We inspected Temple Grove Care Home [formerly known as Manor Gardens] on 29 and 30 November 2016 and the inspection was unannounced. Temple Grove Care Home provides accommodation and support for up to 64 people who require nursing or personal care. The service was split in to four units: one unit was for complex care and the other three units were general nursing. There were 55 people living at the service at the time of our inspection. People living at the service had a range of diagnoses form general frailty, multiple sclerosis, tumours, cancer, end of life care and spinal injury. Accommodation for people is arranged on two units on the ground floor and two units on the first floor. Each floor had its own dining room and people could choose where to have their meals. Each unit had a nurse in overall charge and a nurse’s station in the middle of the unit; however, the service was homely, welcoming and people were free to decorate their rooms as they chose.

The service 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. We previously inspected Temple Grove Care Home on 24 and 25 September 2015 and found improvements needed to be made, relating to environmental risk assessments, safe recruitment procedures, the lack of a registered manager in post and quality auditing systems not being established. At this inspection we found that improvements had been made in all of these areas.

People were safe. The home's equipment was well maintained. Staff understood the importance of people's safety and knew how to report any concerns they may have. Risks to people's health, safety and wellbeing had been assessed and plans were in place which instructed staff how to minimise any identified risks to keep people safe from harm or injury.

There were sufficient staff employed to meet people’s needs and staff knew people well and had built up good relationships with people as they tend to work consistently on the same unit within the service. The registered provider had effective recruitment and selection procedures in place.

The registered manager and staff had received training and were knowledgeable about of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments were needed for people who may not be able to consent to, for example, bed rails.

Staff treated people as individuals with dignity and respect. Staff were knowledgeable about people's likes, dislikes, preferences and care needs. Staff were skilled to approach people in different ways to suit the person and communicate in a calm, friendly manner which people responded to positively.

Peoples' health was monitored and they were referred to health services in an appropriate and timely manner. Any recommendations made by health care professionals were acted upon and incorporated into peoples' care plans. People with complex care needs were given excellent care and the service is used as a first point of call for local health commissioners.

People who wanted to be occupied had busy lifestyles which reflected their lifestyle choices and likes and dislikes. Complaints were recorded appropriately and were used as a tool for improving services.

There was an open, transparent culture and good communication within the staff team. Staff spoke highly of the registered manager and their leadership style. There was an atmosphere of support and inclusion among the staff at Temple Grove. The whole management team had positive relationships with the care staff across and there was a genuine sense of collaboration and teamwork.

The registered manager took an active role within the home and led by example. There were clear line

This inspection was carried out by two inspectors and a specialist nurse advisor. Some people at the home had complex needs and were not all able to tell us about their experiences. In order to get a better understanding we observed care practices, looked at records and spoke with staff. During the inspection we spoke with the manager, eight members of staff, five people who used the service and five visiting relatives.

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

Is the service safe?

There were up to date risk assessments in place for people that used the service which explained the risks and how these were to be minimised. This meant that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

There was an insufficient number of qualified, skilled and experienced staff to meet people’s assessed needs. Although the service used a dependency tool for calculating staffing levels this was not being used effectively. One staff member told us "I feel that staffing levels are not based on dependency". A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We found that the recruitment records of two members of staff held concerning information about their previous employment. Whilst this did not mean they were unsuitable for employment, there was no risk assessment in place to show how they were to be managed in their employment. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We identified a number of gaps in recording which meant that staff records and other records relevant to the management of the services were not accurate and fit for purpose. This meant that people were not fully protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, one person who used the service was admitted under a DoLS order. Proper policies and procedures were in place. Relevant staff understood when an application should be made, and how to submit one.

Is the service effective?

Most people who used the service, and the visiting relatives we spoke with told us that they were happy with the care provided and felt that needs were being met. One person told us "I feel safe and well treated”. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and how to meet them.

The staff we spoke with expressed concerns about the support they received from management. One member of staff said "A bit more support from management would help". Another told us "Morale is the lowest it's ever been". We found that staff were not supported in relation to their responsibilities, to enable them to deliver care and treatment safely and to an appropriate standard. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

We observed that people appeared comfortable in the home and familiar with the staff that worked there. We saw that staff members spoke directly with people and supported them at an appropriate pace. People were supported by kind and attentive staff. For example we saw one staff member assisting two people who used the service. The staff member was caring and communicated well. They explained what they were doing and gave occasional reassuring touches. We saw that people were treated as individuals and given choices where possible. People told us they were happy about life in the home. One person commented “I am well looked after, the staff are kind and helpful”.

