The inspection took place on 22, 24 and 28 August 2018. The first day of our inspection visit was unannounced.

Stretton Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Stretton Nursing Home accommodates up to 50 people within a large adapted building, and specialises in care for older people with physical disabilities and sensory impairments who may be living with dementia. At the time of our inspection, 32 people were living at the nursing home.

The provider had a registered manager of the service. However, this person had not been involved in the day-to-day management of the service for several months. 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. During our inspection visits, we met with the home's deputy manager and the newly-appointed manager who oversaw the management of the home with the support of the provider and their organisational oversight manager.

At our previous inspection in January 2018, we rated the service as 'Inadequate,' and it was therefore placed in 'special measures.' We identified eight breaches of the Regulations. These related to the provider’s failure to deploy suitable numbers of staff and fully safeguard people from abuse, the management of people’s medicines, a lack of clinical leadership and the ineffectiveness of quality assurance processes, the failure to assess and minimise risks to individuals, and the failure to fully promote people’s rights under the Mental Capacity Act. In addition, people’s care plans were not always accurate or reflective of their current needs, and they were not always protected from the risks of malnutrition or dehydration. As a result of the inspection, we imposed a condition on the provider’s registration which meant they needed to tell us, on a monthly basis, how they were monitoring the quality and safety of service provided and inform us of actions taken to bring about improvement.

At this inspection, the provider demonstrated to us that sufficient improvements had been made to the service that it was no longer rated as inadequate overall or in any of the key questions. Therefore, the service is no longer in 'special measures.' However, further improvements were still required to the safety and quality of the care people received, and the provider remained in breach of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s rights under the Mental Capacity Act were still not consistently promoted. Procedures for assessing people’s capacity and, where appropriate, making decisions on their behalf were not followed on a consistent basis. People’s medicines were not always managed safely to ensure they received these as prescribed, and that accurate and complete medicines records were maintained. People’s risk assessments did not always provide clear guidance on how to minimise the risks to individuals, including the management of long-term health conditions, and were not always read by staff. New staff were sometimes permitted to provide personal care without appropriate initial training. This included training in the home’s moving and handling procedures.

The plans for improving people’s hydration and addressing weight loss were not always clear. Screening tools for assessing people’s risk of malnutrition had not always been completed on a consistent monthly basis. The provider’s staff induction programme did not reflect the requirements of the Care Certificate. The provider lacked a clear strategy for cre

The inspection took place on 19, 21, 23 and 24 January 2018 and was unannounced.

Stretton Nursing Home is located in Hereford, Herefordshire and 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 provides accommodation and nursing care for up to 50 older people. On the day of our inspection, there were 41 people living at the home. This included a number of people who lived with dementia.

At our previous inspection in October 2017, we identified breaches of regulation. These were in relation to staffing, governance, protecting service users from abuse or improper treatment, and notification of incidents. The provider was asked to complete an action plan to set out how they would comply with the regulations.

At this inspection, we found the provider remained in breach of these regulations. We also identified further breaches of regulation. These were in relation to person-centred care; need for consent; safe care and treatment; and meeting nutrition and hydration needs.

The overall rating for this service 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 measures.

There was a registered manager at this home, but they had been absent from work for a period of four months. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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.

Staffing levels had not been determined according to the assessed needs of people living at the home, which meant there were not enough staff to care for people safely. The lack of staff had an adverse effect on people's personal care needs, hydration and emotional wellbeing.

Systems and processes in place to protect people from abuse were not always followed. Action had not been taken by the provider to address failures to report alleged abuse or harm.

People did not always receive their medicines in accordance with updated instructions from the prescriber. Medicines were not always signed for, which made it difficult to tell whether prescribed creams or liquid medicine had been a

The inspection took place on 31 October and 8 November 2017. The first day of the inspection was unannounced.

Stretton Nursing Home provides accommodation, nursing and personal care for up to 50 people. At the time of our inspection, there were 42 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.

The registered manager had been away from the service for a number of weeks at the time of our inspection visit. In their absence, we met with the managing director of the service. The nurses and senior staff team had overseen the day-to-day management of the service, during the registered manager's absence, with the support of the managing director.

