This inspection was carried out on the 18 August 2017 and was unannounced. Tadworth Grove Care Home provides residential, nursing and respite care for older people who are physically frail. It is registered to accommodate up to 45 people. At the time of our inspection 29 people were living at the service.

There was a registered manager in post that supported us on the day of the inspection. 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.

At the previous inspection in July 2016 we identified breaches in relation to care and treatment, governance and the deployment of staff. On this inspection we found that these had been addressed.

Care and treatment was not always provided with the appropriate consent from people and staff did always not work within the principles of the MCA and DoLS. People did say that staff asked them for consent before providing care.

People said that they felt safe. There were systems in place to protect people from the risk of abuse. There were appropriate recruitment practices in place.

There were sufficient staff deployed to meet the needs of people. People told us that there were enough staff.

Staff understood the risks to people and steps were taken to reduce the risks. Incidents and accidents were dealt with appropriately. There were plans in place to protect people in the event of an emergency.

Medicines were properly accounted for and dispensed safely. People’s MAR charts included appropriate information about people.

Staff were suitably trained competent in relation to their role however additional training was being organised to ensure that staff were up to date with the most appropriate guidance. Staff received appropriate supervision in relation to their role including clinical support.

People told us that they liked the food at the service and said they had enough to eat and drink. Appropriate assessments of people’s nutritional and hydration needs were undertaken and people had access to professionals to maintain their health.

People told us that staff were kind and caring towards them. We observed that staff people with respect and dignity. Family and friends were welcomed at the service.

Care was delivered to people in a personalised way and pre-admission assessments were detailed before people moved in. Information was shared with staff to ensure that the were aware of people’s ongoing needs.

There were sufficient activities for people and people said they enjoyed the activities on offer.

Complaints were investigated thoroughly and people said that they were satisfied with the way complaints were dealt with.

People and staff were asked for their feedback and improvements were made as a result.

People and staff felt the service was managed well. Staff said they felt supported in their role and they felt valued by the management team.

There were sufficient systems and processes in place to identify improvements in the service records were up to date and accurate.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events.

We identified one breach of the Health and Social Care Act 2008. You can see what action we have taken at the end of this report.

This unannounced inspection was carried out on 7 July 2016. Tadworth Grove Residential and Nursing Home provides residential and nursing care. The service is currently registered to accommodate up to 71 people however due to the recent closure of their dementia unit this is due to decrease. On the day of our inspection 30 people lived in the service.

There was no registered manager on the day of the inspection. 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 were assisted during the inspection by the interim manager and the service recovery team.

On the 29 January 2016 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service was rated as 'Inadequate'. We carried out this inspection to establish whether the requirements were being met. On this inspection sufficient improvements had been made to meet the Regulations and therefore the service is no longer in ‘Special measures.’ We found on this inspection that whilst some improvements had been made the provider was still in breach of regulations around care planning, staffing and quality assurance.

There were not always enough staff deployed around the service to ensure that people’s needs were being met.

People’s rights were not always met under the Mental Capacity Act 2005 (MCA). Assessments had not always been completed specific to the decision that needed to be made. DoLS applications had been submitted to the local authority but these were not always supported by the appropriate mental capacity assessments.

People were not always receiving care from staff who had received appropriate training or supervisions. Appraisals for staff had not been undertaken.

People were not always involved in the planning of their care although this was being addressed at the time of the inspection. People did not always have access to meaningful and person centred activities.

However we did find that people were treated with dignity and respect and staff were caring. Staff were attentive to people and anticipated their needs.

There were not effective systems in place to assess and monitor the quality of the service. Audits and surveys had been undertaken with people but had not always been used to improve the quality of care for people.

Incidents and accidents were recorded however there was not always evidence of any learning from these in order to reduce the risk of falls and incidents in the service.

Risk assessment guidance for people was detailed and being followed by staff. Staff had knowledge of safeguarding adults procedures and what to do in the event of abuse occurring. Appropriate checks were undertaken on staff before they started work. In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

There were clear policies in place to guide staff should they have any concerns. Medicines were stored appropriately and audits of all medicines took place. Medicines Administrations Records (MARs) charts for people were signed for appropriately and all medicine was administered, stored and disposed of safely by staff who were trained to do so.

People said that they enjoyed the food at the service. People at risk of dehydration and malnutrition had their needs met and people were supported to remain healthy.

There was a complaints procedure and complaints were recorded appropriately with information around how there were responded to.

