Garth House is a ‘care home’. People in care homes receive accommodation and nursing or 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. Garth House accommodates 42 people in one building.

At the time of our unannounced inspection on 21 January 2019 there were 29 older people living at the home, some of whom were living with dementia.

There was a registered manager in place. 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 registered manager was not present during our inspection as they were away from the service for a short absence. An interim manager had been brought in to oversee the service in the meantime.

At our inspection in December 2017, the service received a rating of Requires Improvement. This was because we found shortfalls within the environment, activities and records for people. We found at this inspection improvements had been made. However, we have made further recommendations to the registered provider which we will follow up at our next inspection.

People had opportunities to take part in activities, however we found further work was needed to ensure people in their rooms were not at risk of social isolation. We also found one person whose care plan was not being followed. We have issued a recommendation to the registered provider in both of these areas.

Although we found improvements to the environment and décor since our last inspection, further work was needed to help ensure that people lived in an environment that was fully fit for purpose. We have issued a recommendation to the registered provider in this respect.

People’s rights under the Mental Capacity Act 2005 were respected. Staff understood the importance of gaining people’s consent to their care.

Staff said they received good support from their colleagues. Staff had established effective links with health and social care professionals to ensure people received the care they needed. The registered manager had notified CQC of significant events.

People who lived at the home, their relatives and other stakeholders had opportunities to give their views. Important areas of the service were audited regularly and action plans were developed when areas for improvement were identified.

People were supported by sufficient numbers of appropriately skilled staff to meet their needs and keep them safe. Staff understood their responsibilities in safeguarding people from abuse and knew how to report any concerns they had.

Risks to people’s safety were identified and action taken to keep people as safe as possible. Accidents and incidents were reviewed and measures implemented to reduce the risk of them happening again.

People lived in a home which was clean and hygienic. People received their medicines safely and as prescribed. Appropriate equipment was available to suit people’s needs and this was regularly checked for its safety.

People’s needs had been assessed before they moved into the service to ensure staff could provide the support they required. Staff had the training and support they needed to carry out their roles effectively. Where people’s needs changed, staff responded in a proactive way to meet those needs. End of life care for people reflected their choices.

People could make choices about the food they ate. People were supported to maintain good health and to obtain treatment when they needed it.

Staff were kind and caring towards people and there were positive relationships observed. Staff treated people with respect and maintained their dignity. People were supported to make choices about their care and to maintain rela

Garth House is owned and operated by Caring Homes. It provides accommodation and nursing care for up to 42 older people, who may also be living with dementia. We carried out an unannounced inspection on 11 December 2017 and on the day of our inspection 26 people were living in the home.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. There was a new manager in post who assisted us with our inspection. The registered manager assisted us with our inspection.

We last carried out a comprehensive inspection of this service on 2 August 2017 when we rated the service as Requires Improvement overall. We also took some enforcement action against the registered provider as we had found continued breaches of regulations from the previous inspection. Following the inspection in August 2017 the registered provider submitted an action plan to us telling us how they planned to address our concerns. We carried out this inspection to see if the registered provider had taken action in line with their action plan. As such we checked to see if there were sufficient staff, people were being treated with respect and dignity, the requirements of the Mental Capacity Act 2005 were being met, risks to people were being managed and quality assurance processes were in place. We found overall the service people received had improved, however further work was required to ensure sustainability of those improvements.

Staffing levels at Garth House were sufficient; however we spoke with the manager about reviewing deployment of staff during peak times to help ensure people received the support they required promptly. For example, at lunch time. Although we found the environment was generally clean and hygienic, work was required to help ensure the home was of a good standard in terms of maintenance and decoration. The clinical room where medicines were stored was found not to be suitable for purpose.

The registered provider was aware of their statutory requirements to notify us any safeguarding concerns or serious injury. Records for people were not always reflective of the care people needed, however the manager told us this was a piece of ongoing work and we had no concerns that people had not received the care they required.

