The inspection was carried out on the 12 and 17 October 2017. The first day of the inspection was unannounced and the second day was announced.

Staff provided personal and nursing care for up to 33 older people. The accommodation spanned two floors and some rooms had on-suite facilities. A lift was available for people to travel between floors. There were 28 people living in the service when we inspected. People had chronic and longer-term health issues associated with ageing or illness requiring nursing care and some people were living with dementia as a secondary diagnosis.

We carried out our last comprehensive inspection of this service on 05 and 06 December 2016. At that inspection breaches of legal requirements of the Health and Social Care Act Regulated Activities Regulations 2014 were found. The breaches related to Regulation 17, Good Governance; Accurate and complete records were not being kept. Regulation 18, Staffing; Staff were not deployed in sufficient numbers. We also made six recommendations. The recommendations related to medicines audits, Deprivation of Liberty Safeguards applications, staff surveys, residents meetings and meeting people’s social needs. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Whitens Nursing Home on our website at www.cqc.org.uk

At the time of this inspection the local authority in Kent had been working with the provider on an improvement plan. This improvement plan had been implemented in response to recent concerns about incident and safeguarding management in the service. The action plan and the improvements being made had been shared with CQC by the provider. At this inspection, we found that the provider had brought in a team of senior managers to implement the improvements that were required.

There was not a registered manager employed at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. The provider had employed a manager who had made an application to register with the Care Quality Commission on 21 June 2017, but they had left before the registration process had been completed. However, the provider was in the process of recruiting a new manager. At the time of this inspection the service was being managed by an experienced interim manager.

Staff protected people’s privacy and confidentiality whilst delivering care, but at other times, people could be observed in bed as their doors were open. It was not clear if people had consented to their doors being left open. We have made a recommendation about this.

The risk from infection were minimised by safe systems of work by staff delivering personal care and by a planned and actioned cleaning and maintenance routines. However, two areas in the service requiring maintenance posed a risk to infection control. We have made a recommendation about this.

The provider had a system in place to assess people’s needs and to work out the required staffing levels. Since the last inspection, the provider had been making changes to the way staff were deployed and simplifying recording systems to reduce the amount of time staff spent away from care task, for example completing paperwork. A recently appointed nurse deputy manager was leading on the effective delivery of nursing care.

Space in the service for the storage of confidential information was limited. However, since the last inspection, information that staff needed access to when delivering care was kept in people’s bedrooms and other larger care plans were stored in locked cabinets at the nursing station on the ground floor.

We observed safe care. Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. Nursing staff understood their professional responsibility to safeguard people. The interim manager responded quickly to safeguarding concer

We inspected The Withens Nursing Home on 5th and 6th December 2016. The inspection was unannounced. The Withens Nursing Home provides care support and accommodation for up to 33 people with nursing needs. At the time of inspection there were 24 people living at the service.

An acting manager in post was going through the processes of being registered with the Care Quality Commission. 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 our last inspection on 17, 20, 23 May 2016, we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities). These breaches were in relation to staffing levels, recruitment practices and training, medicines management, Mental Capacity Act 2005 (MCA) processes, activities, care plans, records and auditing systems. The provider sent us an action plan stating that they would address all of these concerns by November 2016.

At this inspection, we found that the registered provider had not fully addressed the issues relating to staffing levels and of the provision of meaningful activities.

There were not always sufficient staff on duty to meet people’s needs. People, relatives and staff told us that more staff were needed.

Activities were not consistently provided to people who remained in their rooms. The acting manager had identified this and an additional activities coordinator was being recruited. We have made a recommendation about this in our report.

Trained competent staff were safely managing medicines. An accurate audit trail to monitor the administration of medicines was not undertaken. We have made a recommendation about this in our report.

People were protected against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns.

The provider had ensured that the home was well maintained. Up to date safety checks had been carried out on electrical and gas installations. Equipment, such as hoists, were being checked and serviced.

People’s needs had been assessed and detailed care plans had been developed. Care plans had appropriate risk assessments that were specific to people’s needs.

