This inspection took place on 7, 8 and 15 November 2016. The inspection was unannounced on the first day and we notified the provider we were returning on the second and third days. At our previous inspection on 25 and 26 November and 8 December 2015 we found the provider was in breach of regulations in relation to ensuring people were protected by proper and safe management of medicines, operating an accessible system for managing complaints, ensuring that systems were operated effectively to assess, monitor and improve the quality of the service, maintaining an accurate, complete and contemporaneous record in respect of each person using the service, operating effective staff recruitment procedures and ensuring the deployment of sufficient numbers of competent staff. The provider sent us a plan following the inspection explaining how they intended to address these breaches of regulation. We carried out this inspection to check that improvements had been achieved and sustained in line with the provider’s action plan. At this inspection we found that satisfactory progress had been accomplished in relation to all breaches of regulation.

Farm Lane provides accommodation for up to 66 people on three separate units, which includes 14 rehabilitation beds on the ground floor unit. Central London Community Healthcare NHS Trust are commissioned to provide the therapy for the rehabilitation patients on this unit. The remaining 51 beds are used to provide nursing care for older people with healthcare needs due to frailty and older people living with dementia.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of the inspection the registered manager had resigned and was no longer working at the service. Farm Lane was being managed by an operations support manager (interim manager). People and relatives commented on the recent significant changes in management at the service, as the clinical lead (deputy) had also left the service since the last inspection.

People said they felt safe and staff competently discussed with us their understanding of how to protect people from abuse. Risk assessments were carried out and risk management plans were appropriately developed.

Sufficient numbers of staff were deployed in order to meet people’s needs, and they were provided with relevant training, supervision and support. Staff recruitment was thoroughly conducted so that people received their care and support from staff who were suitable for employment at the service.

Satisfactory processes had been implemented to ensure the safe management of people’s prescribed medicines.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on our findings. DoLS are in place to protect people where they do not have the capacity to make decisions and where it is regarded as necessary to restrict their freedom in some way, to protect themselves or others. The provider demonstrated that people’s rights were protected and staff had received training to understand their responsibilities. Staff understood how to ask people for their consent before providing personal care and other support.

Systems were in place to support people to access health care, including specialist care and support to meet their end of life care needs. Positive comments were made in relation to the quality of the food and we observed that people were supported in a patient and kind manner.

We saw caring and respectful interactions between staff and people. Staff told us about how they supported people to promote their dignity, which was observed during the inspection.

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This inspection took place on 25 and 26 November, and 8 December 2015. The inspection was unannounced on the first day and we informed the provider we were returning on the other two days. At the last inspection in July 2014 we found the provider was meeting the regulations we looked at.

Farm Lane provides accommodation for up to 66 people on three separate units. This includes 21 rehabilitation beds, managed in conjunction with Central London Community Health Care NHS Trust. The nursing and care staff are provided by Care UK Community Partnerships Limited and the specialist team of physiotherapists, occupational therapists and speech and language therapists are employed by the NHS. The remaining 45 beds are used to provide nursing care for older people with healthcare needs due to physical frailty and older people living with dementia.

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.

We found that there were not enough staff deployed at all times to safely meet people’s needs. The recruitment of staff was not consistently thorough in order to robustly ensure that people were cared for by staff with appropriate skills and knowledge for their roles.

Although nursing staff received medicines training and there were systems in place to monitor the management of medicines, we found issues of concern about specific aspects of the medicines service.

People told us they felt safe with staff, who had received safeguarding training and understood how to protect people from abuse.

Risk assessments were conducted as required and people were routinely assessed to identify their potential risk of health care problems associated with the ageing process and frailty, for example risk of skin damage, falls, malnutrition and hydration.

The premises were safely and hygienically maintained in order to provide people with a comfortable environment.

People and their relatives predominantly told us they thought staff had the appropriate expertise to provide the care they needed. However, this did not match information we had received from people and relatives prior to the inspection, who expressed concerns about the skills and approach of the staff team. Records demonstrated that staff received training, supervision and appraisals in order to improve on and monitor their knowledge and performance.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards (DoLS) and to report on our findings. DoLS are in place to protect people where they do not have the capacity to make decisions and where it is regarded as necessary to restrict their freedom in some way, to protect themselves or others. Although staff had received applicable training, some did not understand the principles of the Act.

A varied and balanced diet was provided, although some people indicated areas of the food service that could be improved upon. We observed people being supported with meals and drinks in a patient and respectful manner.

People were able to access health care support from doctors and other health care professionals, including dietitians and community specialist nurses. However, the registered manager and people who used the service told us there were delays in accessing NHS podiatrists, so people sought private services instead.

There were some conflicting views expressed about whether staff were kind and caring, and our own observations indicated that some staff did demonstrate their fondness for people during interactions but were often task orientated due to the busy level of work.

