We conducted an inspection of Tower Bridge Care Centre on 30 November and 3 December 2018. The first day of the inspection was unannounced. We told the provider we would be returning for the second day.

At our last inspection on 1, 2 and 9 August 2017, we identified some concerns in relation to the employment of fit and proper persons and medicines storage. We also found the risks to people’s physical health were not always identified and managed appropriately and people told us they did not always get care from care workers of the gender they wanted.

Tower Bridge Care Centre 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. Tower Bridge Care Centre provides nursing care, respite and accommodation for up to 128 people over four floors. Two floors are for people with dementia who have nursing needs, one for people who have nursing and end of life care needs and the remaining floor is a residential unit for people who are at the early stages of dementia. At the time of our inspection there were 116 people using the service.

There was a registered manager at the service. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people’s safety were managed safely, but the level of risk was not always accurately recorded. We identified some examples of where the level of risks were not clearly identified. Repositioning charts were filled in to document when and how frequently people were being turned whilst in bed to minimise the risk of pressure ulcers.

The provider safely administered medicines, but accurate records were not always kept where the GP advised people’s medicine to be stopped or where PRN medicines were offered.

The organisation had systems in place to monitor the quality of the service, but these were not always effective as they did not identify the issues we found in relation to risk assessments and medicines management.

Feedback was obtained from people through residents and relatives meetings and this was acted on. There was evidence of further auditing in many areas of care and action was taken to rectify any issues identified as a result.

The provider conducted safer recruiting processes to ensure care staff were safe to work with people.

There were enough staff working in the home. Care staff received appropriate training and ongoing monitoring and support.

People told us they felt safe living at the home. There was an appropriate safeguarding policy and procedure in place and care staff had a good understanding of this.

Good infection control practices were operated throughout the home. We found appropriate and effective action had been taken to conduct appropriate test control within the home.

The provider assisted people to meet their nutritional and healthcare needs. Care records contained a good level of information for care workers to meet these and care workers supported people to access external health professionals when needed.

People using the service were involved in decisions about their care and how their needs were met.

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.

People told us care staff were caring and we observed people being provided with compassionate care. Care staff knew people’s likes and dislikes and respected their privacy and dignity. People’s cultural and religious needs were met.

There was an effective complaints policy and procedu

We conducted a comprehensive inspection of Tower Bridge Care Centre on 1 and 8 March 2017. At this inspection a breach of regulations was found in relation to the safe management of medicines. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to this area. We conducted a focussed inspection on 1, 2 and 9 August 2017 to check the provider had followed their plan and to confirm that they now met legal requirements in relation to the breach found. We also followed up some information of concern that was received prior to the inspection. We found the provider was still in breach of the regulation relating to safe management of medicines as medicines were still not stored in line with legal requirements. We identified some concerns in relation to the information of concern.

This report only covers our findings in relation to the above. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tower Bridge Care Centre on our website at www.cqc.org.uk.

Tower Bridge Care Centre is a care home registered to provide accommodation, nursing and personal care for up to 128 people over four floors. Some of the people who live at the home have dementia. At the time of our inspection there were 100 people using the service.

The service had 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.

Procedures were in place to protect people from abuse. Staff understood how to recognise abuse and knew what to do if they suspected abuse was taking place.

Risk assessments and care plans usually contained clear information for staff. However, we found care plans did not always specify how frequently people were required to be repositioned, to reduce the risks of pressure sores. We also found there were gaps on record sheets in regards to how frequently people were repositioned.

At our previous inspection we found that there were some issues with regard to the safe storage of medicines. At this inspection we found issues remained with the storage of medicines. We also identified one error in medicines administration.

There were enough staff employed and scheduled to work to meet people’s needs and keep them safe.

People were supported to meet their nutrition and hydration needs. People were supported to maintain a balanced, nutritious diet.

People were not always supported to receive personal care from care workers of the gender of their choice.

Notifications were submitted to the Care Quality Commission as required.

During this inspection we found a breach of regulations in relation to the employment of fit and proper persons. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 1 and 8 March 2017 and was unannounced.

