About the service:

Whitstable Nursing Home provides nursing and personal care for 35 older people and for people living with dementia. At the time of our inspection 26 people lived in the service.

Rating at last inspection: ‘Requires Improvement’ (report published February 2017)

Why we inspected: This was a planned inspection based on the rating at the last inspection. At our last inspection we found that there were two breaches of regulations. This was because there were shortfalls in the planning, delivery, monitoring and evaluation of the nursing care provided for people with specific healthcare conditions. There were also shortfalls in the completion of quality checks to ensure that people consistently received safe care and treatment. At the present inspection we found that improvements had been made to address the breaches of the regulations to ensure that nursing care was delivered in line with national guidance. We found that in each domain the service now met the characteristics of Good. The overall rating of the service is, ‘Good’.

What life is like for people using this service:

People were safeguarded from situations in which they may be at risk of experiencing abuse.

Risks to people's safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected.

Medicines were managed safely.

There were enough nurses and care staff to provide people with the care they needed.

Background checks had been completed before new care staff had been appointed. Suitable provision had been made to prevent and control infection

Lessons had been learned when things had gone wrong.

Care was delivered in line with national guidance and nurses and care staff had the knowledge and skills they needed to promote positive outcomes for people.

People were supported to eat and drink enough to have a balanced diet.

Suitable arrangements had been made to ensure that people received coordinated care when they used or moved between different services and they had been helped to access healthcare services.

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. The service was compliant with the Mental Capacity Act 2005.

Some of the accommodation was not well maintained. However, there were plans to put the defects right.

People were treated with kindness, respect and compassion.

People were supported to express their views about things that were important to them.

People received personalised care that promoted their independence.

The registered manager, nurses and care staff recognised the importance of promoting equality and diversity.

Complaints were promptly resolved to improve the quality of care.

People were supported at the end of their life to have a comfortable, dignified and pain-free death.

People who lived in the service, their relatives, nurses and care staff were actively engaged in developing the service.

There were systems and procedures to enable the service to learn, improve and assure its sustainability.

The registered manager was actively working in partnership with other agencies to support the development of joined-up care.

More information is in the detailed findings below.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit in line with our re-inspection programme. If any concerning information is received we may inspect sooner.

The inspection took place on 7 December 2017 and was unannounced.

Whitstable Nursing Home is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the car provided, and both were looked at during this inspection.

Whitstable Nursing Home is registered to accommodate care and support for up to 34 people. At the time of the inspection there were 23 people at the service.

At the previous inspection in October 2016 three breaches of regulation were found. The provider had failed to ensure that care plans reflected people’s assessed needs and preferences, failed to maintain accurate care records for each person and failed to ensure that complete information about people’s previous employment had been investigated. Following the inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Responsive and Well Led to at least good. At this inspection improvements had been made and the legal requirements of one of the previous breaches had been met. However, a new breach was identified and there was a continued breach.

The provider had failed to ensure that care plans reflected people’s assessed needs and preferences, failed to maintain accurate care records for each person and failed to ensure that complete information about people’s previous employment had been investigated. At this inspection improvements had been made and the legal requirements of the previous breaches had been met. However, a new breach was identified.

The service had a registered manager in post. A registered manager is a person who is registered with CQC 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.

Potential risks to people’s health and welfare had not been consistently assessed and there was not detailed guidance for staff to follow to mitigate the risks to people.

Checks and audits had been completed on the environment, equipment and all areas of the service. The audits had not identified the shortfalls in the risk assessments to keep people safe. In all other audits when shortfalls had been identified, an action plan was put in place and signed off when the action had been completed.

The registered manager met with people before they came to live at the service to ensure staff would be able to meet their needs. The assessment covered all aspects of their physical, mental health and equality needs. People’s needs were assessed using best practice guidelines and formed the basis of the person’s care plan. Each care plan contained information about the person’s life, likes and preferences. The care plans contained details about how the person liked to be supported.

People had been asked about their end of life wishes and these had been recorded to ensure people’s wishes were respected. Staff had received training appropriate to their role, including end of life care. Staff received one to one supervision and appraisal to discuss their role and their training needs. There were sufficient staff on duty to meet people’s needs, staff were recruited safely. People’s medicines were managed safely and people received their medicines when they needed them.

