The inspection took place on 4 June 2018 and was unannounced. At the last inspection in June 2015, the service was rated Good. At this inspection we found the service remained good. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Swarthdale 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. Swarthdale Nursing Home accommodates up to 43 older people.

The home is in a residential area of the market town of Ulverston in an older building that has been adapted and extended for its current purpose. Accommodation is provided on two floors, with two passenger lifts. There is a seating area and car parking at the front of the building.

There was a registered manager at the home. 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 who lived in the home told us they were satisfied with the way the home was run and the care they received. One person told us, “I would rather be in my own home but they do look after you in here.” We observed that staff were polite and considerate and that people who lived in the home seemed to be at ease with care staff.

Risk assessments had been developed to identify and minimise the potential risk of harm to people during the delivery of their care. These and individual care plans had been kept under review and updated when necessary to reflect people's changing needs. We have made a recommendation that the registered manager review their risk assessments on bedrails and bumpers to follow the manufacturer’s instruction on their use.

Care plans were based upon the individual needs of people and contained information about people's personal needs, likes and dislikes. We have made a recommendation that the service seek advice about ways of supporting people in the home to be more involved in decisions about their care, treatment and support and record this.

The service worked with local GPs, district nurses and health care professionals and external agencies to provide appropriate care to meet people’s different physical, psychological and emotional needs. We found that medicines were being administered safely and records were being kept of the medicines in the home.

Systems were in place to deal appropriately with any complaints or concerns raised about the service. Staff had received safeguarding training and were aware of their responsibilities to report.

We found staff had been recruited safely and were being trained and supported to carry out their roles. Staffing levels were observed to be sufficient to meet the needs of people who lived at the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service support this practice. People's privacy and dignity was being promoted.

People told us they were happy with the variety and choice of meals being provided and that there was always a choice. We observed regular snacks and drinks were provided between meals to help make sure people received adequate nutrition and hydration.

The registered provider continued to improve the environment for the people who lived there. The building was being maintained and was a clean place for people to live. We saw that equipment in use had been serviced and maintained as re

This unannounced inspection took place on 1 May 2015. We last inspected Swathdale Nursing Home on 24 September 2014. At that inspection we found the service was not meeting all the regulations that we assessed. This was because the registered provider had not made sure people were protected from the risk of infection and because adequate maintenance and refurbishment was not being carried out promptly.

We made compliance actions and asked the registered provider to tell us how they were going to make the improvements required. The registered provider wrote to us and gave us an action plan saying how and by what date they would make the improvements to the environment and infection control. They told us that they would be refurbishing the downstairs communal toilets, the laundry, the downstairs and upstairs shower rooms/wet rooms, the sluice rooms, the hairdressing room, the wheelchair storage, some carpets and replace chairs and the damaged and dated furniture in bedrooms and communal areas. In addition they were going to develop the environment to make it more ‘dementia friendly’ and provide new items of equipment for aiding people’s mobility. The nurse call system was being replaced with a modern radio system and the passenger lift was to be modernised.

At this inspection 1 May 2015 we found that the registered provider had made the improvements they said they would. Improvements to the sluice rooms were not complete as there had been equipment delays slowing progress.

Swarthdale Nursing Home provides nursing and residential care and accommodation for up to 43 people. The home is in a residential area of the market town of Ulverston in an older building that has been adapted and extended for its current purpose. Accommodation is provided on two floors, with two passenger lifts. There is car parking at the front of the building.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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 and associated Regulations about how the service is run.

At the time of the inspection there were 39 people living in the home. Those we spoke with told us that they felt safe living there, that staff were “kind” and that there were enough staff available when they needed them.

The home had moving and handling equipment and aids to meet people’s mobility needs and to promote their independence. The home was being well maintained and the facilities were being improved for people. We found that all areas were clean and free from lingering unpleasant odours.

We found that there was sufficient staff on duty to provide support to people to meet individual’s personal care needs. Staff had received training relevant to their roles and were supported and supervised by the registered manager and the care manager. The home had effective systems when new staff were recruited and all staff had appropriate security checks before starting work.

People were able to see their friends and families as they wanted and go out into the community with support. There were no restrictions on when people could visit the home. All the visitors we spoke with told us that the manager was “approachable” and that staff were “friendly” and “available” when they wanted to speak with them.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. The service worked well with health care professionals and external agencies such as social services and mental health services to provide appropriate care to meet people’s different physical and emotional needs.

The staff we spoke with were aware of their responsibilities to protect people from harm or abuse. They knew the action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home.

The staff on duty we spoke to knew the people they were supporting and were aware the choices they had made about their care and daily lives. People had a choice of meals and drinks, which they told us were good and that they enjoyed. We saw that people who needed support to eat and drink received this in a supportive and discreet manner.

The inspection team who carried out this inspection consisted of two inspectors and a specialist advisor in relation to occupational therapy. During the inspection we worked together to answer five key questions, is the service safe, effective, caring, responsive and well led?

