Tiltwood 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. Tiltwood accommodates up to 50 older people, who may also be living with dementia. The service is arranged into five individual units, named: Pines, Elms, Chestnuts, Walnuts and Willows. Titlwood also has an onsite day service which is accessed by some of the people who live at Tiltwood, in addition to being open to the wider community.

The inspection took place on 12 March 2018 and was unannounced. There were 40 people using the service at the time of our 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. The registered manager had been in post since November 2015.

We previously carried out an unannounced comprehensive inspection of this service on 15 March 2017. At that inspection we found one breach of legal requirements in respect of providing person centred support. As a result the findings from that inspection, the service was rated Requires Improvement. The provider sent us an action plan which identified the steps they intended to take to make the required improvements and this inspection confirmed that the provider had done the things they told us they would.

This inspection found that whilst people were experiencing a good standard of service, some staff did not always have the skills and confidence to meet people’s specialist needs. In addition, staff needed to ensure they always worked collaboratively to make sure they delivered the most effective support. The registered manager and provider had already identified these areas of improvement and plans were in place to ensure they were acted upon.

People now experienced a personalised approach to care and most staff had a good understanding about their wishes. Each person had been appropriately assessed and information used to develop a plan of care that outlined how support was to be provided safely and in accordance with people’s preferences. People were given choice and control over how they lived their lives and their right to be independent was inspected.

People were supported to lead healthy lives and encouraged to eat and drink so as to maintain a healthy and balanced diet. The registered manager worked in partnership with other healthcare professionals to ensure people received holistic care. Medicines were managed safely and people received their medicines as prescribed. End of life care enabled people’s final wishes to be respected and allowed people to pass with comfort and dignity.

Staffing levels were sufficient to safely meet people’s needs. Appropriate checks were undertaken to ensure staff were suitable to work people and training and support was provided to enable them to deliver their roles.

Staff understood their responsibilities in protecting people from harm and there were appropriate systems, processes and practices to safeguard people from abuse. Risks to people were identified and managed in a way that balanced both people’s safety and freedom.

The environment was suitable for people’s needs and the Registered Manager was continuously developing the sensory areas around the service. The service was clean with good infection control systems in place.

The atmosphere in the service was relaxed and people were treated with kindness and compassion. Staff respected people’s privacy and took appropriate steps to ensure their dignity was upheld. People had opportunities to participate in activities that were engaging and meaningful to them and the

Tiltwood provides residential care for up to 50 older people, who may also be living with dementia. The service is arranged into five individual units, named: Pines, Elms, Chestnuts, Walnuts and Willows. Each unit has ten bedrooms, a communal dining/living space and toilet and bathing facilities. Titlwood also has an onsite day service which is accessed by some of the people who live at Tiltwood, in addition to being open to the wider community.

The inspection took place on 15 March 2017 and was unannounced. There were 42 people using the service at the time of our 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. The registered manager had been in post since November 2015.

We previously carried out an unannounced comprehensive inspection of this service on 4 November 2015. At that inspection we found one breach of legal requirements in respect of staffing levels and a requirement action was set. We also made recommendations that the provider take steps to improve the outside safety of the service, support staff to better manage people’s anxieties and develop more meaningful activities. As a result the findings from that inspection, the service was rated Requires Improvement. The provider sent us an action plan which identified the steps they intended to take to make the required improvements and this inspection confirmed that the provider had done the things they told us they had.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report. This report also highlights that the registered manager was in the process of implementing a further number of changes to improve the quality of support provided. For example, the deployment of a senior team leader to more closely coach and monitor staff practices, specific training for staff in managing challenging behaviour and the personalisation of people’s rooms and living spaces. We expect these changes to be fully embedded over the coming months and will monitor the service against them at our next inspection.

People experienced varied quality of support at Tiltwood. As such, we found differences in the care and support that people received both across different units and between different staff. In one unit, the quality of some people’s care was compromised by the high needs of one person. This meant that other people did not always receive the same level of support and attention they required.

