This inspection took place on 1 and 3 August 2017, the first day was unannounced.

At our comprehensive inspection on 6 September 2016, we found the provider was not meeting the regulation in respect of medicines management. We also identified improvements were required around the home’s quality assurance processes and the submission of statutory notifications as required by their CQC registration. Following the inspection, the provider sent us an action plan which set out the action they were taking to meet the regulations. At our next inspection in December 2016 we found the provider had met the breach although we identified some improvements were needed in relation to the recording of topical medicines and the management of ‘as required’ medicines.

The home provides care and accommodation for up to 36 older people, some of whom may be living with dementia. This service offers respite care breaks as well as long term residential care. There were 34 people using the service at the time of our inspection.

Although we undertook this inspection as part of our planned inspection programme, we also received some information of concern about the service. This related to staffing levels, staff using unsafe moving and handling techniques and people not being given choice around their morning routines. We looked at these issues during this inspection and found no concerns.

We found there were improvements with the ways medicines were managed. New audits and checks were in place although further work was required to embed and sustain consistent safe practice for the recording of people’s medicines. We have made a recommendation about medicines management.

People felt safe and well cared for. Risks to people’s health and well-being were assessed and kept under review. Staff took action to minimise these risks and keep people safe. Staff knew how to recognise and report any concerns they had about people’s care and welfare and how to protect them from abuse.

The environment was safely maintained and people had the equipment they needed to meet their assessed needs. People’s bedrooms were personalised and furnished to comfortable standards.

At the time of our inspection there were enough staff to meet people’s needs and keep them safe. Staff received ongoing training and support to fulfil their roles and keep their knowledge and skills up to date.

People had clear assessments of their needs and plans were in place to meet them. Information was communicated well within the staff team and people's care plans were reviewed regularly. The home worked well with other professionals and people were supported to access the healthcare services they needed.

There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. People were encouraged and supported to eat and drink well. When people were at risk of poor nutrition or dehydration, staff involved other professionals such as the GP or dietician.

There were positive and caring relationships between staff and people who lived in the home and this extended to relatives and other visitors. People maintained important relationships with family, and relatives felt involved in the care and support their family members received.

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.

Staff were caring, respectful and made sure people’s privacy and dignity were maintained. People and their relatives were supported sensitively during end of life care.

People continued to benefit from an extensive range of activities in and outside the service which met their individual needs and interests.

There was an open and inclusive atmosphere in the service and the registered manager showed effective leadership. Staff were clear about their roles and responsibilities and felt supported by her and

We carried out an unannounced comprehensive inspection of this service on 6 September 2016 at which a breach of legal requirement was found. We found that safe medicines management processes were not followed. We also identified improvements were required around the management of the home including the submission of statutory notifications as required by their CQC registration and the robustness of their quality assurance processes. The service was rated ‘requires improvement’ overall and in two questions: ‘Is the service safe?’ and ‘Is the service well-led?’. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements. They said they would make the necessary improvements by 9 December 2016.

We undertook an unannounced focused inspection on the 20 December 2016 to check they were meeting legal requirements relating to safe medicines management. This report only covers our findings in relation to this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Eothen Residential Homes - Sutton on our website at www.cqc.org.uk.

Eothen Residential Homes - Sutton provides accommodation and personal care to up to 37 older people. At the time of the inspection 36 people were using the service, some of whom were living with dementia.

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’. 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 provider had made improvements and was now meeting the regulation relating to safe care and treatment with regards to medicines management. People received their medicines as prescribed, including their antibiotics. Accurate records were generally kept of medicines administered and the registered manager had improved the stock checking process. However, we found that processes to check medicines stocks were not robust enough in regards to ‘when required’ medicines. There were no protocols to administer medicines prescribed ‘when required’ to ensure these were administered in a consistent way and the recording about the administration of topical medicines were not being carried out in a consistent way. After the inspection the registered manager informed us they had extended their stock control measures to include all medicines at the service and were addressing the other issues.

The provider had made improvements in regards to the management of the service. The registered manager had worked with the provider’s service manager, the local pharmacist and the pharmacist from the Clinical Commissioning Group to improve medicines management and had introduced procedures to review practice and ensure continuous improvement. Statutory notifications about key events that occurred at the service were submitted in a timely manner as required by their CQC registration.

During this inspection we found that significant improvements had been made to the control measures in place to review the quality of service provision. These were made promptly after our inspection and were consistently being used to monitor service delivery and reduce the risk to people’s safety. We found that people now received care from a service that was well-led. We have changed our rating for the key question ‘is the service well-led’ from ‘requires improvement’ to ‘good’. However, whilst the provider now met the regulation relating to safe medicines management, some of the systems still required embedding especially in regards to ‘when required’ medicines and therefore there is not sufficient evidence to show consistent practice. We have not changed the rating for the key question ‘is the service safe?’ and it remains rated as ‘requires improvement’.

