This inspection took place on 25 April 2018 and was unannounced.

At our last inspection in March 2017 we found that the provider was in breach of Regulations 12, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because not all staff had references taken up prior to employment, not all equipment was safe to use and governance systems had not identified the issues we found during the inspection. As a consequence the service was rated ‘Requires Improvement’. At this inspection we found that robust recruitment practices were in place, the environment and equipment were safe and quality audits had improved. As a result we have improved the service’s rating to ‘Good’.

Sweet Homes Limited t/a Carshalton Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to provide accommodation, nursing and personal care for up to 33 people. At the time of our inspection there were 14 people using the service.

The service had 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.

Sweet Homes Limited t/a Carshalton Nursing Home provides care to people over three floors of an adapted building on a residential road. The service is wheelchair accessible throughout. People had single occupancy bedrooms which did not have en suite facilities such as toilets or showers. There was a large bright dayroom on the ground floor which offered access to a large garden and was overseen by the nurses’ station.

People received safe care and support. Staff assessed people’s risks and implemented plans to reduce them. Staff were trained to identify and report any suspicions of abuse and improper treatment. People’s medicines were stored and administered safely. There were enough staff available to meet people’s needs safely. The home environment was clean and staff maintained a state of readiness to respond to an emergency.

People’s needs were assessed and met by trained and supervised staff. People were treated in line with the Mental Capacity Act 2005. Staff supported people to eat and drink well and ensured people had timely access to health and social care services.

Staff were kind and caring towards people. People and staff shared warm relationships that had been built up over time. Staff supported people to maintain contact with loved ones and made visitors to the care home feel welcome. People were treated with dignity and respect and were supported around their spiritual needs.

The service provided personalised care for people. People and their relatives participated in the development of care plans which detailed their preferences for care and support. Staff provided activities for people and supported people to maintain their independence. People and their relatives understood the provider’s complaints procedure. People approaching the end of their lives were treated compassionately.

The care home was well managed. Effective quality assurance processes were in place which resulted in shortfalls being identified and resolved quickly. The service worked with other agencies to benefit people and promoted links within the local community. The registered manager promoted an open culture and staff felt supported in their roles.

Carshalton Nursing Home can provide accommodation, nursing and personal care for up to 33 people. The service specialises in supporting older people living with dementia. At the time of our inspection there were 15 people residing at the home.

At our last comprehensive inspection of this service in January 2015 we rated the service ‘Requires Improvement’ overall and for the three key questions ‘Is the service safe’, ‘responsive’ and ‘well-led?’ This was because the provider had failed to operate effective fire safety procedures, ensure people living in the home had sufficient opportunities to engage in meaningful activities that reflected their social interests and have a Care Quality Commission (CQC) registered manager in post.

We asked the provider to make improvements and undertook a focused inspection in August 2015 to check they had followed their action plan and sufficiently improved to meet the regulations. At the time of that inspection we found the provider had taken the necessary steps to improve their fire safety arrangements and social activities programme.

The service now has a registered manager in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Following this inspection, which we carried out on 14 and 22 March 2017, we have rated the service 'requires Improvement’ again. This was because the provider could not demonstrate they met all the regulations and fundamental standards. Specifically, we found equipment such as a swing arm grab rail in a toilet and all the radiator covers in communal areas were not always properly maintained which could be unsafe to use for their intended purpose. The provider had also failed to operate safe staff recruitment procedures and ensure they obtained two professional and/or character references in respect of all new staff they employed. Furthermore, although the provider had governance systems in place to monitor and review the quality of service delivery, these were not always operated effectively. Consequently, the provider had failed to identify a number of issues we identified at this inspection in relation to the safe maintenance of equipment and the proper vetting of new staff.

These failings represent three breaches of the Health and Social Care (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The breaches and issues described above notwithstanding, people and their relatives told us they were satisfied with the care provided by the service. We saw staff looked after people in a way which was kind and caring. Staff had built caring and friendly relationships with people. Our discussions with people living in the home, their relatives and community health care professionals supported this.

