This focused inspection took place on 6 December 2018 and was unannounced.

We carried out this inspection in response to concerns we received about the care and support being provided to people living at Southwoods Nursing Home. Information shared with CQC raised concerns about a lack of access to hot water, poor management of accidents and incidents and unsafe moving and handling practice. The inspection looked at two of the five questions we ask about services: is the service safe? And is the service well led? This is because we needed to know if people were safe in the service; and that the identified risks associated with the information we had received had been dealt with appropriately.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity, so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At our last comprehensive inspection in February 2017 the service was rated as good.

Southwoods Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or 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. The service can accommodate up to 38 older people, some of whom may require nursing care. At the time of our inspection, 33 people were supported.

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.

Where accidents and incidents occurred, the records relating to this were not detailed and follow-up actions had not been taken to respond to and mitigate potential risks.

Safeguarding concerns had not been consistently notified to the local authority when there were concerns a person who used the service may have experienced physical harm.

The management of prescribed creams was not safe. Creams did not consistently have labels to identify who they were prescribed for and the prescribing instructions. Creams were being used that were out of date or prescribed for a different person. Records for the administration of creams were not consistently completed and did not guide staff on the level of support the person required.

Equipment was being stored inappropriately and risks around cross contamination were poorly managed. A sling, still in use, was worn and frayed around the edges.

Fire drills had not been completed in line with the recommendations from a fire officer visit in 2017.

The premises were not safely maintained. Some people did not have access to hot water in their bedrooms and issues with the hot water system had been long standing. Legionella tests and checks of the hot and cold water temperatures had not been taken to ensure the risks around legionnaires disease had been assessed and mitigated.

The registered manager and provider did not have robust quality assurance systems to identify and address areas of practice where the quality and safety of the care and support provided had been compromised. Issues and concerns identified during the course of our inspection demonstrated ineffective quality assurance systems. Whilst the registered manager was responsive to our feedback and implemented action plans to address areas of concern, this demonstrated a reactive rather than proactive approach.

At this inspe

This inspection took place on 23 February 2017and was unannounced.

At the last inspection on 17 October 2016, we asked the provider to take action to make improvements to administering people’s medicines and this action had been completed.

Southwoods provides accommodation for up to 38 people who require nursing care and personal care. It is situated close to the centre of Northallerton. At the time of our inspection there were 33 people using the service.

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.

Checks were carried out in the home to make sure people lived in a safe environment. The service had a map in place of the home and the bedrooms were colour coded to guide rescue personal to the type of support people needed to evacuate the building. Risk to people had been identified and actions had been taken to reduce any risks to people and staff alike.

Before staff worked in the home they had also been checked to seek if they were suitable. We found the service had carried out appropriate checks and where concerns were identified in a reference these had been addressed by the registered manager.

People were given their medicines in a safe manner based on good practice guidance and a robust policy devised by the service with support from other clinicians in the area.

The food provided to people appeared appetising. Permission was sought from people to switch off the TV so that they could eat their meal uninterrupted.

Family members were listened to and were able to advocate on behalf of people using the service. We saw people’s care planning had been influenced and adapted by family members who knew them well.

We found there were enough staff on duty to meet people’s needs during our inspection. We reviewed the staff rotas and found there was a consistent level of staffing provided.

Accidents and incidents in the home were reviewed by the registered manager to understand if anything could be done to prevent any re-occurrences. This meant people were kept safe.

The staff had addressed people’s end of life wishes. We saw people had plans in place which reflected their needs and wishes.

Staff in the service were caring. They knew about people’s likes and dislikes and understood the best way to manage behaviours which challenged the service. We saw they ensured people’s privacy and dignity were respected. Staff spoke to people using appropriate tone of voice; we saw they kneeled down to have face to face communication with people and people responded warmly to staff.

Staff told us they felt supported by the manager. We found they also received supported through regular supervision, training and appraisal.

The service had in place a complaints procedure which had been followed by the registered manager and outcomes of the complaint had been provided to the complainant.

People’s care plans were detailed and person centred. They included people’s emotional and physical needs and their end of life wishes.

