This inspection visit was unannounced and took place on 15 March 2017. At our last inspection visit on 28 January 2015 we asked the provider to make improvements to medicines people received on an as required basis. The provider sent us a plan explaining the actions they would take to make improvements. At this inspection, we found improvements had been made. The service was registered to provide accommodation for up to 49 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 46 people were using 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.

On the day of the inspection the manager was not present; however the visit was supported by the deputy manager who provided all the necessary information. We saw improvements had been made in relation to the recording of ‘as required’ medicines and prescribed medicines were managed safely and administered in line with people’s prescriptions.

People were supported to make choices and when required, assessments had been completed to ensure decisions were made in people’s best interest. The home had enough staff to support people’s needs. Any staff who had been employed had received a range of checks to ensure they were suitable to work in the home. The manager and provider had established a range of audits to support the improvements within the home. We saw feedback was sought from people, relatives and staff and any areas raised had been considered and responded to.

We found staff had established positive relationships with people. Staff showed respect for people’s choices. They ensured they maintained people’s privacy and dignity at all times. People were able to choose the meals they wished to eat and alternatives were provided. Referrals had been made to health care professionals and any guidance provided had been followed.

Staff obtained information to ensure the care reflected people’s needs and preferences. People were encouraged and supported with activities they wished to engage in. there was a strong link with the local community and people felt able to use these services within the community. Any complaints had been addressed and resolved in a timely manner.

Staff felt supported by the manager and there was a clear process in place to cascade information about the service and the needs of people. Staff had received training and felt confident to share their knowledge to improve their role.

We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check appropriate action had been taken.

We inspected Tall Oaks Care Home on 28 January 2015. The provider is registered to provide accommodation, personal and nursing care for up to 49 older people. This includes care for people with physical needs and dementia care needs. At the time of our inspection, 47 people used 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 and associated Regulations about how the service is run.

At our last inspection of the service on 2 July 2014, we were concerned about how people were respected and involved in their care, how people were safeguarded from abuse, staffing levels, how the provider assessed and monitored the quality of the service provider and how record keeping concerns. We asked the provider to send us an action plan outlining how they would make improvements. During this inspection, we found that improvements had been made in all the areas we were concerned about.

People were protected from the risks of abuse because staff understood what constituted abuse and took action when people were at risk of abuse. There were appropriate numbers of staff employed to meet people’s needs. People’s care needs was planned and reviewed regularly to meet their needs. Their care records reflected the care they received.

People were cared for by staff that had the knowledge and skills required to care and support them. Staff had regular training, and were supported to have additional training which was specific to their roles and responsibilities.

Legal requirements of the Mental Capacity Act (MCA) 2005 were followed when people were unable to make certain decisions about their care. This meant that people’s liberties not restricted inappropriately. The Mental Capacity Act 2005 and the DoLS set out the requirements that ensure where appropriate; decisions are made in people’s best interest.

People told us they liked the food and were supported to eat and drink. We saw that a variety of food and drink were offered during meals and throughout the day. Staff supported people to attend healthcare appointments and liaised with their GP and other healthcare professionals as required to meet people’s needs.

People were cared for and supported by staff who knew them. People told us the staff were kind and treated them with dignity and respect. Peoples care was tailored to meet their individual needs. Care plans detailed how people wished to be cared for and supported and people were involved in the care planning process and in decisions about their care and treatment.

People who used the service, their relatives and the staff were very complimentary about the registered manager of the service. The registered manager had a hands-on management style and people told us that they were accessible and approachable. They were encouraged and supported to provide feedback on the service. The provider had effective systems in place to review the quality of the service provided.

We visited Tall Oaks Care Home on a planned unannounced inspection, which meant that the service did not know we were coming. The home provided care to people with physical needs and dementia care needs. On the inspection, 49 people used the service. The home did not have a registered manager in place.

Some people who used the service told us they were happy with the care they received and others expressed concerns about their care at the home. Most of the relatives of people we spoke with were pleased with the care provided at the home and told us that kind and friendly staff cared for people who lived at the home. Staff members we spoke with expressed concerns about the staffing levels and how it prevented them from providing safe care at the home.

