We carried out this inspection on 27 and 28 July 2017. The first day of the inspection was unannounced. The second day was announced so that we could complete all of the checks remaining from the first day.

Tanglewood Care Home with Nursing can provide accommodation, nursing and personal care for 55 older people and younger adults. It can also provide care for people who live with dementia and/or who have a physical disability. There were 49 people living in the service at the time of our inspection nearly all of whom were older people. The accommodation was a modern two storey building. In the grounds of the main building there were four self-contained bungalows each of which could be occupied by one person.

The service was run by a company who was the registered provider. 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. In this report when we speak both about the company and the registered manager we refer to them as being, ‘the registered persons’.

Nurses and care staff knew how to respond to any concerns that might arise so that people were kept safe from abuse. People were helped to avoid preventable accidents and medicines were managed safely. There were enough care staff on duty. Most of the necessary background checks on new care staff had been completed in the right way.

Nurses and care staff had received training and guidance and they knew how to care for people in the right way. People enjoyed their meals and they were helped to eat and drink enough. Nurses and care staff had ensured that people received all of the healthcare they needed.

People were helped to make decisions for themselves. When people lacked mental capacity the registered persons had ensured that decisions were taken in people’s best interests. The Care Quality Commission is required by law to monitor how registered persons apply the Deprivation of Liberty Safeguards under the Mental Capacity Act 2005 and to report on what we find. These safeguards protect people when they are not able to make decisions for themselves and it is necessary to deprive them of their liberty in order to keep them safe. In relation to this, the registered persons had ensured that people only received lawful care.

Nurses and care staff were kind and people were treated with compassion and respect. People’s right to privacy was promoted and there were arrangements to help them to access independent lay advocacy services if necessary. Confidential information was kept private.

Although one part of a person’s nursing care had not been planned and recorded properly, in practice they had received all the nursing care they needed. Other people who lived in the service had also been provided with all of the assistance they needed and had agreed to receive. Nurses and care staff promoted positive outcomes for people who lived with dementia and people were supported to pursue their hobbies and interests. There were arrangements to quickly resolve complaints.

We carried out an unannounced comprehensive inspection on 20 August 2015. Three breaches of legal requirements were found and reported upon in an inspection report. These breaches are described below.

The report was the subject of a judicial review challenge in the High Court for which permission was granted by Mr Justice Kerr on 18 December 2015. In the light of the report of the subsequent inspection which took place on 16 February 2016 the provider Tanglewood (Lincolnshire) Limited and the Care Quality Commission have agreed that it is no longer necessary for the High Court to determine the judicial review.

The purpose of this inspection was to assess compliance as at 16 February 2016. As part of this inspection we reviewed the disputed breaches we had identified in August 2015.

At the last inspection on 20 August 2015 we found that the provider was not meeting the standards of care we expect in ensuring staff were adhering to guidance on the implementation of the Mental Capacity Act 2005. We also found care plans were not updated and people or their advocates were not involved in the planning of their care. We also found staff did not understand about all the medicines they were giving and that there was poor stock control and storage of medicines.

During this inspection on the 16 February 2016 we found no significant concerns in the areas we had identified in August 2015.

This report only covers our findings in relations to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Tanglewood Care Home with Nursing on our website at www.cqc.org.uk.

Summary

Tanglewood Care Home with Nursing provides care for older people who require nursing and personal care. It provides accommodation for up to 55 people. At the time of the inspection there were 53 people living at the home.

Although the manager was not yet registered on the day of our inspection her application was underway. She has now been registered with the Care Quality Commission. 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 our inspection we found the recently appointed manager had had a positive impact on the service. Staff interacted well with people and people were cared for safely. People told us that their needs were being met. Staff told us that they had sufficient time to meet people’s needs and to help them take part in social activities. The provider had systems in place to ensure they knew the needs of people living at the home and could adjust the staffing levels when required. Staff understood about the medicines they were giving and there was good stock control and storage of medicines. Care plans had been updated and people or their advocates were involved in the planning of their care and treatment. Each person had a personal emergency evacuation plan in place. Staff were correctly implementing the Mental Capacity Act 2005. People were involved in the planning of menus and given choices of food each day.

This report was the subject of a judicial review challenge in the High Court for which permission was granted by Mr Justice Kerr on 18 December 2015. In light of the recent report for the inspection on 16 February 2016 the provider Tanglewood (Lincolnshire) Limited and the Care Quality Commission have agreed that it is no longer necessary for the High Court to determine the judicial review.

We inspected Tanglewood Care Home with Nursing on 20 August 2015. This was an unannounced inspection. The service provides care and support for up to 55 people. When we undertook our inspection there were 45 people living at the home and five in self-contained bungalows within the grounds.

People living at the home were older people. Some people required more assistance either because of physical illnesses or because they were experiencing memory loss. The home also provides end of life care.

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.

We found breaches of the Health and Social Care Act 2008 (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, regarding medicines, how to implement the Mental Capacity Act 2005 and care plans.

We found that the deployment of staff meant that at times staff required more time to ensure the needs of people could be met.

Staff were unaware of the implications for administration for some medicines. Systems were not in place to ensure medicines were stored correctly and safe to use and storage was not stock controlled.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of our inspection there was no-one subject to an authorised restriction. However, the provider had submitted 23 applications to the local authority to clarify whether people should have their liberty restricted. Staff did not always act in accordance with the MCA 2005 as they were unsure of how to implement it correctly.

