The Manor Care Home is a large modern, purpose-built care home with nursing located right on the River Thames. The service is situated in a quiet residential area. It is surrounded by extensive landscaped gardens. The service cares for older adults, many of whom have a dementia-type diagnosis. The service offers people permanent accommodation as well as respite stays. In the last year, the service has decided to link with local hospices, and increase palliative care provision. The service is registered to accommodate 65 service users. At the time of the inspection, there were 62 people at the service. The majority of the time, the service is full. There is often a waiting list of potential new admissions from surrounding hospitals, hospices and the community. This is the only location within the provider's current registration.

At the time of the inspection, there was 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. The registered manager had been in post continuously for some time, and knew the service well.

Our last inspection was on 11 and 12 March 2015 under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The overall rating was good, with all key questions rated good, except for 'Is the service effective?’ which was rated requires improvement. This was because there was a recommendation about people’s covert medicines administration. This was resolved at this inspection. This is our first inspection under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were safeguarded from abuse. There was a system in place to ensure that people’s safety was maintained. Staff and the registered manager were knowledgeable about abuse and how to deal with any allegations.

Planning for people’s admissions was viewed by the service as an important step in delivering good quality care. After admission, people’s care risks were thoroughly assessed, mitigated, documented and reviewed. Appropriate records were kept and readily available to demonstrate this to us at the inspection.

The safety of the premises, equipment and grounds were assessed and managed which protected people, staff and visitors from risk. We viewed maintenance records which demonstrated all required checks for health and safety were completed. We made a recommendation about the prevention and control of Legionella at the service. This was to ensure guidance from the Health and Safety Executive was always used.

There were plenty of staff deployed to support people. People and relatives we spoke with were satisfied that there was sufficient staff. Our observations showed that the staff were neither busy nor task-focussed and this led to them spending time with people promoting their independence and wellness. Staff worked well together in their respective teams, were flexible with the service’s requirements and were willing to assist their colleagues without hesitation.

Medicines were well-managed. We examined the handling of people’s medicines during our inspection and found that people were safe from harm. Registered nurses demonstrated good practice, in line with that set by national standards and guidelines. Regular pharmacist and GP input was sought and obtained for the management of people’s medicines.

Staff were knowledgeable and competent. They received appropriate levels of induction, training and supervisions. There was a passion for learning and development within the service. This was evident by the employment of dedicated trainers, a focus on ensuring the progression of staff careers and training topics not often used in similar services.

The service followed the requirements of the Ment

People we spoke with said staff treated them with dignity and respect. They said they were involved in decisions regarding their care and the delivery of the service. We saw minutes from a resident and relative meeting. One person had commented on how the service responded to feedback at the meeting. They said "I always feel the managing staff listen and act on it." We observed staff delivering care were courteous and communicated well. People's privacy and dignity was respected.

We saw people’s personal preferences were documented, and staff attended to people as they wished. People were able to take part in community activities and their independence was promoted where possible.

The service facilitated people to make comments and complaints, and there was a system to respond to people's complaints.

We spoke with eight out of 43 people who use this service. Some people were not able to communicate verbally so we observed the care they received. We also spoke to 10 members of staff and the manager about the service.

Most people who use the service felt they were listened to and involved in planning their care. However some people felt they were not involved in the running of the home and the changes which had occurred in recent months. Some people were not satisfied with the community activities available to them.

We saw the service responded to people's needs when people requested assistance. Most communication between staff and people was appropriate. People were usually presented with choices or had care explained to them before they received it. People were supported to eat at lunch time by staff. However, staff were not able to help everyone who needed assistance when their food was served.

Care plans contained up to date information on people's needs and their care. However the care delivered did not always match people's preferences as listed in their care plans.

Staff had received appropriate training and professional development. Staff mostly said they felt well supported to undertake their roles.

The service had several monitoring tools which identified risks and improvements to the service. However an audit based on CQC's essential standard's outcome one did not identify problems we found related to this outcome.