There continued to be robust procedures in place to safeguard people from harm and abuse. Staff were familiar with how to recognise and report abuse. There were enough staff to keep people safe. Medicines were managed safely and people received them as prescribed.

People were supported to eat and drink sufficient amounts of nutritious food that met their dietary needs. They also received the support they needed to stay healthy and to access healthcare services. Improvements had been made to the interior design and décor of the services environment, although the registered manager agreed further work was required to make Carshalton Nursing Home a more comfortable place for people to live.

Staff continued to care and treat people with dignity and respect. They also ensured people’s privacy was maintained particularly when being supported with their personal care needs.

People received pers

We carried out an unannounced comprehensive inspection of this service on 20 January 2015 and two breaches of legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to adequately maintaining the premises to a suitable standard, specifically furniture in the main communal area and bedrooms, and having effective fire safety arrangements in place. We also made a recommendation about people who lived at the home having greater opportunities to participate in meaningful activities that reflected their social interests.

We undertook this focused inspection to check the provider had followed their plan and to confirm they now met legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Carshalton nursing home on our website at www.cqc.org.uk

We undertook this unannounced focused inspection of Carshalton nursing home on 12 August 2015. The home provides accommodation and nursing or personal care for up to 33 people. The service specialises in the nursing care and support of older people who may be living with dementia. At the time of our inspection there were 16 people living at the home.

The service is required to have a registered manager in post, but currently does not have one. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. Our records showed the homes acting manager, who was appointed in September 2014, has now submitted the appropriate registered manager application to the CQC.

During this inspection we found the provider had taken appropriate action to ensure furniture in the home was adequately maintained and robust fire safety arrangements were established and operated effectively. This helped ensure people using the service lived in a safe and comfortable environment.

We also saw staff encouraged people to participate in meaningful social activities that interested them. Our discussions with people using the service, staff and the acting manager supported this.

This inspection took place on 20 January 2015 and was unannounced. We last inspected the service on 10 July 2014 and found they were meeting the regulations we looked at.

Sweet Homes Limited, trading as Carshalton Nursing Home, provides personal care and permanent or respite accommodation for up to 33 people. The home specialises in the nursing care and support of older people living with dementia. Accommodation is arranged over three floors and there is a passenger lift to enable people to move freely between floors. All the bedrooms are single occupancy, but people can choose to share. None of the bedrooms have en-suite facilities. Communal space includes an open plan lounge/dining area on the ground floor.

There were 15 older people living at the home when we visited.

The service has not had a registered manager in post for over a year. 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.

The current acting manager, who had been in day-to-day charge of the home since September 2014, had not applied to the Care Quality Commission (CQC) to become the registered manager of the service. The CQC considers this to be an unnecessary delay and therefore regards the service to have breached their legal requirements.

We found a number of breaches of the Health and Social Care (Regulated Activities) Regulations 2010.

Although people told us Carshalton Nursing Home was a comfortable place to live, we found the home’s physical environment was not always adequately maintained. For example, we saw most of the wooden chairs in the dining area were wobbly, the kitchen floor was damaged in places, and wardrobes, dressers and curtains in some people’s bedrooms looked shabby and worn.

The service’s fire safety arrangements were not adequate. Although staff demonstrated a good understanding of their fire safety responsibilities and roles, and had received fire safety training, we found the service had not carried out regular fire evacuation drills and tests of fire safety equipment. This has put people using the service, staff and visitors at risk because the provider cannot be confident the homes fire alarm system will work or that people know exactly what to do in the event of fire. We have referred our concerns about the home’s fire safety arrangements to the London Fire and Emergency Planning Authority (LFEPA) who are the regulator responsible for fire safety.

You can see what action we told the provider to take at the back of the full version of the report.

We also found that people did not have enough opportunities to participate in meaningful social activities that reflected their interests. We made a recommendation about the opportunities people using the service have to participate in meaningful leisure and recreational activities that reflect their social interests.