We visited the home to follow up on a compliance action made at the last inspection 11 June 2014 in relation to consent to care and treatment. We also followed up concerns that had been brought to our attention in relation to staffing, the suitability of equipment in use and the infection control and maintenance of the home environment.

Below is a summary of what we found. The summary is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.

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

Is the service safe?

We saw that risk assessments had been carried out to help make sure that people who lived in the home received safe and appropriate care and treatment. This included in the important areas of nutrition, personal care, skin care and wound management, mobility and moving and handling and the risk of falls.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place. We found that there was evidence that each person's capacity to consent was being assessed and recorded in relation to care and treatment decisions.

We made a tour of the home and the areas used by the people who lived there. We found that the home was in need of an upgrading of the facilities and the environment and some redecoration.

At the previous visit the manager had told us that environmental issues we highlighted to them would be attended to under the home’s general maintenance. The work had not been carried out when we visited again although there was evidence shown to us to indicate that a contractor had been contacted to do some of the refurbishment work.

We observed during the visit that the home environment was not 'dementia friendly' and was not well maintained to promote people’s wellbeing. The laundry environment continued to pose problems with keeping the laundry easily cleanable and hygienic.

We found that the moving and handling equipment being used in the home was regularly serviced. We observed staff undertaking moving and handling procedures and they demonstrated a good knowledge of equipment and techniques. However slings used for moving people were being used communally which can pose an infection risk.

During our visit we looked at the staffing levels, staff deployment and at staff rotas for the previous weeks. We found that there were sufficient staff available to support people. The manager, in collaboration with staff, had made changes in the times staff started and finished work and took their breaks. This change had improved the numbers of staff available at the busiest times of the day when people needed more support.

Is the service effective?

We found that mobility equipment was in place and people had been assessed for its use. The equipment and how it was to be used was set out in people’s care plans.

We saw that there were records in place documenting people’s choice and preferences. There were also records of why and how a person’s best interests had been discussed and their mental capacity assessed. People also had the opportunity to make decisions about future care, treatment and their wishes should their health needs change radically and this was recorded in their plans.

Is the service caring?

People had access to organised activities in the home and to take part in activities that were important to them, for example attendance at their own church.

We could see in people’s care plans that assessments of individual's care and support needs had been carried out using appropriate clinical tools and how they would be managed. Care plans had been written with a focus upon people’s own preferences.

Some of the people living in this home were not able to easily express their views about the support they received. We spent time in communal areas of the home to observe staff interactions and approaches to people living there. We observed that some care staff took opportunities to interact positively with people living there. For example, making conversation with people, offering them more drinks, encouraging them with their meal and asking if they wanted anything else to eat.

We also observed that there were several members of staff who did not take up valuable opportunities to positively interact and connect with the people living there. We observed that there were some staff that did not ask people what they wanted or include them in conversations. This can affect people’s wellbeing and social inclusion.

Is the service responsive?

People living there that we spoke with told us, “I have never found that they (staff) don’t come when I have used my bell for help”. We were also told, “I have never needed to make a real complaint, if I did I would tell the manager or the nurses”.

People living there were able to join in organised activities if they wanted to and some people went out into the local community. We saw people were able to follow their own faiths and attend religious services if they wanted to.

People who lived there told us that they could see their doctor if they needed them and saw them in their own rooms. We could see from care records and speaking with people that they had support from relevant healthcare professionals. This included seeing the chiropodist, the dietician, speech and language team and community mental health team.

Records confirmed people's preferences, interests and different needs had been recorded and personal care had been provided that met their assessed needs.

Is the service well-led?

At our visit in June 2014 we did not find clear evidence that tests, set out in legislation, had been applied to assess the person's understanding or 'capacity' to take a decision. The information about who held held Power of Attorney for people was not clear in their care plans. At this visit we found that the manager and staff had worked well with the local GPs and people’s families and representatives to make sure that all actions were in line with legislation. We could see that all decisions about resuscitation had been reviewed and updated to make sure they were clear and as required by legislation. We found that the information on file for decisions made around resuscitation were now of a consistently good standard.

At our last visit staffing levels in the home had been affected by staff sickness and staff leaving to take up other posts. In response to this the manager had looked at redeploying staff to use them more effectively, this helped to make sure there were sufficient staff to meet people’s need at busy times of day. Additional nursing staff had also been recruited.

Quality assurance processes were in place. We saw that audits were done by the manager to monitor the environment but that these had not been acted upon by the provider. Monitoring of equipment cleaning and visual checks had also not been effectively monitored.

We found that there were shortfalls in the home’s infection control measures. These were related to the environmental issues that needed to be addressed to improve hygiene and minimise the risk of infection.

The inspection team who carried out this inspection consisted of an inspector and an expert by experience. During the inspection we worked together 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 is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.

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

Is the service safe?