Risks to people were identified and managed safely. Although people received the medicines they required, we found improvements were needed with regard to medicines records. Some people did not have appropriate guidelines in place to support the administration of occasional medicines, such as pain relief. Staff understanding of the Mental Capacity Act had improved and assessments of people’s capacity had been completed.

The management support team had recognised that care had previously been provided in a task based way and had taken effective steps to enable staff to deliver a more personalised approach to care. Care plans were being updated and reviewed to ensure they accurately reflected the support people required. Group activities were enjoyed by those who participated. However opportunities were missed to deliver meaningful activities to people on a daily basis, particularly those who spent the majority of their time in their room.

Staff were caring and attentive towards people and we observed respectful, dignified interactions between staff and people. People were enabled to be independent when they could and make their own decisions. Before people moved into Garth House their needs were assessed to help ensure staff could provide appropriate care.

The new manager was working closely with other professionals to ensure people’s health care needs were being met. People were given a choice of fo

Garth House is registered to provide nursing care and support for up to 42 older people whose primary needs are nursing or who may be living with dementia. The home is set in its own grounds and located in a residential area of Dorking. There were 27 people living in the home on the day of inspection.

The service did not have 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 and associated Regulations about how the service is run.

The inspection was unannounced and took place on 2 August 2017.

When the service was last inspected on 14 and 31 March 2017 we highlighted areas which required improvement. During this inspection we saw limited improvement to people’s care however we also identified that some areas had not improved.

The lack of good leadership after the departure of the registered manager had an impact across all of the five key areas we looked at. It affected the safety of the home as staffing levels had not always been maintained at a safe level; how effective the home was at meeting people’s needs; how caring and responsive staff were; and how well the home was led. We have identified five breaches in the regulations. This is the same number as our last inspection, with four being repeat breaches, showing that a lack of leadership was failing the people who lived here. You can see what action we have asked the provider to take at the back of the full version of this report.

When risk of harm had been identified people were not always supported to be kept safe. People’s nursing needs were not always safely monitored and staff did not respond safely to changes in people’s health needs, particularly when they lost weight. For some people we found that call bells and drinks were out of reach which put them at risk.

People were not always supported by enough staff. Staffing levels had consistently not been met over the previous four-week period prior to the inspection. Staff had to be very task orientated and did not have time to ensure people were safe. We had to intervene on two occasions to ensure people received safe care. Staff recruitment processes were safe. Appropriate checks, such as a criminal records check, were carried out to help ensure only suitable staff worked in the home.

People were not supported in line with the principles of The Mental Capacity Act 2005. Staff were not always clear about consent and how it should be obtained from people. Appropriate applications had been made under the Deprivation of Liberty Safeguards (DoLS).

People were not always treated with dignity and respect. We observed times when staff supported people in an undignified way and spoke about their healthcare needs which could be overheard.

Since the last inspection there had been further quality assurance systems put in place to monitor the service provision. Despite this the audits still failed to highlight the shortfalls at the service some of which had been highlighted in previous CQC reports.

Since the last inspection unsafe equipment had been taken away and replaced. Staff had a good knowledge of people’s mobility and were seen to support people safely in this regard.

People were supported by staff who understood the signs of abuse and their responsibilities to keep people safe. Safeguarding concerns had been appropriately reported. Since the last inspection on 14 and 31 March 2017 the provider had referred incidents and accidents to the local authority for further investigation under their safeguarding procedures.

The analysis of accidents and incidents was managed effectively. Measures were in place in order to minimise risk to people or to reduce their reoccurrence. People’s care and treatment would not be interrupted in an emergency as there we

Garth House is a Nursing Home registered to provide nursing care and support for up to 42 people whose primary needs are nursing, elderly or living with dementia. The home is set in its own grounds and located in a residential area of Dorking. There were 33 people living in the home on the first day of our inspection and 31 people living there on the second day of our inspection.

The service did not have 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 and associated Regulations about how the service is run. A regional manager and clinical peripatetic manager were present on both days of the inspection. There was also a peripatetic manager present on the second day of the inspection.

