This inspection took place on 6 and 7 September 2017. The first day of the inspection was unannounced.

Walton house nursing home is registered to provide accommodation for people who require nursing or personal care and treatment of disease, disorder or injury for up to 41 older people. At the time of our inspection there were 40 people in receipt of care from the service.

The service had 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.

At the last comprehensive inspection on 23 September 2015 the service was rated as good overall and was meeting the regulatory requirements relevant at that time. During this inspection we found the provider was meeting the regulations at this time. However we made recommendations in relation to the safe storage and handling of medicines, support with meals, staff deployment and privacy, dignity and respect.

All people we spoke with were happy with the way their medicines were handled in the home. We saw medicines were safely secured when not being administered however we noted where fridge and room temperatures were outside of the required range these had not been acted upon.

People who used the service and relatives were mixed about the staffing levels in the home and how this related to their care. We saw duty rotas in place that identified the skill mix of staff on each shift and where gaps due to sickness or leave was identified arrangements for alternative staff had been arranged. We saw records that confirmed staff had undertaken training relevant to their role. Staff told us they received relevant training that supported them in their work.

People and relatives we spoke with told us they felt safe in the home. Staff had an understanding of the signs and types of abuse and knew what to do if they suspected abuse had occurred. There was an up to date system in place that had been developed by the local authority to support staff in referring allegations to the relevant agencies.

We received positive feedback from professionals about the home and evidence in care records confirmed professionals had been involved in health care assessments.

Records demonstrated consent for the delivery of care had been obtained. We saw some staff knocking of people’s doors and waiting to be invited in but not all staff did this. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

Records relating to capacity assessments had been completed by the home.

Meals provided to people looked appetising and nutritious. Choices of meals were available to people however not all people who used the service or their relatives knew about the choices available to them.

We received positive feedback about the care people received in the home. Some people told us they had been involved in the development, decisions and planning of the care they received.

Professionals were complementary about the care and support people received as they were nearing the end of their life. Records confirmed decisions about peoples choices had been discussed and agreed with them or their relatives.

There was some evidence of people’s privacy and dignity being met however not all peoples experiences in the home maintained their dignity and respect. The registered manager took immediate action to ensure people’s privacy, dignity and respect was maintained.

During our inspection we observed a number of people and their relatives taking part in activities in the home. There were details of the activities programme on display.

We saw positive feedback in thank you cards on

We last inspected Walton House Nursing Home in May 2014. At that time, we found people were not always protected against the risks associated with medication administration and handling. The required systems and procedures were not fully implemented to ensure people who used the service received their medication safely. For example, we observed one staff member who left the medication trolley unattended in a public area of the home with the medication left on top of the trolley. We also looked at medication that was in patch form and found the batch number on the box was different to the batch number on the patch. Additionally, stock checks of controlled drugs had not been recorded for some time.

During this inspection, we checked to see whether proposed changes in the management of medication had been implemented. We found the provider to be compliant. The medication trolley was attended at all times when in use. When unattended, it was locked. Batch numbers on patches and their boxes were found to be the same and controlled drugs had been recorded and checked appropriately by two senior staff members.

We visited the service in response to receiving some concerning information. Two adult social care inspectors carried out this inspection. The focus of the inspection was to answer five key questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

During the inspection we spoke with two people using the service and observed staff practice. We spoke with four care staff, the quality compliance manager and the manager of the home. We also spoke with the local authority. We viewed records which included, care plans and daily care records, policies and procedures and minutes from meetings.

We considered the evidence we had gathered. This is a summary of what we found:

Is the service safe?

We found all rooms we looked at had a call bell fitted. We noted where people were in bed; their call bell was within their reach. People’s ability to use the system was varied and staff told us they checked people regularly.

Where there were known risks such as challenging and unpredictable behaviour, this was considered around safety issues and the impact this would have on the safety and welfare of other people.

