We inspected Thorp house on 9 and 10 January 2019. We returned on 11 January 2019 to give the registered manager feedback and to clarify some of the findings. The first day of the inspection was unannounced. We arrived at 6am on the second day of the inspection so we could talk to night staff and see how people were supported in the early hours of the morning as they were getting up.

Thorp 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.

The home can accommodate up to 41 people. The home supports people with nursing and residential care needs and supports people living with dementia. At the time of the inspection there were 39 people in the home as two were in hospital at that time. The home was full and requests were being received for beds when they became available.

The home was a large extended building set over two floors. There were a number of communal areas on each floor and one corridor from the ground floor led to five self-contained apartments. The main kitchen and laundry facilities were on the ground floor.

The home had a registered manager in place who at the time of the inspection had been registered with the Care Quality Commissions for just over two years. 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 last inspection in January 2018 found the provider in breach of four regulations. The home was found to require improvement overall and in all key questions of safe, effective, caring, responsive and well led. Breaches were found in how the provider managed safeguarding concerns and whistleblowing, how the provider upheld the dignity and respect of people living in the home, how risks were managed and how the provider audited and managed systems to identify concerns and continuously drive improvement.

At this inspection we found action been taken to meet the requirements of the regulations and two of the previously breached regulations were now fully met. We found the provider and all staff at the home were very conscious of upholding people’s dignity and ensured people were respected at all times. We also found all staff had received training in safeguarding and when we spoke with them they displayed a good understanding and knowledge of when and where to report concerns. We found action had been taken to improve how risks were managed but some further action was required. People’s needs were not assessed at point of change and action from the changes was not always evident or easy to find. This regulation remained in breach.

We found the same with the systems and processes in place for auditing and monitoring provision of the service that still required improvement. We found some issues were found in the systems used by the provider and there was still a settling in period for new technology. This included a lack of shared understanding by everyone as to how to use the systems and gather the right information from them. This information was crucial to effectively monitor and audit how they were improving the service received by people living in the home. This regulation remained in breach.

Additional concerns were also found that led to a further three breaches of the regulations. There was a lack of formal consent being gathered from people in the home and the lack of decision specific capacity assessments and best interest decisions. This was specifically the case for restrictive practice such as bed rails and when medicines were given covertly. This means when they were given to people in their food or mixed

Thorp House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Thorp House provides accommodation with both personal and nursing care for a maximum of 41 older people, some of whom may be living with dementia or need support with their mental health. At the time of our inspection, there were 40 people using the service.

This comprehensive inspection took place on 14 and 17 November 2017. The first inspection visit was unannounced.

There was a registered manager 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.

At the last inspection of this service on 14 and 18 April 2016, we found that the service was good in all areas. The registered persons did not therefore need to take any action to comply with regulations. At this inspection, we found that the quality and safety of the service had declined and it required improvement in all areas. There were four breaches of regulations.

The service people received was not as safe as it should be. We found that staff and the registered manager did not act as expected to refer a concern that someone had been assaulted. A concern about rough handling was also raised with us that could place a person at risk of harm. The level of knowledge of staff and their awareness of local procedures for safeguarding people needed to improve. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

There were additional concerns relating to the management of risks, which systems for assessing safety had not identified. This included concerns for trip hazards within the home and in relation to moving and handling, which made some people feel unsafe. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated activities) Regulations 2014.

There was good practice in other aspects of the safety of the service. This included managing people’s medicines safely, with minor anomalies being identified and addressed. Arrangements for cleaning the home contributed to reducing the risk that an outbreak of infection would not be contained.

People were not always treated with respect for their privacy and dignity. This was either through omission when staff did not offer prompt intervention to promote people's dignity, or by action taken that directly compromised privacy and dignity. This was a breach of Regulation 10 of the Health and Social Care Act (Regulated activities) Regulations 2014.

Standards in the service had declined since our previous inspection. Governance and leadership of the service failed to sustain the good outcomes for people we found at our last inspection. Systems were not effective in proactively identifying and addressing the concerns we found. The need to ensure the service returned to good and the slippage in arrangements to properly and effectively evaluate the service represented a breach of Regulation 17 of the Health and Social Care Act (Regulated activities) Regulations 2014.

You can see the action we have told the provider to take in response to these four breaches of regulations at the back of the full version of the report.

Staff did not always receive the support and supervision they needed to support people competently. This included shortfalls in the clinical skills of nurses and gaps in training or assessments of competence for staff. Between the two of our inspection visits, the management team developed an action plan for addressing the shortfalls we pointed out.

People received support and advice about prom

The inspection took place on 14 and 18 April, 2016 and was unannounced. The service provides residential and nursing care for to 41 people over the ground and first floor accommodation. At the time of our inspection 38 people were using the service.

At the time of our inspection the service did not have a registered manager at the service, although a new manager had been appointed and would be commencing shortly. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.

Since the last registered manager left the service in November 2015. The service had experienced two managers come and go in a relatively short time and had not been in post long enough to become registered. During this time the service had not reported these events to the Care Quality Commission. The uncertainty around the management and leadership of the service had been further complicated by the senior clinical post also becoming vacant. The regional manager for the area had begun to oversee the service and had based themselves there for the past few months. During this time a new deputy manager and clinical led nurse had been appointed which had started to bring back stability to the service. The operations manager had recognised the difficulties around staff recruitment, reporting structure to identify and resolve issues and staff support through regular training and supervision. They had implemented a great deal of work to address these issues.