We last inspected the service on 28 June 2016. During this inspection we found the service had taken action to address concerns relating to activities.

Tower Bridge Care Centre is a care home registered to provide accommodation, nursing and personal care for up to 128 people over four floors. Some of the people who live at the home have dementia. At the time of our inspection there were 100 people using the service.

The service had 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.

We have made a recommendation about the management of some medicines.

The service did not always demonstrate safe medicines management. Medicines were not always stored in line with good practice. We raised our concerns with the registered manager who evidenced action was being taken to address our concerns in a timely manner. People received their medicines as prescribed.

People were protected against the risk of harm and abuse. The service ensured staff received on-going safeguarding training to enable staff to recognise and report suspected abuse. Risk assessments were comprehensive and gave staff clear guidance on identifying and managing risks. Risk assessments were reviewed regularly.

People received care and support from suitable numbers of staff that had undergone rigorous employment checks. Staff received a comprehensive induction from senior staff to ensure their suitability to work unsupported. People were supported by staff that were trained to meet their needs. Staff received on-going mandatory training, supervisions and appraisals to reflect on their working practices and improve the delivery of care. Staff were confident in requesting additional training should they feel it would improve their ability to meet people’s needs.

Staff demonstrated sufficient knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People were not deprived of their liberty unlawfully. Where people’s capacity was deemed as lacking the service took appropriate steps and documented decisions made in people’s best interests.

People were supported to access food and drink that met their dietary requirements and nutritional needs. The service involved dieticians and the G.P in assessing people’s dietary requirements and information was shared with the chef. People were offered choices and provided with support with eating their meals.

People received care and support from staff that received on-going training to meet their needs. Training records confirmed staff undertook both e-Learning and classroom based mandatory training. Staff told us the training they received enabled them to gain a greater understanding of their roles and responsibilities. Staff confirmed they could request additional training to enhance their skills. People’s confidentiality was maintained and respected. Staff were aware of the possible implications of breaching people’s confidentiality and ensured information shared was only done so with people with authorisation. Staff communicated effectively with people in a manner they understood and preferred.

The service developed care plans which looked at people’s history, preferences, medical and health care needs. Care plans were reviewed regularly and where possible, people and their relatives were encouraged to develop them. Care plans gave clear guidance to staff on how people wanted to be supported and have their needs met.

People were encouraged and supported to make decisions about the care and support they received. Staff used different techniques to aid people in their decision making process. People

This inspection took place on 28, 30 June and 12 July 2016 and was unannounced.

Tower Bridge Care Centre is a home registered to provide accommodation, nursing and personal care for up to 128 people. Some of the people who live at the home have dementia. At the time of our inspection, 95 people lived at the home.

The service did not have a registered manager in post. A manager had been recruited and in place since February 2016 and had submitted his application to the Care Quality Commission to become registered. At the time of the inspection the application was in progress. 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.

We last carried out a comprehensive inspection of this home on 18 and 23 November 2015 and we found three breaches of regulation.

We carried out a focused inspection on 28, 30 June and 12 July 2016 to look areas of concern identified at the last inspection. This report covers our findings at the inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tower Bridge Care Centre on our website at www.cqc.org.uk

People were encouraged to participate in a wide range of activities and activity coordinators were developing the activity programme. People’s preferences of activities were not always recorded in their care plans.

People were protected against identified risks. Risk assessments in place gave staff adequate guidance on how to manage identified risks in order to protect both people and staff safely. The manager responded to feedback in ensuring risk assessments were comprehensive. People’s care plans were person centred and tailored to their individual needs. A new care plan system was being implemented at the time of the inspection. Care plans were comprehensive and detailed people’s preferences, history and other aspects of their care needs.

People were supported by sufficient numbers of staff to rise from bed when they wished. Staff were available to support people throughout the day and night. People received care and support from staff that reflected on their working practice. Staff received on-going guidance and support from their seniors by means of supervision and appraisals.

People were supported to have their meals in a relaxed and encouraging environment. Staff supported people to eat their meals independently whenever appropriate.

People received care from staff that were attentive to their needs. Staff maintained and encouraged people’s dignity and treated them with respect. Staff were supported by the new management team who operated an open door policy and completed frequent audits to ensure the safety of the service.

