The inspection site visit took place on 17 and 18 December 2018 and was unannounced. Thurlaston Meadows 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. The care home is a two-storey building and is registered to provide care for up to 45 people who do not require nursing care. At the time of our inspection visit there were 31 people living at the home.

There was no registered manager in post. However, a manager had recently been appointed on 3 December 2018 and was in the process of applying to become the registered manager. 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. In February 2018 the service changed its registration from providing nursing care to providing residential care. Since that time, there had been ongoing changes to the management team and two managers left the service.

We last inspected this service in May 2016. The service was rated as ‘Good’ overall, with the key question of well-led rated ‘Requires Improvement’ and the four other key questions rated as ‘Good’. At our last inspection we found there had been numerous staffing challenges, which had left gaps in both the management structure and staff team. Systems to assess the quality of the service were not always effective in identifying where action was needed to make improvement. Audits did not always detail whether actions identified were implemented and some audits had not identified issues that we found.

At this inspection, we found some changes had been made, however further improvements were needed to assure us care was delivered effectively to meet people’s needs. We have rated the service as ‘Requires Improvement’ in the key questions of safe, effective and well-led and ‘Good’ in the key questions of caring and responsive. Therefore, the overall rating is ‘Requires Improvement.’

People were positive about the management of the home and told us staff were approachable. However, there had been staffing changes in the management team and processes to monitor the quality of service were not always effective.

Staff understood their responsibilities to protect people from the risk of harm, however some staff had limited knowledge of local authority adult safeguarding procedures.

Care plans did not always contain accurate information about people’s needs. We found some risks to people’s health and safety had not been properly assessed and some events relating to people’s safety had not been recorded consistently.

Staff’s suitability to deliver care and support was checked during the recruitment process and there were enough staff to meet people’s needs. However, staff training was not up to date and there were gaps in staffs understanding of their responsibilities in relation to the MCA. Improvements were required to ensure best interest decisions were recorded and consents were obtained in accordance with the MCA.

People knew how to complain and could share their views and opinions about the service.

People told us staff were caring and they were encouraged to maintain important relationships. People were supported to maintain their health and to eat and drink enough to maintain a balanced diet. People received their medicines as prescribed. Staff knew people and understood their likes, dislikes and preferences for how they wanted to be cared for and supported. Staff respected people’s right to privacy and supported people to maintain their independence.

We found a breach of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. You can s

The inspection took place on 17and 18 May 2016. The visit was unannounced on 17 May 2016 and we informed the provider we would return on 18 May 2016.

The Warwickshire Nursing and Residential Home provides accommodation, personal and nursing care for up to 46 older people. The home provides care to people living with frailty due to older age or dementia and other health conditions. The home provides end of life nursing care to people. At the time of the inspection 36 people lived at the home and one person was having day care, but not living, at the home. Renovation building work on five unoccupied bedrooms was due to be completed in June 2016.

The home is required to have 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. At the time of this inspection the home had a registered manager in post.

At our previous inspection in September 2014, the provider was meeting the requirements of the regulations. Since our last inspection, numerous staffing changes had taken place and these included the appointment of a new manager in October 2015, who became registered with us in March 2016.

Staff were trained to protect people from avoidable harm and people felt safe living at the home. Staff knew how to respond to emergencies that might arise from time to time. People felt there were enough staff to meet their needs and that staff had the skills they needed. We found people had their prescribed medicines available to them and were supported by staff to take these as prescribed.

Staff undertook training to give them the skills and knowledge they needed and where staff did not follow this, poor practice was addressed by the manager. Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People had choices about what they did and how they spent their time and were offered choices about food and drink.

People described staff as kind and caring and we observed some positive caring interactions that were person centred. People and their relatives felt involved in making decisions about their care and felt listened to. People told us they had no complaints about the service they received.

Systems were in place to assess the quality of the service provided but these had not always been effective in identifying where action was needed to make improvement. There had been numerous staffing challenges, which had left gaps in both the management structure and staff team. This had impacted on the manager’s time and overall management. The manager was aware of some issues that required improvement in the home and where some staff care practices needed to be improved upon.

The inspection was completed by one inspector. Thirty–eight people were living at the home at the time of our inspection. The inspection was unannounced.

At our previous inspection in April 2014 the provider was not meeting the regulations in relation to medicines management, infection prevention and control, having sufficient staff and supporting staff. Following the inspection the provider sent us report to tell us the actions they planned to take to improve. During this inspection we checked whether improvements had been made since our previous inspection.

We spoke with five people who lived at the home and one relative. We spoke with the newly appointed manager, the clinical lead nurse, the head of domestics, a nurse and a care assistant.

We observed care and support being delivered in the communal areas and reviewed relevant records. We reviewed policies and procedures, two care plans, the staff training schedule, the results of medicines’ and infection control audits and minutes of a recent resident and relatives’ meeting.