We undertook an unannounced inspection on 6 September 2016. At our previous inspection on 1 July 2014 the provider was meeting the regulations inspected.

Eothen Residential Homes – Sutton provides a residential service and support with personal care to up to 37 older people, some of whom may be living with dementia. At the time of our inspection 36 people were using the service.

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.

Safe medicines management processes were not consistently maintained. People who required antibiotics did not always receive these as prescribed. There were errors in the recording of medicines administered and accurate stock checks were not always maintained which meant that a clear audit trail about the management of a person’s medicines was not always available.

On the day of our inspection we observed there were sufficient staff to meet people’s needs. Staffing levels were regularly reviewed based on people’s dependency and there were arrangements in place to ensure staff were deployed appropriately to meet people’s needs. However, some people felt there were delays in receiving assistance from staff. The registered manager said they would continue to monitor staffing levels and take action where there was evidence of low staffing levels.

Deprivation of Liberty Safeguards (DoLS) authorisations were applied for when the registered manager felt people needed to be deprived of their liberty in order to remain safe. Assessments were made to identify risks to people’s safety and plans were in place to manage and mitigate those risks. At the time of the inspection the registered manager had not adhered to all of the requirements of their registration, including submission of notifications about the outcomes of applications made under DoLS. However, these were addressed by the time this report was written.

Staff had developed caring relationships with people. Staff were polite and respectful when interacting with people. Staff had the knowledge and skills to meet people’s needs. Care plans detailed the level of support people needed and staff were knowledgeable about the people they supported. Staff assessed the risks to people and management plans were in place to minimise and mitigate the risks. Staff were knowledgeable about recognising signs of potential abuse and how to safeguard people from harm.

Staff supported people with their health needs. Staff liaised with people’s GP and the district nurse if they had any concerns or needed additional advice about how to support people with their physical health. Staff monitored people’s weight and supported them with their nutritional needs.

People were involved in decisions about their care and how they spent their time. Staff adhered to the Mental Capacity Act 2005. People’s preferences were known and respected, including those relating to their culture and religion.

The staff were participating in a number of initiatives to further strengthen the service provided. This included participating in the Vanguard initiative to improve processes to review people’s health needs and enable smoother transitions when people required hospital admission. The registered manager was part of the steering group for the Vanguard initiative in the local borough. The staff were also one of three services in South London participating in the Active Residents in Care Homes (ARCH) initiative, which focussed on providing meaningful activities and engagements to people. There was a group activity programme in place and the service used volunteers to provide additional one to one interactions. The staff were using the ARCH programme to further ta

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. We looked at the care records of seven people; spoke with 10 people using the service, three families and six members of staff.

Below is a summary of what we found.

Is the service safe?

Care plans had details of people's needs and how these were to be met. Risk assessments relating to the care and support being provided were regularly reviewed to ensure people's individual needs were being met safely.

We saw that risk assessments of the environment were regularly carried out and action plans written if required. For example a Legionella test had been conducted and the hot and cold water outlets were checked to help maintain good water hygiene. Infection control audits were carried out to prevent the spread of infection and to ensure people’s safety.

Staff had received training about the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and understood how this could impact on the people they cared for.

Is the service effective?

People received effective care from staff that were trained and supported by the manager. We saw that people were happy, well cared for and treated with respect. Care plans were regularly reviewed with the person using the service.

Staff received a range of training. We evidence in the personnel files that staff received monthly one to one supervision and yearly appraisals.

Is the service caring?

The service was caring. This was confirmed by our observations of staff and people using the service. Staff respected people's privacy, dignity and their right to be involved in decisions and make choices about their care and treatment.

People and their families told us about the visits they had made to the home, before they came to live here. They had the opportunity to join in activities, have a meal and meet the staff. One person said “I’m thankful I came here”. A relative told us, “Staff are very helpful and informative”.

We saw that some people had made a decision of ‘advanced planning’, detailing what they would like to happen when they were near to the end of their life and how they would like to be cared for and treated.

Is the service responsive?

People's needs were reassessed on a regular basis and we saw the service responded to any changing needs. We saw from the daily notes that people enjoyed the activities on offer and the home catered for their individual preferences.

On the day of our visit which was unannounced, we saw that a variety of activities were taking place and people were joining in if they wanted to.

Is the service well-led?

The home employed a manager who knew their staff and people well. The manager told us about the audits that they conducted and showed us the recorded evidence to support them.

