Archived: Donness Nursing Home

In 2017, the service was rated as 'good' by CQC. The appointment of a second registered manager had helped improve the standard of care and the management of staff. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as 'inadequate' and 'requires improvement' following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017.

In July 2018, there was a further inspection and the service was rated as 'inadequate'. This showed the provider was unable to sustain the improvements made. A team of multi-disciplinary health and social care professionals provided further input to support the provider. The provider chose to employ an interim management team to help them make improvements. When we inspected in February 2019, the service was rated as Requires Improvement in all key areas of care. The interim management team withdrew their services in September 2019 and a proposed sale of the home to a new provider did not happen.

At the time of our inspection the local authority adult safeguarding team were investigating allegations of poor care, and the service was being supported by the local authority quality and improvement team. Following our inspection and the number of concerns identified, the provider decided to voluntarily suspend all new placements to the service until improvements were made.

People’s experience of using this service and what we found

The systems to help identify where improvements were required had been ineffective. The systemic failings found at this inspection demonstrated the provider had failed to ensure people received a well-managed service which was safe and compassionate; placing people at risk of potential and continued harm.

Since our last inspection, the ratings for all key questions had either stayed at Requires Improvement or deteriorated to Inadequate.

People told us they felt safe living at the service. However, practices were not safe. Poor monitoring of people’s fluid and nutritional intake put people at risk of dehydration and malnutrition. This risk was increased by poor monitoring of weight loss. Changes to people’s health needs were not routinely addressed in a timely way.

People received or experienced unsafe or inconsistent care. Risks associated with people's care were not always documented and/or monitored effectively by staff. People were not effectively protected from abuse because some staff did not recognise their responsibilities to ensure people were safe.

Communal areas were clean but there were bedrooms that had an unpleasant odour. The environment had been assessed for safety. Fire training did not take place regularly which put people at risk in the event of a fire as staff may not be competent and confident to respond appropriately. The staff training matrix showed some staff had undertaken little training. Staff competency in using a person-centred approach was variable.

The level and standard of activities and meaningful occupation did not meet the social needs and wellbeing of everyone living at the home.

People were not involved in planning their care and support; people’s care was not effectively reviewed and changes to their health needs were poorly managed.

Concerns were not routinely responded to in a consistent manner, so some people lost trust in the staff because their complaints had not been handled appropriately. When the manager was made aware of complaints, they followed the formal process and took steps to address issues and reassure people.

People and relatives said staff were kind and caring. And overall, people's privacy and dignity was respected. People's medicines were generally managed safely.

Rating at last inspection The last rating for this service was requires improvement (published 26 April 2019) and there were multiple breaches of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating and in part due to safeguarding concerns for one person. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We judged five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been repeated. These linked to safe care and treatment, staff recruitment, the cleanliness of the environment, staff training and supervision and good governance.

On this inspection there were a further five new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These linked to staffing arrangements, safeguarding, person centred care, meeting nutritional and hydration needs and need for consent.

We recommended the provider improved some areas of medicine practice and improved the range of activities.

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider, safeguarding team and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any further concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration. The provider voluntarily decided to close Donness Nursing Home. It will be closed by the end of March 2020.

In 2017, the home was rated as 'good' by CQC. The appointment of a second registered manager had helped drive improvement in the home. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as 'inadequate' and 'requires improvement' following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017. In July 2018, there was a further inspection and the service was rated as ‘inadequate’. This showed the

provider was unable to sustain the improvements made. A team of multi-disciplinary health and social care professionals provided further input to support the provider. The provider chose to employ an interim management team to help them make improvements, who were working at the home at the time of this inspection.

People’s experience of using this service:

• The level and standard of activities and meaningful occupation did not meet the social needs and well-being of everyone living at the home.

• The recruitment process was not robust with some required information not in place before staff started work.

• The interim management team were committed to improving the experience of people living at the home. They ensured the provider was updated about progress and barriers to improvement by the completion of a service improvement plan.

• There were on-going problems with equipment to help staff keep in touch with one another, such as radios/pagers. The provider had not addressed these issues in a timely manner.

• Concerns were not routinely responded to in a consistent manner so people were unclear about the outcome and if action had been taken to address their concerns.

• Fire drills did not take place regularly which put people at risk in the event of a fire as staff may not be competent and confident to respond appropriately.

• Maintenance issues, such as hot water temperatures and hot water availability, were not monitored in an adequate way to maintain people’s safety and promote good hygiene practice.

