This inspection took place over two days, 31 May 2017 and 8 June 2017 and was unannounced.

The manager was not available on the first day of inspection and we could not access specific documents we wished to inspect so we returned on another day to complete the inspection.

Our last inspection of the service was carried out on 24 November 2015 and we rated the service as Good overall with a recommendation being made in the well-led section about ensuring there was a good management team in place. At this inspection we found the provider had acted on the recommendation and staff were supported by a robust management team.

Woodlands Nursing Home is registered to provide care and support for 34 people, some of whom were living with dementia. The service provides permanent and short term (respite) accommodation. The service is located in a countryside setting with grounds around the building and disabled access into the building. At the time of our inspection there were 33 people using the service.

The service provided communal space and bedroom accommodation over three floors. There were two units – Poppy unit supported people with nursing needs and Buttercup supported people living with dementia.

The provider is required to have a registered manager for this service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like 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 time of our inspection, the service did have a registered manager. We have referred to them as ‘the manager’ throughout this report.

People told us they felt safe and were well cared for. The provider followed robust recruitment checks, to employ suitable people. There were sufficient staff employed to assist people in a timely way. Medicine management practices were being reviewed by the manager and action was taken to ensure medicines were given safely and as prescribed by people’s GPs.

Staff had completed relevant training. We found that the care staff received regular supervision and yearly appraisals, to fulfil their roles effectively.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. People were able to talk to health care professionals about their care and treatment. People could see a GP when they needed to and they received care and treatment when necessary from external health care professionals such as the district nursing team and speech and language therapists.

People had access to adequate food and drinks and we found that people were assessed for nutritional risk and were seen by the Speech and Language Therapy (SALT) team or a dietician when appropriate. People who spoke with us were satisfied with the quality of the meals.

People were treated with respect and dignity by the staff. People and relatives said staff were caring and they were happy with the care they received and had been included in planning and agreeing the care provided.

People had access to a range of low key activities which they enjoyed. However, the frequency of these depended on the availability of the care staff to carry these out.

People and relatives knew how to make a complaint and those who spoke with us were happy with the way any issues they had raised had been dealt with.

People told us that the service was well managed and organised. People and staff were asked for their views and their suggestions were used to continuously improve the service.

Woodlands Nursing Home is a service which provides personal and nursing care for older people, some of whom are living with dementia. It is registered for 34 people, but on the day of inspection there were only 24 people living at the home. The home had agreed to a suspension of new admissions and then a phased admission of people, following concerns raised by the local authority in March 2015.

At our previous comprehensive inspection on 10 and 11 March 2015 we found a number of shortfalls in the quality of people’s care and safety. For example, we found that the quality and safety of the service was inadequately assessed and monitored and that the home did not sufficiently protect people regarding infection control. Some areas of the premises were not safe and the décor was not sufficiently adapted for the needs of people living with a dementia. There was a risk that people would not receive effective care which met their needs because staff did not receive adequate supervision of their work. People were not always given care that met their clinical care needs.

We carried out a focused inspection on 16 July 2015 where we followed up on the shortfalls in the quality of people’s care and safety. We found that improvements had been made in all the areas where earlier shortfalls had been identified. However, it was too early to judge whether these improvements had been sustained and we planned to return to check on this. Please refer to these earlier reports for details on the action we asked the provider to take and the improvements which were found at that time.

At this inspection on 24 November there was no 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. A new manager had been appointed, and took up post on 16 March 2015, but had not yet registered with CQC. However, an application to be registered had been received by CQC.

At this comprehensive inspection on 24 November 2015 the premises were clean and hygienic. Laundry was well managed to comply with infection control best practice. Staff followed infection control best practice guidelines to protect people from the risk of cross infection. This meant that people were protected from the risk of cross infection.

