The inspection took place on the 11, 12, 18 and 19 October 2018 and was unannounced.

Tabley House was previously inspected in March 2018. During the inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to: person centred care (Regulation 9); safe care and treatment (Regulation 12); safeguarding service users from abuse and improper treatment (Regulation 13); fit and proper persons employed (Regulation 19); consent (Regulation 11); good governance (Regulation 17); and staffing (Regulation 18).

Following the last inspection, the registered provider was placed into special measures by CQC. The registered provider was asked to complete an action plan to confirm what they would do and by when to improve the five key questions we ask. They are: is the service safe, effective, caring, responsive and well led. At this inspection we found that the registered provider had taken action to address the breaches identified at the last inspection and made enough improvements to be taken out of special measures.

Tabley House is a ‘care home’ run by Cygnet Health Care Limited. The care home is registered to provide accommodation to adults with nursing and personal care needs.

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 care home accommodates up to 59 people across two units, each of which have separate adapted facilities. One of the units specialises in providing care for up to 12 people living with dementia. At the time of the inspection 35 people lived in the care home.

The care home had a registered manager. 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 present throughout the four days of our inspection and was supported by their regional operations director and deputy manager. The management team were helpful and transparent throughout the inspection process and demonstrated a commitment to ensuring the continuous improvement of the service.

There was a warm and caring environment in the care home. We observed that staff were responsive to the needs of people living in the care home and that people were treated with dignity and respect.

Information on people's assessed needs and the support they required and received from staff had been recorded on an electronic records management system. This included risk assessments and other supporting documentation. Additional records had been established to enable staff to record the delivery of care contemporaneously. For example, when recording fluid and nutritional intake or when a person had been assisted to reposition. Care plans had been fully reviewed since our last inspection and the registered manager was in the process of meeting with people living at the care home and their representatives where necessary to confirm that people had been involved and were in agreement with the information recorded.

People were supported to attend healthcare appointments and staff liaised with people's GPs and other healthcare professionals as necessary to maintain people's health or support them at the end of life. We observed that a GP visited the care home on a regular basis to ensure the healthcare needs of people were monitored and reviewed.

Policies and procedures had been developed to ensure staff were aware of their roles and responsibilities for ordering, storing and administering medication. The registered manager was in the process of reviewing staff competencies and transferring to a local pharmacist to impro

We carried out an inspection of Tabley House on 22 and 26 March 2018. The inspection was unannounced. Tabley House is registered to provide accommodation for up to 59 adults with nursing and personal care needs. At the time of the inspection 49 people lived at the home.

Tabley House 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 home 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.

On the first day of our inspection, the registered manager was on annual leave, so the deputy manager assisted us with the inspection. On day two of the inspection, the registered manager had returned to work and participated fully in the inspection.

We looked at the care records belonging to six people. We found their needs and risks were not always properly assessed or managed. There was not always adequate information on how to meet people’s needs and to provide their care in the way they preferred. Some of the risk management strategies in place were inadequate and did not provide staff with sufficient guidance on how to manage people’s risks and keep them safe.

People’s capacity was not assessed in accordance with Mental Capacity Act 2005. There was no evidence of any best interest meetings and some of the care practices at the home were restrictive and institutionalised. For example, some people had bed rails in place, their bed heightened so they could not get in them and one person was placed in a recliner chair during the day to prevent them from getting up unsupervised. These types of decision under the MCA are considered restrictive practices, as they restrict people’s liberty or freedom of movement. Despite this the MCA had not been followed to ensure these practices were in the person’s best interests and legally consented to.

Medicines were not safely managed. Stock levels of people’s boxed medications were incorrect and medication could not be accounted for. There was no robust system in place to record the administration of people’s thickening medication or to check the correct amount of thickener had been added to people’s drink to prevent a choking or aspiration incident. We saw that one person's thickener was used for other people in the home who had not been prescribed it. Staff lacked sufficient guidance on the application of prescribed creams and other topical medications.

During our visit, the majority of feedback from the people and relatives we spoke with about the food on offer was positive. When we checked some people’s care records however we saw that their nutritional needs were not always met in a safe way. This was because some people’s special dietary requirements were not always catered for and some people received an unsuitable or insufficient diet for their needs. Catering staff lacked sufficient information about people’s special dietary requirements and lacked an understanding of the importance to cater for these needs. Referrals to the dietician in support of people’s needs had not always been made to ensure people were protected from the risk of malnutrition.

