About the service:

• The service is based on acreage in the Stoke Poges area; a rural setting with expansive grounds.

• The service provided accommodation and personal or nursing care to older adults with dementia. People lived in their own bedrooms. Some rooms had ensuite facilities. There were communal bathroom facilities, lounges and a dining room.

• At the time of our inspection, 24 people used the service and there were 40 staff.

People’s experience of using this service:

• The service had made improvements to the safety of people’s care.

• People were protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe.

• People’s risks were assessed and strategies put in place to mitigate the risks.

• Risks from the premises were satisfactorily assessed and managed. We made a recommendation about reviewing the suitability of the environment for dementia care.

• Staff received improved supervision and training since our last inspection, which provided them with the knowledge and skills to perform the roles they were employed to do.

• People and relatives provided consistently positive feedback about the care, staff and management. They said the service was safe, caring and well-led.

• People’s care was person-centred. The care was designed to ensure people’s independence was encouraged and maintained.

• People were involved in their care planning. End of life care planning and documentation required further improvement.

• There were positive changes to the management team. Improved audits and checks were put in place to ensure the service was well-governed.

• There was a happy workplace culture and staff we spoke with provided positive feedback.

• The service met the characteristics for a rating of “good” in all the key questions we inspected. Therefore, our overall rating for the service after this inspection was “good”.

• More information is in our full report.

Rating at last inspection:

• The service was rated “requires improvement”.

• Our previous inspection report was published on 27 December 2017.

Why we inspected:

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

• We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

• We made recommendations in our inspection report. We will check any actions taken by the provider at our next inspection.

Tithe Farm Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates up to 30 people in one adapted building over two floors. At the time of our inspection 28 people lived at the service.

The conditions of registration require that a registered manager is 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. A registered manager was in place at the time of our inspection.

Following our last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key question well-led to at least “good”. We found that although better systems and checks were implemented for measuring the quality and safety of care, further improvement in the good governance of the service was required. This was a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Further information is in the detailed findings below.

We found people were protected from abuse. Risks related to people’s care were not always assessed, recorded and reviewed. The management of risks from the building were also assessed and mitigated, however a risk assessment for Legionella was not completed. We found inappropriate numbers of staff were deployed to meet people’s needs. Recruitment records did not always contain all of the necessary information recorded by the regulation and schedule. Medicines management was safe.

The level of staff training and support was unsatisfactory. Records showed that staff had not completed sufficient, repeated training, supervisions with line managers and performance appraisals. The service was compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People’s nutrition and hydration were appropriate. People told us they liked the food. Appropriate access to community healthcare professionals was available.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

We received complimentary feedback about the service. Most people and relatives told us staff were kind and caring. People and relatives were able to participate in care planning and reviews and some decisions were made by staff in people’s best interests. People’s privacy and dignity was respected. Confidential personal information was appropriately stored in line with the data protection laws.

Care plans were in place and reviewed regularly. There was a complaints system in place which included the ability for people and others to raise concerns. However, management of complaints, especially investigation and documentation of issues, required improvement. Some people and relatives told us they had complained and when we checked, the service was aware of these. Others we spoke with did not t raise concerns and knew the process for alerting staff to any issues. We have made a recommendation about the management of complaints.

The service had implemented more systems and processes since our last inspection. When we looked at them, they were suitable for use and completed by the management team. Action plans were used to log steps to take and outcomes. We found some staff expressed a negative workplace environment and felt they were not always well-supported by the management team. Surveys were used by the service to gauge people’s and relative’s opinions of the service.

You c

We undertook an unannounced inspection of Tithe Farm Nursing Home on 13 and 14 December 2016.

Tithe Farm Nursing Home is registered to provide accommodation and nursing care for up to 30 people. On the day of our visit there were 27 people using the service.

At the last inspection on 5, 6 and 9 November 2015 the provider was in breach of several regulations. We used our enforcement powers and asked the provider to take action and make improvements to meet the regulations.

The provider had met the enforcement requirements and sent us an action plan outlining the actions they were going to take. At this inspection, we found some improvements were made but further work was required to improve monitoring systems as there were a number of recording errors.

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 in the Health and Social l Care Act 2008 and associated Regulations about how the service is run.

People and their families told us they felt safe at Tithe Farm. Staff understood their responsibilities in relation to safeguarding people. Staff received regular training to make sure they stayed up-to-date with recognising and reporting safety concerns. The service had systems in place to notify the authorities when concerns were identified. People received their medicines as prescribed.

People benefitted from caring relationships with the staff. People and their relatives were involved in their care and people’s independence was actively promoted. We saw and relatives and staff told us people’s dignity was promoted.

Where risks to people were identified, risk assessments were in place and action was taken to manage these risks. Staff sought people’s consent and involved them in their care where possible.

There were sufficient staff to meet people’s needs. Staff rotas confirmed planned staffing levels were maintained. The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role.

People and their families told us people had enough to eat and drink. People were given a choice of meals and their preferences were respected. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

Relatives told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided, but these were not always effective. Systems were in place that ensured people were protected against the risks of unsafe or inappropriate care, however, improvements were needed regarding the retention of documentation.

