The inspection took place on 4 and 5 January 2018. It was unannounced.

Following our last inspection in September 2016, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and responsive to at least good. At this inspection we found the required improvements had been made and sustained.

Steep House Nursing Home is a care home service with nursing. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided. We looked at both during this inspection.

The home accommodates up to 56 people across three floors. At the time of our visit there were 52 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with CQC 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.

Arrangements were in place to make sure people received care, support and treatment safely. These included processes to identify, manage and avoid risks to people’s welfare and wellbeing in ways that did not restrict their freedom unnecessarily. There were enough staff with the right skills who had been assessed for their suitability to work in a care setting. Processes for the management of medicines and prevention and control of infection were in place. If things went wrong, the provider reflected on the experience and identified ways to improve the service.

People received care, support and treatment which were based on effective assessments and care plans which were thorough and based on guidance and good practice. Staff were supported by training and supervision to deliver a high standard of service. Food and menus offered choice and were adapted to meet people’s individual needs and preferences. The service worked with a variety of agencies and services to support people’s wellbeing and access to healthcare services when needed. The premises were maintained to a good standard with adaptations and decoration suitable to meet the needs of people. Staff were aware of the need to seek consent for care and of the legal requirements where people did not have capacity to consent.

Staff supported people with kindness and compassion, providing emotional support when needed. Staff supported people to express their views and take part in decisions about their care, taking into account people’s individual communication needs. There was appropriate focus on respecting people’s privacy, dignity and independence.

People received care, support and treatment which met their needs and reflected their preferences. There had been particular focus on improving people’s care records and providing high quality care at the end of people’s lives. People’s wellbeing was supported by a range of leisure activities and entertainments, including access to the community. People’s individual communication needs were taken into account. The provider used feedback from people and their families to improve the service they received.

There was effective leadership and team working based on a clearly communicated vision to deliver high quality care. This was supported by an effective system of governance, and thorough and wide-ranging quality assurance processes. Outputs from these processes together with the results of engagement from various stakeholders were used as the basis of actions to continuously improve the service.

This inspection took place on the 4th and 5th July 2016 and was unannounced. Steep House Nursing Home is registered to provide accommodation for up to 56 older people who require nursing or personal care. The accommodation is arranged over three floors and has a garden area. At the time of our inspection there were 52 people living at the home.

A registered manager was in post at the time of our inspection. 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 protected from the risk of abuse. The staff we spoke with demonstrated their understanding of how to safeguard people and report any safeguarding concerns. The provider ensured that safeguarding policies and procedures were in place and accessible to staff.

Risks affecting individuals had been identified, appropriately assessed and measures put in place to protect them from harm. People’s risks assessments were regularly evaluated to ensure they remained current. Environmental risks were regularly reviewed and documented and personal evacuation plans were in place to ensure that people were kept safe in the event of an adverse incident such as a fire. Equipment and utilities were serviced regularly, and internal checks protected people and others from potential risks in the home.

The home was adequately staffed to meet people’s care needs on the days of our inspection. Where shortfalls were identified, the registered manager sourced additional off duty staff to cover any shortages and ensure staffing levels were maintained. However some staff and relatives expressed concern that there were not always enough staff to manage if staff were away or off sick.

The provider had not in every case ensured that all the relevant recruitment checks were carried out for newly employed staff. This meant that people might not always be protected from the risk of the provider employing staff who were not suitable for their role.

The provider had appropriate arrangements in place for managing people's medicines safely. There were accurate records of medicines administration by nurses and topical creams administered by care staff and information to support the administration of medicines was available to staff. However, some improvements were required to ensure that medicines were always stored safely to ensure that risks to people were minimised.

New staff followed a period of induction which included the provider’s mandatory training, followed by a period of working alongside more experienced staff, to ensure that they were competent to carry out their role. The registered manager held regular supervisions with staff and staff told us that they felt supported by the registered manager and the head of care. Staff completed a range of training to develop the skills and knowledge they required to meet people’s needs.

