This inspection took place on 30 and 31 May 2017. The first day of the inspection was unannounced.

Sefton Hall is registered to provide accommodation for up to 49 people needing personal and nursing care. People living at the home are older people, some of whom are living with dementia or a physical disability. Accommodation is provided in two areas of the home, a nursing care area which can support up to 30 people, and a more secure dementia care area which can support up to 19 people. There were 42 people living in the home at the time of our inspection.

The home had a registered manager. 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 and associated Regulations about how the service is run.

The registered manager and provider were committed to raising standards of care at Sefton Hall and ensure there was a strong and visible person centred culture in the home. There was a clear vision that was centred around the principles of Dementia Care Matters Butterfly Household Approach. This is a national scheme aimed at improving the lives of people living with dementia. The home was consistently praised by relatives and health professionals for the positive outcomes staff had achieved to ensure that people living with dementia received exceptional care. The ethos and values of the home created a caring and compassionate environment and ensured that the care delivered was truly focused on meeting the holistic needs of people.

People and their relatives were extremely satisfied with the service they received and told us the home was excellent. People and relatives consistently told us they felt cared for, valued and listened to and that their views mattered. There was a strong commitment to developing respectful, trusting relationships. Staff all demonstrated compassion and empathy. People's care was based upon best practice and was constantly reviewed. There was a strong person centred ethos, which was embedded throughout the home. This was to always treat people with dignity, as you would want to be treated. The ethos of the home was intended to make people feel valued, supported and included, with an aim to enhance quality of life. Interactions promoted wellbeing and showed staff knew people well. People were at the heart of care.

There were clear lines of accountability. The home had outstanding leadership and direction from the registered manager, provider and management team. Staff felt fully supported to undertake their roles. Staff were given regular training updates, supervision and development opportunities. For example, staff were encouraged and supported to develop lead roles, becoming ‘champions’ and gain additional skills in areas such as end of life care, quality of lifestyle, diabetes, infection control and health and wellbeing. Champions took on responsibility for attending additional training and then shared their knowledge within the staff team.

Not only was the provider committed to support and develop the staff team, staff achievements were also celebrated. For example, staff were nominated by people and their relatives as ‘employees of the month’ and newsletters contained information about staff such as important events in their lives and their interests. Staff told us this approach not only helped people relate to them but also made them feel valued, empowered and very motivated.

The home was exemplary in responding to people's needs and preferences. People were supported by staff that were devoted to getting to know people and their families. Staff knew each person well and understood how to meet their support needs. Each person’s needs and personal preferences had been assessed before they moved into the home and were continually reviewed. This ensured that the staff knew about

We carried out this inspection in response to concerns received about the care of people living at Sefton Hall Nursing Home.

On the day of our visit we were told there were 41 people people living at Sefton Hall. We spoke with nine people living at the home, three relatives, three members of staff and the acting manager. We looked around the home, examined some records and observed staff providing assistance to people. Following the inspection visit we sought information from health and social care professionals. We spoke with a GP and specialists in tissue viability and the Mental Capacity Act 2005.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. Please note, the person described as the registered manager throughout the report was the acting manager during our visit but had been registered with the Care Quality Commission by the end of the inspection.

Is the service safe?

People's safety was compromised because records were not maintained in a way that protected them. Information was sometimes limited, conflicting, or unclear and confusing. For example, one person's fluid monitoring chart was incorrectly tallied.

Assessments were not always robust or adequately informative for staff. Additional information was not always sought which may have improved safety.

Care plans did not always provide enough information, or provide the clear steps required for staff to meet the person’s needs and wishes.

Is the service effective?

The service was effective in that food and drink were offered on a regular basis. People told us they were happy with the care they received, with comments including, "It suits me. They are all very good. I've never had any complaints".

Health care professionals were involved in people’s care where the home had identified this was necessary.

There was a lack of understanding how to maximise people's ability to make informed decisions when it was not known if they understood the consequences of their actions.

Is the service caring?

People using the service thought the staff were caring and we observed people being treated with kindness and dignity.

