This inspection took place on 7 December 2016 and was unannounced.

Windsor Road Mental Nursing Home provides care and accommodation for up to eleven adults who have enduring mental health needs. The home is a purpose built establishment with facilities on two levels, the upper floor being served by a passenger lift. All accommodation is offered on a single room basis including self-contained bedsit type facilities with private kitchen areas. The home is located on a quiet road in Lytham St Anne's close to local amenities and bus routes.

At the time of the inspection visit eight people lived at the home.

At the last comprehensive inspection on 16 & 30 November 2015 the service was not meeting the requirements of regulation 12 – safe care and treatment and regulation13 - safeguarding, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It was rated as required improvement. A focussed inspection was carried out on 18 March 2016 to check on the breaches. On that inspection we found that the provider had followed their plan to ensure the safety of people and legal requirements had been met. On this inspection the service had improved in all areas.

There was not a registered manager in place. However a new manager was in post and had started the process to apply to become registered with CQC. 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.

People told us they felt safe living at Windsor Road and liked living there. There were procedures to protect people from unsafe care or abuse. Staff were aware of these and had received training in safeguarding adults. They told us they would take action to ensure people’s safety where they became aware of or suspected a safeguarding concern.

Risk assessments were in place to reduce any potential risks of harm to people who lived at Windsor Road, their visitors and staff.

Recruitment and selection was carried out safely with appropriate checks made before new staff started working in the home. This reduced the risk of employing unsuitable people.

People were satisfied with staffing levels. They said staff supported them without rushing. Staff had received training in care which gave them the skills and knowledge to provide support to people.

Staff managed medicines competently. People told us they felt staff gave them their medicines correctly and when they needed them. We saw they were given as prescribed and stored and disposed of correctly.

People told us they were offered a choice of meals which they enjoyed. Drinks were available throughout the day and people’s dietary and fluid intake was sufficient for good nutrition.

The building and equipment had been maintained and was clean, hygienic and safe.

People said staff were caring and helpful. They said their health needs were met and staff responded to any requests for assistance promptly. We saw staff provided safe, attentive and sensitive care during the inspection.

Staff understood the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). This enabled staff to work within the law to support people who may lack capacity to make their own decisions.

People we spoke with said staff were caring and respectful, listened to them and assisted them promptly. They said staff supported them to remain as independent as they could be. People looked relaxed and comfortable with the staff who supported them.

Staff knew the care people needed, which showed us they were familiar with people’s care needs, and preferences.

Staff recognised the importance of social contact, companionship and activities. They supported people to engage in activities and interests in the home and lo

We carried out an unannounced comprehensive inspection of this service on 16 and 30 November 2015. At which a breach of legal requirements was found. This was because there were no sufficient measures to ensure when people had placed themselves at risk of self-harm or self-injury they could be safeguarded. Staff had not always made safeguarding referrals to local safeguarding authorities and the provider had not implemented proper and robust systems to make sure that care and treatment was provided in a safe way for people. This was with regards to the way medicines were managed, ordered and administered.

After the comprehensive inspection, we issued the provider with a Warning Notice requesting that they resolve the issues above and to ensure that they complied with regulations by 15 February 2016. The provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 18 March 2016 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Windsor Road’ on our website at www.cqc.org.uk’.

Windsor Road provides care and accommodation for up to eleven adults who have enduring mental health needs. The home is a purpose built establishment with facilities on two levels, the upper floor being served by a passenger lift. All accommodation is offered on a single room basis including self-contained bedsit type facilities with private kitchen areas. The home is located on a quiet road in Lytham St Anne's close to local amenities and bus routes. There were eight people who lived at the service at the time of the inspection. People told us that they felt safe living at Windsor Road. One person told us, "I feel safe, things have improved here”.

The home’s registered manager has worked in this role since October 2015. 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 our focused inspection on 18 March 2016, we found that the provider had followed their plan which they had told us would be completed by the 15 February 2016 and legal requirements had been met.

People told us that they felt safe and that their risks were being managed appropriately.

We found incidents were reported in a timely manner and support plans were updated. Risk management information was evidenced and shared between staff and management team.

Documentation had been improved to guide staff in understanding people who used the service, this included records of early warning signs, triggers, management techniques and clear instruction on how to seek support if people’s needs deteriorated. Protection plans included clear and concise information for the most effective support to be offered to people who used the service.

We saw staff had undergone training to support people who put themselves at risk. Staff we spoke to told us they felt confident after the training. We witnessed staff reacting to an incident confidently.

Staff on duty had sufficient knowledge of risks around individuals who use the service and what plans they had in place to manage the risks.

We found the service had put in place robust systems for ordering medicines. We did not find evidence of anyone running out of medication or being given medication a day later. We found medication was being administered safely and stock audits had improved significantly.

We found medication support plans contained sufficient detail.