There were safeguarding policies and procedures in place including procedures to report poor practice. All staff had been trained in safeguarding. Staff told us they had a good understanding of the procedures but were not all sure how to escalate a concern further if they considered issues raised was not being dealt with by the manager.

We were told staffing levels had been increased in response to concerns raised by staff. We found there were sufficient staff to meet people’s needs.

Is the service effective?

The manager and staff agreed that seating arrangements had been problematic in terms of available recliner chairs but this was now resolved. An audit of available chairs had been done and three new chairs had already been purchased with a further three on order. We found people were seated in all areas of the home and in their bedrooms.

At the time of our inspection the TV in the lounge was switched off and people were reading or conversing with their visitors. The remote was unavailable although a visitor told us the TV could be used without the remote. We were told people could choose what to watch in the lounge, in agreement with other people in the lounge, or use the TV provided in their bedroom for programmes of their choice.

Is the service caring?

Staff were observed interacting with people in a kind, pleasant and friendly manner and being respectful of people's choices and opinions. Two people told us they were being cared for very well. One person said they were comfortable in their room and staff assisted them when they needed it.

Is the service responsive?

There was a record kept of all activities people had joined in with. We were shown the activity book that showed different activities people had taken part in. In addition to organised outings people were given one to one time. Throughout the week a series of organised activities took place such as, art and craft, gardening and hairdressing.

Records showed people were given position change for pressure relief, given food and fluids and had their comfort needs met. We noted there were gaps in recording this support. We discussed the importance of keeping these records up to date and ensuring staff were providing the right care and support.

We noted there was limited bed linen available following breakdown of one of the washing machines. We discussed plans in operation to ensure people’s comfort was maintained at all times by ensuring there were adequate supplies to deal with this.

Is the service well-led?

Staff told us they were comfortable to raise any issue of concern with the manager or the owner and were confident their concerns were listened to. Staff gave us examples of how their concerns had been responded to.

We brought forward our inspection in view of some concerns that had been reported to the Care Quality Commission. We looked at these concerns at our inspection and spoke with the manager. We were satisfied with the evidence provided in relation to these concerns.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This a summary of what we found:

Is the service safe?

The manager told us there had been no application for deprivations of liberties safeguards. (The Mental Capacity Act 2005 provides a legal framework to protect people who need to be deprived of their liberty for their own safety).

We saw evidence of appropriate care planning in place to ensure people living in the home received safe and effective care. There were up to date risk assessments in place in the care files we looked at for people living in the home. We saw reviews had been undertaken and had been signed by staff undertaking them.

We saw that medications for people living in the home were not administered safely. We saw medication was left unattended on a trolley in a public area of the home. We saw gaps in medication charts and documentation was not completed in relation to medications.

Is the service caring?

We spoke with people living in the home who told us staff were caring and kind. People said, “The staff are beautiful”, “There are enough staff always. They are patient and caring and always have a smile for me but they are so busy” and, “Staff are very nice and friendly. I get the help I need when I need it, I only have to ask".

We looked in people's bedrooms with their permission. We saw they had been nicely decorated and they had been personalised with mementoes and photographs. We saw people living in the home were spoken to kindly by staff and the manager.

We looked at four care files and saw care plans and risk assessments in place. There were regular daily entries in the files however some of the entries were difficult to read.

Is the service responsive?

We saw the home had resident and relative meetings and we saw evidence of these taking place. Visiting family we spoke with confirmed they were able to attend these if they wanted to.

We were told the home completed a recognised staffing tool based on nursing and residential numbers to ensure appropriate staffing requirements were in place to care for the needs of people living in the home. Staff we spoke with told us there were, “Enough staff but sometimes mealtimes are busy”, “We don’t get enough time to spend with residents but i feel the care is good” and, “There are not enough staff on duty we are very busy. The level of care is good but the staff are under pressure”.

Is the service effective?