The provider followed appropriate procedures to ensure people’s rights were upheld in line with the Mental Capacity Act (2005). Mental capacity assessments had been completed for people and people’s consent to care and treatment had been sought accordingly. Best interest decisions were completed when people lacked the capacity to make their own decisions.

People were supported to have sufficient to eat and drink and maintain a balanced diet. Drinks were readily available to people throughout the day. For lunch a choice of freshly cooked meals was offered, with alternatives available. The chef was knowledgeable about people’s individual requirements such as those people who required a soft diet or a diabetic diet.

People were supported to maintain good health through access to ongoing health support. Records showed that other healthcare professionals had been i

This was a scheduled inspection but we also looked at the home’s medicines procedures and arrangements for food due to concerns raised with us.

We spoke to five people who lived at the home. We also spoke to one relative of a person who lived at the home. We spoke to the manager, the head of care and two care staff. We also spoke to a health and social care professional about the service provided by the home.

People said they were satisfied with the service they received. Comments made to us by people included the following:

• “It couldn’t be better.”

• “I am treated with the utmost care. They make sure I have everything I need.”

People said they were consulted about their care and we saw records that the home had sought consent from people and from their relatives about the care and support arrangements.

We found the home has increased the range of activities it provides to people.

We saw people’s nutritional needs were assessed and that records of food and fluid intake were maintained for individual’s to ensure they had sufficient food and fluids. Where needed the home referred people for assessments and advice from community health professionals regarding nutritional intake.

During the lunchtime we used our SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences at mealtimes were. 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 and whether they have positive experiences. This includes looking at the support that is given to them by the staff. We spent 35 minutes observing at lunchtime and found that people had generally positive experiences. Staff were observed assisting people in a calm, friendly and polite manner. People were given choices about the food they would like to eat.

We spoke to five people living at the home during our inspection visit. We also spoke to two relatives of people living at the home. We had discussions with the manager and three staff about the care of people.

People said they were satisfied with the service they received. One person told us how they were able to make choices about food and how they spent their time. Relatives also told us how they were satisfied with the care provided by the home. One relative said how their relative living at the home was clean and well presented.

We saw care records were well maintained with details about how people were supported.

The home was found to be clean. There were cleaning schedules and infection control procedures in place.

We saw the home had looked into complaints brought to the attention of the manager.

During the lunchtime we used our SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences at mealtimes were. 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 and whether they have positive experiences. This includes looking at the support that is given to them by the staff. We spent 45 minutes observing at lunchtime and found that people had positive experiences. Staff were observed assisting people in a calm, friendly and polite manner. People were given choices about the food they would like to eat.

We spoke to three people who live at the home and to two relatives of people living at the home. We also spoke to four staff and the acting manager.

People said they liked living at the home and that their care needs were met. People said they were treated well by the staff. One person said, “You get respect from the staff.” Another person commented that the staff were very helpful and kind but that it was sometimes difficult to understand them due to staff having a strong accent.

We saw each person had assessments of need and care plans detailing how care was to be provided.

During the lunchtime we used our SOFI (Short Observational Framework for Inspection) tool to help us see what people's experiences at mealtimes were. 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 and whether they have positive experiences. This includes looking at the support that is given to them by the staff. We spent 40 minutes observing at lunchtime and found people had mixed experiences. People were offered choice in what they ate and staff were observed to interact with people in a friendly manner. Staff also spoke to people whilst supporting them. We also noted that people did not always get the support they needed for eating their meal and were not treated with dignity. We observed staff to be rushed, distracted and poorly deployed.

The residents told us they liked living at this home. One resident said the staff were “excellent, the home is light and airy and the food is usually excellent”. All the other residents we spoke with agreed with this view.

One visitor said the staff looked after the residents well and they were always made to feel welcome when they visited. Another visitor said their relative had moved to the home one month ago and since then they had started to eat again. This relative added that the staff had been “brilliant and the care couldn't be better” This relative said the home was fresh and clean and they were very positive about all aspects of the care.

The staff said they worked as a team and supported each other.