We spoke individually with the manager, staff and people receiving care at the home. We asked people to tell us about their experiences of living at Windsor Road. We reviewed care records, staff files, policies and procedures, audits and risk assessment documentation.

One person told us, “I’m very happy here. I feel safe and comfortable”. We observed care being provided in a dignified and respectful manner. People were engaged with in an unhurried and supportive way.

The service demonstrated good practice that ensured that people were safeguarded against abuse. One person told us, “I feel safe and staff involve me in decisions about my care”.

Care practice and record-keeping was underpinned by clear, regular auditing procedures. This was enhanced by effective processes to support staff, such as regular supervision and training.

On the day of our inspection we spoke with two people who lived at Windsor Road. They told us they were happy with the support they received, were able to learn new skills and encouraged to make decisions. One person said, "They talk to me about the support that I need; I'm involved in decisions and I can say what I think".

During our visit we observed staff treating people in a friendly and respectful way. People were offered choices and were supported in a way that respected their privacy and encouraged their independence. People made positive comments about the staff team. They said, “Staff are lovely; they are very patient” and “Staff are terrific”. We found all staff received a range of appropriate training to keep them up to date.

During our visit we found the home to be suitable for the people who lived there. People were happy with the home. One person said, "I am happy living here; I am comfortable and have everything I need".

People told us they had no complaints about the service but would raise their concerns with the staff or managers. Comments included, “I am able to speak to any of the staff if I had a problem” and “I have no complaints but they listen to us and would sort things out”.

We spoke with a number of people who live at the home and received some very positive feedback. Everyone we spoke with expressed satisfaction with the support they received and spoke highly of staff and managers. One resident commented ‘’I like it here, we get very well looked after,’’ and another told us ‘’I have absolutely no complaints at all, the staff are very helpful.’’

In discussion, residents told us about the keyworker and named nurse system that was in place. All the residents we spoke with were aware of their keyworkers and said they found the keyworker system helpful. One resident commented ‘’All the staff are there for you but its good to have a keyworker. We go through my goals together and look at the areas I want to concentrate on.’’

People were aware of their care and support plans and what they contained. We asked people if they felt they were involved in their plans and they said that they were. One resident told us about one aspect of his plan which included a Recovery Star. He said ‘’I rate each area with my keyworker and we decide on goals.’’

People that we spoke with were generally complimentary about the quality and variety of food provided. Residents explained that a weekly meeting was held during which menus would be decided and also told us that everyone was encouraged to be involved in shopping for meals and in meal preparation. One person mentioned that staff no longer ate meals with the residents. He said ‘’I think that’s a shame, it was better when we all ate together.’’

We asked people who live at the home about their interests. People described busy and fulfilling lives and told us about a variety of interests and hobbies. One resident told us that he was looking for courses on the internet on Chinese Medicine; he said that the staff had helped him to do this.

We also saw that some residents had been given the opportunity to go on holiday earlier in the year. Residents we spoke with had enjoyed this very much and were looking forward to planning the next one.

This inspection took place across two dates 16 and 30 November 2015. The first day of inspection was unannounced.

The last inspection of Windsor Road Mental Nursing Home was 03, 04, 08, 09 and 16 June 2015. At that time we found concerns in arrangements to safeguard people against the risk of abuse, safe care and treatment, staff training and support. The procedures for obtaining valid consent, care planning and risk assessment were not robust, and we had concerns regarding staffing and the systems in place to monitor and check the quality of the service provided.

These concerns were found to have a major impact on the welfare and safety of people who lived at the service.

As a result of our findings we commenced enforcement action against the provider. They were issued with a notice of proposal to remove conditions from their registration for failing to meet the requirements of regulations 9, 10, 11, 12, 13, 15 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this service was Inadequate and the service was placed into special measures.

During this inspection we reviewed actions taken by the provider to achieve compliance with the notice of proposal issued to the service following the previous inspection in June 2015.

We found that some improvements had been made. These were linked to environment safety, person centred mental health recovery work, staffing and quality assurance.

Windsor Road Mental Nursing Home as a condition of its registration should have a registered manager in place. 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.

There was a new manager who had commenced post in October 2015. An application had been submitted for the manager to become registered with the Care Quality Commission and this was being processed.

Windsor Road Mental Nursing Home provides care and accommodation for up to eleven adults who have enduring mental health needs. The home is a purpose built establishment with facilities on two levels, the upper floor being served by a passenger lift. All accommodation is offered on a single room basis including self-contained bedsit type facilities with private kitchen areas. The home is located on a quiet road in Lytham St Anne's close to local amenities and bus routes.

There were eight people who lived at the service at the time of the inspection.

People told us that they felt safe living at Windsor Road Mental Nursing Home. One person told us "I am happy here, everyone is happy here".

We looked at four people's care records. We found that incidents where people had attempted to take their own life or cause significant injury to themselves had not been referred to the safe guarding authorities.