• The staff training matrix showed some staff had undertaken little training and there was low attendance at some sessions. There was mixed feedback about whether staff were paid to attend training. Staff competency in a person-centred approach was variable.

• A sluice door was not locked on one occasion, which put people at risk of potential harm.

• On one occasion, medicines were left unsecure, which put people at risk of potential harm.

• The main lounge and a person’s bedroom were malodourous, which undermined people’s dignity.

• Work was continuing to embed improvements in the way the home was run to benefit the people living there. Staff were positive about the support they received to carry out their job and the role of the interim management team.

• People’s nutritional needs were identified and monitored. Nutritional care plans contained details to instruct staff on how to support people in relation to eating and drinking.

• People received their medicines in a safe and caring way, although there were some areas of medicines management that needed improving.

• Plans were in place to increase the competency of staff to run shifts and delegate effectively to benefit the experience of people living at the home.

• People’s health, safety and welfare was improved because there were sufficient numbers of suitably qualified, skilled and experienced staff on duty.

• We saw positive interactions between people and staff. We saw staff were kind, friendly and patient when assisting people. However, some staff were not skilled in their approaches with people.

• People enjoyed the choice of meals provided; staff knew people’s preferences.

• There was camaraderie between people living at the home and people were relaxed with one another.

Rating at last inspection: At the last inspection the service was rated as ‘inadequate’ (published September 2018) and was placed in Special Measures. At this inspection we found the service had begun to make improvements and is rated as ‘requires improvement’ overall.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Enforcement

During the inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Follow up: This service has been in Special measures. Services that are in Special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore this service is now out of Special Measures. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. The provider’s action plan submitted to CQC in response to the breaches will be reviewed to ensure improvement actions are timely and appropriately address the identified concerns. If any concerning information is received we may inspect sooner. We will be meeting with the provider jointly with the local commissioners of the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

In 2017, the home had been rated as ‘good’ by CQC. The appointment of a second registered manager had helped drive improvement in the home. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as ‘inadequate’ and ‘requires improvement’ following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017 and the outcome of this current inspection shows the provider was unable to sustain the improvements made.

Prior to this inspection, CQC were contacted by two people who raised concerns about the quality of the care at the home and the poor practice of some staff. This inspection was brought forward due to concerns about staff practice and the care at the home.

Donness Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Donness Nursing Home provides accommodation for up to 34 people; 27 people were living at the home during our visit. The service provides care for older people; most people are living with dementia. The bedrooms are on all three floors, which can be accessed by a passenger lift.

A registered manager was 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’. The registered manager is also the home owner. 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 is also the provider.

During our inspection, we contacted the local authority safeguarding team and made safeguarding alerts for five individuals because we were concerned about their safety and well-being. Following the inspection, we met with the provider and a group of health and social care professionals, which included commissioners. At this meeting, the whole service met the threshold to be monitored under the local authority’s safeguarding process. This meant health professionals began to visit the home on a daily basis to monitor people’s care and well-being and to review people’s care needs to ensure they were being met. Commissioners have taken the decision not to move new people to the home and the provider has agreed not to admit new people.

Staffing arrangements were poorly planned and potentially put people at risk. Rotas were not organised to provide consistent cover. This was despite people with complex physical and mental health needs and end of life care needs living at the home. Low staffing levels impacted on the safety of people at risk of falls as communal areas were not staffed in the early evening. People who had been abused by a person living at the home were not protected as staff did not ensure they monitored people’s whereabouts or observed communal areas in the early evening.

Staff training was not well managed and systems were not in place to ensure all staff practiced in a safe and caring way. There were examples of good care, with staff showing affection and compassion towards people. However, there were also practices which undermined people’s dignity. This was because improvements were needed in staffing levels, skills and knowledge in supporting people living with dementia. People did not always experience meaningful and caring interactions from staff. This was needed to reduce the risks of social isolation and to enable people to feel involved in their care.

Staff recruitment had been problematic, particularly for nurses. There was an on-going reliance on agency staff to supplement the staff team. The same agency nurses usually worked at the home but this was not the case for care workers. There was a core group of staff in different roles who were loyal to the service and who had built good relationships with people living at the home. However, staff said some shifts ran below the registered manager’s preferred level putting extra strain on staff in a job which was already demanding.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection, applications had been made to the local authority in relation to people who lived at the service. However, the local Deprivation of Liberty Safeguards team had not been updated when a person’s needs had significantly increased. This meant people’s legal rights were not protected. Some applications had been incorrectly applied for. They had not been audited to ensure the applications to restrict people’s ability to leave the building were appropriate.