We carried out an unannounced comprehensive inspection of this service on 16 and 17 June 2015. Breaches of five legal requirements were found and we issued warning notices for two of the breaches in relation to safe care and treatment and meeting people’s nutrition and hydration needs.

We undertook this focused inspection on 12 August 2015 to check that they had complied with the warning notices. This report only covers our findings in relation to those two requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tower Bridge Care Centre on our website at www.cqc.org.uk. The provider was not meeting the requirements of the warning notices and we are considering what further action we need to take. We will check on the outstanding breaches at our next comprehensive inspection on the service.

At the time of this inspection 84 people were using the service. A new permanent manager had been recruited and was in the process of registering with the Care Quality Commission. 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 our previous inspection we found that safe care and treatment was not provided as there was not proper and safe management of medicines. We found that medicines were not stored appropriately, adequate stocks were not maintained and medicines were not administered as prescribed. At this inspection we saw that appropriate supplies of medicines were delivered to the service. Medicines were stored securely and on three out of the four floors people received their medicines as prescribed. However, on first floor we saw that people did not always receive their medicines as prescribed and the stocks of medicines did not tally with the numbers recorded as administered on people’s medicine administration records. People’s opened insulin pens were not stored appropriately. People were potentially left in pain, discomfort and anxious as they did not receive their medicines as prescribed. The service continued to be in breach of regulation 12 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.

At our previous inspection we found that some people were not supported to have sufficient to eat and drink. We found that some people requiring their fluid intake to be monitored however, fluid charts were not completed correctly. We saw there were delays in people receiving drinks and some people’s specific dietary requirements were not shared with the kitchen staff. At this inspection people’s nutrition and hydration needs were met. People were supported to eat and drink sufficient amounts to meet their needs. Staff were aware of people’s dietary requirements and liaised with other health care professionals when needed to obtain further advice and guidance about how to support people safely at mealtimes.

Two inspectors carried out this inspection. The focus of the inspection was to follow up on previous concerns we had raised about safe medicines management and completion of care records during an inspection on 10 and 11 September 2014.

Below is a summary of what we found. The summary describes what staff told us, what we observed and the records we looked at. Due to the areas we looked at we did not speak to people using the service during this inspection

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

At our previous inspection we found that detailed records were not kept in regards to people’s topical medicines and that the times that medicines were administered was not always recorded. During this inspection we found that the majority of topical medication administration records contained detailed instructions about directions for use and topical medicines were administered in line with their prescription. The medicine administration records we reviewed were completed correctly and included the times of when medicines were administered.

Is the service effective?

Not reviewed during this inspection

Is the service caring?

Not reviewed during this inspection

Is the service responsive to people’s needs?

At our previous inspection we found people’s care records were not detailed and there was missing information in regards to people’s care and support needs. During this inspection we saw the care records had been reviewed and contained detailed information about people’s care and support needs, and these were regularly reviewed to ensure they reflected people’s current needs. We saw records were kept to ensure people received the ongoing monitoring required to meet their needs, for example, regular repositioning for people at risk of developing pressure ulcers and completion of food and fluid charts for people at risk of dehydration and becoming malnourished.

Is the service well-led?

At our previous inspection we found care records and confidential information was not kept securely. During this inspection records were kept securely.

The registered manager undertook audits and regular checks to ensure care records were detailed and reflected people’s needs. They ensured the required action was taken when areas for improvement were identified.

An inspection team carried out this inspection, including two inspectors and a specialist advisor who has experience of older adults nursing. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, 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.

This is a summary of what we found:

Is the service safe?

People who used the service told us they felt safe at the service. The staff were aware of what to do if they witnessed or suspected abuse was taking place and were confident to challenge unsafe practice and report any concerns to the manager.

There were appropriate staffing levels to keep people safe, and staff had the skills and knowledge to keep people safe.

However, we found that improvements were required with the management of medicines. We found gaps in medication administration records and we could not be assured that people were receiving their medication as prescribed.

Is the service effective?

