This inspection took place on the 1 and 3 August 2018. The first day of the inspection was unannounced, we carried out an announced visit on the second day.

Symphony House 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. Symphony House Nursing Home is registered to provide accommodation and personal care to up to 25 people in one adapted building. At the time of the inspection there were 22 people living in the home.

At our last inspection on the 16 June 2017, this service was rated overall as “Requires improvement”. At this inspection, although some improvements had been made there were areas that needed further improvement. The service remains rated overall as “Requires improvement”.

There was a registered manager 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.

Appropriate systems and processes were not in place to assess, monitor and improve the quality and safety of the service. Quality assurances processes were not always effective at identifying shortfalls and where shortfalls were identified these were not always addressed in a timely manner to minimise the impact on people.

The way in which staff had been deployed had not always been effective in ensuring people’s needs were met in a timely manner.

There were elements of environmental safety that needed to be addressed to ensure that the environment people lived in was safe.

The policies and systems in the service had not resulted in applications being made under the Deprivation of Liberty Safeguards when needed. However, people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

Care plans were written in a person-centred approach and detailed how people wished to be supported. Staff discussed people’s care needs with them and supported them to make decisions about how their care would be provided. However, people did not always feel fully consulted and involved with their care plans.

People were supported and encouraged to eat well and maintain a balanced diet. People were supported to maintain good health. Staff had the knowledge and skills to support them and there was prompt access to healthcare services when needed.

Staff were aware of the importance of managing complaints promptly in line with the provider’s policy. People living in the home were confident that any issues would be addressed and that if they had concerns they would be listened to.

Recruitment procedures protected people from receiving unsafe care from care staff that were unsuitable to work at the service. People felt safe in the home and received care and support from staff that had a good understanding of their role in safeguarding people.

Staff were committed to the work they did and had good relationships with the people who lived in the home. People interacted in a relaxed way with staff, and enjoyed the time they spent with them.

At this inspection we found the service to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.

This unannounced inspection took place over two days on 16 and 20 June 2017.

Symphony House Nursing Home is registered to provide support for up to 25 people who require accommodation and personal care or nursing care. At the time of this inspection there were 23 people living in the home.

There was a registered manager 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.

At the time of the inspection it appeared that we had not received statutory notifications of deaths or safeguarding referrals that had occurred in the home. These are notifications that are required to be submitted by the provider to CQC by law and we are currently looking into this matter.

Appropriate systems and processes were not in place to assess, monitor and improve the quality and safety of the service. The provider did not have sufficient oversight of the service and the registered manager’s workload had impacted on their ability to carry out their role effectively. Records related to training were incomplete and there was no plan in place for future training.

People's capacity to consent to their care and support was not always considered. Applications under the Deprivation of Liberty Safeguards (DoLS) had not been made as required for some people. Some staff had not received training in Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS); there was a risk that staff would not have sufficient understanding of the requirements of the MCA (2005).

Recruitment procedures protected people from receiving unsafe care from care staff that were unsuitable to work at the service; however there was no process in place to review criminal records checks. Although there were enough staff on duty, the way in which they were deployed meant that people sometimes felt rushed.

Arrangements in place for formal staff supervision required strengthening. Records showed that staff did not have regular opportunities to formally meet with their line manager to discuss their role.

People continued to receive safe care. People were consistently protected from the risk of harm and received their prescribed medicines safely. People were supported to maintain good health and had access to healthcare services when needed; relevant health care professionals were appropriately involved in people’s care. Staff supported people to have sufficient amounts to eat and drink to help maintain their health and well-being.

People developed positive relationships with the staff, who were caring and treated people with respect, kindness and courtesy. People had detailed personalised plans of care in place to enable staff to provide consistent care and support in line with people’s personal preferences. People knew how to raise a concern or make a complaint and the provider had implemented effective systems to manage complaints.

The service had a positive ethos and an open culture. People, their relatives and staff told us that the registered manager was a visible role model in the home. There were opportunities for people and staff to contribute to the running of the home.

At this inspection we found the service to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.

This unannounced inspection took place on 19 May 2015. The home provides support for up to 25 people who require personal care and nursing care. At the time of the inspection there were 24 people living at the home.