When risk of harm had been identified there was lack of specific guidance for staff to follow in order to keep people safe. Risk assessments were either out of date or provided conflicting information in order to care for people safely. This was an area that had improved between the two days of the inspection but further work was needed to address this.

People that required equipment to help them move were not always safe. On the first day of the inspection hoists and wheelchairs were not in good working order and placed people at risk. New equipment had been provided by the second day of the inspection to address this.

There were not always enough staff provided to meet people’s needs. People sometimes had to wait for extended periods of time for assistance. Call bells were not being answered promptly. Communal areas of the home were unattended because staff were busy elsewhere. By the second day of the inspection staffing levels had improved and people were waiting less however not all staff were aware of people’s needs or how to support them. Staff recruitment processes were safe. Appropriate checks, such as a criminal records check, were carried out to help ensure only suitable staff worked in the home.

People were not always safeguarded from abuse. The provider had failed to refer incidents and accidents to the local authority for further investigation under their safeguarding procedures. Action had been taken to address this by the managers of the home between the two days of the inspection. Staff had been provided with updated training in this area and were aware of the whistle blowing policy in place. They knew who to contact should they have concerns about people’s care.

The analysis of accidents and incidents was not always managed effectively. Measures were not always in place in order to minimise risk to people or to reduce their reoccurrence. Improvements had been made between the two days of the inspection but further work was needed to ensure these steps were taken to keep people safe.

There were ineffective quality assurance systems to monitor the service provision. The lack of regular auditing of risk assessments, care plans and staffing meant that any issues identified had not been acted upon in order to provide safe care and to meet peoples assessed needs. This had been recognised by the managers in the home who were

If an emergency occurred people’s care would not be interrupted as there were procedures in place to manage this.

As a result of feedback given on the first day of the inspection the provider had begun to make improvements on how risk to people was managed. Some care plans had been reviewed with revised guidance for staff to follow in meeting people’s needs. However not all care plans had been reviewed.

Staff did not always receive appropriate supervision. Nurses had received clinical supervision after the first day of the inspection. Some agency staff were not always aware of how the home was run or what was expected of them.

The Mental Capa

Garth House is a care home which provides care and nursing care for up to forty-two older people, some of who may have dementia. At the time of our inspection 39 people were living at 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.

The inspection took place on 29 September 2016 and was unannounced.

There was positive feedback about the home and caring nature of staff from people who live here. People were safe at Garth House.

Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team, CQC or the police.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. Accidents and incidents were recorded and acted upon. In the event of an emergency people would be protected because there were clear procedures in place to evacuate the building.

There were sufficient staff on duty to meet the dependency needs and preferences of the people that lived there. It was however felt that at weekends the staffing of the home was not always effective.

The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home.

People received their medicines when they needed them. Staff managed the medicines in a safe way and were trained in the safe administration of medicines.

Staff were knowledgeable and received a comprehensive induction and on-going training, tailored to the needs of the people they supported. Staff could access on line training during their working day or at any time that they are not on duty. They also received regular supervision.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people's ability to make decisions for themselves had been completed.

Throughout the inspection day staff were heard to ask people for their permission before they provided care or support.

Where people's liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person's rights were protected.

People had enough to eat and drink, and specialist diets either through medical requirements e.g. diabetic meals, or personal choices vegetarian meals were provided.

People were supported to maintain good health as they had access to healthcare professionals when they needed them. When people's health deteriorated staff responded quickly to help and made sure they received appropriate care and treatment.

The staff were kind and caring and treated people with dignity and respect. Good interactions were seen throughout the day of our inspection, such as staff talking with people and showing interest in what people were doing and comforting them in an appropriate manner.

People could have visitors from family and friends whenever they wanted and there were positive relationships between people and staff which allowed people to express their views.

Care plans were detailed and provided good guidance for staff to reference if they needed to know what support was required. People received the care and support that reflected their needs and preferences.