Staff monitored people’s health and people were referred to specialist healthcare professionals when required. Staff supported people to be involved in discussions about their care. People had access to professionals including opticians, chiropodists and dentists when needed to support people to stay as healthy as possible. Staff worked with health and social care professionals to ensure people received the support they needed. People were supported to eat and drink to maintain a bala

The inspection took place on 11 and 12 October 2016 and was unannounced.

Whitstable Nursing Home provides nursing care and accommodation for up to 34 older people, some of whom may also be living with dementia. The service is an adapted detached building situated near to the seafront of Whitstable. The accommodation is provided on two floors, the upper floor is accessed by three staircases and one passenger lift. There are 20 single and seven shared rooms, three with en-suite facilities. There are two separate lounges and a dining area available for people to use. On the day of the inspection, there were 21 people living in the service.

The service did not have a registered manager in post at the time of our visit, although they had appointed a new manager and told us that they would be applying to register. 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.

Whitstable Nursing Home was last inspected on 11 and 12 April 2016. They were rated as inadequate overall at that inspection and placed into Special Measures. The provider sent us information and updates about actions taken to make improvements following our inspection. At this inspection we found that significant improvements had been made in most areas. In others, however, there were still some improvements required.

People were not fully protected by robust recruitment processes. The employment history of new staff was not explored thoroughly. At this inspection we found that processes had improved significantly but required further improvement.

Care plans had been developed since our last inspection and most contained personalised guidance to ensure that people received care and support that met their needs. However, some plans required more detail to be added to ensure that all people received the most appropriate care and support that detailed preferences and wishes. Audits to check detail in care plans had not been effective in identifying these shortfalls.

There were enough staff deployed to meet people's needs and they had received supervision to help them carry out their roles effectively. Staff were caring and responsive to people's needs and interactions between staff and people were warm and respectful. Most staff that had received appropriate training. This had improved significantly since the previous inspection; however some staff had not completed all of the necessary training. This is an on-going area for improvement.

People's safety had been protected through cleanliness and robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had been serviced regularly.

Medicines were well managed. Registered nurses followed correct and appropriate procedures in the storage and administration of medicines.

Meal times were a sociable event and people told us they were offered choices and enjoyed their meals. Risks of malnutrition or dehydration had been adequately addressed. There was varied programme of activities on offer, with a range of group and individual activities offered to ensure people’s needs were met.

There were opportunities for people and others involved in the service to provide feedback, and the provider had acted on feedback received to improve and personalise the service and support that people received. Effective quality assurance systems had been implanted and were used to identify shortfalls or areas for improvement.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people had been assessed as lacking m

The inspection took place on 11 and 12 April 2016 and was unannounced. The previous inspection was carried out on 3 December 2014 and rated as ‘requires improvement’. There were breaches relating to staffing levels and the potential risks associated with insufficient staff being available to meet people's needs and people did not always have their dignity protected. The service provided us with an action plan telling us how they would resolve these issues.

Whitstable Nursing Home provides nursing care and accommodation for up to 34 older people, some of whom may also be living with dementia. The service is an adapted detached building situated near to the seafront of Whitstable. The accommodation is provided on two floors, with most bedrooms on the ground floor, the upper floor is accessed by three staircases and one passenger lift. There are 20 single and seven shared rooms, three with en-suite facilities. There are two separate lounges and an open dining area available for people to use. On the day of the inspection, there were 25 people living in the service.

The service is run by 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.

At the previous inspection the provider could not demonstrate that there were always sufficient numbers of suitably, qualified, skilled and experienced staff employed to meet people’s assessed needs. Although staffing levels had increased since that time people’s needs continued not to be met by sufficient numbers of suitably, qualified, skilled and experienced staff during this inspection.

There were insufficient staff on duty to demonstrate compassionate person centred care practices.

In between meals people were left for long periods without activity or conversation. Although people’s personal care needs were met staff carried out their duties in a methodical task-led approach spending no time conversing with people except when assisting with personal care.

