Nightingales Care Home

• The service is in a residential area of Maidenhead and close to the River Thames.

• The service provides accommodation and personal care to older adults, some of whom have early stages of dementia. The care home can accommodate 17 people in one adapted building.

• This is the only location that the provider operates. The provider is part of small group of care homes.

• At the time of our inspection, 12 people used the service.

People’s experience of using this service:

• The provider had made a significant investment in the equipment, building and premises since our last inspection. This had improved the environment for people who used the service.

• Infection control and prevention had improved, to protect people from avoidable harm.

• The service had satisfactorily mitigated the risks associated with the premises.

• People continued to like living at the service.

• There was a homelier atmosphere because the adaptation and the decoration of the service was changed.

• People continued to receive care from friendly, dedicated staff who knew them well.

• Appropriate governance processes were in place to ensure quality care for people.

• The registered manager provided good leadership to the staff and was considered an integral member of the team.

• The service met the characteristics for a rating of “good” in the key questions we inspected. Therefore, the overall rating for the service is now “good”.

• More information is in the full report.

Rating at last inspection:

• At our last inspection, the service was rated “requires improvement”. Our last report was published on 28 September 2018.

Why we inspected:

• This inspection was to follow-up enforcement action we took against the provider after our last inspection. This was because we found continued breaches of the regulations. At this inspection, we checked whether the provider made improvements following our previous enforcement.

Follow up:

• We made a recommendation about the redecoration and provider engagement. We will check the provider’s response at our next inspection. We will continue to monitor the service to ensure that people receive safe, compassionate and quality care. Further inspections will be planned for future dates.

Nightingales Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection.

The service can provide care and support for up to 17 older adults. At the time of our inspection, the service accommodated 12 people. Each person had their own bedroom, and there were communal facilities such as bathrooms, dining, lounge and kitchen.

The provider is required to have a registered manager as part of their conditions of registration. 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 time of our inspection, there was a registered manager in post.

At our inspection on 2 March 2017, there were five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued four requirement notices and a warning notice against the provider and required an action plan. At our last inspection on 22 and 24 May 2017, we found the provider had complied with the warning notice. Therefore, at the of this inspection, there were four outstanding breaches of the regulations. We consider that satisfactory changes were made to demonstrate compliance with two of the four breaches.

Since our last inspection, some risks related to the building and premises were satisfactorily mitigated, for example fire safety and the hot water and central heating. However, there remained risks from the premises which were not adequately managed. Although there was a maintenance worker who attended the service, dangerous risks were still present to people and others. This included trailing electrical wires, access to areas that were meant for maintenance, and broken fixtures and fittings. There were insufficient control mechanisms to protect people from the risk of infection, including the lack of appropriate use of deep cleaning of the premises, especially the carpeting.

There was insufficient adaptation, redesign and redecoration of the premises to ensure effective care. Carpets were stained and damaged in places, bedding and linen was stained and some aspects of the building required repair or updating.

People were well-supported by staff who understood how to recognise and report any form of abuse or discrimination. The risks associated with people’s care and support needs had been fully assessed and recorded on admission to the service. Suitable and highly personalised plans were implemented and regularly reviewed to manage any ongoing risks. Staffing levels had improved and meant people’s individual needs were met safely. All prospective staff had pre-employment checks to ensure they were of suitable character to support people who used the service .

People’s individual and personalised needs and requirements were initially assessed when they moved into the service. Staff had received sufficient appropriate training and ongoing support to ensure they had the skills and knowledge needed to work safely and effectively. People received reassurance and physical assistance to safely eat and drink, and associated risks such as choking were recognised and managed. Staff supported people to access a wide range of community and acute healthcare services to ensure their health needs were regularly reviewed and met.

Staff knew people well and clearly demonstrated a kind, thoughtful and caring attitude at work. Staff and the registered manager mainly supported people to express their views and to be fully involved in any decision-making that affected them, although there were few ‘residents’ meetings. People were treated with dignity, respect and kindness, and we observed individual acts of highly-personalised care from a committed workforce. There was popular provision of home cooked puddings, and the commitment of staff to provide regular hydration.

People received consistently-personalised care that reflected their individual needs and preferences. The provider’s complaints procedure demonstrated good previous complaints handling, and this year there were no complaints .

The provider's quality assurance processes were not as effective as they needed to be. There was a basic audit process which, although undertaken regularly, did not provide accurate outcomes for follow-up, and did not provide robust assurance of good governance. Staff told us they worked in a positive workplace culture and liked working at the service.

We found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

This is the only location under the provider's current registration, although operates as part of a small group of residential and nursing homes called Woodgate Healthcare. At the time of our inspection, 14 people used the service. In line with our registration, the location can legally accommodate 17 service users.