The premises was well maintained and safe. Communal rooms, corridors and rooms for individual use had been redecorated and were bright and cheerful. Pictures had been replaced with new interesting ones, which would encourage discussion and reminiscence. Windows were safely restricted. Lighting had improved, particularly in the area of the home devoted to caring for people who were living with dementia. Chairs and other furniture had been replaced. Toilets and bathrooms had been redecorated and repaired. Some floor coverings had been replaced or deep cleaned. Outdoor steps had been highlighted with high visibility paint to reduce the risk of falls. Outdoor spaces had been attended to and now provided pleasant safe areas for people to enjoy.

People told us they felt safe at the home. Risks to people were managed well without placing undue restrictions upon them. Staff were trained in safeguarding and understood how to recognise and report abuse. Staffing levels were appropriate, which meant people were supported with their care and able to pursue interests of their choice. People received the right medicines at the right time and medicines were handled safely.

People told us that staff understood their individual care needs. We found that people were supported by staff who were well trained. All staff received mandatory training in addition to specific training they may need. The home had strong links with specialists and professional advisors and we saw evidence that the home was proactive in seeking their advice and acting on this.

People’s needs were met in relation to food and drink and they received the health care support they required. People were enabled to make choices about their meals and snacks and their preferences around food and drink were listened to and acted on.

The home was clear about its responsibilities around the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and supported people to make informed decisions about their care.

Staff had developed positive, respectful relationships with people and were kind and caring in their approach. When this had not been the case, the manager was aware of this problem and was addressing it through supervision, monitoring and the home’s disciplinary procedure. People were afforded choices in their daily routines and their privacy and dignity was respected.

People were consulted about their care. People told us that most staff understood their needs and what was important to them and made sure that they received the care they needed and preferred.

People were assisted to take part in activities and daily occupations which interested them. However, activities and pastimes were not always tailored for the individual needs of people who were living with dementia.

People were encouraged to complain or raise concerns, the home supported them to do this and concerns were resolved quickly. The home used lessons learned to improve the quality of care.

There was good leadership which promoted an open culture and which put people at the heart of the service. However, there was a vacancy for a deputy manager and the manager was fulfilling the clinical lead role. This meant that a large number of tasks fell to the manager alone. There was a risk that the quality of management would not be sustained without a senior team to strengthen the development of the management role within the home.

Staff understood their roles and responsibilities which helped the home to run smoothly. Communication was clear from the manager to all levels of staff within the home. Staff were encouraged to give their views. The manager understood the home’s strengths, where improvements were needed and had plans in place to achieve these with timescales in place.

Systems were in place to assess and monitor the quality of the service and the focus was on continuous improvement.

We carried out an unannounced comprehensive inspection of this service over two days on 10 and 11 March 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to regulations 9, 10, 12, 15 and 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this focused inspection 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 those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all report’ link for Woodlands Nursing Home on our website at www.cqc.uk.

Improvements were identified in a number of areas. However we could not improve the overall rating from the existing rating because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

Woodlands Nursing Home is a service which provides personal and nursing care for older people some of whom are living with dementia. It is registered for 34 people, but on the day of inspection there were only 17 people living at the home. When we inspected 10 and 11 March 2015 the service had agreed with the local authority to a voluntary suspension on admissions. This was because the local authority had concerns about the safety and quality of care at this service.

At this inspection 16 July 2015 there was no 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. A new manager had been appointed, and took up post on 16 March 2015 but is not yet registered with CQC

At our inspection 10 and 11 March 2015 we found the service was in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a warning notice about this. The provider had failed to ensure that people were protected against identifiable risks of acquiring an infection.

At this inspection 16 July 2015 the premises were clean and hygienic. The laundry had been refurbished and reconfigured to provide a flow of laundry from soiled to clean. This was in line with infection control good practice guidelines. Toilets and bathrooms were clean. Appropriately dispensed sanitising gel was available for staff to use throughout the home. Staff understood about infection control practices and told us how they minimised the risk of cross infection. This meant that people were protected from the risk of cross infection.

At our inspection 10 and 11 March 2015 we found the service was in breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a requirement notice about this. The premises were inadequately maintained and unsafe.