People’s records were kept securely. Services that provide health and social care to people are required to inform the Care Qua

This unannounced inspection was carried out on 29 January 2016. Tadworth Grove Residential and Nursing Home provides residential care for people living with dementia in Pine unit and nursing care in Willow unit. It is registered to accommodate up to 71 people. On the day of our inspection 48 people lived at the service. The accommodation is arranged over three floors that included people with nursing needs on Willow and people who lived with dementia on Pine unit.

There was a registered manager in place who was present on the day of the inspection. 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 were also assisted by the regional manager.

The last inspection of this service was on the 15 July 2015 where we found breaches around the safety of people who lived at the service. People’s call bells were not being answered quickly and we were able to access the building without staff being aware that we were there. We found on this inspection that there were still concerns around people’s safety. We found on the inspection on the 15 July 2015 that people were not always treated with dignity and respect. This was still a concern on this inspection.

There were not always enough staff deployed in the service to consistently meet people’s needs. People were left on their own for long periods of time without the support of staff. There were times where there were less than the required staff needed to care for people safely. Risk assessments for people were not always followed by staff. Incidents and accidents were not always recorded and there was not always evidence of any learning from that had occurred to reduce the risk of falls and incidents in the service.

Medicines were not always being safely stored and there was a risk that people did not receive their medicines when they needed them. Medicines Administration Records (MARs) for people were signed for appropriately and all medicines were disposed of safely by staff.

Staff had good knowledge of safeguarding adults procedures and what to do if they suspected any type of abuse. There were clear policies in place to guide staff should they have any concerns.

Before staff started work appropriate recruitment checks had been undertaken.

Staff at the service were not always caring and did not always treat people with dignity. There were times where people were ignored for periods of time throughout the day and people’s dignity was not always maintained. We did see times when staff were caring and considerate to people. People were not always consulted about the care they wanted.

People’s rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not always been completed specific to the decision that needed to be made around people’s capacity. DoLS applications had been submitted to the local authority but we were unable to see what this related to.

People were not always receiving care from staff who had received appropriate training. There was a risk that people were receiving care from staff who were not up to date with their clinical training, including wound care and end of life care.

Staff competencies were not always assessed with staff as they did not always have regular supervision with their manager. However some staff did have regular supervisions and found these useful.

The environment did not always meet the needs of the people, particularly those who were living with dementia

We carried out an unannounced comprehensive inspection on the 14 July 2014. After that inspection we received concerns in relation to safe care and treatment and the dignity and respect of people. As a result we undertook a focused inspection on the 15 July 2015 to look into those concerns. Breaches of legal requirements were found.

This report covers our findings in relation to this. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Collingwood Grange Care Centre on our website at www.cqc.org.uk.

There was a registered manager at the service. 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.

People’s call bells were not being responded to in a timely way. We found that at times people were waiting a considerable time before staff responded to people’s call bells. We read from a staff meeting in April 2015 that staff had been reminded to answer calls within a reasonable time.

We were able to access the service without a member of staff being aware due to the code to the door being given to visitors.

People’s dignity was not always maintained. Where one person was receiving personal care staff had not ensured that the bathroom door was kept closed.

People were not being given the option of when they wanted to get up. People were being woken by staff early in the morning to provide personal care.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

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

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection that took place on the 14th July 2014. At our last inspection in February 2014 we found the service had met the requirements of the regulations.

Tadworth Grove Residential and Nursing Home provides residential and nursing care for a maximum of 71 people, some of whom are living with dementia. They also provide a convalescence, respite and palliative care service. Tadworth Grove is made up of two units, Pine Lodge and Willow House. At the time of our visit there were 50 people living at the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We identified an issue at the home that could affect people’s human rights and safety. People had their freedom restricted due to the use of keypads on doors to stop them going outside without staff support. While the home had completed the necessary paperwork for the people that needed this, they had not taken into account the impact it had on other people’s freedom.

Other areas that required improvement were around the placement of call bell ropes which could make them hard for people to reach in an emergency. The dim lighting in some main corridors could also cause difficulty for people with poor vision, or mobility difficulties.

Activities were on offer during the week but not at the weekend. Not everyone was interested in the activities that were on offer. One person told us, “More entertainment is needed, particularly for those who remain in their rooms.” The registered manager was responding to people’s feedback and was looking into options for providing activities for people at the weekends.