Records relating to how people were supported with their pe

This inspection was carried out as a part of a national themed inspection programme looking specifically at dementia care. We spoke with people who used the service, used structured and general observation to gain an understanding of how people with dementia who were not able to share their views with us were receiving care and we received feedback from relatives of people who used the service. We left a comments box in the home for one week and received sixteen comments from relatives of people who used the service and three comments from members of staff.

We also spoke with the home manager and members of the care team. We found that the home ensured that people were assessed and that their care plans were up to date and reflected their current needs. We saw that staff had been trained in dementia care.

Some relatives told us that they did not always feel involved in discussions and decisions made about their family members and we saw that there was a lack of emphasis on people's social histories and preferences when their care was planned. Some of the comments we received from family members explained that there were not enough person-centred simulating activities which took place. We saw that the activities scheduled did not take place and not everyone people was engaged in the activities on offer.

The home worked with other health and social care providers to ensure that people received necessary medical care and we saw that the home worked with other agencies to meet the needs of people who used the service.

The provider had systems in place to ensure that the quality of the home was monitored however these were not always consistently applied to ensure that there was an improvement in the quality of dementia care in the service.

As well as the dementia themed inspection, we also looked at the records to follow up on previous non-compliance in the last inspection in this area. We found that there had been some improvement in this area.

We spoke with four people and two relatives of people living in the home, and also with eight people in the rehabilitation unit. The comments we received were positive and demonstrated that people were generally satisfied with the care provided. One person said their relative was "very contented here" and a resident said "I am glad I came here.The staff are excellent."

We saw that staff sought consent on day to day issues, and people gave their views about what they would like to eat, wear and do each day.

Care records were kept securely. The manager had a good understanding of the Mental Capacity Act 2005 which meant decisions were taken in the best interests of people who lacked capacity; however the process that led to these decisions was not always clearly recorded on the electronic records. Records were not always complete.

Two people we spoke with said they felt safe and that staff always came if they needed help. Staff had received training in safeguarding vulnerable adults and understood what was meant by safeguarding. We saw staff attending promptly to people seeking assistance.

Staff and people we spoke with said they felt there were sufficient staff to meet the needs of people living at Farm Lane.

Systems were in place to monitor the quality and risks to the health, safety and welfare of people who use the service and others. Audits were centrally planned and coordinated by Care UK and included annual feedback from people and families.

Overall, people we spoke with were happy at the home and thought that they were well cared for. They told us they felt safe at Farm Lane and would speak to the manager if they had concerns. People who use the service described staff as “nice” “caring” and as “angels”. One person described the quality of her care as “very good”.

People who use the service told us that they were “satisfied” with the quality and amount of food available and were able to request snacks outside meal times. There was a variety and choice of meals available according to people's dietary requirements.

People who use the service told us that they felt safe on the unit and had no complaints “whatsoever”. Most staff felt that there was adequate staffing to carry out care activities with the people who use the service.

People told us what it was like to live at this home and 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 joined by an Expert by Experience, people who have experience of using services and who can provide that perspective, and a practising professional.

We spoke with seven people who use the service and three relatives. Overall, people we spoke with were happy at the home and thought that they were well cared for. They told us they felt safe at Farm Lane and would speak to the manager if they had concerns. One person told us that they sometimes had to wait a while for staff to assist them. Another person told us that the choice of food was "limited" and they were not able to have an egg when they liked one.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. A number of people living at Farm Lane have dementia or find it difficult to communicate verbally.

We spoke to some people who use the service and their families and they were all happy with the care provided at Farm Lane. They felt involved in their care and that staff were friendly and helpful. We saw good interactions between people that use the service and staff.

At the previous inspection in January 2014, the service was non-compliant in Outcome 4, Care and welfare of people who use services and Outcome 16, Assessing and monitoring the quality of service provision. The previous inspection was carried out as a part of the national themed inspection programme looking specifically at dementia care. Some relatives had told us they did not always feel involved in discussions and decisions made about their family members and we saw that there was a lack of emphasis on people's social histories and preferences when their care was planned. Some relatives also told us that not enough person-centred stimulating activities took place. The provider had systems in place to ensure that the quality of the service was monitored, however these were not always consistently applied to ensure that there was an improvement in the quality of dementia care. Following the receipt of our inspection report, the provider sent us an Action Plan which explained how they would address the non-compliance within an agreed timescale.

At this inspection we found that the service had made improvements. The relatives of people with dementia told us they felt consulted and involved in care planning, and they had been asked to provide information about people's life histories and interests. One relative told us, "It's good here, it's really nice. All of the staff are very approachable and helpful. They come and talk with me and update me with what they are doing." Another relative said, "There are meetings and I can give my views at any time. They look after [my relative] beautifully, right down to making sure they get their favourite pudding."

We saw that staff had received training about how to meet the social needs of people with dementia and new therapeutic and recreational equipment had been provided. Records showed that an additional person was being recruited in order to expand upon the existing activities programme.

We saw that the service had addressed required actions within it's own dementia care audits. Records showed that actions had been taken to identify ways of improving the quality of care for people with dementia, such as workshops with specialist practitioners, observations by the manager and staff meetings.