A relative of someone who lived at the home told us the service had improved extensively since November 2012. People who used the service and their relatives told us they were happy with the staff and care provided. They said the home had become more responsive to feedback and complaints in recent months. Two relatives of people who used the service told us they were informed about their relative's care. We saw staff communicating effectively with people to gain their consent before they provided care.

However we saw the service did not always follow legal requirements in relation to the Mental Capacity Act (MCA) 2005. The service did not always make decisions using best interest decision making procedures and did not always assess people’s capacity to make decisions about their care.

We looked at seven care plans and saw they contained personalised information relating to peoples needs and preferences.

Staff cared for people when they required assistance. However, staff were not always aware of information in care plans when caring for people. Some staff seemed to lack confidence undertaking certain tasks.

We found staff did not have appraisals. We looked at a training matrix which indicated nearly all staff had received mandatory training.

Staff were aware of the home’s whistle blowing policy and said they would be confident to use it.

This inspection was carried out to look at new concerns raised with CQC since our last inspection on 28 August 2012. Those concerns related specifically to how the provider was making sure care was planned and delivered in a way that ensured the safety and welfare of the people living at the home.

On the day before this inspection we were notified by the nominated individual the acting manager had resigned. On the day of our inspection we were advised one of the registered nurses had been designated as acting manager and the provider was advertising for a new manager.

There were 41 people living at the home when we visited. Although we spent time speaking with most of the people living at the home, what they told us did not relate to the area of compliance we were inspecting.

We found the provider had taken steps to identify and reduce risks to the safety and welfare of people living at the home. We found the provider was working towards reaching compliance in areas of non-compliance identified at our inspection on 28 August 2012.

We used a number of different methods to help us understand the experiences of people who used the service because some people had complex needs and they were unable to tell us their experiences. Other people who used the service were able to tell us about their experiences.

We observed people received care which respected their privacy and dignity. Staff called people by their name, explained things to them and offered alternatives where possible.

Staff we spoke with told us they felt supported by the new manager and the provider. Staff had already held meetings with the manager and the manager told us that further meetings were planned. We looked at the staff training matrix, which showed some staff had not received refresher training in important subjects. For example only a small percentage of staff had attended basic first aid training and there was no record of staff completing basic life support training.

The care plans we viewed contained assessments of people's needs and how staff would assist with the care provided. Care plans were reviewed regularly, but contained some conflicting information about how to look after people which staff could find confusing.

We noted systems to monitor the quality and safety of the care were lacking. For example infection control audits and environmental risk assessments. However, the new manager told us she was committed to improving the care for people who use the service.

The inspection took place on 11 and 12 March 2015 and was unannounced.

The service provides personal and nursing care to up to 60 older people who live with dementia, mental frailty and or physical disability. Accommodation is provided over three floors each with its own lounge and dining rooms.

The service was required to have a registered manager and one was in place. 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, relatives and external health care professionals told us the service provided good care to the people it supported. They said the manager and staff were approachable and listened to their views. Relatives felt they were kept appropriately informed of changes in people’s wellbeing. People and relatives told us that various aspects of care, the meals and staffing had improved more recently.

Staff received appropriate induction and training and were supported through supervision meetings and appraisals. Staffing levels were sufficient to meet people’s needs and the registered manager could and had varied these where the need arose.

People’s changing needs were responded to promptly by staff and the advice of external health care professionals was sought when required. Staff requested people’s consent before providing care. The service provided a range of activities and outings to meet people’s social and emotional needs and any spiritual or cultural needs were provided for.

People were mostly treated with respect and dignity but we saw a small number of examples of inappropriate language being used by staff verbally and in care notes.

People were given their medicines safely by trained staff. Some improvements were needed to the documentation where people received their medicines covertly to ensure that the agreement of the prescribing GP was clearly recorded. The details of the involvement of others in the decision also needed to be more clearly recorded in some cases.

We have made a recommendation about the recording of consent and ‘best interests’ discussions regarding covert administration of medicines.