We saw in the care files we looked at that care needs were being reviewed by staff and they had been signed. We could not see evidence people living in the home had been involved in their care plans however, people we spoke with told us staff had involved them in decisions about their care.

We saw two visiting healthcare professionals at the home on the day of our inspection. One of these we spoke with told us staff responded to any request from them and acted upon instructions.

We saw there was an activities coordinator in the home. We saw evidence of activities taking place and people living in the home we spoke with confirmed they took part in the activities. There was a hairdresser visiting the home on the day of our inspection and we saw people who used the service having hair treatments.

We were told the representatives from different faiths attended for people who used the service and we saw religious material in the lounge for people to use.

We asked about staff training. We were shown a training matrix which detailed planned training and training that had been undertaken for staff working in the home.

Is the service well led?

The manager was in the process of registering with the Care Quality Commission as he was new to the home. We received comments about the manager on the day of our inspection, “I like (Named Manager) he is doing a good job. (Named manager) is very nice as a person you can go to him”. We were told the owner visits regularly and staff could raise concerns with him if they needed to.

We saw there were regular meetings for staff and people living in the home. We saw notes on attendees and topics that had been discussed. Staff we spoke with on the day of our inspection confirmed team meeting were taking place. We were told the staff had been asked to discuss their concerns with the manager outside of the meeting.

We asked about audits taking place in the home. The manager told us they had recently recruited a member of staff to the organisation to undertake audits and reviews in the home to ensure quality was maintained. We saw evidence of a quality assessment audit that had been completed in the home in January 2014 however we could not see any notes for actions recorded with this.

People told us:

"I feel like all my needs are met...I'm treated with care and respect."

"The food is wonderful."

"Every so often I get asked what I think about the home...We have residents meetings where we can all have our say."

"If I had any concern at all I'd be happy to raise it without fear."

The provider undertook holistic assessments and formulated person centred plans of care for people who used the service, to ensure their needs were met and their wellbeing promoted.

People had a choice of nutritious food and drink available at mealtimes and throughout the day. Specialist input was sought where people were considered to be at risk from inadequate nutrition or hydration. Special diets were provided for people as required and sensitive support was given for people who needed it at mealtimes.

The provider minimised the risk of abuse by only employing people of good character and they had appropriate policies and procedures in place with regard to safeguarding vulnerable people. Staff had undergone training in safeguarding and were confident when it came to discharging their responsibilities.

The provider had made considerable improvements with regard to staff supervision and appraisal. The staff team felt well supported by the new manager and had opportunities for professional development.

The provider sought peoples views and had suitable systems in place to assess and monitor the quality of care provided at the home.

At our visit in September 2012, we had major concerns about the management of medicines in the home. As a result of our findings at the visit a Warning Notice was issued to the Registered Provider in regard to non-compliance with Regulation 13. This inspection was carried out to check whether appropriate arrangements were now in place for the safe management of medicines.

We found that medicines were generally recorded and administered safely and appropriately. Information was available to care workers that enabled them to support people living in the home to take and use their medicines appropriately.

We spoke with four people living in the home, two visitors, four members of staff, and discussed all matters with the manager. The people we spoke with told us they had choices in their routines. They said they could go to bed and get up whenever they liked and could spend time in their rooms. One person said, "I go to bed early because I get tired, I read and watch TV. I choose to go to bed early and get up early.”

One person told us, I’m looked after well and get on very well with all the staff.’’ Another person told us, ‘’I think there has been an improvement in the management since this manager took over. I’m very happy here.’’

Since the previous inspection a number of concerns had been reported to us and the safeguarding procedures had been used ensuring that the local safeguarding authority has been informed. However at the time of our visit we found one concern had not been raised with the local authority.

Staff told us that they had undergone induction training, one member of staff told us, ‘’ My induction checklist is at home but it’s not completed.’’ The staff records we looked at showed that not all staff had not completed aspects of induction training including moving and handling.

