The inspection took place on 20 and 26 June 2018 and was unannounced. At our last inspection in April 2016 we awarded an overall rating of Good. At this inspection we found the provider had improved and was now rated Outstanding.

Tenlands 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 care home accommodates 39 people across two floors. At the time of the inspection 34 people were being supported in the home, 16 of which required nursing care.

At the time of the inspection the service 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.’

People received exceptional end of life care which was personal to them and their relatives. Relatives felt staff provided excellent care and support and demonstrated a high level of compassion and kindness to people at the end of their lives. Relatives were supported during the time up to and following the death of their loved ones.

People, relatives and staff we spoke with, told us the service was extremely well-led and managed. A vision to drive improvement was central to the service’s ethos and this was evidenced in the quality assurance system along with the actions of the registered manager and staff across the service.

Staff were particulary positive about the registered manager. They confirmed they felt supported and could raise concerns at any time. We observed the registered manager was visible in the service and found they interacted with people and their relatives in an open friendly manner. People and relatives felt the management of the home was extremely positive. The provider recognised the importance of staff input by regularly giving out achievement awards.

Staff were aware of safeguarding processes and knew how to raise their concerns. Where lessons could be learnt from safeguarding these were used to improve the quality of the service. Accidents and incidents were recorded in detail and monitored as part of the provider’s audit process.

Medicines were administered by trained staff who had their competencies to administer medicines checked regularly. Policies and procedures were in place for safe handling of medicines for staff to refer to for information and guidance.

The provider ensured appropriate health and safety checks were completed. We found up to date certificates were in place which reflected fire inspections and gas safety checks.

Recruitment processes were in place with necessary checks completed before staff commenced employment. The provider checked nurse’s personal identification numbers (PINs) to ensure they were up to date. Staff completed an induction into the home on commencement of their employment. Inductions included mandatory training and an introduction in the provider’s policies and procedures.

Staff levels were appropriate to the needs of people using the service. The provider used a dependency tool to ensure staff levels met the needs of the people living in Tenlands.

Risks to people and the environment were assessed and plans put in place to mitigate against these. The provider had a continuity plan in place for staff guidance in case of an emergency. Personal Emergency Evacuation Plans (PEEPS) in place for people which were updated regularly providing support and guidance for staff in case of an emergency.

The provider used best practice and current legislation when assessing people’s needs to develop effective outcomes.

Where people were at risk of poor nutrition, risk assessments were in place with associated care pl

The inspection took place on 3 and 4 February 2016. The inspection was unannounced.

Tenlands is a residential care home with nursing based in Ferryhill, County Durham. The home provides personal care and nursing care to older people and people with dementia. It is situated close to the town centre, close to local amenities and transport links. On the day of our inspection there were 36 people using the service.

The 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.

We spoke with a range of different team members; care, nursing, senior, kitchen staff, students and volunteers who told us they felt well supported and that the registered manager was caring, passionate and approachable. Throughout the day we saw that people who used the service and staff were comfortable, relaxed and had a positive rapport with the registered manager and with each other. The atmosphere was welcoming, homely and relaxed. We saw that staff interacted with each other and the people who used the service in a friendly, supportive, positive and respectful manner.

From looking at people’s detailed care plans we saw they were written in plain English and in a person centred way and they also included a ‘one page profile’ that made good use of pictures, personal history and described individuals care, treatment and support needs. These were regularly reviewed and updated by the care staff and the registered manager.

Individual care plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care records we viewed also showed us that people’s health was monitored and referrals were made to other health care professionals where necessary, for example: their GP, continence advisor or chiropodist.

Our observations during the inspection showed us that people who used the service were supported by sufficient numbers of staff to meet their individual needs and wishes.

When we looked at the staff training records they showed us staff were supported and able to maintain and develop their skills through training and unique development opportunities were accessible at this service. The staff we spoke with confirmed they attended a range of valuable learning opportunities. They told us they had regular supervisions and appraisals with the registered manager, where they had the opportunity to discuss their care practice and identify further mandatory and vocational training needs. We also viewed records that showed us there were robust recruitment processes in place.

We observed how the service administered medicines and how they did this safely. We looked at how records were kept and spoke with the registered manager about how senior staff were trained to administer medicine and we found that the medicine administering process was safe.

People were consistently actively encouraged to participate in numerous activities that were well thought out, organised, personalised and meaningful to them including, outings and regular entertainers. We saw staff spending their time positively engaging with people as a group and on a one to one basis in fun and meaningful activities. We saw evidence that people were not only being supported to go out and be active in their local community, but were also valued members of the local community.

We saw people were encouraged to eat and drink sufficient amounts to meet their needs. We observed people being offered a varied selection of drinks and fresh homemade snacks. The daily menu that we saw offered choices and it was not an issue if people wanted something different.

We saw a complaints and com

We found care and treatment was planned and delivered in a way which ensured people's safety and welfare. One person said “They (the staff) make sure I’m OK. I am well looked after. If you want anything the girls will get it for me.” Another person said “They are a happy bunch of carers, they really cheer me up. The terms of endearment they use put me at my ease .”

We found the provider had made suitable arrangements to manage and store peoples' medicines safely. One person told us “The nurse looks after my medicines and brings them on time to me every morning and night time. If there are any changes to my medicines the nurses explain it all to me.”

The home was clean and appropriate procedures were in place to prevent, detect and control the spread of infections. One person told us “They (the staff) are particular about cleanliness. They clean my room every day and the beds are always changed.”

We found that there were sufficient staff to meet peoples' needs.

There was an effective complaints procedure in place so people knew their views would be listened to. People using the service and visitors all said they would have no hesitation in speaking with the manager if they had any concerns. One person said “The manager listens. She is very good.”

We spoke with several people who used the service and four visitors. Everyone spoke positively about the service.

People told us they could choose how to spend their day and the staff treated them with dignity and respect. One visitor told us “If my mam wasn’t treated with respect she would let me know.” A service user said “They treat me with dignity."

People told us they had a keyworker who looked after them. One person said “My key worker makes sure my clothes are all alright. If I want or need anything they get if for me.” People also explained to us how their care and welfare needs were met. One person said “The staff got me a walking frame and always remind me to use it so I don’t fall.”

Everyone said they would have no hesitation in making a complaint if they were unhappy.

Other comments from people included:

“It’s a lovely home. Its kept well.”

“I’m well looked after here.”

“We do a lot of activities here.”

“It’s very friendly.” And

“The staff are very good.”

A visitor said “Everyone of them (staff) is lovely.”

We watched how the staff supported the people in their care. We saw people were treated with dignity and respect. For example, when staff talked with people they made sure that they got down to their eye level. When people were supported to walk, they were not rushed but supported to move at a pace comfortable for them. We heard staff address people respectfully, speaking quietly about private matters.