We saw that risk assessments had been carried out to help make sure that people who lived at Swarthdale received safe and appropriate care and treatment. This included the important areas of nutrition, personal care, skin care and wound management, mobility and moving and handling and the risk of falls.

We saw that the premises and grounds were being maintained and were accessible to the people living there. Appropriate measures were in place to ensure the security of the premises to keep people safe. The service had systems in place to manage and monitor the prevention and control of infection.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place. The home had appropriate policies and procedures regarding The Mental Capacity Act

2005.

We saw that people who had capacity to make decisions about their care and treatment had been supported to do so.

However we did not see clear evidence that tests, set out in legislation, had been applied to assess a person's understanding or 'capacity' to take a decision. The information about who, if anyone, held Power of Attorney for people was not clear in care plans. (Powers of Attorney concern who has legal authority to make decisions on a person's behalf).

We found that the information on file for decisions made around resuscitation were not of a consistent standard.

Is the service effective?

We found that people’s health and care needs had been assessed and care planned to meet their identified needs and preferences. People were supported to carry out as much of their care as they could themselves, with the care staff assisting them with tasks they couldn't manage on their own.

We saw records that showed staff had undertaken accredited end of life training to give them the skills and knowledge to look after people properly. Where people had been identified as at higher risk due to complex needs, appropriate specialist services had been contacted for advice and support.

The manager had a small bank of nurses and carers who would cover for staff. The manager had used agency staff who knew the home to help maintain effective staff levels

Is the service caring?

People who lived at Swarthdale that we spoke with made positive comments about the staff employed at this home. We were told, “They (staff) take good care of me” and also “I have nothing bothering me, I’m happy here, thank you, as a matter of fact I feel quite fortunate”. People we saw in the home were supported by suitably trained and supportive staff.

We saw many positive interactions between the staff on duty and people who used this service. People told us that staff were, “polite” and “pleasant”.

A relative told us “They (staff) have taken on board any suggestions we have had and changed to suit us”.

Is the service responsive?

We saw that there were meetings for people living there and relatives to attend to discuss what they wanted in the home. People were able to take part in activities they wanted to inside and outside the home and to decide for themselves how they spent their time.

People's needs had been appropriately assessed before they moved into the home. We saw from the sample of care plans we looked at that the management plans of care, treatments and support were subject to evaluation, review and alteration in response to changes in people’s needs and preferences.

We could see that the manager and staff monitored people’s conditions and weight. Staff had made timely referrals to other agencies, health care professionals and specialist nurses and to access the care or support people needed.

Is the service well led?

Quality assurance processes were in place and people living there and their relatives were asked for their feedback on the service they received. This was done through satisfaction surveys and via regular home meetings.

The staff told us that the management team was supportive and they had been given opportunities to train and develop professionally.

There were regular meetings to promote good communication. Staff told us they were supported by the management team and that the manager had “High standards”.

Staff expressed confidence in the manager to support them in reporting poor practice and in maintaining confidentiality. We were told the manager was “approachable” and that their ideas and suggestions were listened to and some taken forward.

The service worked well with other agencies involved in people’s care including the community mental health team, the local authority and safeguarding teams.

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if something bothered them. We had evidence to show that complaints were recorded and managed appropriately. The home had systems in place to protect people from abuse and to promote their rights. We found that there were adequate staff to meet people's needs. We spent a lot of time observing daily life in the home and the lunch time meal where there were staff available to help people with their meals and prompt them to eat and drink.

People told us they were satisfied with the care they received although they knew staff were often busy they "do their best for me". One person told us that "I go into the lounge and meet up with a lady I know and her visitors and we have a laugh and a joke with the girls."

Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We did not observe any overtly negative or harmful interactions between staff and people in the home. People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.

On our walk around the building we saw that people had been able to personalise their rooms with their own pictures and personal items.

People told us they were happy with the care at Swarthdale, and that standards had risen under the current management. One person saying:

“The new manager is absolutely wonderful, the staff seem to be much happier and they home is better organised. We have meetings now for residents and relatives. We made suggestions at the last one and are planning to go out for more trips and to the ballet.”

Other comments included:

“The Girls are very happy and make time for you”

“Theres always staff in the lounge to help you out, there seems to be more staff these days”

People told us they had choice of what to eat, how to spend their day and when to go to bed.

Relatives told us they trusted the manager and staff and found them approachable and responsive.

The people living at Swarthdale we spoke with during our visit told us that they felt safe living there and were happy with the support they had received. One person told us that, ‘’They are very good staff, I am well looked after". Another person told us "I leave medicines to staff they know what they are doing, I trust them’’.

People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if something bothered them. We had evidence to show that complaints were managed appropriately. People told us they liked the staff who worked there.

We spent time observing daily life in the home and at the lunch time meal and saw that there were staff available to help people with their meals and prompt them to eat and drink. Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We observed lively and positive interactions between staff and people in the home which made for a relaxed and friendly atmosphere. We also observed staff responding sensitively to people and picking up cues from body language when they needed assistance or reassurance.