The home had in place partnership working arrangements with other professionals to ensure people’s needs were addressed. The staff had made referrals to different services and the advice given had been incorporated into people’s care planning.

Surveys about the home had been carried out by the registered manager; the results of the surveys were available to all in an easy to read format. We saw people had been complimentary about the home.

We found records in the home were accurate, reflected people’s needs and were up to date.

We carried out an unannounced comprehensive inspection of this service on 23 November 2015. A breach of legal requirements was found relating to the safe administration of medicines. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach.

We undertook this unannounced focused inspection on 17 October 2016, to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Southwoods Nursing Home on our website at www.cqc.org.uk

Southwoods Nursing Home is registered to provide personal and nursing care for up to 38 older people. At the time of our inspection the service was providing care to 33 people.

The service 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 2008 and associated Regulations about how the service is run.

At this inspection we found that improvements had been made to the way staff administered medicines and this was now done safely. Competency checks took place to ensure staff administered medicines safely and there had been no serious medicine errors since our last inspection. Medicines were stored safely and records relating to oral medicines and controlled drugs indicated that these had been administered in accordance with prescribing instructions.

Improvements were needed to ensure that clear written information was available to support the safe use of topical medicines [medicines applied externally], medicines used only when required and medicines used covertly [without the person knowing]. The recording of the administration of topical medicines and transdermal patches also needed to improve, to ensure that these medicines were being administered correctly and as prescribed.

The medicine policy and procedure had been updated recently by the registered manager, but did not adequately reflect current best practice guidance, such as the NICE (National institute for Health and Care Excellence) guidelines on managing medicines in care homes.

These findings evidenced a repeated breach of Regulation 12 Heath and Social Care Act (Regulated Activities) Regulations 2014, and we have required that the provider and registered manager make further improvements to the management of medicines.

This inspection raised questions about how the provider and registered manager monitored the safety and quality of the service, to effectively identify and make improvements when needed.

Arrangements were in place to review and update policies and procedures annually, but did not currently ensure that up to date best practice guidance was always incorporated appropriately.

The registered manager and other staff completed audits and monitoring activities. However, audits had not always been effective at identifying areas for improvement and had not resulted in action plans to ensure that issues identified were addressed effectively.

The provider carried out visits and talked regularly with staff to monitor the service and people’s satisfaction levels. There was currently no other formal scrutiny or external support provided to the service, although this had been tried in the past with limited success.

These findings evidenced a breach of Regulation 17 Heath and Social Care Act (Regulated Activities) Regulations 2014, and we have required that the provider and manager make improvements to ensure that good governance systems are in place.

We will undertake a further comprehensive rating inspection in the near future to monitor what action the provider has taken to make improvements.

You

This inspection took place on 23 November 2015 and was unannounced. The service was last inspected on 16 May 2014 and was found to be compliant with the regulations we assessed at that time.

Southwoods Nursing Home is registered to provide care with accommodation for up to 38 older people. At the time of our inspection 33 people lived at the service. The service is registered to provide general nursing care to people in the user band ‘older people’. The service is situated close to the centre of Northallerton, with its local amenities close by.

The service had a registered manager, who had been registered with us since October 2013. 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 safely stored and there was evidence that people received the medicines they had been prescribed. However, we saw two examples of potentially unsafe administration practice during our visit and have required that the registered manager make improvements.

Staff were recruited safely. People who used the service told us that sometimes care staff were busy and they had to wait a little while for assistance. However, observations, discussions with staff and review of rotas showed that safe numbers of staff were on duty.

People using the service, and their relatives, told us they felt safe at the service. Staff knew how to report any concerns about people’s welfare and had confidence in the registered manager taking action if needed. People had individual risk assessments in place which helped ensured staff were aware of the risks relevant to each person’s care. Maintenance contracts and checks were in place to help ensure the premises were safe.

Staff were supported to have the skills and knowledge they needed through relevant training. Staff felt supported and received support through formal supervision and staff meetings.