Is the service responsive?

People’s needs were continually assessed. Records confirmed people’s preferences, interests, goals and needs had been recorded and support had been provided in accordance with people’s wishes. People's needs were reviewed regularly to make sure that any changes were identified and appropriate support provided. We saw evidence that external professional advice was sought where concerns in health and well being were identified.

Is the service well-led?

People who used the service and their representatives were given opportunities to express their views about their care and treatment. We found that there was not an effective system for gaining the views of staff and acting on them. Staff told us that they felt their views had not been listened to by the manager of the service. It was of concern that the low morale and high stress levels expressed to us by staff had not been picked up by the provider. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

After the inspection we spoke with the provider who took immediate action to support staff in discussing their views and concerns. As a result of this, action was taken to provide alternative management arrangements.

We found on this occasion that suitable practices were in place for the safe management of medicines.

This inspection was carried to follow up on areas of non-compliance identified at our last inspection in January 2014. We found that improvements had been made.

At this inspection we met with the provider, manager, deputy manager and four people who used the service. People told us that they felt they were looked after. One person said "I find it very good here". Another commented "I am well looked after. Staff try very hard".

We found that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Care plans and risk assessments were up to date and reviewed regularly. There was evidence that care and support was provided in line with care plans. The service monitored the health and welfare of people who used the service and took appropriate action when changes in needs were identified.

The records we looked at were up to date and maintained to an appropriate standard. We saw that monitoring charts were filled in correctly. Care plans reflected people's most recent assessed needs. Records were stored appropriately and were accessible to those that needed to see them.

Prior to this inspection we had received some concerning information which related to recruitment practices in the service. We carried out a responsive inspection to look at how the service carried out pre-employment checks. We found that appropriate checks were undertaken before staff began work and that there were effective recruitment and selection processes in place

During the inspection we spoke with the manager, six care staff and nine people that used the service. Most people told us they liked living at the home. Comments included "I'm looked after well. Staff are pleasant", "There's nothing that isn't nice" and "Staff are helpful".

We found that people were given opportunities to express their views about the care and support they received. People had the opportunity to express their preferences although it was not always clear what action had been taken to accommodate them.

We found a number of concerns which related to the care and welfare of people who used the service. Care plans did not always have up to date information and did not have all the information required in order to meet people's assessed needs. We found that people were placed at risk because care plans were not always followed. There was an inconsistent approach to the management of people's complex needs which placed people at risk of harm.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines safely. We found that controlled drugs were not managed appropriately. We also identified issues in relation to the timely receipt of medication and the monitoring and use of "as required" medicines.

Care staff told us that they felt supported and that they had opportunities to discuss any issues. We found that mandatory training was provided although not all staff had received specialist training in supporting people with complex health needs and end of life care. The provider told us that this had been arranged.

People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained. We identified concerns about the management of records in the service. Some care plans were found to be confusing and did not hold all the information needed to support people who used the service. We also found that a number of records that related to the management of the service were inaccurate or not available at the time of our inspection.

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.

There were sixty one people in the service at the time of our inspection.

People received a good quality of support. People were encouraged to express their views and to live their lives as they wished. We saw that people had access to full and varied social lives.

People we spoke with told us they were "very happy here” and “couldn't fault any of it, the staff especially”. People told us they felt involved in their care plans. Other people told us their families were involved on their behalf.

Staff worked in person centred ways. For example, being courteous and knocking on doors before entering people's rooms. Staff were knowledgable about people’s care needs and treated people respectfully. They were relaxed, supportive and patient. We saw that staff explained and reassured people when necessary.

The service had a good quality assurance system in place. Complaints and concerns were listened to and acted upon immediately. People told us that they felt safe and were able to talk to staff if they had any concerns.

We saw that care records reflected each person’s needs and preferences. One person said "the staff always ask me when they want to know something about me".

When we carried out an unannounced comprehensive inspection at Manor Gardens on the 27 and 28 January 2015. Breaches of Regulation were found and two Warning Notices were issued in respect of ensuring people’s safety and the management of medicines. We undertook this inspection on 24 and 25 September and 2 October 2015 to follow up on whether the required actions had been taken to address the previous breaches identified. At this comprehensive inspection we found Manor Gardens had taken appropriate action to address all breaches to Regulations identified at the last inspection. The service was found to be fully compliant with all required Regulations and establishing ongoing improvements for the benefit of people using the service. Details of previous breaches will be found under each of the five question headings.