People were not fully protected by robust recruitment processes. The employment history of new staff was not explored thoroughly. Processes in place to protect people from abuse were not robust, because staff had not received up to date training, which helped them understand abuse and how to keep people safe. Staff did not receive the necessary training, supervision and support in order to provide the knowledge and skills to care for people.

Choices of food were supplied, but people were not supported to eat and drink in a way that supported their independence. Staff were not effectively monitoring people under observation for dehydration.

People’s care, treatment and support needs were assessed before they moved to the service and a plan of care developed to guide staff on how to effectively support people’s individual needs.

Plans of care were not personalised to ensure that people received the most appropriate and safest care and treatment, which took into account their needs, preferences and choices.

Information in the care plans were not kept up to date. Reviews of people’s care did not contain evidence of the involvement of people in their care and treatment.

There were limited opportunities for people and others involved in the service to provide feedback, and the provider had not acted on feedback received to improve services. Quality assurance systems were either out of date, absent or had not been used as indicators of where the service needed to improve.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people h

The inspection visit was carried out on 03 December 2014 and was unannounced. The previous inspection was carried out in May 2014, when non-compliance had been found with three regulations. This inspection included following up the action taken by the service in response to the non-compliance. The inspection was brought forwards because of concerns raised to the Care Quality Commission (CQC) from an anonymous source, in regards to people’s general care and welfare.

The premises are an old detached building situated near to the seafront of Whitstable. The service provides nursing care and accommodation for up to 34 older people, some of whom may also be living with dementia. The accommodation is provided on two floors, with most bedrooms on the ground floor. On the day of the inspection, there were 27 people living in the home, with one admission during the day, taking the total to 28 people.

The service is run by a registered manager, who was present on the day of the inspection visit. 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.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. The manager and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some of the people in the home had been assessed as lacking mental capacity to make complex decisions about their care and welfare. There were clear records to show who their representatives were, in order to act on their behalf and in their best interests, if any difficult decisions needed to be made about their care and treatment.

All staff had been trained in safeguarding adults, and discussions with them confirmed that they understood the different types of abuse, and knew the action to take in the event of any suspicion of abuse. Staff knew about the whistle blowing policy, and were confident they could raise any concerns with the manager or senior management. Senior managers visited the home on a regular basis, and three visited the home on the day of our inspection. Staff knew that the senior managers were accessible to them.

The service had suitable arrangements in place to protect people from assessed risks. These included risks of fire, and other risks such as trips and falls, legionella and use of equipment. Each person living in the home had individual risk assessments based on their own personal care and treatment. These included a Personal Evacuation Emergency Plan (PEEP) in the event of fire or other emergency. Other risk assessments were in places for people’s individual needs.

The manager had systems in place to determine the numbers of staff needed in relation to the dependency needs of people living in the home; and the overall numbers of people living in the home at any one time. She told us that she was able to increase staffing levels if people’s dependency needs rose significantly, and used bank staff who were known to the home for additional shifts. However, it was evident that care staff were very busy and appeared to be rushed, and people were left unattended in the lounges for periods of time, especially people living with dementia. The service could not demonstrate that sufficient numbers of staff were employed at all times to meet people’s assessed needs.

You can see what action we told the provider to take at the back of the full version of this report.

There were reliable recruitment practices in place to check that staff were suitable for their job roles. Staff showed kindness, empathy and patience with people during our inspection. People said that the staff “Looked after them well” and responded quickly when they called for assistance. Staff were supported through individual supervision meetings, group supervision, regular training, formal training qualifications, staff meetings, and yearly appraisals. All staff were trained in dementia care.

People’s medicines were administered by trained nurses. These were stored and managed in accordance with current guidelines and legislation.

People told us that they liked the food, and had plenty of choice. The menus provided a suitable range of foods to meet people’s different nutritional needs. The catering staff were familiar with different diets, such as fortified diets for people with low weight, and diabetic diets. Staff took time to assist people with eating and drinking where necessary.

People’s health care needs were assessed and managed by trained nurses, in association with other health care professionals. Referrals were made to GPs, and to other health care professionals as needed, such as dieticians, speech and language therapists, dentists, and the mental health care team. People’s care plan records contained detailed information about their health and personal care needs. People’s preferences were clearly recorded, and staff showed that they were familiar with these, such as calling people by their preferred name.