Whilst there were systems in place to train and support staff, these was not always consistently reflected in the behaviours and practices of staff. For example, some staff had an excellent understanding of people’s needs and engaged effectively with people. Other staff however, lacked either the necessary skills or empathy to effectively support older people living with dementia.

People’s care records did not always provide easy access to current and detailed guidance about how to support people. Good communication between staff mitigated some of the risks associated with this, but some people did not receive the most personalised and consistent support.

Staff were working hard to improve the quality of activities across the service and many were seen to take opportunities to engage with people in a positive and creative ways. Whilst staffing levels were now safe, the quality of people’s social experiences were affected by both the availability and skill of the staff deployed to work with them.

Risks to people were assessed and actions taken to manage avoidable harm. The processes

Tiltwood is a residential home which provides care and accommodation for up to 50 older people who are living with dementia. People have varied communication needs and abilities. Some people are able to express themselves verbally; others use body language to communicate their needs. The home is divided into separate areas called bungalows each identified by the name of a tree; for example ‘Chestnuts' where up to 10 people live.

Tiltwood also has a day care provision, known as The Club, where people from the home and community can come together to join in activities and where friendships can be made. Tiltwood also benefits from being within close proximity to the village facilities which are easily accessible to people.

On the day of our inspection there were 40 people living in the home.

This inspection took place on 7 November 2015 and was unannounced.

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.

There were not always sufficient numbers of staff to meet people’s needs. People were left on their own throughout the home which was a risk to their safety. We observed people being left unattended for periods of ten minutes or more. One relative said “One staff is not enough to look after all the needs of 10 people.”

People were at risk of not always receiving care from staff who staff did not initiate action when people needed support or recognised when people needed support. Staff did not always take time to speak with the people who they supported. We have made a recommendation about staff undertaking training in dealing with people experiencing anxieties in dementia.

We observed some positive interactions and it was evident people enjoyed talking to staff. However not all staff interacted with people in a social way and addressed people only to provide a task e.g. “It’s lunch time, Have a drink etc.

We saw staff had written information about risks to people and how to manage these in order to keep people safe. Tiltwood has all main doors locked to the outside environment. Access could be gained into the garden arranged in such a way as to provide a measure of freedom. An alarm sounds if a person cannot be located, and staff are aware of the procedure to manage a search. During our inspection a person went ‘missing’ during the inspection, an alert went out immediately the situation arose and the person was found within a matter of minutes. On their return they said, smiling, “I got lost.”

Information was displayed for people and visitors on how to raise any safeguarding concerns. Staff had received training in safeguarding adults and were able to tell us about the different types of abuse and signs a person may show. Staff knew the procedures to follow to raise an alert should they have any concerns or suspect abuse may have occurred.

Processes were in place in relation to the correct storage and auditing of people’s medicines.

Medicines were administered to people with dignity and disposed of in a safe way.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLs) which applies to care homes. The registered manager and staff explained their understanding of their responsibilities of the Mental Capacity Act (MCA) 2005 and DoLS and what they needed to do should someone lack capacity or needed to be restricted to keep them safe. They had undertaken the appropriate assessments on people who lacked capacity to make certain decisions and the appropriate DoLS had been submitted to the local authority.

People were provided with a choice of cooked meals each day. The meals were not cooked on the premises but provided by an outside catering company. Facilities were available for staff to make or offer people snacks at any time during the day or night.

People were able to see their friends and families as they wanted and there were no restrictions on when relatives and friends could visit.

People and their families had been included in planning and agreeing to the care provided. We saw that people had an individual plan, detailing the support they needed and how they wanted this to be provided. Staff ensured people had access to healthcare professionals when needed. For example, details ofdoctors, opticians, tissue viability nurses visits had been recorded in people’s care plans.

People’s views were obtained by holding residents’ meetings and sending out an annual satisfaction survey. Complaint procedures were up to date and people and relatives told us they would know how to make a complaint if they needed to.

Staff recruitment processes were robust to help ensure the provider only employed suitable people.

