The inspection at Thomas Tawell House was undertaken on 12, 13 and 16 November 2018. The first day of the inspection was unannounced.

Thomas Tawell House 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.

Thomas Tawell house is a care home supporting people living with visual impairments. The home was designed to support the independence of people living there. The home was a large one-story building with communal areas to allow people opportunity to have varied spaces in which they could relax, dine, undertake activities and even host events.

The home was registered to support 37 people, at the time of the inspection there were 24 people living in the home. Following the last inspection, the provider had taken the decision not to admit any further people to the home until improvements had been made. Shortly before this inspection new people had begun to be placed at the home.

Thomas Tawell had a registered manager who had been in post for approximately six months. 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.

At the last inspection we found six regulations to be in breach of the Health and Social Care Act (Regulated Activities) 2014. The home was found to be inadequate in the key questions of safe, responsive and well led and to require improvement in the key questions of effective and caring. The home was rated as inadequate overall. Since the last inspection there has been a change in the management structure of the home with a newly appointed registered manager and deputy in place. The nominated individual has also taken on a more proactive role in ensuring the service improved. The provider had recruited a consultancy company who had supported the service and had introduced basic and emergency plans including risk assessment and care planning to ensure people were kept safe.

Since the introduction of the new registered manager these were to develop and become a more comprehensive assessment tool which in turn would feed into more person-centred care plans. Work had begun to put this in place. We found the new management team including senior managers and the board members motivated and committed to continually drive improvement at the home.

Previous breaches had been found in regulations associated with staff and we had concerns about both the number of available staff and the training and support staff had received. We had concerns around how risks were assessed and mitigated and how restrictive practice had been assessed for people who lacked capacity. We found breaches in the regulation associated with person centred care and found people were not involved as they should be with deciding their care. We found their preferences had not been met once they had moved into the home. We also found a lack of dedicated and appropriate activities. We had concerns that complaints procedures were not accessible to people and complaints had not been handled appropriately or recorded. Lastly, we had concerns around how the provider had monitored the service delivered and the accuracy of any monitoring undertaken as it had not been effective at identifying concerns.

A consistent approach to service improvement had been adopted since the last inspection. A comprehensive action plan had been provided to the Care Quality Commission following the last inspection and we were given an up to date one at the start of the inspection This showed us ongoing systems were in place to identify, discuss and action any concerns or issues. The new registered manage

This inspection took place on 13 November 2017 and was unannounced. We also returned on the 14 and 15 November 2017. The registered manager and chief executive officer [CEO] was given notice of the other dates, as we needed to spend specific time with them to discuss aspects of the inspection and to gather further information.

At our last inspection on 20 and 21 September 2016, we found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found there were not sufficient systems in place for assessing, monitoring and improving the quality of the service provided. Improvements were needed to develop risk assessments in relation to people’s welfare. Records relating to people’s care were not detailed.

At this inspection, we found the service had further deteriorated. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At our last inspection for the key question, ‘is the service responsive?’ we found the service was not always responsive to people's individual needs and preferences. The staff interactions were limited to focus on tasks rather than conversational and individual. There was a survey in place for people to give feedback on the service. We found that where people requested something to be altered, this was not always considered. The care records were not always detailed and individualised. We saw in some people's care records that they had variable continence. There was no further information, risk assessment or guidance about how best to support them. Where some people had a catheter in situ, there were no risk assessments in place concerning potential problems with them. Visiting agency staff or new staff did not always have clear, concise guidance to follow about people's care within the records.

At this inspection, we found the service had deteriorated resulting in six breaches of Regulation.

Thomas Tawell House 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.

Thomas Tawell House accommodates 37 people in one adapted building. There were 29 people living in the home on the day of our inspection. The home supported people who were over 65 years of age, some of whom were living with sensory impairment.

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 of the Health and Social Care Act 2008 and associated regulations. The CEO visited the service on the second day and third day of our visit at the request of the inspector.

Although the provider had systems in place to protect people from harm, we found these were not always effective. The majority of staff were trained in safeguarding adults yet the training was not always implemented in practice whilst supporting people. Staff told us they were aware of their responsibility to keep people safe however, they failed to identify some of the practices within the home which were abusive and breached people's rights to receive safe, respectful and dignified care. At the time of our visit, we requested the registered manager to complete a safeguarding referral to Norfolk local authority safeguarding team reporting our findings. The registered manager told us she did not know how to do this and we were given assurances from the CEO this would be done without delay. Evidence of this was seen before the end of our third day.

