiences with them.

The service had an effective leadership structure in place which provided good support, guidance and stability for people, staff and their relatives. However records of management actions and information were not always kept. We have made a recommendation about this. People, their relatives and staff knew the registered manager and spoke of their clear visibility and support in the service.

We spoke with members of staff who told us the home was clean and tidy. We found there were effective systems in place to reduce the risk and spread of infection. The registered manager had put in place a system for daily checks of pressure cushions and mattresses and we found members of staff were aware of how to undertake these checks. We checked two mattresses and three pressure cushions and found them clean.

People we spoke with were not able to share their views about the service due to nature of their illness. Therefore, we used our Short Observational Framework for Inspection (SOFI). This tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. During the lunchtime we used the SOFI tool to help us see what people's experiences at mealtimes were. We spent thirty minutes watching at lunchtime and found that people had positive experiences. We found the home clean and tidy. However, when we looked at mattresses and pressure cushions, we found some were soiled. These were immediately cleaned by the provider. We saw that personal records, including medical records, were accurate, fit for purpose, held securely and remained confidential.

Ranvilles is a nursing home providing care and treatment for up to 53 people. On the day of our visit there were 51 people living at the home. During the visit we spoke with three people who use the service and four staff, the manager and the provider.

We spent time with people who use the service in the lounge / dining area observing the support people received during and after their meal. We saw that not all of the staff were respectful or aware of people’s needs. Whilst people were not seen to be unhappy or distressed, staff did not always respond in a timely manner to meet people’s needs. We saw that two people did not receive support or fluids when they clearly indicated they wanted or needed it.

Staff told us that they felt they did a good job. Comments included “We are a good team, we work together well”. “We have everything we need to be able to care for people living here at Ranvilles”. This was supported by the care plans which detailed the support that nursing and care staff were to give people. Although care staff could tell us what support they would offer to people not all the staff we observed, did so safely or in a timely way. Other documents which supported the care plans to show what care had been given were not always completed for example wound care and records of prescribed lotions and creams.

This report relates to an inspection carried out in February 2013. There has been a delay in the publication of this report due to a complaint made by the provider regarding the inspection, which we have investigated and was not substantiated.

During our visit we spoke with two people who live at the home, three visitors, five staff and the manager. We observed interaction between staff and people using the service in the dining area and lounges.

We observed lunch being served and how staff interacted with people and ensured choice. Visitors told us that they are happy with the care and that staff are very friendly, “ten out of ten”.

Staff told us that they receive regular training, are supported by the management of the home and that they can speak with senior staff about any concerns they have about the running of the home.