Is the service safe?

The required health and safety checks and servicing were completed and the provider had a designated maintenance person to carry out maintenance jobs around the house. We saw that the provider had a maintenance log where staff logged in maintenance concerns and we noted that most of the concerns recorded in the book were acted on.

Prior to the inspection, we received information of concern relating to staffing levels at the home. During the inspection, people who used the service, their relatives and staff told us that the service was always short of staff. Some of the people who used the service were at risk of falling and a number of people who used the service had memory problems and were sometimes unsure of their whereabouts. We saw that people were left for long periods of time unattended or without structured activities. The service had insufficient numbers of staff on the day of the inspection.

One person who used the service was very concerned about their safety because other people who used the service kept coming into their bedroom. The person told us that they had been threatened by another person who used the service and could not do anything because of their physical disabilities. The acting manager told us that they were taking action to ensure that the person concerned felt safe, but we did not see records of risk assessments or actions taken to ensure that the person’s safety was ensured.

The local authority had recently carried out safeguarding investigations relating to some people who used the service. They notified us that they had concerns that records were not completed as advised by professionals and people who used the service were at potential risk of neglect. During this inspection, we noted that people’s care records were not always up to date and did not always reflect the care that had to be provided.

We have asked the provider to provide tell us what they are going to do to meet the requirements of the law in relation to ensuring the care and welfare of people who used the service.

Is the service responsive?

Some of the people who used the service told us that they had to wait for long periods if they needed assistance because the call bells were not always responded to in a timely manner. Staff we spoke with confirmed to us that there was a technical fault with the call bell system. This had been reported. The acting manager told us that the problem was reported and initial checks took place but no technical faults were identified. Further checks were planned. The service did not have a system in place for monitoring the response times to call bells.

We saw records that other healthcare professionals visited the home regularly. We saw that people were referred to other professionals when there were concerns about their health or welfare.

One person we spoke with told us that staff did not always give them their painkillers when they were in pain and requested them. We saw that people’s medication administration records (MAR) did to provide clear guidance to staff on how ‘as required’ medication (PRN) should be administered. We also noted there was conflicting information within people’s care records about how their PRN medication should be administered. This meant people were at risk of being left in pain because their medicines were not managed appropriately.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the welfare and safety of people who used the service.

Is the service caring?

Most of the people who used the service who spoke with us told us that the staff were very good and they liked staying at the home. One person who used the service said, “I’ve never seen ill things going on here”. Relatives of people told us that staff were kind and friendly.

We observed staff interaction with people who used the service and noted that the staff were friendly and treated people with compassion. All of the staff we spoke with told us that they did not have enough time to spend with people who used the service. One of the staff members we spoke with told us, “I think carers are good but they’ve got so much paperwork in place that they haven’t got enough time to spend with the residents and do personal care”.

We saw that sometimes, people’s dignity was not always maintained. For example, when we arrived at the home in the morning, we noticed that one person was lying in bed with the door wide open and their pyjamas and bed linen soiled.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring that the dignity and privacy of people who use the service.

Is the service effective?

People’s health and care needs were assessed with them and care plans were put in place but we saw that people’s care plans were not always implemented by the staff. For example, one person we spoke with told us that the required assistance with their personal hygiene and care needs but they were not receiving this on a regular basis. The person’s records did not show that they received the required support with their personal hygiene and care needs.

People’s mobility and other needs were taken into account in relation to signage and building adaptation, enabling people to move around freely and safely. We noted that people’s personal evacuation plans (PEEP) did not provide details of the level of support they required in case of an emergency.

We have asked the provider to tell us how they will ensure that people are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them.

Is the service well led?

All the staff we spoke with said that if they witnessed poor practice they would report their concerns to the manager or to the nurse in charge. Staff we spoke with did not demonstrate an awareness of how to raise safeguarding concerns or whistleblowing concerns with other authorities.