The premises were visibly clean. However, the premises did not provide an environment that facilitated the care of people with nursing needs and/or dementia. For example, the main lounge was long and narrow, which meant that chairs could only be placed around the room. The paintwork and walls were painted in light colours to increase the lightness in the property, but there was a lack of pictures or signage to aid and stimulate people with dementia; and a lack of activities to meet their assessed needs. An activities audit showed that this was in the process of being addressed.

We recommend that the staff follow the guidelines provided by the National Association for Providers of Activities for older people (NAPA); and the National Dementia Strategy for England (in association with Alzheimer’s Society), to support the staff in providing a suitable range of activities for people living with dementia to enjoy.

Staff were aware of people’s preferences to stay in their own rooms or to socialise with others. The activities co-ordinator carried out individual time with people during the mornings, which was enjoyable for the people concerned, but meant that other people were left without any activities or stimulation apart from watching television or having music playing. Group activities were carried out during most afternoons, but on the day of our visit some people said they were tired after lunch and did not wish to join in. Staff enabled people to go out of the home, and some had recently visited the town’s cenotaph to celebrate Remembrance Sunday.

People said that staff were friendly, and a relative said “The staff are pleasant and welcome me when I come in. They do their best.” One of the people told us “I am very settled being here”; and another said “I am as settled as I could possibly be with having had to leave my own home.” Personal care was given in the privacy of people’s own rooms or bathrooms; and suitable screening was available for people in shared rooms. Two people’s dignity was compromised during the day, as one person was wearing someone else’s clothing; and another person was weighed in the lounge in view of other people.

You can see what action we told the provider to take at the back of the full version of this report.

People told us that if they had any concerns they would talk to the nurse on duty, or the manager or her deputy. They were confident that if they raised any concerns they would be dealt with appropriately. Formal complaints had been responded to in a timely manner, and except for one complaint which was ongoing, had been satisfactorily resolved.

The manager had been in post for eighteen months, and staff told us that she had brought about positive changes in the home. This included more liaison with staff about bringing in changes, and allowing staff to take more part in discussing different ideas to improve the home. The company provided on-going support from senior management, which included a visit to the home at least once per month to monitor the quality of the service. However, auditing processes had not highlighted the need for people living with dementia to have more supervision and stimulation available. There were systems in place to obtain people’s views and ensure that their views were listened to and taken into account, so as to provide ongoing improvements. The manager was acting as the nurse on duty throughout the day of the inspection, and said she usually worked approximately one shift per week as the nurse. This helped her to maintain first hand knowledge of how care was being delivered.

We asked the provider to make improvements following our inspection in April 2013. We went back to check that improvements had been made. We found that the service was now compliant with the essential standards of quality and safety.

People’s privacy and dignity was respected. We saw that staff knocked on doors before entering and called people by their preferred names. Staff now engaged more and spoke with people as they passed them. What people could do for themselves was recorded and this maintained people’s independence.

Any form of restraint was now risk assessed and agreed to. For example, the use of bed rails to prevent people from falling out of bed. People’s private possessions were safeguarded in that inventories were completed and lockable storage provided.

Staffing levels had been reviewed and were now sufficient to meet people’s needs. This meant that staff were visible and present in communal areas and so able to respond to people’s needs. One person told us “I like it here. The staff are very helpful and kind.”

Visiting professionals from the local authority told us that the service had improved. Their monitoring visits had found that people using the service appeared happy with the service and that the home was clean and smelled fresh. A relative reported that they were happy with the care and that they had noticed some improvements in the last few months.

This follow up inspection found that improvements had been made and the two warning notices issued in April 2013 had been complied with.

Since our last inspection the provider had sent us an action plan showing how they intended to improve the service and achieve compliance. The provider had sent us updates about the action being taken to improve the service.

A new manager had been recruited and started work at the home 1 July 2013. The manager had started to audit care plans and risk assessment and had made referrals for extra support for people where needed. Care plans were now complete and up to date so gave staff guidance about how people preferred to be supported. Care plans and risk assessments had been reviewed and updated where needed and had been reorganised with a content list and dividers added to make them more organised.