The principles of the Mental Capacity Act 2005 (MCA) were adhered to. People were being assessed appropriately and best interests meetings took place to identify the least restrictive methods of keeping people safe. Staff had training on MCA and had good knowledge.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

Spot checks were not being effectively recorded and fully implemented by the acting manager. We have made a recommendation about this in our report.

People were supported to have a healthy and nutritious diet. Staff could identify when people required further support with eating and appropriate referrals were made to health professionals and staff were seen to be following the guidance provided.

People and their relatives told us they were involved in the planning of their care. Records also confirmed people’s involvement. Care plans and risk assessments were being reviewed on a monthly basis by staff and at any time when it was required.

People had freedom of choice at the service. People could decorate their rooms to their own tastes and choose to participate in any activity. Staff respected people’s decisions.

People’s private information was not always kept secure. We found that

We carried out this inspection on the 17, 20 and 23 May 2016, it was unannounced.

The Withens Nursing Home is owned by Ranc Care Homes Ltd, a company who own several care homes. The service provides accommodation for up to 33 older people and provides nursing care to people with high needs, including people who are nursed in bed, people living with dementia, and people receiving end of life care. Accommodation is provided over two floors, with a passenger lift providing access between the floors. At the time of the inspection, 29 people lived at the service, all of whom were receiving nursing care.

The service had not had a registered manager since February 2015. There had been two managers since February 2015, both managers had transferred to other services owned by the company. 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 provider had appointed a manager who was present on the first day of the inspection visit and had worked at the service for three months. The manager was in the process of applying to become the registered manager. They were not present on the second and third days of the inspection visit due to the findings on the first day of the inspection visit. The head of quality and care services was in day to day control of the service on the second and third days of the inspection visit.

Nursing staff managed and administered medicines for people. Medicines were not always appropriately managed, administered and recorded.

Staff were recruited using procedures designed to protect people from unsuitable staff. However, robust recruitment checks had not always been carried out.

There was not always sufficient staff on duty to meet people’s needs. Staff had not received all of the training they needed to meet people’s needs and had not received regular support, supervision and appraisal from their manager.

Procedures and guidance in relation to the Mental Capacity Act 2005 (MCA) was in place which included steps that staff should take to comply with legal requirements. The manager failed to act in accordance with the Mental Capacity Act as capacity assessments did not follow the principles of the Mental Capacity Act and deprivation of liberty safeguards applications had not been made to the local authority supervisory body in line with agreed processes to ensure that people were not unlawfully restricted. The service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were not always provided with a diet that met their needs and wishes. Menus did not offer varied choices. Before the inspection visit was completed the menus had been changed and the new menus offered more variety as well as different choices.

Person centred care planning records were not fully completed and showed inconsistencies therefore; people may not have received care and support that met their needs.

At the time of the inspection visit there were no meaningful activities taking place in the service to keep people alert and occupied.

There were risk assessments in place for the environment, and for each person who received care. Assessments did not always identify people’s specific needs, and did not show how risks could be minimised.

The provider and the manager investigated and responded to people’s complaints. People knew how to raise any concerns. We found that concerns had not always been dealt with appropriately and in a timely manner. We have made a recommendation about this.

The provider regularly assessed and monitored the quality of care to ensure standards were met and maintained. However, the manager had not maintained the monitoring of quality of care, and had not followed up on previous action points

When we inspected the service in August 2014, we found that the provider was non compliant with the regulation 23 of the Health and Social Care Act 2008 because the staff had not received appropriate training, supervision and appraisal. Some staff's feedback indicated they were dissatisfied with previous instability of management as there had been several managers appointed over the past three years and periods of time where no managers were in post.

We requested the provider to submit a remedial action plan in a set time frame to remedy this. The service had provided us with an action plan that demonstrated how they planned to address these issues. During our inspection, we found that this action plan had been implemented and that the issues had been addressed to achieve compliance.