Some of the staff we spoke with told us that they did not always feel listened to or feel supported by management if they raised concerns. One staff member we spoke with said, “If we raise a point, it’ll just end up being a staff notice but no further action. We haven’t seen any action for concerns we’ve been raising”.

The service had a quality assurance system. The audits carried out did not systematically ensure that potential risks were identified and dealt with in a timely manner.

The provider had a complaints procedure and a complaints log in place. We did not see records of complaints or concerns raised with the provider. The service did not routinely keep a log of informal complaints and concerns raised by people who used the service.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring that they have effective systems designed to enable them to protect people who use the service against the risks of inappropriate or unsafe care.

During this inspection we met with the registered manager of the service and we spoke with five members of staff. We met three sets of visitors and we spoke with seven people who used the service.

Staff were helpful, polite and friendly and there was a pleasant homely atmosphere in the home. People we spoke with felt that their needs were met by staff who were responsive and caring but some people felt there could be more attention to detail, a visitor commented,"It's the little things that don't always get done."

The provider had developed the home to include the provision of a unit dedicated to meeting the needs of people with dementia. People's nursing and care needs were met well here but the provider may wish to review how they meet people's individual social and therapeutic needs. The manager explained that the provider would be introducing the "pearl programme" which is a programme run by the company in order to improve the quality of care and support delivered to people with dementia care needs.

People who used the service were protected from harm and their human rights were respected and upheld.

There was a skilled and competent staff team working at the home and staff felt supported by the manager.

The service was well-led and there was a robust quality monitoring system in place which ensured that people received safe quality care.

The registered manager Mr Shafi Ullah was no longer working at the home. There was a new manager in post who was in the process of applying to become the registered manager.

We found that people who used the service were happy with the care and support they received. They said, "The care is very good here" and "I have no concerns."

We saw that people were comfortable and that staff were attentive to individual needs. People's care needs had been met, people had been supported to take their meals and drinks, and there was detailed documentation to support this.

We identified that half of the total number of people now accommodated in the home had dementia and other related mental health needs. The layout of the home was not conducive to meeting everyone's needs and the manager explained that there were plans in place to re-organise the home in order to address this.

Staff had received training to meet the needs of people who used the service and the provider had plans in place to deliver more comprehensive training around dementia care. This will help staff to meet the more complex dementia care needs of some people.

The manager could demonstrate how changes had been implemented over the last few months in order to bring about improvements for people who used the service. Staff and the people who used the service felt supported by the manager and felt that the management style was open and inclusive.

We carried out this inspection in order to assess whether the service was compliant with outcome four. This outcome encompasses the care and welfare of people who use the service.

Due to concerns we found during our visit about the numbers of staff on duty we also looked at outcome thirteen.

During our visit we spoke with people who live in the home and a visitor. We also spoke with the acting manager, the regional manager and staff who work for the service.

People who live in the home were very complimentary about the care and support they receive there. They felt that their needs were met by the staff and that they were treated with dignity and respect.

The visitor we spoke with told us that their relative was safe and well cared for and said, “It is a good job we have places like this”.

People told us that they could raise any concerns they had and that these were “Usually dealt with pretty quickly”.

Staff who work for the service felt well supported and felt that they had the necessary skills to meet people's needs.

However staff on the second floor were very rushed and we observed that there was not enough staff on duty to guarantee that people would be kept safe. When we spoke with the managers of the service they had identified this as a concern and were planning to increase the staffing.

We spoke with six people who use the service and two groups of relatives. All were very complimentary about the care provided in the home. One person told us they are assisted to get up and go to bed at a time that suits them. They said that staff were very approachable and that the manager comes and has a ‘chat’ with them regularly. They went on to say that the food was excellent and said, “I always have an empty plate”

Relatives told us that they and their relative were involved with the plan of care. They felt this was positive as their views were listened to and acted on so ensuring the person’s health care needs were met.

We saw that several people were sat in the lounge area for long periods of time with little to do. Two people told us they were bored and would like more to do in the day. One person said they were unable to take part in activities due to the fact they had limited mobility.

We saw that the provision of activities was limited within the home so people using the service may not be kept as active and stimulated as needed.