Staff spoke positively about the support they received from the registered manager and all of the team at the home. Staff supervision and other meetings were scheduled as were annual appraisals. People, their relatives and staff told us all of the management team were approachable and there was a good level of communication within the service.

Relatives told us the service was very friendly, responsive and very well managed. Comments received included “Really well run”. The service sought people’s views and opinions and acted on them.

We have made a recommendation that the service reviews and ensures compliance with the Mental Capacity Act 2005 and the associated Codes of Practice.

We found a continued 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.

The inspection was carried out by one inspector. When we visited the service 14 August 2013, we had concerns how one standard management of medicines, was managed. We set a compliance action for the provider to improve practice.

The provider sent us an action plan which outlined how they intended to become compliant. We returned to the service on the 11 September 2014 to check if improvements had been made.

Below is a summary of what we found. The summary describes what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found the provider had responded to our concerns around management of medicines. We found the medication room was locked and medications were kept securely in locked cupboards. The service had procedures in place for the appropriate disposal of medication.

This meant the service was safe.

We spoke with five people who lived at the home, and heard many positive comments about the care they received there. Some people said there were not many activities during the daytime, but one person had recently enjoyed an outing to a local pub for lunch.

We heard from people who use the service that the manager was pleasant and approachable and responded to any concerns raised. Staff also told us they found her helpful and supportive. Relatives told us that the atmosphere in the home was calm and understanding of people's specific needs.

Medications were appropriately ordered and administered, however they were not securely stored.

The home had good recruitment practices, and provided training opportunities, supervisions and appraisals for their staff. The numbers of staff on duty were usually sufficient for the day to day needs of the people who used the service.

The management of records was generally satisfactory.

People told us that they and/or their family had been given the opportunity to visit the home before they moved in to ensure it met with their needs and expectations. They said that the staff treated them as individuals and respected their views and choices. They said they were provided with opportunities to take part in activities and were happy with the care and support they received.

Tithe Farm Nursing Home is registered to provide accommodation and nursing care for up to 35 older people. On the day of our visit there were 28 people using the service.

The registered manager has been in post since July 2014. 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 spoke positively about the care they received. One person commented, “I like them (care workers) they do a great deal for us and they never query what I want, and they are so polite.” We saw one care worker made good eye contact with a person, stroking their hair gently and speaking to them in an affectionate manner.

Reviews of care were not consistently undertaken. Some care records showed when people and their relatives met to review the care being delivered whilst other care records showed no evidence that this had occurred.

The service did not capture people’s preferences in regards to end of life care. Where people received end of life care, there was no care plan put in place and staff had not undertaken the relevant training.

Most people said they felt safe and were never shouted at or abused. One person commented, “I feel safe my daughter put me in here because I was falling all the time.” Another person said they felt safe in the environment but went on to say, “Some of the staff are a bit rough and I have had a bruise or two.” We found where people sustained unexplainable injuries, no action was taken by the service to investigate or escalate them to the appropriate agencies. This placed people at risk of unsafe care and inappropriate care.

Health and safety audits undertaken were not able to identify safety risks for example, fire doors not opening or jammed and the stair gate being left opened by staff. There were no systems in place to mitigate identified risks relating to people’s health. For instance, no risk assessments were put in place for people assessed with identifiable risks. This placed people at risk of unsafe and inappropriate care.

The staff dependency assessment tool used to ensure there was enough staff to meet people’s needs, did not accurately reflect the dependency needs of people. During the first of day of our visit we observed staff were rushed; task focused and had little time to interact with people. One staff member told us they had to work through their morning break due to the workload. We found there were not sufficient numbers of staff deployed to meet people’s care and treatment needs.

Necessary recruitment processes and checks were in place and being followed. People received support from staff with their medicines to ensure they were managed safely.

People were not always supported by staff who received appropriate induction, training and supervision.

People spoke positively about the food. For instance, one person commented, “The dinners are very nice and if you want anything different they will cook it for you.” Some people were able to eat and drink independently however; we found a lack of staff impacted on how other people were supported during mealtimes.

Where restrictions were put in place in order to keep people safe, best interest meetings records evidenced discussions were held with people; their representatives; staff and relevant health care professionals. We saw the least restrictive options were considered.

We did not however, see documentary evidence to show what legal powers people’s representatives had. This meant there was a possibility the service obtained consent from people who did not have the legal power to give it. We recommend the service finds out more about obtaining consent, based upon current practice, in relation to the MCA.

The home had recently been refurbished and the floors had been laid with wood laminate which made it much easier for people who use wheelchairs and walking frames to get about. The director told us special lights had been installed which were designed to help people who had dementia. We saw no memory boxes or personalised signs to help people with cognitive impairments to orientate them around the home.

People’s social needs were not being met. People told us they were bored and activities did not occur regularly.

People and their relatives said they knew how to make a complaint. One person said they knew how to raise a complaint and thought staff listened to them.

Quality assurance systems were in place was not effective in assessing, monitoring and improving the quality and safety of services provided.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We are taking enforcement action. You can see what action we told the provider to take at the back of the full version of this report.