Risks to people's health and wellbeing were not appropriately assessed and reviewed. Care plans were not sufficiently detailed to provide an accurate description of people's care and support needs. Our c

This inspection took place on 20 and 21 September, 2016. The visit was unannounced.

Thomas Tawell House is a residential care home which supports older people living with sensory impairment, for a maximum of 37 people. There were 35 people living in the home when we inspected. All of the people living there were visually impaired.

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. There was a registered manager who had been in post for several years.

Staff were trained in safeguarding and were aware of who to report any concerns to, and people felt safe living in the home. There were risks assessments in place for people with regards to their physical safety, and these provided guidance to staff on how to safely support them.

The home was making improvements to the recording around some medicines. Medicines were administered by staff who were trained to do so, and some people were supported to take their own medicines.

The home had safe recruitment practices in place so that only staff who were deemed suitable could work there. There were enough staff to keep people safe.

People felt that staff were competent in their roles. Staff had received training relevant to their role and felt confident. There was an induction procedure in place, which helped to train new staff. Staff asked people for their permission before delivering care.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Although staff did not always have training in these areas, we found that they were following the principles of the MCA. We have made a recommendation around training with regards to people’s mental capacity.

People were supported to eat a sufficient amount of food with a good choice of meals. There were drinks available at various intervals throughout the day, and people had drinks in their rooms.

Staff were compassionate towards people, and they encouraged people to be independent where they were able. They encouraged privacy when carrying out personal care with people. Staff supported people to maintain relationships with loved ones and involve them in their care. We did observe that there were some practices in place which did not always promote people’s dignity.

Although staff were cheerful and kind to people, the interactions were task-led. People were not always supported to participate in social events or activities which followed their interests. People did not always receive support to engage with others and follow their interests and hobbies.

Care records did not always contain clear detail and guidance about each individual’s life, preferences, and personal health needs. This meant that staff did not always have consistent guidance about how to support people effectively.

Although people we spoke with felt that they were involved in aspects of their care, there were some decisions that were not supported. This included bath and meal times. We spoke with the registered manager about this and they said they would review flexibility of the service.

There were not sufficient auditing systems in place to assess, monitor and improve the service. We found that the registered manager had not picked up on areas that required improvement, including monitoring staff competency, checking health and safety and medicines administration.

You can see what action we told the provider to take at the back of the full version of the report.

The people living at Thomas Tawell House told us that they were happy there and felt well looked after. One person said, “The staff are good girls, they look after me well and do all that they can”. Another person said, “The girls (staff) know us all really well here, what we like and what we don’t like, there are never any complaints”.

Care plans showed that people were involved in making decisions about how they wished to be supported and were regularly asked what they would like to do. Some of the information in people’s care records was limited but staff were observed giving individual and personalised care.

There were choices from the menu at meal times and all of the people we spoke with said they enjoyed the food. Nutritional assessments had been done and there was evidence that people’s nutritional needs had been met.

People using the service told us that they felt safe and had no concerns. We noted that the premises and environment promoted people’s safety and security.

We saw that there were enough suitably trained and experienced staff to meet the needs of people using the service, although some people told us that they wished the carers had more time to speak with them.

The service had various methods that were used to ensure the quality of the service was monitored and audited. Meetings, reviews and audits were in place and records were available.

People were supported in promoting their independence and community involvement. We observed lunch time at the home and noted that staff encouraged people to be independent where this was appropriate. For example, for those people able, plastic aprons were left on the table for them to put on themselves. We saw that staff encouraged conversation and spoke with people in a dignified and respectful manner.

In total, we spoke with seven people using this service who all told us that they were very happy living at the home. One person told us “I feel extremely lucky to be here, you hear of all these bad places on the television, I wish they would do a show about the good homes and we could show them how it’s done”. Another person commented “I am very well cared for, I could not ask for a better environment and to be with people that understand me”. A third person told us “it’s a wonderful place to live”.

Appropriate arrangements were in place in relation to obtaining and disposing of people's medication. We spoke with a member of staff, responsible for medication, who told us that medication for people living at the home was received on a four weekly basis from their nominated pharmacy.

We spoke with two members of staff who all told us that they were happy working at Thomas Tawell House, felt completely supported by their managers and confident in raising concerns should they need.

Records were well kept and secured safely.

People living in the home told us they felt staff knew about their needs and gave any assistance without rushing them at all. People told us that staff always provided help appropriately and as they had chosen.

Another person said that they were more than satisfied with the way they were treated and assisted. One person explained that they had been able to chat with staff recently when the person was feeling a bit low. We were told that staff worked hard and were very good.

People told us that they had wonderful meals and that they enjoyed all the meals that were provided for them.