Recruitment practice ensured all the necessary information was in place before staff started work at the home, which included checking nurses were registered with the Nursing and Midwifery Council. However, information linked to people’s suitability to work was not addressed as part of their induction and training.

The home was clean but poor infection control practice put people’s health at risk. Medicines were generally well managed; although people said nursing staff did not always ensure people had taken their medicines. During the week, social activities were arranged in communal areas but further work was needed to ensure people had their individual social needs met.

The service was not managed well: the leadership of the home was weak. During our inspection, we found a number of areas that needed to improve to maintain the safety and well-being of people that had not been identified by the registered manager. Systems to address previous concerns linked to the safety of people living in the home had not been sustained.

Statutory notifications, required by law, were not always sent to the CQC. These linked to safeguarding concerns and staffing arrangements. This meant CQC was not able to effectively monitor the operation of the service.

We found multiple breaches of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.]

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

The overall rating for this service is 'Inadequate' and the service is therefore 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. 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.

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 last inspected the service on 14, 15 and 23 June 2016 when it was rated as Requires Improvement overall. At that inspection, we found three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the running of the home, supporting staff and notifying CQC about incidents that affected the running of the service. The provider had produced an action plan to ensure improvements were made and sustained. Following the last inspection, the provider worked with local health and social care professionals and with the local authority quality monitoring team to improve the service as part of a whole home safeguarding process; this process is now closed because of the improvements that had been made to reduce risk to people’s safety and well-being.

At this inspection, we found that improvements had been made and the breaches were met. We made two recommendations linked to staffing and the environment.

People said they felt safe and secure living at the home. People were protected from potential abuse and avoidable harm. Staff had undertaken safeguarding adults training and understood their responsibility to reports concerns immediately.

Since the time of the last inspection, a second registered manager had been appointed. We have referred to them as the day to day manager in the report. They were present on both days of the inspection. 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 service had two registered managers; one was in day to day charge of the running of the home and had been in post for approximately six months. They said they had worked closely with the provider in the running of the home. The second registered manager was also the provider. They visited the home two to three times a week and provided support for policies, procedures and managed the budget. Neither of the registered managers were practising nurses, although one had a nursing qualification. The service had a designated ‘clinical lead’ nurse to oversee and advise on clinical decisions at the home. There was also a deputy manager.

The registered manager who was in day to day charge of running the home was leaving at the end of March 2017. In preparation for their departure, they were developing the deputy manager to take on increased responsibilities. They had delegated some duties to them, for example auditing care records. The provider said they were considering what changes they would make to the management team following the registered manager’s departure.

People described their relationships with the staff as positive. For example, speaking about a staff member, one person said, “She is a lovely girl”, another person described staff as “kind and gentle” and a third person said staff were “very good.” People looked relaxed with staff. This included staff who worked as part of the housekeeping, activities and catering team. Care staff were able to describe their practice to ensure they respected people’s dignity, for example when supporting people with personal care.

People's safety and wellbeing was promoted because there was sufficient staff to keep people safe and meet their needs at a time and pace convenient for them. The atmosphere in the home was not rushed and organised; staff worked in an unhurried way and were able to spend time with people. However, we have made two recommendations to the provider to look at deploying staff consistently and improving the information on the rotas, to include when the management team were on duty.

People had individual risk assessments and care plans to minimise risks identified. For example, people at risk of choking. Staff preparing food understood the risks for people of choking and had clear information about how their food should be prepared. Accidents and incidents were reported and reviewed to identify ways to further reduce risks and highlight trends or increased risks for individuals. For example, analysing falls in detail to see if further measures could be introduced to reduce the risk of reoccurrence. People received their medicines safely and on time. People were cared for in a clean, hygienic environment.

The day to day registered manager had introduced a robust system for health and safety monitoring around the home. Staff received regular fire, health and safety, safeguarding and infection control training. A maintenance team undertook an ongoing programme of repairs, maintenance and redecoration to maintain the environment of the home. The home’s environment was maintained to high standard.