We used the evidence we collected to answer the five key questions: is the service safe, effective, caring, responsive and 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, staff and visiting relatives told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

At this inspection we found appropriate improvements had been made to ensure the provider was meeting the regulations.

People told us that staff were always available to help them when they needed support. We observed there were enough staff to meet people’s needs. The manager had re-assessed everyone’s needs and had recruited additional nurses, care assistants and support staff according to the needs analysis. Nurses told us the additional staff meant they were able to spend more time engaged in hands on nursing and getting to know and understand people’s individual needs. The increase in permanent staff meant the provider did not have to employ agency nurses.

Two people we spoke with told us they were happy that staff managed their medicines on their behalf. The new manager had reviewed and updated the medicines policy and procedures. A new clinical lead nurse had been appointed to lead on medicines management. Nurses told us they received updated medicines training. They told us the new arrangements for obtaining, managing, administering and recording medicines gave them confidence that medicines were managed safely.

People we spoke with told us the staff cleaned every day. We saw the home was clean and some areas had been refurbished since our previous visit. The new manager had reviewed and updated the infection prevention and control policy and procedures. The head of domestics showed us the new cleaning schedules, which they used to check that cleanliness was maintained throughout the home. The manager had taken advice to make sure they followed the Department of Health Code of Practice for infection prevention and control.

Is the service effective?

At this inspection we found appropriate improvements had been made to ensure the provider was meeting the regulations.

Staff told us they had discussed their training needs at supervision sessions with the manager. A nurse told us they had attended specialist training that gave them more confidence to support people’s individual needs. Records showed that all new staff completed the Skills for Care common induction standards during their probation period. A newly appointed care assistant told us they had already discussed their career options with the manager.

All the staff we spoke with told us they attended handover meetings and were well informed about people’s needs. Staff told us they understood their responsibilities and were guided and supported by experienced staff.

Is the service caring?

People we spoke with told us, “I haven’t got a worry in the world now” and “I love it here.” We saw staff treated people with kindness and understood people’s needs.

The manager had implemented a review and reformat of care plans. Records we looked at showed that people and their relatives were involved in reviewing their care plans.

We saw that visitors were welcome to visit at any time. Two relatives told us they visited every day. One relative told us the staff and manager encouraged and supported them to spend as much time as possible with their partner who lived at the home. They told us staff supported them to spend time privately, separately from other people who lived at the home.

Is the service responsive?

People told us staff encouraged them to maintain as much independence as possible. One person told us they went out when they liked and enjoyed the company of other people and the staff. We saw that staff respected people’s decisions for their everyday living.

We saw minutes of meetings for people and their relatives that showed people were encouraged to express their views. We saw recently printed posters which explained the provider’s complaints policy in an easy to understand format.

The manager had recently sent a survey to people’s relatives. This was awaiting analysis at the time of our inspection. The manager planned to ask an independent organisation to survey people who lived at the home as this would enable them to express their views anonymously.

Is the service well led?

People told us they liked the manager because he took a personal interest in their welfare. One person told us the manager was as observant and caring as the staff. Another person told us, “The manager’s ideas are brilliant.”

All the staff told us they appreciated the manager’s leadership because the changes he had implemented were effective and they had a clear understanding of their roles and responsibilities. The manager told us they were empowered to make clinical decisions and the provider made strategic decisions.

The manager had reviewed and updated all of the provider’s policies and procedures to make sure staff had effective guidance. Each nurse took a lead role in designated areas of care, such as medicines, infection prevention and control and care plan reviews. We saw a programme of regular audits had been implemented. Staff told us they knew the outcome of the audits and the actions they needed to take to improve.

During our inspection we looked to see whether we could answer five key questions: is the service safe, effective, caring, responsive and well led?

When we inspected the service the home had 38 people living there who required personal or nursing care. Some people who used the service had limited verbal communication skills but were happy to be introduced to us. We observed people moving freely around the home, taking part in activities and making choices about how and where they wanted to spend their time.

We spoke with an acting manager as the registered manager shown on this report had recently left the service. The acting manager explained the previous manager had left suddenly and they had only been in their post for three months. We also spoke with five members of care staff.

We spoke with seven people who lived at the home and two relatives. We looked at records at the home. Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The staff we spoke with understood the procedures they needed to follow to ensure that people were safe. They were able to describe the different ways that people might experience abuse and the correct steps to take if they were concerned that abuse had taken place.

Before our inspection a staff member had raised some concerns with us. We raised these concerns with the acting manager of the service. They explained that no whistle-blowers had raised concerns with them. However, we found staff could raise issues of concern with the service, because staff were told about the whistle-blowing policy and procedures when they started working at the home. The whistle-blowing procedure ensured staff were protected during any subsequent investigation.

Recruitment procedures were rigorous and thorough. We looked to see whether there were the right levels of staff working at the service. We looked at the staff rotas which showed there were not enough staff to meet people's needs at all times. We have asked the provider to send us an action plan stating how they will improve in this area.