One staff told us “We care. I talk to people in the way I would want to be spoken to”. One staff explained how they used a syringe to provide liquid to a person who was unable to drink from a cup. Another explained how a very sick person required additional care the day of our visit and the staff were attending to their needs.

Staff were improving people’s lives through decorating a ‘shop’ for people to use within the home.

Is the service responsive?

Assessment and care planning was not robust and did not ensure person centred care. Some care plans provided detailed information about people's health and social care needs but others did not ensure people’s needs and wishes were understood and met. For example, one person found comfort from their faith but there was no care plan as to how their faith needs might be met or contact details for their church.

Risk assessments and monitoring records did not always provide adequate information from which further decisions about people's health and care needs could be made. For example, one monitoring record stated the person was complying with their care plan when they had been at the home for only one day and they were already refusing that care.

Is the service well-led?

Staff told us about changes, which they said were improvements, at the home. They told us they felt the home was well-led.

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?

This is a summary of what we found –

Is the service safe?

There were enough staff on duty to meet the needs of the people living at the home. People felt safe and staff had been trained in safeguarding. Safeguarding policies were in place and relevant contact numbers were displayed for staff use.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to nursing homes. While no applications had needed to be submitted, proper policies and procedures were in place.

Is the service effective?

People told us that they were happy with the care that had been delivered and their needs had been met. It was clear from our observations and from speaking with staff that they had a good understanding of the people’s care and support needs and that they knew them well. One person told us “They are very good at taking care of me. The nurses are very good.” Another person told us “It’s very good. I feel well looked after.”

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. We saw that people were able to do things at their own pace and were not rushed. One person told us “They’re very caring. They look after you well, I love it here.” Another person said “I’m very happy here, they meet my needs and all the staff are lovely.”

Is the service responsive?

Records showed that people’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People had access to activities that were important to them and had been supported to maintain as much independence as possible.

Is the service well-led?

Quality assurance processes were in place in the home. We saw that people had completed a survey asking for their feedback. We saw that issues identified had been acted upon by the home. Staff told us they felt listened to by the management and were often asked for their feedback and opinions.

We carried out this inspection because we had received information of concern about people's health and safety.

We spoke with seven people who lived at the home and we observed the care of one other person as they were unable to verbally communicate with us. Many people at the home suffer from some form of dementia type illness.

One person told us the care was good. They said “They are very nice, they look after me well” Another person said, "the staff are very nice". However, not everyone we spoke with was completely happy with the care they received. One person said “it’s awful you always have to wait, there are not enough people to help me”. We found that three of those seven people we saw were not having their basic care needs for personal hygiene, nutrition, continence and pressure area care met.

We spoke with four care workers throughout the morning, they were all kind and helpful. Care workers were seen to be very busy. People told us it was “always like that”. One person said “I always wait ages, sometimes they never come and I have to ring again”.

We found that staff with the appropriate skills had not been adequately deployed to meet peoples needs during this inspection.

Some parts of the home were clean and tidy but others were not.

On our visits to the home we spoke with the people living there about the ways in which people are involved in the services they receive.

We looked at four care plans for people living at the home. We saw some evidence that the individuals themselves had been consulted about these plans and there was some evidence that representatives had been consulted. One person told us that they were aware of their care plan and knew what was in it, but didn’t want to be involved any further. We were told by the manager that care plans are continually being improved to help staff easily find the information they need.

We ate lunch with people in the main dining room and saw that the food served was well presented, nutritious and plentiful. We heard people being offered something else when they didn’t want what they had ordered. We saw evidence that people who required high protein diets were given regular snacks. We also saw that people who required assistance with their food, received help in a respectful and dignified way.

Staff that we spoke with told us that they had received training on safeguarding people and they were able to tell us about different types of abuse and what they would do if they suspected abuse was occurring.

During our visit we looked at the communal areas of the home and some bedrooms. Areas that we saw were generally clean and tidy and there were no unpleasant odours.

All medicines are stored appropriately in lockable cupboards and trolleys and records are generally well maintained. We saw the medication trolley being secured whenever staff moved away from it.