The day to day practice of staff and feedback from people living at the home showed staff had an understanding of the principles of the Mental Capacity Act. Throughout our inspection, staff took time to check with people that they understood their wishes and gained their permission to help them. Staff changed their approach to meet the individual needs of people, for example rephrasing their questions if the person seemed unclear what they were being asked. Staff did not rush people and gave people eye contact. Mental capacity assessments were undertaken to assess people’s capacity to give their consent to live at the home to receive care and treatment.

Formal observations of staff practice and competence had been established as part of the supervision process for staff. The day to day registered manager said this offered a valuable opportunity to give individual staff feedback on their practice and interactions with people and helped identify any specific training needs. Staff said they felt supported and were positive about the purpose of having their practice observed. Training records showed staff received training on a range of subjects.

Staff members commented there was good communication between shifts to ensure people’s changing needs were shared when staff came on duty. They also said staff worked well as a team. Staff were provided with equipment and information to meet people’s health needs and to recognise changes in people’s health.

Adaptations were made to the home to meet the individual needs of people with physical disabilities. There were two passenger lifts to help people access the upper and lower floors. However, further work was needed to consider the needs of people living with dementia. Some people chose to regularly walk around communal areas of the home, staff chatted with them as they walked alongside them. There were few pictures and objects around these routes for people to talk about with staff to stimulate their memories or interests.

Care records were well laid out and easy to navigate. People's records had person centred details about each person, their likes and dislikes, information about their life before they came to live at the home and their medical history. Staff used the knowledge of people’s previous interests and employment to engage with them. People responded well to this approach, for example a person became animated and spoke enthusiastically about their life to staff.

Improvements had been made and were continuing regarding the provision of activities for everyone living at the home. People told us about the activities which they preferred and they chose to participate in, which records confirmed. Photos showed people participating in a variety of events including flower arranging. Staff involved in activities knew people’s individual preferences and records showed how they catered for this through group work and one to one sessions.

People and relatives said they had no concerns or complaints about the home. They said if they had any concerns, they would feel happy to raise it with the management team and were confident it would be dealt with straightaway.

The day to day registered manager said the morale of the staff team was good. They were pleased with the improvements to the service but acknowledged this was “work in progress” with more time needed to embed the changes/improvements in practice. Staff praised the impact of the day to day registered manager on the culture of the home and the improvements that had been achieved. They said the day to day registered manager was approachable and listened to their ideas.

Following the last CQC inspection the provider had met with people and families to outline the findings and steps being taken to improve. The day to day registered manager said people and relatives said they were happy with their care. A newsletter had recently been produced to keep people, relatives and staff updated about the changes and improvements at the home. The January 2017 newsletter encouraged people and families to provide feedback on things that mattered to them about the running of the home in person or via e mail.

During the inspection in December 2015, we shared our concerns about staff practice and staffing levels with the local authority safeguarding team, commissioners and clinical commissioning group. They reviewed and monitored people’s care as part of a whole home safeguarding process. A further CQC inspection took place in March 2016. This was to check on the warning notice for staffing which we judged was not met as there were low staffing levels on some night shifts.

Services in special measures are 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. This inspection on 14,15 and 23 June 2016 took place because the home was in ‘Special Measures’. At this inspection, we found they were progressing with their improvement action plan and had met the majority of legal requirements.

However, there had been occasions when the registered manager had not notified us about issues that impacted on the running of the service. For example, changes linked to nursing arrangements within the home and when there had been problems with staffing levels on shifts. This meant the CQC was not being kept up to date with issues relating to risk. This also meant that this regulation had not been met since it was first reported on after an inspection in December 2015. We also found the warning notice served following the inspection in December 2015 had not been fully met. Records to ensure people received safe and good quality care needed further improvement. Quality assurance systems were not yet embedded as part of the regular quality assurance system because they had not been fully established and were not fully effective.

In the last six months, there had been significant changes in the home including the staff structure and the staff working at the home. The action plan had identified multiple areas for improvement and most of these had been addressed. We have made recommendations in relation to the design of the building for people living with dementia and the use of a nationally recognised staffing tool to assess staffing levels. We recommended improvements were made to ensure there was a consistent approach to induct new care staff following nationally recognised current induction standards.

Donness Nursing Home provides accommodation for up to 34 people who require personal care with nursing; 22 people were living at the home during our visit. The service provides care for older people, some people who are living with dementia. The bedrooms are on three floors, which can be accessed by two passenger lifts.

