This unannounced inspection took place on 26 and 27 October 2016. This residential care home is registered to provide accommodation and personal care for up to 72 people and is split over two floors. At the time of our inspection there were 37 people living in the home. Tusker House provides residential care for older people many of whom are living with Dementia.

People were safeguarded from harm as the provider had effective systems in place to prevent, recognise and report concerns to the relevant authorities. Staff knew how to recognise harm and were knowledgeable about the steps they should take if they were concerned that someone may be at risk.

Staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately.

There were sufficient numbers of experienced staff that were supported to carry out their roles to meet the assessed needs of people living at the home. Staff received training in areas that enabled them to understand and meet the care needs of each person. Recruitment procedures protected people from receiving unsafe care from care staff unsuited to the role.

People’s care and support needs were continually monitored and reviewed to ensure that care was provided in the way that they needed. People had been involved in planning and reviewing their care and had detailed individualised plans of care in place to guide staff in delivering their care and support.

People’s health and well-being was monitored by staff and they were supported to access health professionals in a timely manner when they needed to. People were supported to have sufficient amounts to eat and drink to maintain a balanced diet.

Staff understood the importance of obtaining people’s consent when supporting them with their daily living needs. People experienced caring relationships with staff and good interaction was evident, as staff took time to listen and understand what people needed.

People’s needs were met in line with their individual care plans and assessed needs. Staff took time to get to know people and ensured that people’s care was tailored to their individual needs.

People had the information they needed to make a complaint and the service had processes in place to respond to any complaints.

People were supported by a team of staff that had the managerial guidance and support they needed to carry out their roles. The quality of the service was monitored by the audits regularly carried out by the registered manager and by the provider.

We used a number of different methods to help us understand the experience of the people who used the service, because they had complex needs which meant not everyone was able to tell us their experiences. On the day of the inspection 49 people were living at Tusker House. We spoke with people who lived at the home and their relatives. We spoke with care staff, kitchen staff, housekeeping staff, senior care staff, deputy manager and the manager. We left comment cards at the home, for people to complete if they wished, and we received 15 completed cards. All of the comments were positive about the support and care provided at Tusker House. The comments stated that the staff were very caring, the home was welcoming and that the activities provided were very good.

We found that people were happy living at the home and felt the staff provided the care and support they wanted. One person said, "I have everything I need, including nice friends and good carers." A relative we spoke with told us that the staff looked after people very well, and they were sure of this as a number of their relatives had lived at Tusker House.

We observed that staff treated people with respect and protected their dignity.

The manager had developed good relationships with allied health professionals and other health providers, consequently the home had access to a range of services.

We carried out an inspection on 4 August 2013 in response to concerns raised, that there were not enough staff on duty to meet people’s needs. The provider had contacted us following the inspection stating that they were compliant, and we assessed this during this inspection. We looked at the staffing rota and discussed staffing levels with people, staff and visitors. We were told, and observed, that there were sufficient staff working in the home during the inspection.

There were systems in place to assess and monitor the quality of the services for people with dementia.

We were not able to speak to people using the service because we carried out our inspection at night and people were being assisted to go to bed. We gathered evidence of people’s experiences of the service by reviewing care plans, records of people’s falls and staff rotas. We also spoke with six staff, the provider and the assistant manager.

The records that we looked at showed that people’s preferences for bedtime routines were documented. We saw that there was a high incidence of falls between the hours of 10pm and 2am, and 6am and 10am. The provider had introduced additional checks on people during high risk times. We did not see any evidence to show that staffing levels had been altered to reflect these increased demands.

Four staff told us they did not have enough time to provide the level of care that they wanted to.

We found that there were not enough staff on duty to meet people’s needs.

We used a number of different methods to help us understand the experiences of the people who used the service, because they had complex needs which meant not everyone was able to tell us their experiences. We observed care being provided by staff in attentive and caring ways.

We did speak with three people who used the service. They all told us that they liked living at Tusker House. One person said, “I am happy here. I have friends here and recommend the home to other friends.”

One relative we spoke with told us the person had settled well in the home. They felt that staff were attentive and responded to the person’s needs. When a concern had been raised they felt that appropriate action had been taken by the management.

The service had processes and procedures in place to ensure that equipment was available when people needed to use it. Staff had received training to use equipment safely. There were records in place that showed that routine and regular maintenance was carried out. Staff told us that it ‘was a good place to work’ and ‘the home had a welcoming atmosphere’.

We saw evidence that showed that appropriate arrangements were in place to recruit, support and develop staff. We looked at staffing rotas which showed there was a consistent number of staff on duty.

We looked at a range of records retained by the home. These records were monitored and reviewed frequently.

We used a number of different methods to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not always able to tell us their experiences. We observed how people interacted with staff and the management of the service. We saw they felt free to express their opinions and were listened to. We saw that people were comfortable in the environment and were usually able to find their way around.

One person told us, ‘I like it here, I have a lovely room and the staff are very friendly.’

We spoke to some relatives who told us that, ‘I can’t fault it. The staff know the signs to look for as my relative is unable to communicate verbally.’

One relative told us, ‘mum always smells nice and is clean and tidy.’

Another person told us ‘the food here is excellent every day…the bacon pudding looked lovely, I wouldn’t have minded eating it myself’.