The provider has a continual programme of upgrading and maintaining the property. We saw some rooms that had been refurbished to a good standard with good quality furnishings and fittings.

People told us that the staff at the home were “very good” and ”very caring”. There were no negative comments about any of the staff. Friendly banter and laughter was shared throughout the day between staff and people living in the home. Staff were able to communicate with people using different styles according to the behaviour, need or personality of the individual. We saw staff working with people, supporting them with their mobility, eating, drinking and general care. Staff supported people well, and the interactions we saw showed people were treated with respect and courtesy. We saw and heard people being offered choices and support when needed.

Regular ‘get together’ are held for people who live at the home and for their representatives to enable them to express their views on the quality of care provided.

Staff told us that they knew people well and were able to identify if they were unhappy about anything. They would then do what they could to alleviate any concerns or problems. They said that the manager was very approachable and would deal with any concerns anyone had.

This inspection took place on 14 and 15 April 2015 and the first day was unannounced.

Sefton Hall is a care home situated in Dawlish. The home is registered to provide nursing care for up to 52 people who may have dementia or a physical disability. Accommodation is provided in two areas of the home, a nursing care area which can support up to 39 people, and a more secure dementia care area which can support up to 13 people. There were 35 people living in the home at the time of our inspection.

At our last inspection of the home in August 2014 we had identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, in relation to obtaining people’s consent to care and treatment, care records that did not accurately reflect people’s care needs and the safety of the care provided to people.

We took enforcement action against the home in relation to the care and welfare of service users under Regulation 9 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered provider sent us an action plan on 6 January 2015 telling us they had completed improvements to put these issues right.

At this inspection we saw the improvements needed had been made and sustained.

The service 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.

People were supported in a home that was safe. Risks to people’s health and safety were clearly identified and managed. Staff understood people’s rights and how to protect them from potential abuse or harm. People told us they felt well cared for and supported by the staff. One person said “I had a good feel about the home as soon as I came” and another, “it’s lovely, always a lovely atmosphere.”

There were sufficient staff on duty to keep people safe and meet their needs and this was supported by comments received from people and relatives. One person said staff have time for her, “I feel I can always ask the staff”. Staff had received training in topics relating to people’s care needs such as dementia care and pressure ulcer prevention, as well as health and safety topics such as infection control. People’s medicines were managed safely.

Care staff were well organised and it was clear each day who they were responsible for. Staff told us they received good support at the home and Sefton Hall was a good place to work.

People had access to community healthcare support services. Health care professionals involved in providing support to the home confirmed their confidence in the home’s ability to care for people with complex mental health and nursing needs. Staff told us that they were proud of the care they delivered to people, particularly at the end of their lives, and felt it was something the home did very well. One member of staff said “it’s a privilege to care for them.”

People told us they enjoyed the meals at the home and were provided with a wide variety. People who needed support to eat were given this sensitively and in ways that respected their dignity.

Care planning was individual and personalised: staff had a good understanding of people’s backgrounds, needs and wishes. People’s capacity to consent to care was recorded, and where they could not do this, records and assessments showed decisions had been made in people’s best interests. For those people whose liberty was restricted to maintain their safety, such as with the use of coded locked doors, applications for authorisation had been made to the appropriate authority.

People had access to interesting activities that met their needs and wishes. The home’s activity organiser had used innovative and creative approaches, including the use of hand held computers, to support people to remain active and involved.

Communal areas of the home and people’s rooms were clean with no unpleasant odours.

The home managed any complaints or concerns well. People told us they felt able to raise any issues and be confident of a resolution without recrimination. The culture at Sefton Hall was open and the registered manager told us their door “is always open”.

Robust recruitment practices were in place which included appropriate pre-employment checks to ensure prospective staff had not been barred from working with vulnerable people.

Quality assurance and audit systems ensured people’s views were sought and learning took place to develop the service further. The home met its legal obligations to the Care Quality Commission, and was operating in accordance with their conditions of registration.