Staff received on-going training to give them the skills to meet people’s individual needs. We noted that some staff were behind on their training. The registered manager had already identified the issue and a plan was in place to get them up to date with their training.

People were positive about the service. When asked what the service did well people gave us examples such as, “Carers here are very nice, very kind.” A relative told us, “My family member’s quality of life is far superior here than they could have at home.”

When asked if the service could improve we had a mixed response. Some people were very happy with the service, while others thought improvements were needed. One person said, “There are times when you wait ages for tea, or if I want to go to the toilet.” People felt there needed to be more staff. The registered manager was aware of the issue, which was down to staff sickness and action was being taken to address this. During our visit we did not see any instances where people’s care needs had not been met due to numbers of staff.

People were complimentary about the standard of food provided by the service. People received a nutritionally balanced choice of food, and on the day of our visit we observed that lunch was relaxed and unhurried.

Care staff were kind to people. The staff knew who people were as individuals and their care needs. These care needs were consistently met.

The registered manager had a good understanding of the issues the home was facing; primarily ensuring staff sickness was effectively covered so people received consistent care. They had a number of plans in place that they were working on with the provider to improve the service.

When we asked people what they thought about the standard of care provided by the service, generally the response was positive. Comments such as, “Good” or, “Excellent” were used, others felt that the service, “Was improving, but there was still some work to do”. The comments about a need for improvement matched with what we found.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We visited Tadworth Grove Residential and Nursing Home to look at the care and welfare of people who used the service. This was a follow up visit to see if the service had made improvements after our visit in October 2013. We spoke with seven people who lived there, and three relatives. We also spoke with 5 staff, which included the manager.

We saw that the manager had reviewed and monitored the levels of staff to ensure people’s needs were met. We were told eight new care staff and a nurse had been employed since our previous visit in October.

People told us they felt there had been an improvement since our last visit, but there were still issues every now and then due to staff sickness. This meant that agency staff had to be used. On the day of our visit there was only one agency worker in use.

We saw that there was a plan in place to further increase the permanent staffing levels by transferring staff from a nearby Bupa home that was due to close. This would further reduce the homes use of agency staff.

We visited Tadworth Grove Residential and Nursing Home to look at the care and welfare of people who used the service.

This was a follow up visit to see if the service had made improvements after our visit in May 2013. We spoke with eight people who lived there, and three relatives. We also spoke with 11 staff, which included the acting manager and an area manager. We were assisted by an expert by experience who spent time with people who lived on the dementia unit. They observed activity provision and lunch time meal service.

We saw that since our last visit an activities worker had been added to the staff team where we had previously identified people had not received the activities that had been planned.

We saw that the acting manager had carried out an assessment of people’s needs. As a result the staffing levels had been increased. People told us they felt there still needed to be more staff. We saw examples where people had to wait for assistance due to staff not being available at that time.

Some of the staff we spoke with said that things had improved since our last visit. They felt more supported. However some staff had still not received regular supervision. We saw a plan was in place to address this.

We saw that staff training had improved. There was now a clear training plan in place and we saw that regular training had been provided.

We visited Tadworth Grove Residential and Nursing Home to look at the care and welfare of people who used the service. We spoke with seven people who lived there; four relatives; eight staff; and a visiting health care professional.

People who lived there told us they were happy with the service, and had no complaints. One person said “I am happy here, they support me with my independence.” Another said “I’m very happy here, it suits me down to the ground.”

The relatives we spoke with were mostly satisfied with the level of care being given, but they felt the service could improve.

People told us they had been able to express what was important to them in relation to their care.

We saw that people and relatives had been involved in the planning of care.

The provider had systems in place to ensure the safe management of medicines.

People told us they felt there needed to be more staff. We saw examples where a lack of suitably qualified staff had had an effect on the care being provided.

All the staff we spoke with told us they had not had a one to one meeting with their manager in at least six months.

The provider had systems in place to enable people to complain if they were unhappy with the service. People told us they knew how to complain, and that the manager would respond to what they said.

A new manager was in place and we saw they had already identified some areas that needed improvement.

We made an unannounced visit to Tadworth Grove Residential and Nursing Home. We looked at the care and welfare of people who used the service.

During our visit we spoke with six people who use the service and seven members of staff who were on duty (including the registered manager). We also spoke to four relatives and visitors.

We spent time observing people and how staff interacted and supported them. We looked around the location and saw communal areas, bathrooms and toilets (including en-suite) were clean and free from unpleasant odours.

