The inspection took place on 30 October 2018 and was unannounced.

Chiswick House provides residential care for up to 26 people, some of whom may be living with dementia. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 22 people living in the home. Chiswick House is a large Victorian property with a modern extension and people benefit from communal areas and a garden.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service, like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about the service is run.

At the last inspection, in February 2016, the service was rated as Good. At this inspection we found the service was Outstanding. The reasons for this are:

There were effective systems in place to assess and manage any potential risks identified. Staff understood fully the significance of health and safety management.

Medication was stored, administered and recorded safely and people received their medicines as prescribed.

Staff were recruited appropriately and there were always sufficient members of staff available to ensure people were kept safe.

The service delivered very effective care. The service worked in partnership with other health professionals to ensure a person-centred and preventative approach. Very good outcomes were achieved.

Staff were encouraged to undertake comprehensive and advanced training to cater for the needs of people in the home.

People’s nutritional and hydration needs were met particularly well.

People’s needs were assessed holistically.

The service had a solid understanding of its responsibilities regarding the Mental Capacity Act (MCA) 2005 and had followed best practice in respect of assessing capacity and arriving at decisions where capacity was lacking.

Staff showed exceptionally kind, compassionate and caring qualities. They were consistently attentive and went the extra mile to meet people’s needs.

Staff demonstrated a genuine desire to ensure people were comfortable, stimulated and content. They treated people with the utmost respect and ensured their dignity was maintained.

Staff made every effort to ensure communication was facilitated and that people’s choices were recognised. Staff maximised people’s independence.

The service’s approach to person-centred planning ensured that people’s needs were met and the support they received was personalised to suit their views and beliefs.

The service provided a wide array of activities and events that people could engage with. The service strove to ensure people’s individual wishes were met and created the circumstances for people to live a fulfilling and enriched life.

The service provided personalised care to people and their relatives when people reached the end of their life.

The service demonstrated outstanding management and leadership which created a caring, inclusive and respectful culture. Staff were fully aware of their responsibilities. They felt valued, supported and empowered to deliver high quality care.

The service was exceptionally inclusive and responsive to feedback and suggestions. It was always keen to listen, learn and improve. The quality management framework was of a very high standard.

The service actively embraced opportunities to work with external agencies to enhance its provision of care.

We inspected Chiswick House on 24 February 2016. This was an unannounced inspection. Chiswick House is registered to provide accommodation and personal care for 26 older people, some living with dementia.

There were 20 people living in the home when we inspected.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff understood what protecting people from harm or abuse was, and had received relevant training. Staff understood their roles and responsibilities in keeping people safe and actions were taken when they were concerned about people’s safety. Individual care plans had risk assessments to ensure the safety of people using the service. The provider had effective processes in place to minimise risk.

Robust recruitment processes were in place to ensure that staff employed in the service were suitable for the role. People were safely supported with medicines administration by trained staff. Staff were confident in reporting incidents and accidents should they occur. The service had robust quality assurance systems to drive continual improvement in the service.

Staff understood the importance of gaining people’s consent to the care they were providing to enable people to be cared for in the way they wished. Two people had applications in for the lawful deprivation of their liberty (Deprivation of Liberty Safeguards (DoLS)) and staff were able to explain how they promoted choice where people had variable capacity. The home complied with the requirements of the Mental Capacity Act 2005 (MCA).

People were supported to access healthcare wherever necessary and in a timely manner, with prompt action taken in response to changes to a person’s health needs. People’s nutritional and hydration needs were well met by the service, in line with recommendations such as speech and language therapy.

Staff had good knowledge about the people they cared for and understood how to meet their needs. People planned their care with staff and relatives, and activities were carried out in line with people’s preferences.

Staff were kind and compassionate. They consistently demonstrated humour and warmth in meaningful interactions with people. Feedback from people and their relatives about the care they received was complimentary. Staff respected people’s privacy and dignity.

Staff were well motivated and spoke positively about their job and understood the importance of providing a high standard of care to the people living in the home. There was an inclusive culture including good teamwork within the service. Staff felt supported in their roles.

The people we spoke with told us that they were cared for well and that they had their individual needs met. One person said, "I am offered what I like for my meals, go to bed when I wish and take part in activities if I want to." Another person said, "I have a nice room with my own belongings, I see my family often and the staff support me well. I am very content with what I have in my old age."

The care plans we looked at showed that peoples needs were fully assessed and that individual support was recorded and offered as and when required.

When walking around the home we found all areas seen were clean, there were no unpleasant odours and that staff were aware and were using suitable protective clothing. Staff had designated cleaning schedules to ensure all areas were cleaned correctly to promote appropriate standards of cleanliness and hygiene.

Medication was stored, recorded and audited safely. We found that risks had been identified and new procedures introduced, that staff could follow, to ensure the management of medication was carried out correctly.

We were shown records and staff told us that the induction, training and support offered enabled them to carry out their job competently and correctly.

People were asked their views of the quality of the service in 2012 and comments received were acted upon. There were systems in place to check the quality of all aspects of the service provided.

We spoke with people who told us what it was like to live at this home. They described

how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met. The inspection team was led by a CQC inspector and an "expert by experience" (people who have experience of using services and who can provide that perspective).

We spoke with six people who were using the service. Everyone we spoke with confirmed that the staff treated them with respect and provided them with choices wherever possible. People spoken with were satisfied about the care and support that they received.

For example one person told us that, "The staff are very helpful and kind, pleasant people, they are very caring.” and another confirmed, “The staff treat me very kindly and are friendly, they always use my first name”. Another person told us, “Staff are very pleasant and helpful, they are like friends and always treat me with respect”.

One person told us, “if I want a drink, hot or cold I just ask and they will bring it for me. I like it here, the staff are very professional. Someone else told us that, “The staff treat me very well, they are knowledgeable, helpful, kind and always respectful. They accept that I don’t always want to join in the activities”.

All the people we spoke with were pleased with the meals provided. One person told us, “I think the food is very good, it’s almost like home cooking”. Some people chose to eat in their rooms and one person said, “I would say the food is excellent, I choose to eat in my room and if I don’t like the choices they will cook an alternative for me, they are very helpful". Other people reported that the staff bring the menu round daily and that they get two choices of main course and a choice from the dessert trolley.

Everyone that we spoke with told us that they felt safe in the service and were confident that the manager would resolve any concerns they might have. For example one person confirmed that, "Staff always have time for me". Another person said that "The staff are kind and helpful". The people we spoke with were aware of what to do if they had any concerns and were confident that these would be addressed promptly by senior staff in the service.

People told us that they did not have to wait for staff assistance if they required it. For example one person told us,”I like it very much here. I had to go to the hospital and the staff stayed with me all the time and were very supportive”.

Some people we spoke with confirmed that they had discussed their care needs with staff. Whilst other people told us that their family had been involved in making sure that care staff understood their needs.

People with whom we spoke said they are happy at Chiswick House.

We were told that staff do provide help when needed and people also said they are happy with the care they receive in the home.

One person told us that they enjoy their food and that they can make choices about what they do and when they do it. Another person said that they like the food and eat what they want, if they want an alternative, they just ask the staff. However, another person commented that some meals can be ‘a bit boring’ and when we asked if staff ask people what they would like on their meals, we were told they do not.

We were told by one person that the home is one of the best around and they are glad they are living at Chiswick House.