People were being protected from the risk of abuse as established senior care assistants and care staff were knowledgeable in this area and training had been planned for all staff to attend in the near future. There were emergency plans in place at the service and we saw that people had risk assessments which was reviewed regularly and as required.

People were now supported by a sufficient number of suitably qualified nursing and care staff. The service had appointed permanent nursing staff to replace agency nurses. The provider had ensured appropriate recruitment checks were carried out on staff before they started work. Staff had been recruited safely and completed an induction procedure for working at the service. Further on-going training has been arranged for all staff and a person had been appointed to lead upon the activities at the service.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely. Although the service appeared to have sufficient nursing and care staff day to day needs of people,the service did not use a dependency tool to determine how many staff were required to be on duty to meet people’s needs.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice. The Act, Safeguards and Codes of Practice are in place to protect the rights of adults by ensuring that if there is a need for restrictions on their freedom and liberty these are assessed and decided by appropriately trained professionals. People at the service were subject to the Deprivation of Liberty Safeguards (DoLS). Staff had been trained and had a good understanding of the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Understanding and empathic relationships had been developed between people and staff. Staff responded to people’s needs in a compassionate and caring manner. People were supported to make day to day decisions and were treated with dignity and respect.

We considered our inspections findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found-

Is the service caring?

People told us that they received consistent and respectful support from care and nursing staff and felt able to make choices and changes when required. Staff told us that they were well supported and supervised so that they could provide safe care and support to people.

Is the service responsive?

We saw that people’s personal care and social support needs were assessed and met. This also included people’s individual choices and preferences as to how they liked to be supported. People we spoke with told us that they felt well cared for and observations we made during the inspection confirmed this to be the case.

Is the service safe?

Risk assessments regarding people’s individual care and support needs had been improved to ensure there were measures in place to minimise any potential harm to people using the service. Carers understood their roles and responsibilities in making sure people were protected from harm. The provider had taken appropriate action to ensure that there were appropriate levels of staff to meet people’s needs at all times. Improvements had been made to ensure safe infection control procedures were in place. We saw that Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) assessments had been undertaken where appropriate and that staff received training regarding these issues.

Is the service effective?

We found that nurses and care staff were knowledgeable about people’s individual care and support needs. People that we spoke with confirmed that staff provided consistent and kind support. Care planning documentation was well coordinated and reviewed to ensure that individual care and support needs were being met. The acting manager confirmed that support documentation was regularly audited to ensure it met people’s assessed needs.

Is the service well led?

The home does not have a registered manager in place. However, a registered manager application has been received and is currently being assessed. Staff that we spoke with told us that they felt well supported by the management team and were regularly trained to safely provide care and support. People that we spoke with told us that they felt they were listened to and support was consistently and safely provided. Quality assurance systems were in place to regular audit the care and services provided. Surveys were carried out to gather opinions from a people using the service, relatives and healthcare professionals to ensure that ongoing improvements could be made.

Staff discussed various areas of care with people who used the service and their families, as appropriate. People's choices were respected.

We found concerns that people may not always receive care and treatment in line with their plan of care because staff members did not all have access to this guidance.

Staff were knowledgeable about what to do if they saw or heard abuse and were able to explain different types of abuse.

There were effective systems in place to reduce the risk and spread of infection, however we found that these systems were not always followed by staff.

We found that the provider was in the process of taking additional steps to improve the environment for people who used the services.

Staff told us that they felt they could not always provide the care needed. There were not always enough qualified, skilled and experienced staff to meet people's needs.

Thorp House is currently in the process of submitting an application for a manager to be registered, this is why a registered manager does not appear in this report.

We spoke with two people who used the service and two visitors who told us that the staff looked after people very well. One person said, "When you buzz for the toilet they (staff) come, you get well fed and they look after you very well". However, we noted that assessments carried out contained differing information to that specified within a person's care plan, which did not provide staff with clear information about a person's needs.

We saw that there were systems in place to ensure safety checks were carried out on a regular basis. However, people who used the service, staff and visitors were not protected against the risks of unsafe or unsuitable premises.

Comments and complaints received were used to develop the service and were discussed at staff meetings so that learning could be shared.

We spoke with four people who lived in the home. People told us that their needs were met and that they were consulted about the nursing care and support that they were provided with. People were complimentary about the staff that cared for them and told us that they always treated them with respect and that their privacy was respected. They told us that sometimes they had to wait for help because staff members were very busy. They also told us that activities were not provided everyday and that sometimes they were bored. They explained that the environment was comfortable and clean and that they were provided with good quality meals.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not comment. We observed two groups of five and six people for forty-five minutes. We saw that when staff members were with people that they used explanation and negotiation when working with the person and used reassurance and praise appropriately. We noted that each person had their opinions respected and were included in the general conversations that occurred. We saw that staff responded well to the needs of people, gave them individual attention, listened and spoke to them in a positive manner and encouraged them to make choices.