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’. The service is owned by a provider, who is a registered person. 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 Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. We discussed DoLS with the registered manager and looked at records. We found the provider was following legal requirements in the DoLS. At the time of the inspection, an application had been made to the local authority in relation people living at the service. This meant people’s legal rights were protected.

Significant changes had been made to how staffing levels were managed. This meant there were sufficient staff on each shift, which helped keep people safe and their care and social needs met. Agency staff were used to fill staff vacancies with the same staff used where possible to be provide continuity for the people living at the home. Improvements were needed to ensure one staff member was fully supported and supervised.

Improvements had been made to recruitment practice to ensure all the necessary information was in place before staff started work at the home. Changes had been made to the management of staff training and staff were better supported to work in a safe and caring way. Systems had been introduced to monitor staff practice to ensure people were moved in a safe way and treated respectfully.

There were many examples of good care, with staff showing affection and compassion towards people. Staff practice had improved, which helped support people’s dignity. Staff had good relationships with people who used the service and spoke about them in a caring and compassionate manner.

People were supported to see, when needed, community health care professionals. Care staff recognised changes to people’s physical well-being and knew to share this information with nurses working in the home. Medicines were well managed and administered appropriately. People were supported to have enough food and drink, and people’s weight and nutrition was monitored.

Steps were being made to create a regular activities programme to meet the needs of people in communal areas and those who chose to stay in their bedrooms. However, this was a new development and was not yet an established part of the care and support provided at the home.

After our December 2015 inspection, out of the five key questions the service had three requires improvement and two inadequate ratings. After this inspection, the service had received four requires improvement and one good rating across the key questions. Therefore, with this report, we have determined that the service is no longer in ‘special measures’. We will inspect again within 12 months to determine further progress and improvement in the care of people who use Donness Nursing Home

There are breaches of regulation. You can see what action we told the provider to take at the end of this report.

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 27 people living at Donness Nursing Home. The summary is based on conversations with three people using the service, five staff supporting them, two people's families, two health care professionals, the registered manager (known as matron), observation and records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was safe because staff had a good understanding of people's needs and ensured those needs were met. This included close monitoring of diet, blood sugar levels, falls and psychological needs. Advice was sought appropriately and within a reasonable timescale. Necessary equipment was provided. People who had been admitted with pressure sores or whose diet was a concern were making considerable improvement.

Care plans included considerations of the Mental Capacity Act (2005) and staff demonstrated an understanding of the Mental Capacity Act (2005). People were protected through the Deprivation of Liberty Safeguards (DoLS) which were properly managed so as to protect people from being deprived of their liberty unlawfully. The registered manager had taken advice about an application under DoLS the day before our visit.

The service was safe because checks were completed prior to new staff starting work at the home. This ensured those staff members were suitable to work in a care home environment. There were sufficient staff to meet people's needs in a safe way but this was marginal some nights whilst an additional night care worker was being employed.

The service would be safer if all accidents were better recorded and investigated in a timely manner.

Is the service caring?

The service was caring because people's individual needs were understood and met. For example, one person had decided they wanted to stay in bed permanently. They were made comfortable and protected from risks from inactivity. They appeared happy and settled when we visited them.

Staff were attentive to people's needs and dignity. We saw care workers act quickly when one person started removing their clothes. Other care workers were discreetly monitoring a person's diet. That person's family told us 'They care. They go beyond the basic needs. It's about mum as a person'.

We heard and saw staff interact with people in an unhurried and respectful way. One person told us 'Most staff are caring'.

The service was caring because people's well-being was seen as the priority. People appeared to be comfortable and relaxed at the home.

Is the service effective?

The service was effective because people's health and welfare were promoted. People received an assessment of their needs prior to admission. Risks were assessed and risk management planned. The person's care plan was then completed and updated as the person settled into the home. The care plans were reviewed monthly following discussion with the person and/or their family representatives and health professionals. One person's family told us "I feel the staff are geared to his needs".

Health professionals had no concerns about the standards of care provided.

People received a nutritious diet which they told us they were happy with. Comments included "Food is pretty good" and "Not too bad. Quite good".

Is the home responsive?

The registered manager (matron) was clearly well known to people and their families who felt they were able to take any issues to them, the office manager and the staff. The home also sought staff and people's views through an annual survey of opinion.

The home had responded to changes in people's needs and circumstances. We saw how people's needs were reviewed and their plan of care amended where necessary. We saw how people's health had improved since admission to the home.

Is the home well-led?