The service was following the principles of the Mental Capacity Act 2005. At the time of the inspection six people were subject to a Deprivation of Liberty Safeguards (DoLS) authorisation. The registered manager understood DoLS and when they were needed.

People told us that the food was good. People’s dietary needs were assessed and monitored and support was requested from relevant health care professionals if there were concerns about people’s nutritional wellbeing.

People told us that they were cared for and usually treated with dignity and respect. We saw some good examples of person centred care and a caring attitude by staff members.

People had their needs assessed and all but one person had detailed care plans in place. Care staff knew people well and were able to describe people’s individual needs. We have recommended that the registered manager reviews care planning arrangements to ensure that they are always in place and up to date.

People had access to some activities and social events, but feedback from people using the service was that this area of their care could be improved. We have recommended that the registered manager reviews arrangements for activities and social stimulation, to ensure that people’s individual interests and preferences are recognised. Visitors were made welcome and could visit when they wanted.

A complaints procedure was in place and information about this was available in the reception area. The registered manager encouraged feedback from people who used the service and their relatives, through meetings, surveys and making themselves available for discussions.

Audits and checks were completed and the registered manager was supported by the company director, who visited the service regularly.

We identified one breach of regulations relating to safe care and treatment, in particular the proper and safe management of medicines. You can see what action we told the provider to take at the back of the full version of the report.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continuously improve.

The home had appropriate policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We also found that relevant staff had been trained to understand when an application should be made, and how to submit one. This meant people would be safeguarded as required.

When people were identified as being at risk, their care plans showed the actions that would be required to manage these risks. These included the provision of specialist equipment such as pressure relieving mattresses, hoists and walking aids.

The service had been well maintained and we found that it was comfortable and clean. This meant that people were not put at unnecessary risk.

Recruitment practices were safe and thorough. Policies and procedures were in place to make sure that any unsafe practice was identified; this helped to protect people who used the service.

Procedures were in place for dealing with emergencies and staff were able to explain these to us.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in

developing their plans of care. People told us they were included in making decisions about how their care and support was provided.

New staff had received relevant induction training which was targeted and focussed on improving outcomes for people who used the service. This helped to ensure that the staff team had a good balance of skills, knowledge and experience to meet the needs of people who used the service.

Is the service caring?

People told us they were supported by kind and attentive staff. People we spoke with said that staff were kind and "friendly". One person said “It’s like a 5 star hotel; the staff are wonderful; I have been spoilt to death.”

We saw that staff acted in a kind and respectful way People looked well cared for and appeared at ease with staff. The home had a relaxed and comfortable atmosphere.

Is the service responsive?

People's needs were met in accordance with their wishes. We saw evidence of the service ensuring people were able to continue with interests and hobbies; for example assisting people to complete crosswords.

The service provided specialist equipment to meet people’s needs; for example the service had sourced bariatric equipment for individuals who needed it.

People we spoke with knew how to make a complaint if they were unhappy.

People using the service, their relatives and other professionals involved with the service completed an annual survey. This enabled the manager to address any shortfalls or concerns.

Is the service well-led?

The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better had been addressed promptly. As a result we could see that the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and the quality assurance systems in place. This helped to ensure that people received a good quality service. They told us the manager was supportive and promoted positive team working.

We used a number of different methods to help us understand the experiences of people using the service including talking to relatives, staff and observing the care provided.

We saw that people appeared relaxed and comfortable with their surroundings and with staff. We saw that staff spoke at a pace which met people’s needs and engaged with people in a calm and patient way.

We talked to people about the meals provided and without exception they said that the quality of food was very good. They said there was always a choice.

We spoke with relatives who were very satisfied with the care and support that was provided. One person said "They look after us very well". Another person said ”Staff are thoughtful and considerate. I have been involved in decisions about the care provided and communication between me and the home is very good”.

We saw that medicines were kept safely and that appropriate arrangements were in place for the recording and administration of medicines.

We spoke with staff who were able to demonstrate a good understanding of the needs of the people who lived at Southwoods. They told us that they were well supported by managers of the home and there were good opportunities for training.