At this inspection 16 July 2015 we saw that the premises were well maintained and safe. Records were kept about maintenance work which was required and the manager had drawn up a comprehensive schedule of works to address the previous shortfalls. Communal rooms, corridors and rooms for individual use had been redecorated and were bright and cheerful. Toilets and bathrooms had been redecorated and repaired. Some floor coverings had been replaced. Outdoor steps had been highlighted with high visibility paint to reduce the risk of falls. Outdoor spaces had been attended to and now provided pleasant safe areas for people to enjoy.

However, more work was planned to the environment to ensure it was suitable for people with a dementia. For example, the manager had begun to replace old pictures with new interesting ones which would encourage discussion and reminiscence. This was work in progress. Some aspects of the environment needed attention to improve safety. For example, window restrictors in some rooms would not resist a determined effort to break them and therefore created a potential risk of people falling from windows. All unsafe lampshades at mid- wall level in people’s rooms were not yet replaced so there remained a risk that a person may break a glass shade and injure themselves. The manager told us about those areas which needed attention and they had a plan to address them.

At our inspection 10 and 11 March 2015 we found the service was in breach of regulation 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 18(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a requirement notice about this. Staff were not receiving regular supervision or appraisal of their work. This meant that they were not adequately supported in their role.

At this inspection 16 July 2015 we found that staff had received regular supervision which they found helpful and constructive. This meant that they were supported in their role and were in a better position to offer people effective care.

At our inspection 10 and 11 March 2015 we found that the service was in breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 18(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a requirement notice about this. The service had not taken proper steps to protect people against the risks of inappropriate or unsafe care. This was in relation to eating and drinking and pressure care. People did not have the risks associated with their food and drink or their pressure care properly assessed or acted upon which had resulted in people suffering harm. The service did not involve specialists in a timely way and did not always follow advice when this was given. The conclusion of a safeguarding meeting with the local authority was that people had been harmed and others were at risk of harm.

At this inspection 16 July 2015 we found that the service had transformed the way in which it assessed people’s needs in relation to eating, drinking and pressure care and how staff acted to ensure people were cared for safely. Each person had been reassessed to ensure that the risks associated with their clinical and other care needs were recognised. Continuity of care was achieved through more consistency in the nursing staff who attended the home. Previously there had been a number of agency nursing staff visiting the home who were unfamiliar with the people who lived there, however now people told us they recognised the same nurses day after day. Specialist health care professionals were consulted in a timely way for advice and support. Staff told us and specialists we spoke with confirmed that their advice was followed. Care records showed that advice was recorded and incorporated into care plans. This meant that people were protected from harm. People told us that staff went out of their way to ensure they were comfortable, that they were consulted about their clinical care needs and felt they were receiving safe care. Though significant improvements had been made the manager agreed that there were areas which still required attention. There were issues around consistency in staff always using new paperwork. Also, improvements had not yet been sustained over time.

At our inspection 10 and 11 March 2015 we found that the service was in breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a warning notice about this. There were inadequate systems in place to monitor and audit the quality of service for people. The checks which did take place did not result in improvements in the quality or safety of people’s care or the environment. We found that the service did not have effective management. There was no manager in post and the service was inconsistently attended by managers from other services owned by this provider. Staff did not feel supported and were unsure of the culture, vision or values of the home.

At this inspection 16 July 2015 we found that the service had strong direction from the newly appointed manager. A system of audits and checks had been introduced which had resulted in significant improvements in people’s quality of care and the environment. Staff meetings had been introduced and staff told us they were encouraged to make their views known and that they were listened to. Meetings for the people who lived at the home had taken place, and the manager had openly explained to people some of the challenges they had faced in relation to the quality of care and the plans they had put in place to improve. The manager had also organised meetings with relatives and friends and had spoken with visitors on a one to one basis to explain what was being done to improve things. Staff reported that communication was good between them and the manager and that they were approachable, supportive and visible around the home.

At our previous inspection in December 2013 we had identified issues regarding the upkeep and maintenance of some areas of the premises. The provider submitted an action plan to us stating what action they were going to take.