The home was well-led because the service was monitored. For example, we saw how a missing record had been highlighted as an issue. People's views were sought and audits undertaken. There were efficient arrangements for communication between the registered manager (matron), office manager, nursing, care and support staff at the home. However, we saw matron did not always act quickly enough and one staff said 'or show us that she has acted'.

We saw the registered manager was 'very approachable' and people using the service, their families, health professionals and some staff wanted to tell us this. However, some staff members did not take issues they had to the manager.

The home was well-led because it ran effectively and there were contingency plans in place for any foreseeable emergency.

We looked at whether people received the care and treatment required to maintain their health and safety. Most people were unable to tell us their experience of living at Donness Nursing Home but we saw staff providing appropriate care in an unhurried way. We saw that people's personal care needs were being met and that people looked comfortable and had equipment in place for their safety, such as pressure relieving mattress. We found that staff were knowledgeable about people, people's care was planned according to their individual needs and delivered in a safe way.

We looked at whether there were enough staff to meet people's needs and whether those staff were skilled and competent in their work. We found that care workers had a clear understanding of people's needs, had been trained to meet those needs and there were sufficient staff for the number and needs of people receiving the service.

People told us, 'They look after me very well'; 'Good staff here. Well organised' and 'It's lovely; when you ring the bell the carer will answer it.'

Work towards ensuring people consented to their care and treatment had not adequately led to consistent or properly documented evidence that their consent was always sought and recorded. This meant that people might not always be at the centre of their care arrangements.

People's care and welfare needs were being met by competent, knowledgeable, kind and thoughtful staff.

People benefitted from staff whose training needs were being better organised and completed. We were told, "The staff are excellent. They really look after you' and 'The staff are nice.'

Service improvements were evident, such as risk better managed, an example being accident monitoring. People confirmed that any concern would be dealt with promptly by the registered manager. One person told us, "(The Matron) is very good. Any ideas you have got - they listen."

Two staff said that record keeping had improved and we saw that care and medication records were detailed, complete and available to inform staff and monitor people's care. Improved record keeping protected people from unsafe or unsuitable care.

At our last inspection in February 2013 we found that people were not protected against the risks associated with medicines. We issued a warning notice. The provider sent us an action plan to show how they would address this. During this inspection we saw that action had been taken to address the issues raised in the warning notice.

We looked at people's care plans and found that they had been re-written recently with good guidance for staff in how people liked their care to be provided. We saw good practice with respect to people's care and welfare. One person told us the family had chosen this home for their relative because it was smaller than others in the area and offered the quality of life that suited them.

We found that staff were not always clear about how decisions should be made when a person was not able to decide for themselves. However, we found that staff offered choice and asked people what they wanted.

Some staff training had been delivered recently but there were significant gaps in training provision, management support and supervision for staff which meant that we could not be confident that people would always have their care provided by staff who were competent to meet their needs

One person told us, 'You couldn't have people wait on you better.' Staff told us that people joined in keep fit sessions and a musical entertainer visited regularly.

However, we found that care planning and risk assessment had not been carried out consistently. Guidance for staff was not updated and accurate. Staff did not always record accurately what they had done and in some instances there was no evidence that they had done what the care plan said was needed. We saw staff moving a person from their wheelchair to an easy chair in a way that might cause the person harm.

Recording of medications was unreliable. It was not always clear that people had been given medication according to the instructions from the prescriber. We found instances of unsafe practice when staff had given medication without carrying out a check that was necessary beforehand.

We found that there were insufficient checks in place to ensure that the home was run in a safe way. This included a lack of medication reviews, to ensure that people were being given the correct medicines to promote their well being and lack of evaluation of accidents and incidents to see whether there was anything more that could be done to prevent people falling.

We saw that staff treated people with consideration and respect. We saw that staff quickly responded to people's care needs to ensure that they were kept comfortable and informed about what was happening, such as discreetly assisting someone to the toilet and informing them about when lunch would be.

Staff had knowledge of privacy, dignity, independence and human rights. For example, how to maintain privacy and dignity when assisting with personal care. They showed an understanding of the need to encourage people to be involved in their care. For example, staff recognised the need to explain tasks to people before assisting them.

Care plans that we saw reflected people's health and social care needs and demonstrated that other health and social care professionals were involved.

We spoke with staff about their understanding of what constituted abuse and how to raise concerns. They demonstrated a good understanding of what kinds of things might constitute abuse, and knew where they should go to report any suspicions they may have.