People were safe living at the home. Staff knew how to protect people if they suspected they were at risk of abuse or harm. Risks to people’s health, safety and wellbeing had been assessed and staff knew how to minimise and manage these to keep people safe from avoidable harm or injury.

There were enough properly trained and supported staff working at the home to meet people’s needs. People told us, and we saw for ourselves, that staff had built up good working relationships with people using the service and were familiar with their individual needs and preferences.

People received their medicines as prescribed and staff knew how to manage medicines safely.

People told us they were happy living at Carshalton Nursing Home and staff who worked there were kind and caring. Our observations and discussions with relatives during our inspection supported this. For example, we saw staff treated people with dignity, respect and compassion.

Staff supported people to keep healthy and well through regular monitoring of their general health and wellbeing. Staff also ensured health and social care professionals were involved when people became unwell or required additional support from external health care services.

People had a choice of meals, snacks and drinks and staff supported people to stay hydrated and to eat well.

Each individual was involved in making decisions about their care and had personalised care plans that they had helped create. People had agreed to the level of support they needed and how they wished to be supported. Staff supported people to make choices. Where people's needs changed, the provider responded and reviewed the care provided.

When people were nearing the end of their life they received compassionate and supportive care.

People were encouraged to maintain relationships that were important to them. There were no restrictions on when people could visit the home and staff made visitors feel welcome.

There were effective systems in place to monitor the safety and quality of the service provided at the home. The provider regularly sought people’s views about how the care and support they received could be improved.

The registered manager understood when a Deprivation of Liberty Safeguards (DoLS) application should be made and how to submit one. This helped to ensure people were safeguarded as required by the legislation. DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

During our last inspection of the service on 4 June 2014, we identified essential standards of quality and safety were not being met in respect of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Following that inspection we asked the provider to take appropriate action to achieve compliance with these regulations. The provider sent us an action plan on 28 June 2014 setting out the steps they would take to achieve this. During this visit we checked these actions had been completed.

This visit was carried out by a single inspector who helped answer one of our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with the home’s deputy manager. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found at this visit the provider had taken appropriate steps to protect people using the service from the risk of abuse. They had done this by ensuring staff had received appropriate training and information to identify the possibility of abuse and to prevent abuse from happening.

A single inspector carried out this inspection. Below is a summary of what we found. The summary describes what three people who used the service and six members of staff told us, what we observed and the records we looked at during our inspection.

If you want to see the evidence supporting our summary please read the full report.

The focus of the inspection was to answer five key questions we always ask;

• Is the service safe?

• Is the service caring?

• Is the service responsive?

• Is the service effective?

• Is the service well led?

Is the service safe?

People told us they felt safe living at Carshalton Nursing Home. One person said “I’ve always felt safe here” and another person told us “The staff look after us and make sure nothing bad happens”.

However, although people told us they felt safe and we saw the services safeguarding procedures were robust; we found that not all staff had received up to date safeguarding adults training or fully understood their safeguarding prevention and reporting roles and responsibilities. This meant that people who used the service may have been placed at risk of abuse and neglect. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to protecting people from the risk of abuse and neglect.

The home had proper policies and procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one.

People were given medicines they had been prescribed when they needed them, and in a safe way. This was because the home had appropriate arrangements in place to manage medicines and staff understood how to handle medicines safely.

People were cared for in an environment that was safe, clean and hygienic.

People were protected from unsuitable staff because the provider had effective staff recruitment and selection processes in place.

Is the service caring?

People were treated with respect and dignity by staff. We saw staff were kind, attentive and patient when supporting people who lived at the home. One person told us "The staff are alright” and another said “The staff treat you well here”.

People who were able to talk with us were positive about the standard of care and support they received at the home. Comments we received included, “It’s not a bad place to live”, “It’s a very good home”, and “No complaints”.

People’s diverse needs, preferences and interests had been recorded in their personalised care plans, and support was provided by staff in accordance with people’s wishes.