When we inspected in March 2014 we found that the provider had carried out repairs and refurbishment to several areas of the home, and those identified issues in the previous report had been fully addressed.

The home was now in a better condition.

We visited Woodlands and spoke with people who used the service about the care and support they received. One person told us “I get all the support I need. If I ring the bell they are not bad at all at coming”. Another person told us “I am happy here. I get looked after. The staff know how to care for me properly”. We found that care plan files were detailed and individualised. We observed that staff knew people well and were patient and considerate in their approach.

We found that nutrition was monitored and food and drink was available at all times. People told us they were able to choose what they wished to eat and kitchen staff knew peoples nutritional needs well. Staff knowledge of safeguarding procedures was reasonable and reporting mechanisms were used appropriately.

We found that there were some improvements needed to the environment to ensure that the building was maintained in an appropriate state. This was particularly the case with sluice areas which required immediate improvement.

Appropriate procedures were followed when recruiting staff and the induction programme followed enabled staff to complete appropriate training and shadowing prior to working alone. There was a quality assurance system in place which was undergoing improvement at the time of our visit. There needed to be some improvement in the ways the service gathered feedback from residents and staff about the service.

We had visited Woodlands in October 2012 and identified some issues with infection control. There had been a lack of organisation and recording of cleaning and a minimum amount of domestic hours utilised to manage the cleanliness and hygiene of the home. There were also several areas within the home that needed to be addressed to make them clean and hygienic. There were pieces of equipment that were not fit for purpose.

We asked the provider to submit an action plan and we then revisited in January 2013 to check that they had taken these actions.

We found that the provider had renewed and refurbished all of the areas of the home we had previously identified. This included ensuite toilets and bathrooms, and communal bathrooms. It also included equipment which had been replaced or refurbished.

We saw that cleaning schedules had been put in place and there had been an increase in the amount of hours domestic staff were employed for. This all resulted in an improvement in the general cleanliness of the service.

During our visit we saw that people were being supported in a patient and caring way. Records showed that people’s care plans and risk assessments were up to date and were regularly reviewed, and that consent was sought in written form and verbally when any care was carried out.

There were a range of activities available for people and we observed that people were not bored or passive, but were engaged with staff, each other and the activities and environment. One person told us “I feel safe. I am still independent even though I am living in the home”.

Staff were observed to be encouraging and motivating people, and were treating people with dignity and respect. Staff were given various training opportunities and were able to discuss their needs with the manager and senior staff.

Audits and surveys were carried out on a regular basis. Staff and relatives meetings were held to allow people to have a role in the running and ongoing improvement of the service. One person told us “They have asked me about what activities I might like on several occasions”. Another told us “We always get lots of choices”.

Infection control procedures were followed in some areas, but bathrooms, toilets, and toileting equipment needed updating and replacing in many cases to minimise the risk of infection.

This scheduled inspection took place over two days on 10 and 11 March 2015. It was unannounced. There were no breaches of regulations at the last inspection which took place on 25 March 2014

This is a service which provides personal and nursing care for older people some of whom are living with dementia. It is registered for 34 people, but on the day of inspection there were 22 people living at the home. The local authority had discussed with the service a voluntary suspension on funded admissions which the nominated individual had agreed to. This is because the local authority had concerns about the safety and quality of care at this service. The home had a registered manager until the end of February 2015. At the time of the inspection there was no registered manager in place although a new manager had been appointed, and was due to start in their new role on 16 March 2015. They have subsequently done so but are not yet 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.

On the 10 March 2015 there were two managers on duty who were registered for other establishments owned by Hexon Ltd. We have referred to these members of staff as ‘the manager’ throughout the report.