Staff did not always fully understand, or fulfil, their individual responsibilities to protect people from abuse. The provider had, at times, been unable to maintain planned staffing levels over recent months, particularly on weekends. People’s rights under the Mental Capacity Act 2005 were not always fully promoted. The provider lacked a clear overview of the status of people’s DoLS authorisations and conditions on these were not always reviewed and complied with. Staff were not always invited to regular one-to-one meetings with senior staff or management, in accordance with the provider’s supervision policy. Staff did not have the time with people to provide personalised care that was responsive to people's needs. The management, leadership and line management structure of the service was not as effective as it needed to be. The provider had not always notified us of safeguarding issues involving people who lived at the home in a timely manner. The records maintained in relation to people’s care and support were not always accurate or complete. The provider’s quality assurance had not enabled them to identify and address significant shortfalls in the quality of the care and support provided.

The risks associated with people’s care and support needs had been assessed, recorded and plans put in place to manage these. People’s medicines were handled and administered in accordance with good practice guidelines by registered nurses.

Staff received an induction and ongoing training to help them fulfil their duties and meet people’s individual needs. People had enough to eat and drink, and any associated risks were assessed, recorded and managed. When people were unwell, they were supported to access professional medical advice and treatment.

Staff took a caring approach towards their work, and knew the people they supported well. People’s views about their care and support were welcomed and listened to. People were treated with dignity and respect.

People’s friends and relatives contributed to the assessment and planning of their care. People’s care files included details of their preferences and what was important to them. People had support to participate in one-to-one and group activities. People and their relatives understood how to raise concerns and complaints about the service, and felt comfortable doing so.

People and their relatives and friends were satisfied with the overall management of the service.

We found breaches of Regulations of the Health and Social Care 2008 (Regulated Activities) Regulations 2014 and a breach of the Care Quality Commission (Registration) Regulation 2009. You can see what action we told the provider to take at the back of the full version of the report.

This inspection was carried out on 8 and 9 August 2016 and was unannounced.

Stretton Nursing Home provides accommodation, nursing and personal care for up to 50 people. At the time of our inspection there were 42 people living at the home.

There was 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 and associated regulations about how the service is run.

People were kept safe by staff that knew how to recognise and report any concerns about people's safety. Staff understood people's needs and about risks and how to keep people safe. There were enough staff on duty to make sure that people got the right support at the right time. The provider completed checks to ensure staff were suitable and safe to work at the home.

People were positive about the support and care that they received. People were treated with dignity and respect and staff were kind and caring in their approach with people. People's care and support was centred on their individual needs.

People had their health needs responded to effectively. People were supported to access doctors and other health professionals when required. People were supported to have their medicines when needed. Medicines were stored and administered appropriately.

People were asked and gave staff permission before any care or support was given. Time was taken to make sure that people could make choices and decisions about the care and support they received.

People were supported by staff that had the skills and knowledge to understand and meet their health needs. Staff had access to on-going training and support to meet people's specific health and wellbeing needs. Staff felt that they were able to contact the registered manager at any time if they needed support or guidance.

People and their relatives found the staff and management approachable, willing to listen to their views and opinions. People knew how to complain and who to complain to.

Audits and checks were completed regularly to ensure that good standards were maintained. There were established links with organisations relevant to the care and support provided.

We considered our inspection findings to answer the 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?

The people who lived in the home and their relatives we talked with were pleased with the care provided. They felt that their views were respected and listened to.

People told us they felt safe. We saw that people were free to go about their daily routine. One person told us, “The staff are brilliant”. Another person said, “It’s very nice here”.

Staff understood about the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and how they would be put this into practice. No DoLs applications had been submitted.

Is the service effective?

People told us that they were happy with the care they received. They told us that the manager and the staff had asked them what their needs were and how they would like them met. A relative said, “Mum is well looked after.” One person said, “They talk to me about what I want.”

One person said, “They look after me very well.” Care records confirmed people’s needs and preferences had been recorded and care and support had been provided in accordance with their wishes.

People and their relatives were involved in the assessment of their needs. One person said, “They talk to me about what I want”.

People and their relatives told us they were happy to discuss their personal preferences with staff. They said that staff obtained help for them if they were unwell. This meant people were supported to keep in good health, have access to health care services and received ongoing support.

Is the service caring?

The people we talked with told us they felt that their wishes were respected and they were helped to live their lives as they wished. Staff took the time to find out about people’s past. Staff we talked with knew people’s needs well and how they wished to be cared for. This meant that staff cared about the person as an individual and showed concerned about their well-being.

People and their relatives were encouraged to make their views known about their care. People that we talked with told us that they found the registered manager and the staff easy to approach about any issues they had. This meant that people were listened to and they felt that their views mattered.

Is the service responsive?

People had been assessed before they moved into the home so that arrangements could be made to meet their needs.

People and their relatives told us they talked with the staff about what was important to them. They talked about the activities they took part in and how they liked their meals prepared. They told us that staff had changed their care packages as a result.