People told us that the “Catering is very good.” Another person said that “If I am unhappy about they food, I just tell them and they change it for me.” A visitor told us that “what they have got here is very good; I wouldn’t put my relative in another home.” A relative told us that “Staff are very good with people.”

We saw staff talking and interacting with people in a friendly and respectful way.

In total we spoke to seventeen people. Nine of these told us that they felt that the service needed more staff. No one expressed a concern with the quality of care being provided. We were told that some people have to wait for staff to help them sometimes, others felt that they wanted more time for staff to “stop and chat” with them.

During this visit we observed staff talking to people with respect. We observed a person being offered the choice to join activities. This was carefully explained to them in a manner and tone, which they understood and responded to.

A mobile snack shop has been created which is being run by a person using the service. The person told us that they enjoyed doing this.

Some people who live in the nursing units said that they were happy with the care and support provided.

We observed that the home’s menu on display was now for the right day, unlike the menu on display at our previous inspection. We observed people being shown the meals so they could make a choice.

People that we spoke to said that they enjoyed their meals.

Improvements have been made in the residential unit (Pine Lodge) . Both units are now working as one home. People are able to access the home more freely. A new quiet lounge has been created. A person using the service told us how they like using this new room.

People told us variable things about the environment depending upon which part of the service they lived. People who live in the nursing unit described the environment as lovely and very homely.

Some people who live in the nursing unit also told us that they were happy with their care and how nice it was living at the service. A person’s carer said that staff always act promptly if their relative needs a doctor.

People who live in the residential dementia unit described the close confines of their environment. They described their life as boring and that there was nothing to do and that it was depressing to live in the unit.

A person using service said, “staff can be busy talking to each other and it does not feel as though they are paying attention to my safety".

People who live at the service consistently told us that they had to wait for staff when they called for assistance.

Some people told us that they are given choices about what time they wished to go to bed and rise.

A carer said that their relative is always dressed in their own clothes and appropriately in accordance with their preference and personality. People told us how the service helps them to maintain their personal appearance through access to regular hairdressing.

People living in the service said how lovely the food was and how it was the best thing about living at Tadworth Grove.

A church service is held every Sunday at the home, which several people said they really enjoyed. Other people spoke about visiting a local church.

Many people commented on how they enjoyed the music sessions held at the service on the day of our site visit.

People who use the service said that they liked living at Tadworth Grove. Their feedback included “its wonderful being here the care and attention they give to me” and “In the main I like the way I am treated”. Carers consistently said how welcomed they are made to feel when they visit, including what a friendly clean place it was. Carers generally spoke positively about their experiences with the service. A carer commented “Fairly happy with the overall care they seem to know what they are doing”. Most carers felt that their relatives were treated with dignity.

Staff said that there is generally a range of activities provided including craft sessions, musical entertainers, outings and games.

People who live at the service told us that they felt safe. People told us that most of the time they are hoisted by two people, they commented “Only occasionally am I hoisted by one staff most of the time it is with two girls” and “Staff seam to know what they are doing when they hoist me I have no worries about that”. Two staff said that they were aware of some poor manual handling practices occurring. It was made very clear to staff about the services policies regarding safe manual handling.

People and carers told us that they generally felt confident to raise any concerns they had with the manager and felt that this would be dealt with promptly.

Carers told us about their positive experiences with the staff. People who use the service told us how kind some staff are to them. A carer spoke about how some of the staff had the skills to be able to support their relative and interpret what their relative who has dementia is trying to communication.

None of the carers or people who use the service consulted said that they were aware if they had one point of contact or a named nurse or a key worker. A carer commented that “You do tend to see a lot of different staff especially at weekends it can be difficult to know who to find out information from”. A Staff member said “We do not have enough staff who know the residents”.

People who use the service consistently feedback that they felt they had to wait an inappropriate amount of time for their calls for assistance to be answered. People consistently said that they are asked to “hold on” when calling for assistance during the morning and late evening. Variable feedback was received from staff regarding staffing levels, with the majority saying that they felt that currently there was not sufficient staff on duty during the morning period to be able to meet peoples needs in a safe and timely manner. Several staff spoke about how anxious some people who live at the service become when having to wait to be assisted in the morning. Staff gave us examples of how their care practices are affected because they felt that there was not enough staff on duty at peak times. This included not being able to: provide choice, engage with people during personal care, rushing and cutting corners.