At the time of the inspection, there was 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 last inspection was conducted on 2 March 2017. At that inspection, we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. To ensure people’s safety and quality of care, we issued civil enforcement against the provider. A warning notice was given for staffing. We required the service to be compliant with the applicable regulation within seven days following the warning notice.

The purpose of this inspection was to focus on the regulatory breach and enforcement we issued related to staffing deployment we found at our prior inspection. This inspection looked at only one key question; “Is the service safe?”

We found improvements were made at Nightingales Care Home following our last inspection. Not all aspects of the changes were obvious to some observers but further time was required to fully implement them and ensure sustainability. Changes included the deployment of an additional night time care worker. This meant that the risk to people from a fire or other emergency was reduced. Another change was the creation and implementation of a ‘hostess’-style position for supper time. This had enabled people to receive meals in a timely way and ensure extra supervision during the evening period.

People did not comment on the changes in staffing. Relatives we contacted were unaware what changes in staffing had occurred. However, staff themselves provided positive feedback about the changes. They clearly explained that the increased staffing had improved their ability to care for people and provide better support to those who required it.

Documents we obtained and viewed corroborated with the provider’s plans for sufficient staffing. People were safer because more staff were deployed and the risks to people were further reduced.

We made recommendations about the call bell system and deployment of activities staff.

This is the only location under the provider's current registration, although operates as part of a small group of residential and nursing homes called Woodgate Healthcare. At the time of our inspection, 14 people used the service. In line with their registration, the location can accommodate 17 service users.

At the time of the inspection, there was 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 had been in post continuously for some time, and knew the service well.

Our last inspection of the service was on 3 December 2014 under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The overall rating was good, with all key questions rated good and no breaches or recommendations. This is our first inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were safeguarded from abuse. There was a system in place to ensure that people’s safety was maintained. Staff and the registered manager were knowledgeable about abuse and how to deal with any allegations.

People’s care risks were assessed, mitigated, documented and reviewed. Appropriate records were kept and readily available to demonstrate this to us at the inspection.

The safety of the premises and equipment were inadequately assessed and managed which placed people, staff and visitors at risk. The service had some checks in place, but without oversight by a regular maintenance person. The registered manager was required to complete some of the health and safety checks, which was inappropriate.

Not enough staff were deployed to support people. People we spoke with were not satisfied that there was sufficient staff, and told us they felt staff were helpful but rushed. Our observations showed that the staff were busy at certain times and this led to them not being readily available if people requested assistance. Staff were expected to perform multiple roles. Night time single care worker deployment was unsafe and placed people at risk, especially in the event of an incident or emergency.

Medicines were usually well-managed. We examined the handling of people’s medicines during our inspection and found that people were safe from harm. We made a recommendation related to national medicines safety guidance.

Staff were knowledgeable and competent. They received appropriate levels of training and supervisions.

The service followed the requirements of the Mental Capacity Act 2005 (MCA). The recording of consent and best interest decisions meant the service complied with the MCA codes of practice. There was clear information at the service regarding people’s applications, reviews and expiry dates for standard DoLS authorisations. 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.

People received ample food which they had divided opinion about. Hydration was offered to people to ensure they did not become dehydrated. Snacks and treats were available if people wanted or chose to have them. We made a recommendation about allowing people to have better menu choices for breakfast and drinks.

We found the service was caring. People told us staff were kind. We observed staff were warm and friendly when they interacted with people.

Responsive care was not always provided to people. People's wishes, preferences, likes and dislikes were considered and accommodated. The service’s complaints procedure was not robust and required improvement.

People told us they felt the culture at the service was negative. People’s observations of the everyday running of the service had influenced their opinion about whether it was well-led. Staff told us they enjoyed their roles, felt supported by the management but were often busy. Audits were used to check the quality of care. We made a recommendation that the service considers the scope of their audits. We found the service had failed on several occasions to follow the requirements set out in the duty of candour regulation. The ratings poster was not conspicuously displayed.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We were told that they felt they had good choices about their care and about the food offered to them. We observed the carers to speak kindly and respectfully while we were there and to offer choices about food and promote freedom around the home.

We spoke with one visitor who stated their family member was treated with respect although they felt the carers could offer more help. We saw that the carers tried to promote the independence of people with personal care and eating and drinking. This was reflected in the care plans which had a wide variety of assessments completed to enable carers to give individualised care to people.

We noted that the environment of the home was a little tired and the staff had limited awareness of ensuring some of the general maintenance were adhered to i.e. maintenance of the automatic fire door system.

We spoke with three members of staff who said they all enjoyed working at the home and felt the manager gave them appropriate training and supervision to perform their role.

We spoke with staff during visit. They were positive about their work and people they looked after. They told us that they were aware of ensuring people were treated with respect and dignity. The told us that they enjoyed talking to people as they had wonderful stories to tell about their lives. This ensured that people were treated as individuals. Staff were aware of peoples care plans. They told us that they had regular supervision and staff meeting.