We inspected the service on 24 October 2018. The inspection was unannounced.

The Firs 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 Firs Nursing Home can accommodate 31 older people and people living with dementia and nursing needs in one adapted building. Accommodation is provided on three floors; a passenger lift is available. At the time of our inspection 21 people were using the service.

There was a registered manager at the service. 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 previous inspection in September 2017 we identified some improvements were required in three key areas we inspected; ‘Safe’, ‘Caring and 'Well-led'. This resulted in the service having an overall rating of 'Requires Improvement'. We identified four breaches in Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to how risks were assessed and managed, staffing levels and deployment of staff, how staff respected people’s dignity and the governance of the service. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve the key questions to at least good. The provider sent us an action plan and told us they would make the improvements by 31 January 2017.

At this inspection, we found the breaches in regulation had been met. However, further time was required for improvements and new systems and processes to be fully imbedded and sustained.

Improvements had been made to how risks associated with people’s needs were assessed and managed. Staff had received additional training and guidance in how to mitigate risks. Following the last inspection, staffing levels had increased but had recently decreased, without appropriate assessments being completed. Senior management agreed on the day of the inspection, to increase staffing levels with immediate effect and to complete an assessment of people’s dependency needs. Safe staff recruitment procedures were in place and followed.

Improvements had been made in how staff respected people’s dignity and people’s meal time experience was positive. However, there remained some inconsistencies in staff’s approach.

National best practice guidance in the management of medicines were not consistently followed. This included the administration and record keeping of medicines. Accidents and incidents were reviewed and action was taken to reduce further reoccurrence, but were not consistently sustained. Infection control practice was used and understood by staff, but two people were exposed to unnecessary risk of cross contamination due to seating that could not be cleaned effectively.

Staff were aware of their responsibilities to protect people from abuse and avoidable harm. The management team had worked with the local authority safeguarding team to investigate safeguarding incidents and concerns.

Staff received an induction and ongoing training and support. Staff were knowledgeable about people’s health conditions.

People received a choice of meals and drinks and were assisted to eat and drink where required. People’s health care needs were assessed and monitored, and staff worked with external healthcare professionals in meeting people’s needs.

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 supported this practice.

Independence was encour

We inspected the service on 26 September 2017. The Firs Nursing Home is a purpose built care home. They are registered as a care home with nursing and provide accommodation for up to 31 older people. The service offers accommodation over three floors, with a lift to access the first and second floor. On the day of our inspection 30 people were using the service.

The service had a registered manager in place 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.

Risks in relation to people developing a pressure ulcer or who had a wound were not always assessed or monitored appropriately. People’s needs were not always met in a timely way due to the way staff were deployed in the service.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. Medicines were managed safely and people received their medicines as prescribed.

People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. People were supported to make decisions and staff knew how to act if people did not have the capacity to make decisions.

People were supported to maintain their nutrition and staff responded to people’s changing health and sought advice and guidance from health and social care professionals.

People were not always supported in a caring and compassionate way and their dignity was not always upheld. People who lived with a dementia related illness were supported by staff when they became distressed and staff respected people’s rights to privacy.

The systems in place to monitor the quality of the service were not always robust in identifying where improvements needed to be made. People were involved in giving their views on how the service was run. The management team were approachable and supportive.

We inspected the service on 7 October 2015. The inspection was unannounced. The Firs Nursing Home is a purpose built care home. They are registered as a care home with nursing and provide accommodation for up to 31 older people. The service offers accommodation over three floors, with a lift to access the first and second floor. On the day of our inspection 31 people were using the service.

The service had a registered manager in place 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 managers are also the registered providers of the service.

People felt safe in the service and staff knew how to protect people from the risk of harm. However recruitment processes were not robust and supervision of staff who needed further guidance in good practice was not consistent. Medicines were managed safely and people received their medicines as prescribed. There were enough staff deployed in the service to meet the needs of people and to ensure they received care and support when they needed it.

People were supported by staff who had the knowledge and skills to provide safe and appropriate care and support. People were supported to maintain their nutrition and hydration and staff ensured healthcare advice was sought when people’s health needs changed.

People were supported to make decisions about their care and support and where people lacked the capacity to make certain decisions, these were made in their best interests. People were supported to maintain their health needs. Referrals were made to health care professionals for additional support or guidance if people’s health changed.

