The inspection took place on 14 and 15 February 2017. On 14 February 2017 the inspection was unannounced. We returned to complete the inspection on the 15 February 2017, this visit was announced.

At the last Care Quality Commission (CQC) inspection on 8 July 2014, the service was rated as Good in all of the domains and had an overall Good rating.

At this inspection we found the registered manager and provider had consistently monitored the quality of their service to maintain a rating of Good.

The registered manager had been in post since January 2014. 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 home provides accommodation, nursing and personal care for up to 88 older people, some of whom may be living with dementia. The nursing and care was provided in a modern environment that had been designed to enhance people’s experience of the care and provide flexibility in order to meet people’s longer term needs. This is a large home, but has been split into smaller, manageable wings to promote care consistency, homeliness and comfort. There were 79 people living at the home at the time of our inspection.

The registered manager and provider were consistent in measuring the quality of people’s experiences and continued to put people at the heart of the service.

The quality outcomes promoted in the provider's policies and procedures were monitored by the registered manager and leaders in the home. There were multiple audits being undertaken based on cause and effect to support learning and improve quality. All staff understood their roles in meeting the expected quality levels and staff were empowered to challenge poor practice. The provider shared their learning with all the homes in the group.

Nurses and care staff demonstrated they shared the provider's vision and values when delivering care. People were supported to maintain their purpose and pleasure in life.

People’s right to lead a fulfilling life and to a dignified death was understood and respected at all levels.

There were picture boards that were designed to stimulate memories, make people curious about each other and promote inclusion by prompting questions and discussion. The facilities included therapy baths, meeting lounges, a modern hair-dressing salon and a chapel for prayer and reflection. The home continued to be well resourced and maintained by the provider.

People, their relatives and health care professionals had the opportunity to share their views about the home either face-to-face, by telephone and by using ‘on-line’ feedback forums.

There were enough nursing and care staff on duty to meet people’s physical and social needs. The registered manager checked staff’s suitability to deliver personal care during the recruitment process. The premises and equipment were regularly checked to ensure risks to people’s safety were minimised. People’s medicines were managed, stored and administered safely.

All staff understood their responsibilities to protect people from harm and were encouraged and supported to raise any concerns. Staff understood the risks to people’s individual health and wellbeing and risks were clearly recorded in their care plans.

Risks to people’s nutrition were minimised because people were offered meals that were suitable for their individual dietary needs and met their preferences. People were supported to eat and drink according to their needs, staff supported people to maintain a balanced diet.

Staff received training continued to be that matched to people’s needs effectively and nursing staff were supported with clinical supervision and with maintaining their skills and their professional registrations.

The registered manager

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This inspection was unannounced. Charing House is a home that provides both residential and nursing care and is registered with the Care Quality Commission (CQC) for up to 88 people. There were 83 people living in the home when we inspected. The home provided residential care, nursing care and support to adults, some of whom people had been diagnosed with dementia. The home was located in a residential area close to local amenities and the accommodation was spread over five wings on three floors.

The home had a manager who is registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

The home provided nursing care for up to 38 people in two of its wings. The Freddie Cooper Wing could accommodate 16 people and the George Smith Wing 22 people. People who lived in these two wings had high care dependency levels. High care dependency levels meant that people received care or nursing in bed, required specialist equipment to meet their needs or needed constant supervision.

The home also provided residential care for 22 people with medium to low care dependency levels in the Bessie Parr Wing and eight low dependency residential care beds in the Barry Hodgeman Wing. Low care dependency levels meant that people only required care for certain tasks and that generally they could do more for themselves. The home also provided residential care for up to 19 people who had dementia in the William Griffin Wing. People who lived in this wing had varying degrees of dementia. Dementia could affect people’s ability to make decisions and could impair their cognitive abilities. Some people were able to tell us about their experiences of the home, whilst others were unable to communicate this verbally.

All of the people we talked with as part of the inspection told us they were happy with the home and felt safe. People said, “I feel safe, well treated and happy”. Relatives told us that they felt their family members were cared for safely and were satisfied with the care people received. We observed staff had good professional relationships with the people they cared for. People were encouraged to join in activities and those that could, moved freely around the home. At the same time staff ensured people were kept safe. Staff were kind and caring, treated people with respect and maintained their dignity. Others said, “Wonderful care and attention from staff” and “Staff have been very caring.”

Staff had received safeguarding training and showed a good understanding of what their responsibilities were in preventing abuse. They knew the procedures for reporting any concerns they may have and had confidence the manager would respond appropriately to any concerns they raised. Records showed safeguarding incidents had been recorded and reported to the local authority and the Care Quality Commission (CQC). Medication was managed safely.

People were treated with respect. One person said, “The staff treat me with respect, they certainly do”. The manager had a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). MCA and DoLS is legislation which ensures that people who are unable to make certain decisions for themselves are protected.

The provider had robust recruitment policies that had been followed. This ensured safe recruitment practices. No concerns were raised about the staffing levels at the home. The manager told us staffing levels were kept under review and adjusted according to the dependency levels of people who lived at the home. People received care and treatment in a timely manner.

People who used the home and where appropriate their families had been involved in planning their care. Staff asked people about their preferences and choices. People told us that portion sizes were good and the meals were tasty and hot. All of the people we talked with had good things to say about the staff. One said that “All staff were good, but some are excellent’.