Regular checks were made of medicines by management and any mistakes noted and action taken. The supplying Pharmacy conducted six monthly checks; there were no areas for improvements that had been identified during the last audit.

Staff from the organisations head office conducted monthly, quarterly, and half yearly audits. Audit areas included what people think of the home, the care they were receiving and the staff, and the premises were inspected.

People were asked for their views about the service and we reviewed the returned questionnaires which were all positive. People were asked to comment on their involvement with the home, privacy and dignity, if they received sufficient support in the home and if they felt safe and about the staff. People and relatives who we spoke with commented “staff are very kind”, “it’s very nice here”, and “I’m happy to be here”.

The provider also conducted a staff survey and we saw the following comments, ‘we work well as a team’, ‘(the place) very clean and tidy’, ‘I enjoy all the training I receive’ and ‘the manager is very supportive’.

Residents meetings to which family and friends were invited were held and a monthly newsletter was produced, informing people of outings and activities, new people or staff joining the service and any other changes taking place.

We spoke with the home manager, four members of staff, six people that used the service and three visiting relatives and a social care professional.

We asked people about their experiences of the care and support provided at Eothen. All the people we spoke with gave complimentary feedback. One person said, “I couldn’t ask for better” and another person told us, “I had a look round before I moved here and I am very happy so far.” Comments about staff included, “they are so kind and patient” and “always helpful and they work so hard.” A visiting professional told us, “The staff know about people’s needs”.

Visiting relatives we spoke with were pleased with the service. One told us “they are always welcoming, lovely staff.” Another relative said, “I’m very happy and everyone is so kind.”

People received the right amount of support to enable them to consent to their care and make decisions. People using the service and those close to them were asked how they wanted their care and support to be provided. Records provided staff with accurate information about people’s care needs and how to support them.

Staff had the skills and expertise to support people's collective and individual needs because they received on-going training and regular management supervision.

Since our last inspection, the provider had improved upon the way medication was managed so that people were more fully protected from the risks associated with medicines.

People knew who to talk to if they had any worries or concerns, and had confidence they would be dealt with.

We carried out this inspection as we had been told anonymously about some issues of concern in relation to the care and welfare of people. We visited the service unannounced and started the inspection at 05.45am. During the visit we spoke with the manager, members of staff, people that used the service and two relatives.

All the people we spoke to were complimentary about the service and the standards of care provided. Our observations and feedback from residents showed that people were offered choice in their lives and that staff respected their preferences. Example comments included, “I can get up when I want, I don’t like to get up too early,” “we are offered choices” and “they ask me what I want to wear each morning.”

Comments about staff included,” they are very kind” and “very helpful, I have no complaints.” A relative told us, “The staff are absolutely wonderful”.

We observed positive interactions between the staff and people living in the home.

Staff felt well supported by the manager and that they had made some positive changes. One staff told us the night duties had recently changed and the manager had explained things really well and why they were needed.

There were systems in place for ensuring that the service was operating effectively and that where issues were identified, action was taken where necessary. We found that some of the arrangements for the management of medicines needed strengthening however.

The people who live at the home prefer to be known as residents, so this term has also been used in this report.

Due to their needs, some people that we met during our visit were unable to share their views about the standards of care. People who were able to comment said that they were pleased with the care and attention they received. Individual comments included, “The staff are all very kind” and “I couldn’t be in a better place!” Others said, “They look after us well, “and “I am happy here, no complaints”

We met several visiting relatives who all gave complimentary views about the home. They told us they were kept well informed about any changes to their relatives’ needs and well being.

Residents spoken to were very complimentary about the service and the good standards of care provided. Comments about staff included, “they are all very nice,” and “always someone available if I need them.”

Individuals said that they enjoyed the meals in the home and find the staff to be helpful and attentive. Comments included, “the food is very good” and “we always get a choice”. Another person said “lovely meals, they give us too much sometimes!”

People told us there were activities to join in with and outings to go on. One resident said, “I enjoyed a visit to the garden centre at Christmas and went to Worthing last summer.”

People knew who to talk to if they had any worries or concerns, and felt assured that staff would respond to these in an appropriate manner. Visiting relatives also had confidence that the home would address any issues.

Residents told us the home was kept very clean and well maintained. They said that their rooms were comfortable and homely.

Staff told us that they were supported by the manager and were happy working at the home. They felt that they had the training and information they needed to care for people. For what the service does well, one staff said, “it provides high standards for the residents and a good environment.”

Please refer to each outcome below and within the main report for more detailed comments about specific aspects of the service.

All those who contributed to this inspection are thanked for their time and for sharing their views about Eothen.