Staff demonstrated an understanding of the support needs of people who used the service, including people with dementia. A training programme had been implemented to provide staff with updated skills and knowledge to support people who used the service. Staff told us the recent training they received in wound care management had led to them being able to provide a better quality service.

People who used the service told us, “[the staff] are as good as gold. Everything is good when they are here. The staff are very polite and I feel safe here.” Another person said, “The staff are not bad they are doing a good job.”

However, we found that care records relating to people who used the service were in the process of being reviewed. Those that had not yet been updated were unclear and disorganised. They also lacked detail regarding people’s support needs, which meant there was a risk that people did not receive the care they required.

Is the service caring?

One person using the service told us, “they look after me well.” Another person said, “I’m satisfied here.”

We saw positive interactions between people who used the service and staff. On the second floor there were a number of anxious people wandering around the floor and repeatedly asking questions. We saw that staff answered people’s questions patiently, reassured them and spoke to them kindly and with respect.

Is the service responsive to people’s needs?

Staff were busy but were responsive to people’s needs. We observed people’s call bells being answered in a timely manner. One person who used a call bell told us “my favourite thing is this call bell. They always come if I use it.”

Staff were spending time talking with people and providing one to one interactions with people. This ensured people had someone to talk to and did not feel isolated. The staff at the home were continuing to look for ways to engage people at the service.

Is the service well-led?

Since the new manager had been in post staff commented that the leadership they were lacking was now in place. We were told about additional senior positions that had been recruited to including unit managers, and senior care assistant roles to provide leadership to different staff groups at the home.

There were systems in place to review the quality of the service provided, and we saw that areas identified as requiring improvement were being addressed.

We carried out our inspection on 30 October 2013 to follow up non-compliance we had identified for two regulations at our previous inspection on 15 May 2013. At the previous inspection the provider was not meeting the standards for management of medicines and supporting workers.

We found the provider had made significant progress in implementing actions to address the concerns identified at our previous inspection. There were appropriate arrangements in place to ensure that people were protected against the risks associated with the unsafe management of medicines. Suitable arrangements were now in place to support staff through appropriate supervision and appraisal.

At our inspection on 15 May 2013 we found the provider was meeting the standard relating to safeguarding people who use the service from abuse. However, we inspected this standard again because of the volume of safeguarding casework reported on our records and concerns that the local authority commissioners had raised with us about this. We found, as previously, that there were appropriate arrangements in place to protect people from abuse. The local authority commissioners told us that despite their earlier concerns, the majority of safeguarding cases investigated had not been substantiated and the volume of cases had decreased recently.

The local authority commissioners reported to us from their monitoring visits carried out at the service that there had been significant improvement in areas of concern previously identified at the home. On 30 September 2013 they relaxed the restrictions that had been in place for placements to the home.

At our inspection we spoke with a visiting social worker who had been supporting the service following the transfer of a group of people from another home to occupy the new dementia wing at the service. They told us that after some initial difficulties the service had worked hard to settle the new people in and had brought about significant improvements in their engagement with staff, activities and other people in the home.

We used a number of different methods to help us understand the experiences of people because some people using the service had dementia and could not contribute fully to the inspection process.

The people we were able to speak with said they satisfied with their care. One person said, “The staff are well trained and are generally available if I want to discuss things with them. If they are busy, they say they will come back to me and they do.” Another said, “It’s a very good home and is always kept clean and nice. The staff always listen to me, are polite and do a good job.” One person was satisfied that there care needs were met but said, “The staff keep changing and I get a lot of different carers.”

We found that people’s care, treatment and support needs were met in most respects and we observed that staff interactions with people were mostly positive. The service worked in co-operation with other providers and there were appropriate arrangements in place to protect people from abuse.

However, we found shortcomings in the management of medicines and the arrangements for supporting staff.

We carried out an inspection of Tower Bridge Care Centre on 6 December 2011. At that inspection most people we spoke with were generally positive about the care and treatment they received. Although these views were borne out by some of the care and interventions we observed, we found concerns in the following areas of service provision: respecting and involving people; care and welfare; safeguarding; medicines management; safety and suitability of premises; supporting staff, and quality assurance.