We found that people’s health care needs were assessed, and care planned through the use of a care plan. People or their advocates were not involved in the planning of their care and had not always agreed to the care provided. The information and guidance provided to staff in the care plans was clear, but not updated. This could result in people’s current needs not being met. Risk assessments were not in place for people in the event of a fire, which could put them at risk of harm.

People were treated with kindness, compassion and respect. The staff in the home took time to speak with the people they were supporting. We saw many positive interactions and people enjoyed talking to the staff in the home. The staff on duty knew the people they were supporting and the choices they had made about their care and their lives.

People had a choice of meals, snacks and drinks. And meals could be taken in dining rooms, sitting rooms or people’s own bedrooms. Staff encouraged people to eat their meals and gave assistance to those that required it.

Our inspection team on this occasion was made up of two inspectors who visited on 14 August 2014. We considered our evidence to help us answer 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, speaking with people who use the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve. Regular checks were undertaken to ensure the environment was safe.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, policies and procedures were in place. DoLS safeguard people who can not make decisions for themselves.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly. Therefore people were not put at unnecessary risk.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely.

People told us they could express their views at group meetings and meetings on a one to one basis.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, "When I need the staff they're there for me" and "If I need help they always help me and they're nice about it too."

People who used the service, their relatives, friends and other professionals involved with the service attended meetings throughout the year. Where shortfalls or concerns were raised these were addressed. People told us they felt their opinions were valued.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People told us they could speak with staff each day and share their concerns. They told us staff acted quickly. Relatives told us they could speak with staff about their family member's needs, when that person could not make decisions for themselves.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system. Records seen by us showed that identified shortfalls were addressed.. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

The complaints process was on display and records showed any concerns raised were replied too quickly. However, people we spoke with were not aware of the written process to make complaints known to the provider. They were not concerned as they told us they could approach all staff at all times.

We walked about the home and saw all areas were clean and all furniture and equipment was in a good state of repair. We found there were no unpleasant odours.

People and their families told us the home was always clean. One person’s relative said, “The standards of cleanliness are very good.” One person said, “It always smells nice.”

We conducted a Short Observational Framework for Inspection at lunchtime (SOFI) in the upstairs dining room. SOFI helps us to understand the experience of people who are unable to explain this for themselves. We observed staff assist people to the dining room. We saw people were given a choice of where to sit and some people sat in friendship groups.

We spoke with several relatives. One person’s relative told us, “The food is beautiful; I want to move in here.” Another person’s relative said, “The staff were very helpful with settling in. This is the best place for my mum at the moment.”

We saw there was a comments box and a suggestion box situated in the main reception area. This was accessible to people and their visitors. We saw a copy of the complaints procedure in people’s bedrooms. This was available in large print and in several languages to reflect the needs of the local community.

We asked people if they knew how to complain. One person told us, “They always ask if I’m happy. They ask for your feedback if you are unhappy.”

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

When we visited the home we spoke with five people who lived there. Everyone we spoke with told us they had been well looked after and were satisfied with the care they had received. One person told us, "I have no complaints, the care workers are lovely, they give you a nice kiss and cuddle. I'm quite happy."

Another person said, "They are very good, they treat you very well. I realise how lucky I am to be here. You can join in with the activities, you are not forced to do anything you don't want to do."

We also spoke with two relatives who were visiting the home. One family member told us, "Mum's only been here a week, but we are happy with things so far." Another relative told us, "We do get the chance to have our say, you can always talk to Matron if you have any concerns. One thing I will say is they do arrange lots of activities."

The service had introduced a new staffing role called a 'Lifestyle Assistant'. We spoke with this member of staff and they told us, "I provide extra one to one time with residents. I help new people to settle in, make contact with families that don't live near by, take people out shopping and accompany them to hospital and other appointments. I also provide pampering sessions such as nail manicures."

We saw staff provided care and support to people in a sensitive and caring manner. One person who was receiving end of life care looked comfortable and well cared for.

As part of this review we carried out a visit on 6 January 2012 and an additional visit on 5 March 2012.

The Care Quality Commission had received information from relatives and staff with concerns about people who had dementia walking into other people’s bedrooms and also concerns that people’s needs were not being fully met as staffing levels appeared to be insufficient.

Some people told us about their concerns in January, however the outcomes for people during our second visit had improved and people told us they were satisfied with the service they were receiving.

People told us they were being well looked after. One person who lived in the home told us, “The staff are so good, they are marvellous and would do anything for you.”

Another person said, “It’s very nice actually, I’m being well cared for, I have my own private room and the staff treat me with respect.”

We spoke with a relative who told us, “The care they give my Dad and us as relatives is fantastic. Anything we ask for we get.”

During the visit to the home on the 6 January 2012, three people living in the home told us they were unhappy that people who had dementia had gone into their bedrooms without being invited. In order to find a solution to this problem, the previous manager had installed safety gates on people’s bedroom doors. People had given consent for the gates to be fitted and risk assessments had been completed to prevent any risks to people.

During our visit on the 5 March 2012, people told us that action had been taken by the home to overcome the problem. One person told us that she felt safe as long as the safety gate was kept in place. They told us, “It’s not so much of a problem now, the manager is arranging for me to move to a more suitable bedroom.”

People told us they were happy with the care and support they received and they felt it was a safe place to live. One person told us “I have been living here for just under a year, it’s excellent. I lived locally and my family and friends visit frequently. I am definitely well cared for.” Other people said “I get the help I need. Staff know how I like to be treated”. “It’s quite nice here, staff know what to do, they’re very good, there is nothing I need or want, I am well cared for.” And, “Staff look after me, there is never a cross word.”