People’s relatives were regularly invited to complete a customer satisfaction survey and it was clear from their written comments that they were happy the overall quality of the care and support provided by the home.

Is the service responsive?

Staff were familiar with people's health care needs and took appropriate action to refer people to the relevant health care professionals, as and when required.

People who used the service and their representatives were regularly involved in reviewing care plans, which staff updated accordingly to ensure they reflected people’s current needs.

In-house and community based social activities were available for people to participate in. However, we have asked the provider to note that we observed long periods of inactivity with people sleeping in their chairs and an over-reliance on the use of the television in the communal lounge/dining area. Furthermore, several staff told us they felt people’s social needs and community involvement would be better served if the home employed an activities coordinator and had age appropriate rummage boxes that could also be used to aid interaction and engagement. This meant that people may not have been sufficiently stimulated.

Is the service effective?

People’s health and personal care needs were assessed and clearly identified in their personalised care plans. This meant staff were provided with detailed guidance about how they should be meeting the needs and wishes of the people they supported.

People were provided with a choice of nutritionally well-balanced food and drink. People told us they were happy with the quality and choice of food and drink at the home. One person told us “The food is very good here”, and another person said “We can pick what we want to eat from the menu”.

People received care from suitably trained and supported staff who were clear about their nurse or support worker roles and responsibilities.

Is the service well-led?

The service has not had a registered manager in post for over six months. We have written to the provider and asked them to tell us what they are doing to meet the conditions of their registration in relation to having a suitably qualified and experienced manager in day-to-day charge of the home.

The provider had effective systems in place to regularly assess and monitor the quality of service that people received. The service also learned lessons from mistakes and events that adversely affected the health and wellbeing of people who used the service, such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

At our last inspection of this service we found that not all of the essential standards of quality and safety that we looked at were being met. Some of the records we asked for could not be located promptly. There were also some concerns regarding the records of how people’s finances were being managed on their behalf.

We asked the provider to send us an action plan to tell us what action they intended to take to meet these essential standards. The provider sent us an action plan stating that these concerns would all be addressed by the end of January 2014. At this inspection we saw that these issues had been addressed.

When we visited Carshalton Nursing Home there were 18 people using the service. The majority of them were sitting in the lounge together. We spoke with four people and three of them spoke positively about their experiences. They told us that the staff were kind and helped them. They said “they will ask you what you’re worried about and then will explain things to you”. However one person told us that they would like more to do. They said “we just sit here all day, I could do with more activities going on”.

At our last inspection in July 3013 we had raised concerns that the provider was not meeting the essential standards of quality and safety. The provider sent us an action plan to show how theses would be met. We carried out this inspection visit to check on the progress the provider had made in addressing our concerns and achieving compliance with the regulations of The Health and Social Care Act (2008).

We saw that some improvements had been made. However, we have raised serious concerns about the continued lack of cleanliness in the home. We also found exposed hot water pipes in one bathroom and a cupboard containing lift machinery unlocked. This could have been a risk to the people using the service.

We saw that there were some bedrooms without hot water and pedal bins in some bedrooms were broken. This meant that staff would not have been able to wash their hands effectively after delivering personal care to people.There was also evidence that waste products were not always disposed of appropriately. This may have put people using the service and staff at risk of exposure to a health care associated infection.

We undertook this inspection because we had been made aware of some concerns of a safeguarding nature. This is where one or more person's health, wellbeing or human rights may not have been properly protected and they may have suffered harm, abuse or neglect. We had previously referred these concerns to the local authority for them to investigate according to the ‘London Multi-Agency Policy and Procedures to Safeguard Adults from Abuse’. A social worker from their team accompanied us.

On the evening that we visited 19 people were living in Carshalton Nursing Home. Their feedback was generally very positive. They told us “staff here are very kind” and “we’re very well looked after”.

People told us that the home was comfortable but we found that they may be at risk because the environment was not safely maintained. The surroundings in which the care was being provided did not promote the wellbeing of the people using the service, their visitors and staff members. The home was uncomfortably hot, some areas were malodourous and chemicals which would be harmful to people’s health were left in unlocked cupboards.