One person told us, ’’If I’m not happy with anything I tell one of the nurses.’’ Another person using the service that we spoke to said ‘’ I have no complaints and would tell the manager if I had.’’

We carried out an inspection at Walton House because we had received some information of concern about a shortage of staff, and a high use of agency staff who did not know the home or the needs of the residents. We were told this was resulting in a deterioration of the standard of care.

People told us they were well cared for at Walton House but there had been a lot of different staff in the home recently who didn’t know them or the home. This meant care was not always as good as usual.

The manager and the staff confirmed there had been staffing problems in recent months due to high staff absenteeism and heavy reliance on agency staff to fill shifts. Shifts had generally been filled but sometimes there was a high proportion of agency staff working in Walton House who did not know the home or the residents. We were told these problems stemmed from management difficulties, and the absence of the registered manager. There had been inadequate planning for staff holidays and sick leave over the summer which had resulted in short notice requests for large numbers of agency staff. There was also a delay in the recruitment process and vacancies had not been filled.

The newly appointed manager and the staff also told us improvements had been made. Many of the problems were being resolved with better use of agency staff and some permanent members of staff returning to work after periods of leave. We saw evidence of this on the inspection visit.

We were unable to talk to many people living in Walton House about their medicines. However one person told us that they didn’t like taking medicines, but got their painkillers when they needed them. We found out what people experienced with medication mainly using ways other than talking to the people living there.

Looking at records and checking people's medicines showed a number of serious concerns with the administration and management of medicines in the home. These concerns meant the home was non compliant with Regulation 13 and that they had to make urgent improvements.

People living in the home, and their visitors, with whom we spoke on the inspection visit told us they felt staff treated them respectfully and upheld their dignity. People said personal care was carried out 'properly and respectfully'. One person said "The staff are very good". Another said, "Staff treat me respectfully and they are there when you need them". Other comments made by residents and relatives were: "I like all the staff; they're very good to me", "Staff are caring and professional", "Staff help to maintain his dignity and independence" and, "Staff attitude is good here and people are treated as individuals". A relative told us there was a 'dignity in care' initiative in the home, with views about this being sought and events organised to help promote it.

People also felt they had sufficient involvement in the planning and delivery of their care and support. People told us they had a choice in such matters as spending time in their rooms, a choice of communal areas, and when to get up and go to bed. Two people told us that they enjoyed spending time in the 'quiet lounge' where there wasn't a television. However some people felt, though the food was of 'good quality', there wasn't much choice.

We were also told people filled in questionnaires about the service and were able to express choices and preferences to the manager and staff. 'Residents meetings' also gave people a chance to air their views and influence developments.

People living in the home told us they received the care and support they needed and that they felt their needs were met. People said: "Staff are there when you need them", "Staff are caring and professional", "I'm very happy here there couldn't be a better place", "It's beautiful living here, I wouldn't swap it for anything, I love it, it's A1", "He (the resident) is happy with the care he receives - he gets all the care he needs when he needs it" and, "It's perfect here; everyone is very nice".

Some people felt there were sufficient suitable activities to keep them active and entertained, but one person said 'there wasn't much going on'. This person later said, "Things (activities) are getting better".

Some staff told us they had sufficient, experience, training and support that enabled them to feel skilled and competent in their work. However others told us there were gaps in their training, such as medication and up to date mandatory training.

We carried out an unannounced inspection of Walton House Nursing Home on 23 and 24 September 2015.

Walton House Nursing Home provides accommodation, personal care and nursing care for up to 41older people, including people living with dementia. At the time of the inspection there were 38 people living at the service.

The home is a purpose built two storey building located on a main road in Walton-le-Dale, on the outskirts of Preston in Lancashire. There are shops and other local amenities nearby. Bedrooms and facilities are located over two floors and a lift is available. There is a lounge and dining room on the ground floor and all rooms have wheelchair access. All bedrooms are single occupancy. Not all bedrooms have ensuite facilities however there is access to suitably equipped toilet and bathroom facilities on both floors.