Staff were not always recruited in a robust way and staffing levels were insufficient to meet people’s needs. As a result people experienced falls and incidents due to a lack of adequate supervision. This was because some people who required close monitoring and supervision often fell when staff were not present to supervise them appropriately. In addition records showed that people did not always receive the care

This inspection was unannounced and took place on the 18 August 2015.

The service was previously inspected in May 2013 when it was found to be meeting all the regulatory requirements which were inspected at that time.

Tabley House provides accommodation and nursing, personal and intermediate care for up to 59 older people, some of whom are living with dementia. The service is provided by Cygnet Health Care Limited.

All 51 rooms have en-suite facilities. The majority of rooms are for single occupancy, however a small number of shared rooms are available. On the day of our inspection the service was accommodating 49 people with different levels of need.

At the time of the inspection there was a registered manager at Tabley House. 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 manager was present during the day of our inspection and engaged positively in the inspection process. The manager was observed to be friendly and approachable and operated an open door policy to people using the service, staff and visitors.

People living at Tabley House were observed to be comfortable and relaxed in their home environment and in the presence of staff. People spoken with were generally complimentary about the care provided at Tabley House.

For example, comments received from people using the service included: “I feel very safe here”; “I’m very well looked after and everybody is kept an eye on”; “There is a good level of staffing”; “This place does a good meal and the service is good” and “Staff are absolutely fabulous and very caring’’.

Likewise, feedback from relatives included: “We’re very satisfied with the care provided”; “People are very well cared for at Tabley House. We have been happy with the choice we made” and “I have never heard a bad word about this place in Knutsford”.

We found interactions between staff and people were positive, responsive to need and caring. We also observed people’s choices were respected and that staff communicated and engaged with people in a courteous manner. Staff were also seen to be attentive to the individual needs of the people living at Tabley House and people’s preferred routines.

People using the service had access to a range of individualised and group activities and a choice of wholesome and nutritious meals. Records showed that people also had access to GPs, chiropodists and other health care professionals (subject to individual need).

Systems had been developed by the provider to assess the needs and dependency of people using the service; to obtain feedback on the standard of care provided and to respond to safeguarding concerns and complaints.

We have made a recommendation about staff induction, training and supervision to ensure staff are inducted and trained in accordance with Skills for Care and receive regular supervision.

We have also made a recommendation to develop the dementia care unit to ensure the environment is more suitable to meet the needs of people living with dementia.

On our unannounced inspection on 1 May 2013 we spoke to the registered manager, three members of staff, four people living at the home and two relatives.

We spoke to one relative who said; "Staff meet her needs, we would not be here otherwise." Another relative said; “She can choose whatever clothes she wants, and there is a great choice of meals.”

We looked at four care plans for people living at the home. We saw that care plans were detailed and well ordered.

We saw that staff were very patient with people who took a long time to eat. One staff member told us “It is important to me that if I am helping someone, I do so from start to finish.”

We asked about staff appraisals and were told that these were structured to meet organisational and individual needs as well as promoting high standards of care within the home.

We were shown a number of risk assessments and audits of various areas within the care home including; building maintenance, infection control, people’s weight, equipment, medications, training and staff surveys.

During our visit we spoke with people who use the service, relatives and a healthcare professional.

People who use the service told us that they were able to make choices in their daily lives. This included what time they went to bed, choice of meals and where they wished to spend their leisure time. They also told us that staff treated them with respect.

The relatives told us that during their visits to the home they had seen staff treat people with respect and maintain their dignity. One person told us that they were made aware of changes to their family member’s plans of care. They said a member of staff usually told them about any changes.

The relatives and healthcare professional told us that people living in the home were cared for by staff who respected them. The relatives we spoke with also told us that they knew who to speak to if they had any worries or concerns about the care their family member was receiving.

The people who use the service told us they ‘‘feel safe living in Tabley House’’ Another person told us that they could no longer live at home because ‘‘they kept having falls’’. They said that although ‘‘living in Tabley House is not living in your own home they felt safe having staff around to help them’’.

People who use the service told us that staff were kind and caring. They told us they felt safe having staff around to care for them.

The relatives told us staff made them feel welcome when they visited the home. They told us they saw staff supporting the people who use the service in a safe and caring manner.

They told us they were asked for their views about the service and that they had completed questionnaires about the quality of the service offered by Tabley House.

The relatives spoken with told us they would speak with the manager or staff if they had any worries or concerns. They also told us that any worries or concerns they had were listened to and acted upon.