People received care from staff who had been trained to meet their individual needs. People told us that staff were well trained. One person said, “The staff are very competent.” Staff had used good systems to help them quickly identify any changes in people’s needs. Such as monitoring people’s health and wellbeing and seeking people’s views about their health.

People had accessed appropriate health, social and medical support as soon as it was needed. The environment had been adapted and appropriate facilities had been provided to meet the individual needs of the people who use the home.

We spent time in the communal areas and observed staff how staff communicated with people. These interactions were friendly and respectful. The home had been designed and refurbished to ensure that the facilities were personalised and suitable for the people who used it.

Staff communicated with other health and social care professionals to make sure that they had enough information about people’s needs when they were admitted. Such as when people had come to the home following hospital discharge. Staff had established effective ways of communicating with people so that they could express their views about their experiences of the home and what changes they may have wanted. People’s care needs and wishes were included in their care file records, such as end of life care. Where they were able to, people consented to their care. For those who could not, the manager had made sure that proper steps were taken so that decisions were made in people’s best interest. During our inspection we noted that staff responded quickly and appropriately to people’s needs.

The manager had made links with the local community. They had promoted family involvement and people took part in meaningful activities in the home or their local community. Two people told us they had just returned from participating in a Tai Chi session. Others told us they had attended special events, ‘like singers’, and one person told us that they had chosen to watch ‘two weeks of solid tennis’. One person said, “I have been to activities, I really enjoyed the games.”

Staff said they felt well supported and were aware of their rights and their responsibility to share any concerns about the care provided at the home. Managers monitored incidents and risks to make sure the care provided was safe and effective. The manager used a range of systems to make sure there were enough staff to care for people safely.

People told us that managers were approachable and listened to their views. One relative said, “I raised an issue with the manager and this was resolved to my satisfaction”. Managers demonstrated a desire to constantly maintain and improve standards within the home. They used local and national best practice standards as well as new and creative practice we observed during our inspection.

Two inspectors and a clinical specialist visited Charing House during this inspection. All areas of the home were visited and we spoke to staff, people who used the service, their relatives and healthcare professionals. We made observations about how people were cared for and how staff interacted with people.

People we spoke with told us that they were given choices about their day to day care such as choosing what they ate and what they wanted to wear. People had appropriate assessments in place to assess their capacity and people had their preferences taken into account.

We looked at care records and spoke to people about the care they received. People made comments such as “I get well looked after here” and “the staff always come when we call for help”. Care records showed that people were having their health and social needs met.

We observed medication being administered, looked at medication records and where medication was stored. We saw that appropriate records were in place and staff followed protocols to ensure medication was administered in line with people’s prescriptions.

We looked at staffing rotas, made observations and spoke to staff, people and their relatives about the staffing levels at the home. We saw that all shifts had appropriate staffing levels.

We spoke with staff about the training they received. We looked at staffing records and training records and saw that staff received training and regular supervision with their managers.

People told us that they liked the home. They said that it was always clean and staff were nice.

A person told us that they thought there wasn’t enough for them to do. They said “There is too much inactivity – I get bored”.

A relative of a person who lived at the service told us that they thought the staff were easy to talk to, but there had been times when there was not enough and they hadn’t been able to find anyone when they needed them.

We were able to talk with some of the people who lived in the home and they told us about their experiences. Other people who lived in the home were not able to tell us their views as they had dementia or limited verbal communication. We also had the opportunity to speak with relatives who were visiting people in the home.

People we spoke with told us that the regular care staff were “kind and caring” towards them. These people also described the carers as ‘very nice’ and ‘very friendly’. People told us, however, that there were often agency nurses on duty and that they did not always understand their needs. For example one person told us that when he had requested pain relief at night, an agency nurse had said that he could not have any and he had not been given any explanation as to why he could not have pain relief.

People we spoke with told us that they had a choice of meals. One younger person, who used the service, told us that the food did not offer choices they preferred, although they could order in 'take away' meals if they wanted. Two people told us that they thought the portions were quite large and they sometimes found this 'Off-putting'.

Visiting relatives told us that they did not feel that people were given drinks on a regular basis and often had to ask staff to supply drinks.

The people on the residential units told us about the different activities that they took part in and that they were able to choose what they wanted to do. We did not speak to the people on the nursing unit about activities, but we observed that one of the activities coordinator spent some time during the morning in one of the communal areas, where there were four people seated. Observations showed us that people who remained in their rooms did not have much interaction from staff. Relatives had mixed views about speaking to staff or raising any concerns. One person told us that they had made a complaint and felt that it was being dealt with appropriately. Another relative told us that they felt communication with staff was not good and that often staff were too busy to speak to her.

People who used the service told us that the home was welcoming to visitors, and a relative told us she was able to join the person she visits for a meal.

We had previously inspected the service in February and June 2012 and found that the service was not compliant with the regulations in a number of areas. We also received concerns about the service from the public and the local authority.

The provider sent us an action plan which told us how they planned to make improvements. During this inspection we found that whilst some improvements had been made, there remained some areas which still needed to be improved.

We found that improvements had been made to Park View which had meant that people were receiving care and treatment that met their needs. We found that there were still some areas of Charing House where improvements needed to be made.

During this inspection we talked to people, we looked at care and staffing records and made observations. We also spoke with the local authority and other healthcare professionals to gather their views.