Manor Gardens provides accommodation and nursing care for up to 64 people living with a range of complex care needs, including end of life care, diabetes, stroke, heart conditions and Parkinson’s disease. Many of the people needed support with their personal care, eating and drinking and mobility. Some people were also living with dementia. The service also provided respite care to give people and their supporters a break from caring roles.

You can read a summary of our findings from both inspections below.

Comprehensive Inspection of 27 and 28 January

2015.

There were 43 people living at the service on the days of our inspection.

We identified a number of areas of practice which potentially placed people at risk of receiving inappropriate care and support. Risks had not been identified through auditing or quality assurance.

Management systems for medicines were not consistently safe. For example some medicines were signed for as being administered and taken when they had not been taken.

The service was not following best practice guidelines on moving people in a safe way. For example we observed staff moving a person in an unsafe way in front of a more senior member of staff.

Where people had undergone assessments for bed rails or lap belts, these had not been reviewed to reduce potential risk. There was a lack of best interests’ decisions about the use of devices that included bed rails and lap straps, corresponding risk assessments had not been reviewed. There was no consideration if these matters should be considered under Deprivation of Liberties Safeguards (DoLS).

The service had not identified environmental hazards and had not taken action to reduce risk this included the security of the home.

Some people felt the service was not caring and we found it did not always promote people’s dignity. For example some staff did not explain the care they were giving and net underwear was shared.

Some people’s records were not completed accurately, so their needs could not be fully assessed and evaluated. People’s social needs were not assessed and documented, so there was no evaluation to assess if people’s individual needs were met in this area.

Some people told us the service was not well led, particularly commenting on changes in managers. Although audits of service provision had taken place they did not consistently identify areas for action or detail action plans for improvements. The service’s aims and objectives had not been updated to reflect changes in the service.

People commented on the difficulties caused by high staff turnover and communication issues relating to some staff. We saw a few areas where attention was needed to cleanliness, for example bed rail covers.

Comprehensive Inspection of 24 and 25 September and 2 October

2015.

There were 39 people living at the service on the days of our inspection.

After our inspection in January, the provider wrote to us to say what they would do to ensure all regulations would be met. We found the Warning Notices had been met and significant improvements had been made. These will need to be embedded into everyday practice to ensure they are consistently met. However we found no breach of regulations at this inspection.

The service had appointed a new manager in August 2015 who had applied for registration with the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

We found people’s safety was not always fully promoted. Environmental risk assessments did not ensure all risks were identified, monitored and responded to effectively. Therefore risks to people may not be minimised. Recruitment practice did not ensure all checks were undertaken in a robust way to ensure suitable people were employed.

The new management team needed further time to establish and embed best practice. The quality monitoring systems needed further development to ensure they were used to identify shortfalls and demonstrate effective responses. This included the establishment of care documentation that was accurate up to date and completed in a consistent way.

People were looked after by staff who knew and understood them well. Staff treated people with kindness and compassion and supported them to maintain their independence. They showed respect and maintained people’s dignity. Care plans were personalised and reflected people’s individual needs and preferences.

All feedback received from people and their representatives through the inspection process was very positive about the care, the approach of the staff and atmosphere in the home. One relative said “Everything is absolutely fine here. When my mum rings her bell staff come she is happy staff are friendly food is good and mum is very content.

All feedback from visiting professionals was very positive. They appreciated the improvements made to the service and endeavour to drive further improvement with a commitment to learning.

Staff had a good understanding of safeguarding procedures and knew what actions to take if they believed people were at risk of abuse. Staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They had a clear understanding of DoLS and what may constitute a deprivation of liberty and followed correct procedures to protect people’s rights.

Staff were provided with a full induction and training programme which supported them to meet the needs of people. Staffing arrangements ensured staff worked in such numbers, with the appropriate skills that people’s needs could be met in a timely and safe fashion. The registered nurses attended additional training to update and ensure their nursing competency.

People were given information on how to make a complaint and said they were comfortable to raise a concern or complaint if need be. A complaints procedure was readily available for people to use.

People were complementary about the food and the choices available. Mealtimes were unrushed and people were assisted according to their need. Staff monitored people’s nutritional needs and responded to them.

People were supported to take part in a range of activities maintain their own friendships and relationships. Staff related to people as individuals and took an interest in what was important to them.

The management of the service responded positively to feedback received from safeguarding investigations and information identified through the inspection process. Feedback was regularly sought from people, relatives and staff. People were encouraged to share their views on a daily basis and satisfaction surveys had been completed an action plan had been written to respond to information received.