At the last inspection in November 2013 we asked the provider to improve on notifying the Care Quality Commission of all deaths at the service. At this inspection we found the improvement had been completed.

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 2008 and associated Regulations about how the service is run.

People told us that they felt safe in the home. Staff understood the need to protect people from harm and abuse and knew what action they should take if they had any concerns. Staffing levels ensured that people received the support they required at the times they needed. We observed that on the day of our inspection there were sufficient staff on duty. The recruitment practice protected people from being cared for by staff that were unsuitable to work at the home.

Care records contained risk assessments to protect people from identified risks and help to keep them safe. They gave information on the identified risk and informed staff on the measures to take to minimise the risks.

People were supported to take their medicines as prescribed. Records showed that medicines were obtained, stored, administered and disposed of safely. People were supported to maintain good health and had access to healthcare services when needed.

People were actively involved in decision about their care and support needs There were formal systems in place to assess people’s capacity for decision making under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People felt safe and there were clear lines of reporting safeguarding concerns to appropriate agencies and staff were knowledgeable about safeguarding adults.

Care plans were in place detailing how people wished to be supported and people were involved in making decisions about their care. People participated in a range of activities both in the home and in the community and received the support they needed to help them do this. People were able to choose where they spent their time and what they did.

Staff had good relationships with the people who lived at the home. Complaints were appropriately investigated and action was taken to make improvements to the service when this was found to be necessary. The registered manager was visible and accessible. Staff and people living in the home were confident that issues would be addressed and that any concerns they had would be listened to.

We spoke with six people who used the service, they all told us that they liked living at Symphony House Nursing Home and they were well cared for. One person told us “it’s as good as it gets”, another person told us “I like it here, I get to do the things I like doing, like joining in with games or being left in peace.”

People spoke highly of the staff that looked after them. One person told us “I can’t find fault with the staff they are lovely”, another person told us “the staff help me maintain my dignity” and people told us that their visitors are always made to feel welcome.

We spoke with two relatives of people who used the service, they told us that the care was outstanding. One relative told us, “I could not fault the excellence and commitment of the manager in providing the best care possible for my father.” Another relative told us “the care is brilliant, we are kept well informed so we understand what is going on, the nurses really do care.”

We found that people’s needs had been assessed and care had been provided safely. We saw that people’s dignity was maintained and people were involved in planning their own care.

However, we found staff had not completed all of their mandatory training and there was no up to date information available to staff regarding procedures to make a safeguarding alert.

People who lived at Symphony House Nursing Home spoke highly of the staff and the care they received. The relatives who visited the home expressed their satisfaction with the care that people received and praised the attitude and skills of the staff.

We found that people living in the home were well cared for that and their needs were provided for. We also found that there were initiatives to make living at the home more homely by involving relatives and friends in social activities. We found that people were given the opportunity to choose how they wanted to live and make plans for the future.

We spoke with six residents and two relatives during our inspection visit. All spoke highly of the care provided. Residents told us that staff respected their views and wishes. Examples were given of rising and retiring times to suit individual preferences. Three residents that we spoke with were pleased that there were opportunities for mental stimulation at Symphony House.

Residents told us that the manager and staff were available as and when needed. They said that they did not have to wait long for assistance when they rang their call bell day or night and one resident said “I can have a cup of tea and something to eat when I want it”.

Residents told us that staff treated them with respect and they felt safe at Symphony House and that they felt able to talk to the manager or staff if they had a concern. One resident summed up comments made by others and said “I like it here”.

We spoke with three people who used the service; they all told us they were happy at Symphony House Nursing Home. One person told us “the staff couldn’t be any better”.

We spoke with the relatives of two people who used the service, they all told us that they were happy with the care that was provided. One person told us that if they were in need for a nursing home, that they would be happy to live at Symphony House Nursing Home.

We spoke with six members of staff, they all told us that they had received training in the safeguarding of vulnerable adults and had their appraisals yearly.

We found that the home had improved by ensuring that there was an up to date safeguarding policy and the staff had received mandatory training. However, we found that the provider had not reported any deaths to the Commission since February 2013.