Following the inspection, the organisation provided us with an action plan to tell us what they were doing to make improvements. We visited on 24 May 2012 to see whether they had made these improvements.

During our recent inspection all of the people we spoke with told us that they were given a good standard of service and received the care and support they needed. One person told us that they were “very happy at the home”. Another said that “the staff are very nice”. Two relatives we spoke with told us that communication with staff, cleanliness and the range of activities had improved over the last few months.

Overall, we found that the concerns we identified previously had been addressed and the home was now meeting the essential standards of quality and safety.

The people we spoke with were generally positive about the care and respect they received from staff, the choices they had and the information they were given. They said they liked the home and staff were good at looking after them and gave them the care they needed. They said that there were things for them to do if they wanted to take part. However, one person was unhappy about how they had been treated by one member of staff and we drew this to the attention of the home manager to look into.

Although the generally positive views were borne out by some of the care and interventions we observed, our report identifies concerns in respecting and involving people; care and welfare; safeguarding; medicines management, safety and suitability of premises, staffing support and quality assurance.

Tower Bridge Care Centre was taken under new ownership on 31 October 2011. The new provider, HC-One Limited, carried out a full quality audit of the home in November 2011 and found that improvements were necessary in the quality of care and support, home environment, staffing and management and leadership. At the time of our inspection the home was implementing a detailed action plan to address these findings.

This inspection took place on 18 and 23 November 2016 and was unannounced.

Tower Bridge Care Centre is a home registered to provide accommodation, nursing and personal care for up to 128 people. Some of the people who live at the home have dementia. At the time of our inspection, 75 people lived at the home.

A manager had been recruited and her application to be registered with the Care Quality Commission had been submitted and our assessment was underway at the time of the inspection. The manager was registered in early January 2016. 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 comprehensive inspection of this service was in June 2015 and a follow up inspection was carried out in August 2015. At the last comprehensive inspection, the provider was placed into special measures by CQC. This inspection in November 2015 found that there was enough improvement to take the provider out of special measures. We found improvements compared to our visits in June and August 2015. In particular, we found improvements in the way medicines were managed. We also found that care was delivered in line with advice from specialists, particularly in relation to pressure ulcer care, nutrition and hydration. Previous requirements relating to those areas of care were met. We also found the new management team had established processes to assess monitor and improve the quality and safety of the service.

We found three breaches of regulation at this inspection. We found not all risk assessments were clear or in place and so people and staff were potentially at risk of harm because staff did not have appropriate guidance. We have made a recommendation about the frequency of formal supervision for staff. We found two breaches of regulations which were repeated from our last inspection in June 2015. We found that people did not always receive care when they wished because staff were not always available. We also found the provider did not monitor the quality and safety of the service when there was no manager in place.

Staff were knowledgeable about abuse and the manager had taken prompt action when allegations were made to ensure they were investigated. Medicines were managed safely and this was an improvement on previous inspection findings. Safe recruitment practices were followed.

People were given assistance with meals when they needed it but the records were not adequately detailed to monitor their preferences. Records of other care tasks were not always kept and we could not be sure they had been carried out.

The manager and staff were aware of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The manager made applications to protect people under DoLS when this was judged appropriate and improvements were being made in relation to assessments of people’s capacity to consent and holding ‘best interests’ meetings.

We saw many instances of staff being kind and caring to people but we saw a minority of staff were not. We saw two instances where staff who helped people with meals were disrespectful and inconsiderate. One of these staff members raised their voice while assisting the person. The second staff member did not inform the person what the meal was, and did not look at them so they could assess their reaction and needs in relation to the meal. In other situations we saw that people’s dignity was respected.

People and their relatives did not always have the opportunity to contribute to care records and plans so they did not adequately reflect people’s wishes and needs about their care. There were activities provided but they did not always reflect people’s recorded wishes and interests, and in some cases these were not recorded.

Staff did not always work well together to benefit the people who lived at the home and a sense of teamwork was not always present. The manager had introduced quality audits with a view to making improvements. These included making spot checks on the home at night time to make sure that staff  provided effective care at all times. She was proactive in addressing problems.