We spoke with the manager and five members of staff and one relative of a person who used the service. We looked at staff training records and at the system in place to support and appraise staff and to gather their feedback.

During this inspection, the inspector focused on answering our five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that people who used the service were protected from the risk of abuse because all care staff were trained in the safeguarding of adults, in the principles of the Mental Capacity Act 2005 and in the Deprivation of Liberty Safeguards (DoLS).

Members of staff we spoke with were able to demonstrate their knowledge and were positive about their responsibilities. One member of staff said, "We are trained to protect the people we care for".

Is the service effective?

We found that the staff had received the training they required to meet the needs of people who used the service and that additional training was available and scheduled. This was to make sure that staff were knowledgeable about people's individual conditions and individual needs.

Is the service caring?

We found that people who used the service were supported by kind and attentive staff. A relative of a person who used the service told us, "The staff appear to be knowledgeable and we trust them to care for our family member well".

Is the service responsive?

One member of staff told us, "Training has taken off in a big way, and now that it is built-in in our hours, cover is no longer a problem, it is great". The manager had implemented a permanent system to collect staff's feedback and analysed the findings every week to identify and address any staff's dissatisfaction.

Is the service well-led?

The new manager had driven improvements in the service. This included an open door policy, an effective communication system and comprehensive maintenance of staff's records such as training, supervision, appraisals and relevant audits. All the staff we spoke with confirmed the manager was approachable and receptive to ideas or suggestions. Four members of staff told us, "We are now much better organised, and staff are valued more", "We get good support from the manager, it is good to have a manager who intends to stay", "I am encouraged to go for a higher diploma and it is really nice to feel valued like this", and "This manager is really good, she properly listens to us".

The inspection was conducted by two inspectors over the course of ten hours. At the time of our inspection, a new manager had been in post for three months and their registration with CQC was in progress. We spoke with the manager, the regional operations manager, a visiting GP, seven care workers, the activities coordinator, the chef, four people who lived in the home and five of their relatives. We looked at seven sets of records for people who used the service, staff’s training and supervision records, the service's satisfaction surveys, activities programme, menus and policies and procedures.

During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

CQC monitors the operation of Deprivation of Liberty Safeguards (DoLS) which applies to residential care homes. We spoke with the manager and they demonstrated their knowledge of the procedures to follow if an application needed to be made to deprive a person of their liberty. We found that no person who lived in the home were deprived of their liberty at the time of our inspection. All care staff had been trained in the safeguarding of vulnerable adults. However not all care staff had been trained in the principles of the Mental capacity Act (2005 (MCA) and in first aid. We found that risk assessments with clear action plans were in place to ensure people remained safe. Emergencies measures were in place and the people who lived in the home had personal evacuation plans.

Is the service effective?

People and their relatives told us they were satisfied with the quality of care that had been delivered. A relative of a person who used the service said, "All the staff are extremely kind and professional, they understand what needs to be done". We saw that the delivery of care was in line with people's care plans and assessed needs. Care plans, risk assessments and handovers reflected people’s current needs. Changes in care plans were effectively communicated to staff.

Is the service caring?

We found that the people who lived at the home were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff provided encouragement, reassurance and practical help. Requests for assistance were responded to promptly. We saw that staff showed kindness and patience when they supported people at mealtimes or during activities. A relative of a person who used the service told us, "The staff are really very nice and efficient". Two people who lived in the service said, “People are nice to me” and “The staff are very kind and polite”.

Is the service responsive?

People's needs had been assessed before they moved into the service and their support plans were reviewed regularly to reflect any change in their needs. We saw that people's records included their life history, wishes and preferences and desired outcomes to be achieved. People were able to choose what they preferred to eat. The chef met with people on a daily basis to ask what they would like to eat. Requests that were made during residents meetings or expressed in satisfaction surveys were followed through and responsive action was taken. We found that some members of staff had expressed dissatisfaction about their working conditions and felt they were not listened to. We found that additional training for staff was not sufficient to address specific needs of people who used the service. The service had failed to provide regular and consistent one to one supervision and appraisals to the staff.