In this report the registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

At the previous inspection we identified some serious areas of concern with the care and support that people were receiving at the home. Because of this we asked the provider to make improvements, so that people were living in a clean and tidy home, where their identified care and support needs were being met. The provider sent us an action plan that told us how they were going to do this. At this inspection we saw that things had improved , people looked cared for and the home was clean and tidy.

People looked cared for and they were clean and comfortable. Comments made by people who used the service included 'I feel really well, and it's all down to the staff looking after me.' And 'The girls ask if I need anything and remind me in a nice way about things I may have forgotten to do. They always treat me with care and talk very nicely to me.'

When we talked to the staff on duty they were knowledgeable about the care and support people needed. The care records we inspected had been completed properly and some new recording systems had been implemented since our last inspection.

At the time of the inspection the manager and clinical lead nurse were interviewing for new staff. This was in addition to extra staff who had already been appointed at the beginning of the month. The staff on duty said that things had improved greatly since the previous inspection.

We carried out this inspection to Southwoods Nursing Home over two days. Initially we had been given some information of concern regarding poor staffing levels especially at weekends, substandard care practices and a dirty, poorly maintained environment. Upon visiting the home on the first day the inspection team decided to return to the home to look at further outcomes in more detail.

On the second day of inspection we carried out a short observational framework for inspection (SOFI) on the unit caring for people with dementia. SOFI is a tool which inspectors can use to capture the experiences of people who may have cognitive or communication impairments. We observed that people received very little interactions from staff. This could have a negative impact on people’s wellbeing. Staff should be mindful of this.

We asked people who were visiting the home about what they thought of the service. Everyone spoke very highly of the care staff and said they were very caring. However everyone without exception said that there was not enough staff on duty to meet the needs of the people living at the home. One person described the staffing situation as ‘Ludicrous’, whilst another said it was ‘Unsafe’. One person said ‘The staff do their very best in the most terrible circumstances. They never stop. It’s dreadful they do not have time to do anything properly. For most of the time they don’t even get a break. They all want to do a good job but the staffing levels don’t allow them to.’

People and visitors had many positive comments to make about the way they were cared

for by staff. People described staff as "kind" and "friendly."

One person said, "All the staff are very good. They look after us."

People told us that there were activities on some days and said "there's always something

to do if you want to do it."

One person said, "You couldn't get better staff. They are brilliant."

some people commented on the "tired and shabby " environment. One person said "the decors not good but the care and the happy atmosphere make up for that."

People told us there have been improvements at Southwoods Nursing Home following the review in June 2011. People said they now felt more comfortable in approaching the temporary manager with their concerns.

Some people told us overall it was “ok’ living at Southwoods Care Home, the staff were “kind” and they were “well looked after”. Another told us they enjoyed joining in with the staff “banter”. However we were also told that staff don’t always “notice” what help people need and “I prefer the older carers, the young ones can be unintentionally rough”.

People and staff told us snacks and drinks were available during the early evening and throughout the night. However people did tell us they have to wait until breakfast for a hot drink following rising in a morning and other’s commented upon the “poor” quality of the food.

Staff told us they have received training about safeguarding people and would know what actions to take to protect people.

Some people who use the service and their relatives told us that they were very happy with the care and support they received and that they had no concerns about living at Southwoods. Some people told us that the home’s staff were very good, making comments like ‘all of the staff are very pleasant’ and 'they are all good staff'.

However, some people who use the service and their relatives told us that they had sometimes experienced staff speaking to them in a way that was not polite or respectful. People also made comments to us like ‘some you like better than others’, ‘staff are lovely, most of them’ and ‘they respect me most times’.

Some people and their relatives told us that they would feel able to raise any concerns they had with staff. However, other people told us that they did not feel comfortable expressing their views or raising concerns about the home, because they were worried about how some staff might react.

We spoke with people who live at Southwoods Care Home and visitors to the home during the inspection. People told us they were very happy with the care and support they were receiving. One person said ‘it really is home from home’ another said ‘ staff can not do enough for you, they are really caring’. Visitors to the home said they could see a ‘marked improvement’ in the care and management at the home in recent months.