People told us they enjoyed the activities on offer. There was a range of activities that met their social needs however these were offered from Monday to Friday. One person told us that over the weekend activities were not always available.

People knew how to make a complaint if they needed to. Complaints had been effectively re

Garth House provides accommodation and nursing care for up to 42 older people, some of whom were living with dementia. At the time of our visit 36 people lived here.

The home is a converted domestic detached property and care is provided over three floors. Stairs and a passenger lift provide access to all floors. Communal space consists of lounges, a dining room, a conservatory and large mature very well maintained landscaped gardens to the side and rear of the property.

The inspection took place on 6 August 2015 and was unannounced. At our previous inspection in August 2013 we had identified one concern at the home. This was regarding the safety and suitability of the premises. These concerns had been addressed by the registered manager when we checked during this visit.

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.

Overall there was positive feedback about the home and caring nature of staff from people and their relatives. One person said, “Staff are extremely good; without their care I would be lost; They’d do anything for me.” However there were three areas of concern we identified – deployment of staff; Where best interest decisions had been made for people this had not followed the requirements of the Mental Capacity Act; and lack of meaningful activities that interested people.

The lack of staff to meet the identified needs of individuals had an impact across three of the key questions that we looked at. It impacted on the safety of people as staff were not always available to give support that had been identified; It affected the caring ability of the staff as they had little time to spend with people to talk with them, as they were very task focused to try to do everything at once; It reduced the responsiveness of the service so that activities were not based around individual’s interests.

When people did not have the capacity to understand or consent to a decision the provider had not followed the requirements of the Mental Capacity Act 2005. Where decisions had been made for people an appropriate assessment and review had not been completed. People told us that staff did ask their permission before they provided care.

Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards to ensure the person’s rights were protected.

People did not always have access to activities that met their needs. The home had a dedicated activities person, however much of their time was taken up with assisting with care needs due to lack of care staff. Activities were not always based around the individual interests of people, and activities for people living with the experience of dementia, such as one to one time with staff did not happen on the day of our inspection.

The staff were generally kind and caring and treated people with dignity and respect; However we did identify some actions by staff that could have been more caring, such as interactions when supporting people to eat, and when giving medicines.

People were not always safe at Garth House. Risks to people’s health and safety had been identified and guidelines to minimise the risk were in place.

Staff had a good knowledge of their responsibilities for keeping people safe from abuse. The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home. Staff received training to support the individual needs of people in a safe way.

People received their medicines when they needed them. Staff managed the medicines in a safe way and were trained in the safe administration of medicines.

People told us that they enjoyed the food and had enough to eat and drink. They were involved in the food choices on the menu and had a choice of what to eat. People on specialists diets, either medical or due to religious or cultural beliefs had these needs met.

People were supported to maintain good health and they had access to relevant healthcare professionals when they needed them.

Care plans gave a good level of detail for staff to reference if they needed to know what support a person required. People and relatives told us that they had been included in the development of the care plans, and in reviews.

People knew how to make a complaint. Feedback from people was that the registered manager and staff would do their best to put things right if they ever needed to complain.

People and staff had the opportunity to be involved in how the home was managed. Meetings were held with them, and surveys were sent out asking for feedback about how well the service was doing. The registered manager used the feedback to improve the service.

Quality assurance checks were regularly undertaken by the provider and the registered manager to monitor health and safety, medicines, and quality of care provided and to identify areas for improvement. This was to ensure people received a good quality service.

We identified two breaches of the regulations. You can see what action we told the provider to take at the back of the full version of this report.

People told us the staff were nice and they liked the food, got enough to eat and could choose what they wanted to eat.

People also told us they liked the gardens and their room was warm enough in winter and cool enough in summer and that their taps worked properly.

One person told us their bed was broken and we saw the covering manager arrange to repair it.

We found that although the building was in reasonable decorative condition, hygienic and clean, the provider had not always taken steps to provide care in a home that was adequately maintained in all areas.

We saw that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found that documentation pertaining to the people who used the service and staff were held securely, confidentially and properly managed.