Is the service well-led?

The manager had been in their post for three months. They operated a system of quality assurance and completed audits to identify how to improve the service. Additionally, an operations manager carried out compliance checks and developed improvement plans. When audits identified the need for an improvement, this was implemented. People and their relatives or representatives and staff were consulted about how the service was run. Annual survey questionnaires were provided and their results were analysed. A member of staff told us, "The new manager is approachable and we have hope that they will stay and continue to improve the home”. Another member of staff said, “We have had too many changes of management and we need some stability. The staff morale is low but we like the new manager”.

This was a follow up visit to check that the provider had completed compliance actions set at their last visit on 25 and 26 February 2013. The provider sent us an action plan on 13th June 2013 detailing how they were going to meet the compliance actions. There is no Registered Manager named for this location. The provider has just appointed a new manager and their registration with the CQC is in progress. The provider’s Regional Operations Manager and the newly appointed manager were present throughout the visit.

We spoke with three people who used the service and two representatives who used the service. Comments included “I am well looked after” and “I have recently been involved in reviewing my relatives care plan and it meets their needs. We are really happy with the care my relative is getting”. We found that the provider had reviewed the care plans for all the people using the service with input from the person using the service and their representative and care staff. We found that staff had received refresher training and there was a plan in place for staff to receive supervision and appraisals to ensure they maintained the relevant competencies to carry out their job role.

We found that the provider had developed a more robust system to monitor the quality of the service provided. We found that the provider had reviewed personal information held on people using the service and staff and these were now up to date and accurate.

This was a follow up visit to check that the provider had completed renovation work which was outstanding from our visit of 15th August 2012.

People who used the service and their representatives told us that they were involved in making decisions about their or their relatives care.

People who used the service and their representatives told us that they or their relatives felt they were treated with dignity and respect. They had no concerns and felt safe living in the home.

People told us that they were informed of any changes to their care and representatives of people who use the service told us that the home also contacted them to keep them informed of any changes.

Representatives of the people who use the service told us that they felt their views were taken into account in the way care was provided to their relative and that the new manager was “efficient” and “1st class”. They told us that they had seen a “great improvement” since the new manager was appointed.

One representative told us that “on the whole it’s a good home and they meet my relative’s needs” and that “we chose this home because it had a homely feel to it”.

During the visit we talked with six people living in the home, and briefly met several others.

People were mostly very positive in their outlook and made comments such as:

“Everything is fine here. They look after me very well. I have no problems.”

“The food is lovely; most of the carers are lovely.”

“It’s very good really. The staff are lovely.”

One person expressed concern that there was only one toilet on the ground floor that was suitable for people who needed to be moved using the hoist.

Another person said “two of the care staff are idle; but the rest are lovely, and work hard.”

We talked with a total of ten relatives for different people living in the home.

Their comments included:

“We have been very happy with all aspects of the care. It was the best move she ever made to come in here.”

“We can’t fault the home. They have looked after X wonderfully. He has always been kept clean and comfortable.”

“I am very pleased my mother is here. Everyone is very friendly, and everyone has helped me with the process of her coming in here.”

One relative expressed concerns about the number of care staff on duty, as they felt there were insufficient staff on duty, especially in the afternoons and evenings.

This was a responsive inspection following receipt of information of concern. In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at this time. The Regional Manager was present throughout the visit.

We spoke with seven representatives of people who used the service and two people who used the service. Comments included, “I am happy with the care that my relative receives, the staff do their best”, “The staff are kind to my relative” and “I have asked that my relative be socialised more and for them to be more actively stimulated, but they don’t seem to be able to do this. I think this is because there are not enough staff”. People also told us that although they were aware of a care plan being in place for themselves or their relative, they did not remember seeing their care plan. We spoke with staff who told us that they liked working in the home. Comments included, “We have a good team here” and “It would be good to have some direction from the nurses and the manager”.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Our observations showed that people who used the service did not always get the care and support that they needed.