Safeguarding procedures were robust. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLs). We saw no recent applications had been submitted. Relevant staff were trained to understand when an application should be made and how to submit one.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistle-blowing and investigations. This reduced the risks to people and helped the service to improve.

We checked whether people's medicines were being managed safely. We found people's medication was not being appropriately administered and safely managed. We have asked the provider to send us an action plan stating how they will improve in this area.

Is the service effective?

People's health and care needs were assessed before they came to the home to determine their needs and make sure the service could meet them effectively. Specialist dietary, communication and equipment needs had been identified in care plans where required.

We saw arrangements were in place for care plans to be reviewed regularly to make sure information about people's care and support needs remained appropriate and accurate.

People had access to a range of health care professionals some of which visited the home.

It was clear from our observations and from speaking with staff they had a good understanding of people's care and support needs and that they knew them well.

Is the service caring?

We saw staff were attentive to people's needs throughout our inspection. Staff interacted positively with people and staff gave people time to respond. We found staff showed patience when communicating with people who lived there.

People and relatives we spoke with were positive about the care provided by staff. One person who used the service told us, “The staff are kind and friendly." A relative told us, “I am very happy with the care provided to X."

Is the service responsive?

We saw people were able to access help and support from other health and social care professionals when necessary. One person told us, "My own doctor comes here to see me."

People were able to participate in a range of activities both in the home and in the local community. One person told us, "I'm looking forward to gardening when the weather is better."

People who used the service, their relatives and other professionals involved with the service completed satisfaction surveys. Where shortfalls or concerns were raised these were analysed and addressed.

We looked at how complaints had been dealt with at the service and found that complaints were investigated and dealt with in a timely way.

Is the service well-led?

The service had a quality assurance system in place to identify areas of improvement. Records seen by us showed that identified improvements were addressed promptly. As a result the quality of the service was continuously improving.

We found staff employed to work at the home did not have all the necessary skills needed to support the people who lived there. We have asked the provider to send us an action plan stating how they will improve in this area.

People's personal care records were up to date and complete.

During our visit we spoke with six people about their experience of living in the home. We were told, “I am looked after very well” and “I am settled and comfortable.”

We spoke with five visitors who made positive comments about the care and support their relatives received. We were told, “I have been a visitor for three years. I have no concerns” and “The staff are wonderful.”

We looked at the care records for four people and found that their needs were assessed prior to admission so that plans of care and support reflected the way people liked and needed to be cared for. We found that care records were reviewed on a regular basis to make sure they accurately described the care people needed.

The members of care and nursing staff we spoke with told us that training took place on a regular basis so that the team could update their skills and knowledge. We were informed that information about people’s needs was discussed at the daily hand over at the start of each shift.

We observed that staff responded promptly to people when they asked for support and treated people with respect whilst providing care.

We found the home to be clean with systems in place to prevent the risk of the spread of infection.

We were told that people were given information about their rights to raise concerns and complaints. A visitor commented, "The manager responded quickly when I raised an issue I was unhappy with."

We visited The Warwickshire Nursing and Residential Home on 5 July 2012. Our visit was unannounced which meant no one who lived or worked there knew we were coming.

During our visit we spent time observing how people were supported by the staff team on duty and spoke with five people about their experience of living in the home. We did this because some people were not able to tell us about their experiences due to complex health care needs. We also spoke with the provider, manager and eight members of staff.

We looked at four sets of care records, staff training records and the procedure for storing and administering medication. We sampled health and safety records and some of the systems for monitoring quality within the home.

We last visited The Warwickshire Nursing and Residential Home on 4 January 2012. At that time we had concerns about some aspects of people's care and service. We checked that the concerns we had raised had been addressed during this visit.

People told us they were happy and comfortable. We were told, "The staff are all nice. They look after me well."

We saw that staff were friendly and respectful to people. We were told, "I have no complaints."

We completed a visit to this home as we had received anonymous concerns regarding staffing levels, staff training and nursing staff professional identification numbers. We arrived at the home at 8.25am and saw three people seated in the dining room awaiting breakfast.

We spoke with people who live at the home, visitors to the service and staff. One member of staff told us that staff shift times have been changed so that they work a 12 hour shift with only a short break in the morning and afternoon. Duty rotas seen show that some staff are working between the hours of 8am - 2pm, some 8am - 4pm and some 8am - 8pm. Nursing staff work a 12 hour shift.

The home was warm and clean on the day of our inspection and people appeared to be at ease in their surroundings. However, people spoken with commented that occasionally they felt the home was short staffed. One person said, "staff don't come quickly." Another person said "I am not sure if they check to make sure you are alright at night but I think they must do."

One member of staff spoken with said that the home were poor at providing training. Records seen confirmed this.

We saw that staff were polite and friendly but did not have the time to stop and chat to people whilst undertaking their duties.