This inspection was carried out on 06 and 07 November 2018 and was unannounced. Windy Knowe Nursing Home is a large detached three-storey house with a large back garden and is situated in Oxton, Birkenhead, Wirral. The home is registered to provide nursing care for up to 49 older people and at the time of our visit the service was providing support for 35 people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

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.

Following the last inspection, we asked the provider to complete an action plan to show how and when they would make improvements to the décor of the home, increase washing facilities, and ensure regular checks where completed on door guards. These actions have been completed.

Although there have been improvements made in the service, we found there will still improvements required to the key questions, ‘safe’ and ‘well-led’. This is the second consecutive time the service has been rated ‘Requires Improvement’.

The service ensured people had an assessment before moving into the home. Care plans

contained important information relating to peoples likes and dislikes, their previous occupation and families. Care plans detailed people’s needs, and risk assessments were in place, however we found the information wasn’t always sufficient to support people’s needs safely.

Record keeping was inconsistent. There were areas of good practice but also evidence that information in records was not updated and were not always completed in a timely manner.

Our observations throughout the day showed that people were treated with dignity and respect. People received comfort when needed. Staff used their knowledge of people to engage them and help build positive relationships. Staff understood people's individual needs for care and were able to talk to us about the ways in which they provided this.

Since the last inspection, improvements had been made to the recording of the administration of people's medicines. However, there was a lack of guidance in place for staff on the support people required to take medicines which had been prescribed to be taken 'as required'.

The home had undergone a full refurbishment since the last inspection and looked clean throughout. However, there were still areas of the home that were malodorous.

Staff told us that they didn’t always feel there was enough staff. They also reported some issues with some of the agency staff used. The home had tried to manage issues and ensured agency staff were suitable by following safe recruitment practices. The registered manager told us new staff had been recruited and were in the process of having checks completed.

The management team completed various quality audits, including infection control, care plans, medicines and health and safety. However, not all of these audits had proved effective at identifying issues. For instance, care plan audits had not identified inconsistent care information.

The registered manager and the management team had created an open and supportive culture in the home. Staff told us they felt the managers were approachable and accommodating.

This inspection was carried out on 06 September 2017and the inspection was unannounced. Windy Knowe Nursing Home is a is a large detached three-storey house with a large back garden and is situated in Oxton, Birkenhead, Wirral. The home is registered to provide nursing care for up to 49 older people and at the time of our visit the service was providing support for 37 people. The home offers single and double accommodation and seven bedrooms are ensuite.

The home has 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 registered manager and deputy manager were in attendance at the time of the inspection.

People we spoke with told us they felt safe at the home and people’s relatives also told us they felt people were safe. During our visit, however, we identified concerns with the service.

We also identified a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We saw that there were insufficient bathing facilities in the home. However, we were able to see that the registered manager had been in contact with the provider over a significant amount of time, to attempt to remedy this. The home looked clean in some areas, however there were areas that needed updating as they were becoming an infection control concern.

Medications were not always managed safely, staff administering the medication were distracted and times were not specific for when medications were to be given.

Each person living in the home had a personalised care plan and risk assessment. However, we identified that some risk assessments needed to be more specific. Staff knew of the people’s needs but this was not always clearly documented.

Staff were recruited safely and the registered nurses had the appropriate checks regarding their registration with the Nursing and Midwifery Council. We saw evidence that staff had been supervised regularly and staff told us that they felt well supported in their roles. Staff had access to a wide range of training which equipped them to deliver their roles effectively.

The Mental Capacity Act 2005 and the associated deprivation of liberties safeguards legislation had been followed in the home. The provider told us that some people at the home lacked capacity and that a number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority in relation to people’s care. We found that in applying for these safeguards, peoples’ legal right to consent to and be involved in any decision making had been respected.

The people who lived at the home and their relatives were happy with the support that staff gave them and there was a good rapport between them.

We saw that the people living in the home knew who the registered manager and deputy manager was. People and relatives we spoke with said they would know how to make a complaint; none of the people or their relatives we spoke with had any complaints.

People had access to sufficient quantities of nutritious food and drink throughout the day and were given suitable menu choices at each mealtime; we were told that the food was good and was enjoyed.

The home had quality assurance processes in place including various audits, staff meetings, quality questionnaires and residents meetings. The home also had up to date policies in place that were updated regularly.