We have also contacted the fire safety officer who will be undertaking their own inspection of the premises.

When we visited Carshalton Nursing Home there were 23 people living there. The home was an older style property, registered some time ago and the facilities would not meet the requirements of a newly registered home. Bedrooms were without en-suite facilities and some were smaller than would now be acceptable. There was only one lounge/dining area and this was in the form of a conservatory.

However, the people we spoke with all told us that they were very happy, they thought the staff were kind and they had no complaints. Their comments included “I like the people here, they’re all really nice”, and “they (staff) are so kind, they’re all nice, you just have to ask them something and they do it or go and get someone”.

People told us that they were free to spend their days as they pleased. Some chose to sit in the communal area while others preferred to stay in their rooms. Those who were mobile were free to walk around the home as they wished. On the day we visited it was very sunny and several people had chosen to sit in the garden. Some people found it more difficult to communicate with us because of their dementia but we saw that they showed signs of positive engagement with the staff and their surroundings. We saw that staff were constantly interacting with people talking to them as they carried out their work and stopping to encourage them to have a drink.

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 who has personal experience of using or caring for someone who uses this type of service.

We used the Short Observational Framework for Inspections (SOFI).SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Through the use of SOFI we were able to observe that people’s experience of the service was a positive one. We saw staff support being provided in a way that protected the dignity of people and that the service was meeting the nutritional needs of the people using the service.

Most people found it difficult to communicate with us, however comments included "I enjoy being here, very nice, clean, they spoil me, no complaints and everyone's helpful". Another person said " I like being here, they look after me well".

All of the people who live in this home, who are known as residents, have dementia. Some of them were able to speak with us and said " I like it here" and "I'm quite happy".

They also told us "the food's alright".

Those who were unable to communicate with us showed signs of positive engagement with the staff and their surroundings and all of them appeared to be comfortable and quite happy.

All of the people who currently live in this home appeared to be happy and looked well cared for. They all have some degree of dementia or mental health needs and their frailty means the majority of them are not able to contribute to the inspection processes. However, those who could speak with us agreed that staff are very kind and caring. All of the staff have worked in the home for some time and this provides good continuity of care and familiarity for people.

We saw that the food that was served looked appetising and residents said it was always very good. Although there is no formal process for them to choose what they have to eat, staff have a good understanding of their likes and preferences and lists are kept of any particular dislikes.

A limited range of activities, provided mainly by care staff, are organised although the current acting manager is hoping to improve this with the employment of an activities person.

At our inspection on the 12th October 2013, we had identified a number of areas where the registered provider had not been meeting the essential standards of quality and safety. We had particular concerns regarding the safety of the premises, the cleanliness of the premises and also the measures in place to protect people from acquiring a health care associated infection. We found that the registered provider had failed to comply with regulations 12 and 15 of the Health and Social Care Act (Regulated Activities) 2008. We took enforcement action by issuing warning notices in relation to these regulations.

On 12th November 2013 we undertook an inspection visit to check that the registered provider had taken appropriate steps to comply with the warning notices. A number of improvements had been made to make sure that the premises were safe for people living there, working there or visiting. The home was clean and smelt fresh. Improvements had also been made to the management of waste products. However, we found that the supply of hot water to the home was still intermittent and there was no hot water supply to the first and second floors.

Following this the registered provider submitted an action plan informing us that they had taken steps to comply with the warning notices. Therefore we undertook a further inspection visit on 10th December 2013 to assure ourselves of their compliance. At this time we found that there was an adequate supply of hot water to all parts of the home.

During our inspections we have raised additional concerns about the bathing and showering facilities in the home. There was only one shower available to be used. Baths did not have any adaptations to make them easy to use for people with limited mobility. This limited people's ability to make choices about how they were supported with their personal care needs.

We have also highlighted shortfalls in relation to the standard of record keeping within the service.