Is the service well led?

One of the individuals identified as registered manager at this home no longer works there. They have yet to apply to deregister with us. The management and staff demonstrated values that included involvement, compassion, dignity, respect and independence. Staff we spoke with showed they understood those values as they discussed their role and responsibilities in their work. This meant the service promoted an open culture that was centred on the individual and empowered them to take control of their life as much as they were able.

The provider had systems in place to assess and monitor the home so that potential improvements in meeting people’s care needs could be identified and put into place.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. The provider had appropriate arrangements in place to manage people’s medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

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 relative told us, "They know her needs and are very good at dealing with things”.

Not all staff had received all the training that was needed to meet people’s needs. This meant the provider could not demonstrate that the staff employed to work at the home had the skills and experience needed to support the people living there.

Is the service caring?

People were supported by kind, compassionate and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. What we saw confirmed this. One person’s relatives told us, “This is the best place she could have been".

Is the service responsive?

People’s needs had been assessed before they moved into the home. People told us they regularly talked with the staff about what was important to them. Records confirmed people’s preferences, interests, wishes and needs had been recorded. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well led?

A new manager had recently been appointed and registered with us. They had made improvements in a number of areas. Staff told us they were very supportive of the new manager and were confident that the improvements would continue. One person said, “It’s nice to see changes happening, not just talked about”.

We identified further improvements as being necessary. There was no structured reviewing process carried out by the provider to ensure that any necessary changes were identified.

We carried out this inspection because we needed to check that the provider had made improvements following our inspection in January 2013.

We spent time in the lounges, to see how staff supported people. We also visited people in their bedrooms. We spoke with people living at the home and relatives. We also spoke with staff and checked care records.

People were very positive about the home. One relative described the staff as, "extremely understanding". Another relative told us how pleased they were with the care their family member was receiving, saying, "I can't fault the care here".

We saw that staff were attentive to people’s needs. Staff were making sure that people had regular drinks.

Some people were at risk of pressure damage to the skin. We saw that people were being supported to change position regularly, and were using appropriate pressure relieving equipment.

Although staff were providing some social activities for people, we found that these were not all appropriate for the people living at the home.

Some people had been prescribed creams and ointments for skin conditions. Records of when and where these creams had been applied were inconsistent and incomplete. This meant that it was not possible to know if people had received them as prescribed. Some other aspects of the management of medicines were not safe.

We carried out this inspection because we needed to check that the provider had made improvements following our inspection in November 2012. We had also been made aware of concerns about the way that the home was managing people’s pressure area care.

We found that the home had made improvements to the way they supported people who were at risk of pressure damage to the skin. However, we found that people were not being given sufficient fluids to drink. This put them at risk of dehydration and other health problems.

The home was providing a wider range of social and leisure activities for people to take part in. One person said, “at least it’s not quite as boring as it was”. The registered manager acknowledged that there was still work to be done in this area.

Many of the people living at the home were not able to tell us their views because of their health conditions. We therefore spent much of our time observing the care and support provided.

We saw that staff were kind and caring in their approach to people. We saw some staff talking between themselves about people, without involving the person in the conversation. Records showed that staff made sure that people were as involved as they could be in planning and reviewing their care.

Visitors told us that they were always made welcome at the home. People who were able to tell us about their experience said that they were generally happy with the care and support provided. Records showed that people received a good standard of care which met their physical needs.

People told us that they felt safe at the home. They said that they knew they could speak to the manager if they had any concerns. Staff knew how to report any concerns about possible neglect or abuse.

There were effective recruitment and selection processes in place. We saw that appropriate checks were undertaken before staff began work.

People were made aware of the complaints system. We saw that each person had a copy of the complaints procedure in their bedroom. People told us that they would feel comfortable raising any concerns with the manager.

In this report the name of a registered manager appears who was not in post at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

We carried out this inspection because we needed to check if the home had made the necessary improvements to the way medicines were managed. We found that the improvements had not been made. We also found other areas of concern.

People told us that they were happy with the care and support they received at the home. We saw that staff were kind and caring towards people.

Staff lacked knowledge and understanding about their legal responsibilities when people became unable to make informed decisions for themselves. Staff had not received training to support them when working with people living with dementia.

Some care plans did not provide a consistent or accurate record of people's needs and how they should be met. There was no effective system for monitoring care records to ensure that people received the support that they needed.

The management arrangements for the home did not provide sufficient time for the interim manager to carry out their management duties. There was no evidence available of a planned approach to monitoring the quality of the service.