At the time of our inspection the service did not have a 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. The acting manager told us she had been employed at the service for eight weeks and planned to submit an application to the Commission to become the registered manager shortly after our visit.

A previous inspection of this service was carried out in May 2014 when we found that action was needed regarding the management of medicines. During our follow up inspection in March 2015, we found that the necessary improvements had been made. We carried out a further inspection in July 2014 in response to concerns received about the service and during that inspection we found that the standards we reviewed were being met and no action was required.

During our inspection people told us they felt safe. They said, “I always feel safe when staff are supporting me”. Relatives told us, “My mum is always kept safe. The care is very good. I’m very pleased with it”.

We noted that staff had been recruited safely and had received an appropriate induction and training. They had a good understanding of how to safeguard vulnerable adults from abuse and what action to take if they suspected abuse was taking place.

People living at the service, their relatives and staff told us that more staff were needed to meet people’s needs, particularly in the mornings. The manager told us she had received feedback about this issue in a recent satisfaction survey and showed us evidence that staffing levels were being increased from the week after our inspection.

There were appropriate policies and procedures in place for managing medicines and people told us they received their medicines when they needed them.

People living at Walton House Nursing Home told us staff had the skills to meet their needs. They told us, “The staff can’t do enough for you” and “There’s nothing to be unhappy about. It’s like a five star hotel”. Relatives told us, “The care is good. We’re pleased with it” and “We’re happy with the care. The agency staff are not always as good as the home’s staff but they never work on their own. They always work with permanent staff”.

We found that staff were well supported. They received regular supervision and could access training if they needed it. They told us communication between staff was good at the service and they always felt up to date with people’s needs.

Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and understood that mental capacity related to a person’s ability to make specific decisions at specific times. We saw evidence that people were involved in decisions about their care and where people lacked capacity to make decisions, their relatives were consulted.

We saw that people at the service were supported with their nutritional needs and most people we spoke with liked the meals.

People were supported with their healthcare needs and were referred appropriately to health care services. A nurse clinician who visited the service weekly told us the care at the service was good.

The people we spoke with told us the staff at the service were caring. They said, “The staff know me well and they’re kind to me”. However some people told us that some of the agency staff who attended the service were not as caring as the permanent staff. Relatives told us, “The staff are very caring and work very hard “and “The care here is very good, the staff have been good for my mum”.

We saw evidence that people were actively involved in planning their care and they told us they had the freedom to make a variety of choices including what time they got up and went to bed and where they ate their meals.

People told us staff respected their privacy and promoted their dignity. We observed staff seeking consent before providing care including knocking on people’s doors before entering and asking people if they were ready to receive their medicines.

We observed that people’s needs were responded to in a timely manner and saw evidence that their needs were reviewed regularly. We saw evidence that where people were unable to contribute to reviews of their care, their relatives had been consulted.

People were encouraged to plan and take part in social activities and told us they enjoyed the activities on offer at Walton House Nursing Home. They said, “The activities are much better than they were, we play games, watch films and entertainers come in”.

We saw evidence that the manager requested feedback about the service from the people living there, their visitors and from staff members. The feedback received was used to develop the service and to contribute to decisions about issues such as activities and staffing levels.

People living at the home and their relatives told us the staff and the manager were approachable and they felt able to raise any concerns. They felt the service was well managed, particularly since the new manager had been appointed.

We saw that the service had a clear statement of purpose which focused on the importance of high quality care and meeting people’s individual needs. The staff and the manager communicated with people, their visitors and each other in a polite and respectful manner.

The manager and staff had a caring and compassionate approach towards the people living at the service and the people we spoke with told us they were approachable.

We saw evidence that the manager carried out a variety of regular audits to ensure that appropriate levels of care and safety at the service were maintained.