We walked around the premises accompanied by one of the managers. We found the premises were dirty and unhygienic. Toilets and bathrooms were dirty and the flooring was dirty in every toilet we saw. It was damaged in two toilets on the first floor. Bedrooms were dirty; windowsills were dirty and covered with dust. The laundry room was dirty; the floor was dirty and difficult to clean as it was damaged and uneven. There was no way of keeping soiled and clean laundry separate because of the lay out of the room. This was an infection control risk. Surfaces were cluttered and dirty and an infection control risk. Lounges and dining areas were dirty; furniture was dirty and soiled, there were stains and marks on walls and soft furnishings. The kitchen appeared to be clean and the latest food hygiene rating awarded in February 2015 was 4, where the highest is 5 and the lowest 1. (The food hygiene rating or inspection result given to a service reflects the standards of food hygiene found on the date of inspection or visit by the local authority.) People were not protected from the risk of infection because the environment was not maintained in a hygienic clean state. You can see what action we asked the provider to take at the back of the full version of the report.

The environment of the home was not well maintained. There were holes in some walls and ceilings. In one room a radiator had come loose from the wall and was a danger to the person whose bedroom it was. A number of light bulbs were not working in rooms and corridors which meant people were at risk of falling when they could not clearly see where they were going. The steps to the outside of the home were not well defined and were a tripping hazard. The maintenance book was missing and so there was no clear way of organising jobs which needed to be done. There were no assessments of risk for the environment in place which meant people were at risk of harm. You can see what action we asked the provider to take at the back of the full version of the report.

Staff were not effectively deployed in the home so that the lounge which specialised in caring for people with a dementia were short staffed at times, at other times the lounge for people who required nursing care was short of staff. Agency staff were sometimes on the rota at the weekends without a manager present. This meant that people with little experience of the home and the people who lived there were on duty without management support which meant there was a risk that people would not have their needs met. Skill mix and experience had not been effectively considered in drawing up rotas so that people did not benefit from a range of skills and experience at all times. This placed people at risk of not having their meets fully met.

Medicines were safely managed, although some medicines needed to be disposed of as they were out of date.

Staff were not receiving regular or effective supervision or appraisal to support them in their role. You can see what action we asked the provider to take at the back of the full version of the report.

The use of monitoring tools for nutrition and hydration was inconsistent which meant people were at risk of not having their needs met. People had not been cared for safely regarding their pressure areas. Pressure ulcers had developed and four safeguarding alerts regarding the way the home managed people’s pressure care had been received by the local authority in the past two months. All of these were under investigation, however, it was clear from reviewing individual’s care plans that pressure care monitoring documentation had not been consistently used to protect people. Changes in skin integrity had not been acted upon in a timely way to protect people from harm. You can see what action we asked the provider to take at the back of the full version of the report.

The nominated individual had not taken account of published best practice guidance for providing an appropriate environment which promoted the well-being of people living with a dementia related illness. There was insufficient signage to assist people to orientate themselves around the home, there were no objects of interest, rummage boxes or interesting photographs or paintings to stimulate reminiscence and wellbeing. This meant that the environment did not support people’s needs in relation to dementia. You can see what action we asked the provider to take at the back of the full version of the report.

Staff received induction and training in mandatory areas so that they had the skills to care for people effectively, however, recording of this was not up to date.

People’s mental capacity had been assessed in line with the Mental Health Act (2005) and people were encouraged to make choices about their day to day care. The service had referred those people who may be deprived of their liberty for assessment by the relevant authority. This meant the service had taken people’s mental capacity into consideration in planning their care.

People had access to health care professionals and the home referred to these professionals, however, they did not always do this in a timely manner to protect people.

Some staff were kind and caring, others were not skilled or confident at managing the behaviour of people who were distressed or demonstrated behaviour that challenged and they did not assist in a compassionate way. This meant that people did not always receive a kind and caring service.

Although some staff appeared to know people well, care plans emphasised clinical care and did not focus upon social, spiritual, recreational and cultural needs or aspirations. Plans contained inconsistent information about people’s life histories and what was important to them. This meant that there was a risk staff would not know people well or be in a position to offer personalised care.

The service did not effectively monitor or assess the quality of care it offered. This meant that people were at risk of inappropriate or unsafe care and that their views and the views of staff did not inform practice. There was a risk that any shortfalls in care practice were not identified and acted upon. You can see what action we asked the provider to take at the back of the full version of the report.