The provider had quality assurance systems in place, including regular audits on health and safety, infection control and medication. The registered manager met CQC registration requirements by sending in notifications when appropriate. We found both care and staff records were stored securely and confidentially.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This was a follow up inspection to review improvements related to the provider’s staff recruitment practices. It was not necessary to speak to people who used the service on this occasion.

We found during our inspection in June 2013 that full recruitment procedures had not been followed by the provider. During this inspection we found that the concerns that had been identified then had now been addressed.

We visited four ‘bungalows’ within the home, and the activities club annex during our visit. Due to their special communication needs we were not able to hold in-depth interviews with most people living at the home. We had structured discussions with five residents, three relatives, a community nurse, and a visiting cleric during this inspection.

People who lived at this home indicated that staff gained their consent to care, and that their care needs were well catered for. Comments on this question included “Staff are pretty good” and “Yes, we do get the help we need.”

We asked people if they felt safe living at this home and they told us that they did feel safe. One person added “Yes, quite safe.”

Some people told us they had been involved in the recruitment of new staff and said the manager “Did bring new staff to meet us.” However, we noted some shortfalls in relation to the recruitment records we sampled.

People we spoke with said they would know how to make a complaint if they had one. One person who told us they would report any concerns to the manager added “She is so nice and would make sure everything was alright.”

We visited the home to see if improvements had been made following an earlier inspection in September 2012. During the follow up visit in January 2013, we did not ask for feedback from people about the quality of the service they received, however, on our last visit, most of the people using the service told us that they were pleased with the quality of the service they received.

The inspection on the 25 January 2013 focussed on checking that records and quality assurance processes had improved and improvements to the quality of the service had taken place.

We visited the home to check on compliance actions that had been made during an earlier inspection in April 2012. As many people who live in Tiltwood had a memory impairment, and some had special communication needs, we made some detailed observations in two of the bungalows and used the CQC tool called SOFI (Short Observational Framework for Inspections) to assist us. This supported us to record interactions, mainly between staff and residents, to enable us to make a judgement about the quality of life of people living in this home.

We also interviewed four people who lived at Tiltwood in some detail, as they were able to discuss their care with us, and we spoke to one visiting relative. We also spoke more briefly with 10 other residents throughout the home over the lunch period and during the afternoon.

During our visit we asked people if staff were respectful to them, and to the other residents. Without exception people told us they and their fellow residents were treated respectfully. Responses to this question included “Yes, they (staff) are all very good” and “They are wonderful.”

The people we spoke with were not familiar with their care plans, but when asked if they got the care they needed, they told us they did. One person said “Staff seem to know in their heads what people need”, and another person told us “They look after me nicely. They give me help if I need it. I only have to ask, and help is there.”

When we asked people if they thought staff appeared to be well trained, we received only positive comments including ”I think they are fully trained” and “Definitely – they seem to anticipate your needs.” Overall, people told us they were well looked after. One person summed up the majority of the comments we received: “I am very happy here. Staff are very kind. I’ve nothing to complain about at all.”

Our inspection visit involved two compliance inspectors and took place between 10.00 18.00 hours. Our visit was carried out on an ‘unannounced’ basis. This means that staff working for the organisation and location were not told beforehand that we would be visiting. On the day of our visit there were forty-eight people living at the service.

The majority of people who live at the service were involved in the review through either their feedback or our observations of their interactions at the service and with staff. We spoke with one visitor on the day of our visit and four carers (relatives) of people who use the service by telephone following our visit. We also spoke to a visiting health care professional and six staff members.

We were consistently told by people who use the service and carers that the staff were very caring, their comments included that they “had a special kind of patience”, were “very good and caring” and that staff “obviously care” about the people who use the service.

However people also told us that they found it “annoying that I can’t go out unless someone is with me” and that there were a “lack of activities”, Carers told us that there was “not enough staff” and that “staff are very, very busy”.

We saw that staff’s approach towards people using the service was respectful, supportive and accommodating.