It is clearly outlined in the Health and Social Care Act 2014 that acts of self-neglect are reportable to local safeguarding authorities. This meant that the service had failed to follow clearly defined safeguarding adults at risk procedures.

We pathway tracked four people who lived at the service and looked at how the service managed the risks associated with their care and welfare. 

We found that two out of four people we pathway tracked had not been effectively risk assessed or protected against the risk of self-injury and attempt to take their lives. Significant incidents had occurred on a frequent basis and the service had failed to undertake comprehensive risk assessments to formally assess, monitor and prevent self-injury and suicide attempts. Therefore we judged the impact for people who lived at the service with such needs to be a major risk.

We found that the service had improved on accident and incident reporting. Communication internally and externally with health and social care professionals had greatly improved. This meant that risks to individuals were being assessed by the team on a more frequent basis.

We looked at the way the service managed people’s medicines. We found that medicine ordering systems were not robust, therefore placing people at high risk of not receiving their medicines as prescribed. However we found no instances where people had gone without their medicines.

Medicine ordering systems were chaotic and the service did not have a sufficient ordering schedule: this meant that people's medicines were not always ordered in time. We found examples of people's medicines running out and an emergency prescriptions being requested. A lack of stock control placed people at high risk of not receiving their medicines as prescribed.

We observed safe administration of medicines during the inspection.

We looked at the standard of safety in people's bedrooms. We found that rooms were free from fire risks and clean.

Significant investment had been made at the service to improve the standard of environment. Compliance with health and safety regulations had been achieved and the service had worked in partnership with people who lived at the service to implement a no smoking policy that was due to commence 01 December 2015.

We looked at staffing rotas and found that the manager had good oversight of staffing at the service. The service had an agreement with health commissioners to send weekly updates of staffing levels at the service to ensure that contractual agreements were being met.

We received positive feedback from people who lived at the service regarding the support they received and we did not receive any concerns about staffing levels.

We looked at training records and found that courses identified at the last inspection as not being completed had been planned and undertaken by most staff. These included safeguarding adults, Mental Capacity Act 2005, fire training, medicine management including competency assessments for administration of medicines and health and safety.

We found that the service had not considered training for staff around known risks to individuals at the service. For example instances of self-injury and attempt of suicide. The provider had not arranged suitable training for staff to ensure that they were competent in understanding how to deal with these risk factors. We discussed this with the manager during the inspection and immediate actions were taken to obtain training.

We asked staff if they felt supported. All staff we spoke with confirmed that they were supported in their role and understood their responsibilities.

We looked at the provider's policy and procedures around the Mental Capacity Act 2005. We found that new documents had been created since the last inspection to encourage engagement from people's care co-ordinators when assessing a person's mental capacity [if required]prior to admission. We looked at mental capacity assessment documents and found that the service had made necessary improvements to enable compliance with principles outlined in the Mental Capacity Act code of conduct.

During this inspection we looked at four people's care records and found that effective communication had been maintained with involved health and social care professionals.

We looked at how the service helped people maintain a balanced diet. We found that people were actively engaged in and independently cooked their meals. We observed people who lived at the service access the main kitchen area and they told us "Yes I have all the food I need". And "I like the freedom to cook what I like".

We noticed that the level of engagement with people who lived at the service had improved. Staff told us "It is more positive than it has ever been to work here". And "The best thing about working here is the sense of achievement when we have got something done with a client and staff work together to achieve people's goals".

We looked at four people's care records. We found that people were encouraged to participate in the creation and review of their own support plans. We saw that people received regular one to one time with their key workers. People who lived at the service told us that this was a great improvement.

From the four care plans we looked at, we found that many support plans had been written in a person centred way, with involvement from the individual. For example we saw people's recovery goals and aspirations had been recorded. We also saw that people's life stories were referenced in care records and people had been provided with an opportunity to say what they wanted their care plan to involve.

We saw reference in people's care records regarding 'moving on'. One person told us that the service had helped them fight for a place at a service that would be beneficial for their recovery.

People told us that they felt confident to raise their concerns. We asked to look at complaints and the compliments receivedsince the last inspection in June 2015. The nominated individual told us that no complaints or compliments had been received.

We looked at staff meeting minutes and found that the provider had developed regular opportunities for staff to attend meetings and express their views. We found that meeting agendas were positive. This was an improvement since the last inspection.

We found that the service had systems in place to assess, monitor and evaluate the quality of care and support. We found that quality assurance was in place and action was taken when issues had been identified.

Audits were in place for medicines, recruitment, health and safety, training and care records.

We looked at the medicines audit and found that issues identified at this inspection had not been highlighted. We discussed this with the new manager who reassured us that robust management oversight would be undertaken.

We found that the provider was still in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to safeguarding and safe care and treatment.

The overall rating for this service is ‘Requires Improvement’. However, we are keeping the service in 'Special Measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in Special Measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.