We found that the home was cleaner and smelled fresher. Visiting professionals told us that they had noticed the smell was better and the home was cleaner. There were now more cleaning staff on duty covering every day of the week and a head of housekeeping had been employed to oversee the cleaning staff. Staff had had training about infection control and the infection control policy had been updated so it was in line with current legislation. Systems were now in place to detect, prevent and control infections.

People told us that their views were not always asked for and listened to in relation to their care and treatment. People’s dignity was not maintained. One person said “Some bits go missing; sometimes we have to wear other people’s clothes.” People were not addressed by their given and preferred names but with general names like ‘sweetheart’ and ‘boys’.

Community access and activities were not being provided. There was no activity person and people told us that they were bored.

Peoples’ needs were assessed but care and treatment was not always planned and delivered in line with their individual care plan. Some care plans had not been completed when a need or a risk was evident. This meant that staff had no guidance to follow about how to support people’s needs and reduce potential risks.

Forms of restraint were used that had not been assessed and that people had not consented to. People were at risk of unsafe, outdated moving and handling procedures. There were not sufficient skilled staff to meet people’s needs.

People told us that items of their personal property had gone missing. People who were at risk of falls did not always have a care plan or risk assessment to show how to reduce this risk. Some people were suffering injuries from falls; however the accident reports were not analysed to see if a pattern or trend emerged to show if the risk could be reduced.

The home did not smell fresh and was not clean and hygienic.

We spoke with 4 people living at the home, and we observed interactions between staff and other people living at the home throughout our visit. People were generally happy living at the home and they said they liked the staff. People said the food was good and that there was a choice at every meal time. People commented that sometimes they had to wait for help particularly around mealtimes, but staff were happy to help them, and assisted them in the way they preferred. People were addressed by their preferred name. Comments made included “Nothings ever perfect” and “The staff are very kind”, “The food is fine, there’s always a choice”.

Our inspection team was made up two inspectors and we spent two days visiting the service. We spoke with some of the people who used the service and their relatives, the manager, nursing staff and care staff. We also observed staff supporting people with their daily activities.

We considered our inspection findings to answer 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 is a summary of what we found. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people, relatives and the manager:

Is the service safe?

We saw that although people were protected against the risk of abuse, there was a lack of continuity of care when responding to people’s behaviour that may be challenging.

We looked at the management of staffing levels, and found that the home had suitable numbers of staff on duty, although we noted that sometimes staff were not always deployed effectively.

People’s care needs were met and staff understood the support people needed with regard to their personal care.

Is the service effective?

Records were maintained for different aspects of people’s care and support. They were generally well maintained although food and fluid charts did not always accurately record people’s intake to ensure that individual needs were fully monitored.

Staff had received training and supervision appropriate to their role. Further training had been planned in order to meet the individual needs of the people who lived in the home.

We found that the home provided a suitable variety of food to meet people’s nutritional needs and to provide them with sufficient choice.

People were supported appropriately with their healthcare needs.

Is the service caring?

People and their relatives were encouraged to make their views known about their care and support.

People made positive comments about the staff. We observed that overall staff treated people with kindness and respected their privacy and dignity. We noted, however, that when one person had a telephone conversation they were not given the opportunity have their conversation in private. Some parts of the care plans were not always written in a respectful manner.

Is the service responsive?

Some of the aspects of the service were not responsive. For example we found that a complaint had not been dealt with in accordance with the providers’ procedures.

The home had not been proactive in accessing support with regard to one person who may have been subject to Deprivation of Liberty procedures.

The home had recognised that there was a lack of meaningful activities and the activities coordinator was in the process of gathering information about people likes and dislikes.

Staff were clear about their roles and responsibilities.

Following our visit we met with the provider to discuss our findings. The provider understood their responsibilities in relation to ensuring people received a service that met their needs.

Is the service well-led?

There were some systems in the home that did not monitor risk effectively. There was a lack of effective systems to monitor behaviours and incidents to reduce the likelihood of reoccurrence.

Staff told us that they felt supported by the manager.

The manager took an active role in the home.