People were treated with dignity and respect and had their choices acted on. We saw staff were kind and caring when supporting people.

People enjoyed the activities and social stimulation they were offered. People also knew who to speak with if they had any concerns they wished to raise and they felt these would be taken seriously.

People were involved in giving their views on how the service was run through the systems used to monitor the quality of the service. Audits had been completed that resulted in the manager implementing action plans to improve the service.

The three people we spoke with told us they were supported by staff appropriately and they were happy with the care and support they received. One person told us, “I receive excellent care. I have been in hotels with lower standards.” We also spoke with a relative of a person using the service and they told us their relative was, “extremely happy and received good care.”

Medicines were prescribed and given to people appropriately. We spoke with three people using the service about their prescribed medicines. They told us that staff gave them their medicine and they were given at the times prescribed by their doctor. We saw medication was stored and administered in line with safe practice.

There was enough equipment to promote the safety and comfort of people who use the service. We saw people had specialist equipment such as chairs to promote good skin integrity. People told us they had equipment they needed to make them comfortable.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an “expert by experience” (people who have experience of using services and who can provide that perspective).

To help us understand people's experiences we used the Short Observational

Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us

understand the experiences of people who could not talk with us. We chose to use

SOFI in the main dining room on the ground floor, because this was where people most people ate their lunch. We observed the lunch time for a period of 35 minutes noting the experiences of four people.

People who use the service understood the care and treatment choices available to them. For example we heard staff trying to reassure someone who was not happy with the chair they were sitting in, trying to find out what the problem was and offering alternative chairs and re-positioning. Staff explained fully what they were going to do throughout the actual use of a hoist to transfer the person from an armchair to wheelchair in preparation for lunch.

People were supported to be able to eat and drink sufficient amounts to meet their needs.

During our SOFI observations staff were seen to encourage one person who we knew to be nutritionally ‘at risk’ to eat more. They gave a smaller portion to this person and sat with them supporting them throughout the meal. The result was that the person finished all of their meal and with encouragement drank two glasses of juice.

People told us that if they had any concerns they would speak with the staff. One person said, “I’d mention it on the quiet to one of the staff” and another said, “I’d ask (friend) to write to Abbeyfield.”

During our visit there appeared to be a sufficient number of staff available to meet the needs of the people using the service.

People’s personal records including medical records were accurate and fit for purpose. We found records were kept securely and could be located promptly when needed.

We spoke with three people using the service and all three said they were happy living in the home. One person told us, “the staff are kind and they work very hard. If there was anything I wasn’t happy about I would just have to tell them and they would sort it out.”

We observed staff during lunch and we saw that where special equipment to enable people to eat independently was needed, this was in place. There were enough staff available to give people using the service the level of support needed throughout the meal.

We spoke with five people using the service and asked them if they were supported to make choices about their daily life. One person told us, “I can choose what I do during the day and where I spend my time. If I want to spend time in my bedroom I can and if I want to eat in the lounge instead of the dining room I can.” Another person using the service said, “we have a good choice of what to eat and if I don’t like what is on offer I can choose something else.”

We observed one person using the service who was eating their lunch in a small separate lounge. We saw that a member of staff gave the meal and then left the person to eat. We saw that the person dropped most of the food before it reached their mouth and they picked some small pieces of potato up with their fingers and ate that. The person only ate a very small amount of the meal and a member of staff came to take the plate away without trying to encourage this person to eat more. We spoke to the person using the service and asked if they would have liked some help to eat their meal. They said, “I keep dropping the food. I would have eaten more if I had some help, I prefer to eat in this room but if I had eaten in the dining room I would have had help from staff.” We asked if the person wanted anything else to eat with support from staff but they declined.

We spoke with five people using the service and all five told us that they felt safe. One person said, “I feel the place is secure and I feel safe here” and another said, “I feel safe and if I was worried about anything I would tell the manager.”

We spoke with five people using the service and some of their relatives. One person using the service told us, “I get on well with the staff, they are very kind.” Another said, “the staff are very good.” One relative told us, “staff are extremely willing, pleasant and helpful.” Another relative told us, “staff make visitors very welcome, I feel like a part of the family.”

We observed staff interacting with people using the service during our visit. We saw that staff were kind, helpful and polite and treated people with respect.