Another said they were very impressed with the care in the home, ‘the staff are very caring….no complaints’.

We did observe how staff cared for people and seeing whether people seemed to be happy and had their needs met. We found that people were treated with respect by staff.

During our visit a planned residents meeting was held. People were asked by the manager for their views on the menus, the activities and the general standards of the home. People said that they were happy with the care they were receiving and that they had no complaints. One person said “The staff are good, the food is good, the home is good”.

People were offered the opportunity to have a say about what meals were included on the menu and some suggestions were made. One person asked for condiments to be placed on all the dining tables rather than having to ask for these. The manager said she would arrange this. People were also asked for their views of the social activities provided in the home and for suggestions of things they might like to do. One person asked for a music quiz and the manager said this would be arranged. People’s comments about the activities included:

“The music for health is excellent”.

“I think the activities are very good” and

“I enjoy doing my model making, I wasn’t doing that before”.

We received feedback from some relatives who told us that the care provided was of a good standard. People said they felt safe in the home and knew who they could talk to if they had a concern about their care.

People told us that they had not had to wait an unreasonable amount of time for their personal care that morning and that they were satisfied that there were enough staff to meet their needs.

People and their relatives told us that they had looked around the home before they moved in. One relative told us “we were shown a variety of rooms and chose one”. Relatives also confirmed that the home had undertaken an assessment of their family member’s needs before they had moved in. People that use the service told us that they were happy with their care. Comments included “It’s all very nice” and “I’m happy as I am, nothing needs improving”. One relative said “Compared to any of the homes we have seen we couldn’t wish for a better home, we couldn’t want for her (their family member) to be in a better place”. Other relatives said “It’s quite good, no fault with it” and “Overall I am satisfied”.

One person told us they could get up when they wished to as they were able to get out of bed themselves, but others said they were not able to choose when to get up, as they had to wait for the staff to be available to help them. When asked if they could go to bed when they liked one person said “not when I like, no”. They explained that there were “several who go up in the lift and we all go together when the night staff come on”. People told us that they had been helped to have a bath recently; with most saying that this had been within the last few days.

People told us they were happy with the food and most people said that although they did not get a choice of meals they could ask for something else if they did not like what was provided. One person said “it’s very nice and if there’s nothing I like they always offer me something else, like today I didn’t like gammon and I had fish and they also asked me if I was happy with it”. One relative told us that the food was “lovely” and that people did get an alternative when they didn’t like what was on the menu for the day. People told us that they always had a choice of drinks.

People told us that when they were unwell they had access to a doctor or nurse. Relatives we spoke with confirmed that they were always kept informed about their family member’s health and gave examples of when the staff had telephoned them due to their family member being unwell.

People that use the service said that there were some activities in the home and one person told us that “X (the activities staff) does things, sometimes we have a game of ludo, I enjoy that”. Relatives confirmed they had seen activities going on such as music and exercise, dancing, singing and they said that newspapers were delivered everyday.

People using the service told us that the home was always clean. One person said “the cleaner is nice she does my room when I come down in the morning”. Relatives confirmed that the home was always clean and tidy. One person said “Its always spotless and sweet smelling”. People that visit the service told us that the odour in the entrance hall had improved. One person said “Its always spotless and sweet smelling”. Another said “there is an odour sometimes, but I would expect it and I don’t think it can be helped”. People said that they were happy with their rooms. One person said “it’s very nice” and they told us that they had brought things in such as photographs to make their room feel comfortable.

People using the service told us that the staff were kind, caring and sensitive when helping them with their personal care. One person felt that staff were knowledgeable about their care needs. They said “they are all very nice people”. Relatives told us that interactions between people using the service and the staff were very good. Comments from relatives about the staff included “the staff show such compassion”, “very good” and “The members of staff are purposeful, professional and caring beyond the call of duty.”

People using the service told us that they felt safe in the home. They said that they were not formally asked their views of the service, but most knew how to make a compliant if they needed to. One person said they had not made any complaints but said they would complain to the “office” if they needed to and felt confident things would be sorted out. One relative did not feel they were often asked their opinion of the home, but did confirm that they had completed a questionnaire recently. Another person told us they had never made a formal complaint, but had raised some issues which were always resolved, so they felt confident any complaint would be sorted out.

The people that use the service at Tusker house have dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us about their experiences and we also spoke with visitors to the service and other health professionals.

People who regularly visit the service told us that generally they saw people being treated with respect and one person told us that their relative had continued to be able to make their own decisions, for example if they chose not to shave that day this was respected.

Visitors generally commented positively about the approach of the staff and one person said “99% of the staff put that extra bit in and are really friendly” and another said “the activities worker circulates all the time in the lounge giving people a boost”. However, one person commented “Some staff are great, but I have seen others just dumping people down in chairs with no respect”. Some people told us that they had seen people sitting in the lounge for long periods of time without any staff talking to them.

Some people told us they were not happy with how often people that use the service were helped to the toilet. One person said “I am not always sure that people get toileted very often. X is continent but doesn’t know how to ask staff to take them to the toilet. Several times I have come in and X has been soaked up their back. Once I had to ask staff to take them to the toilet to and when they brought them back they went to sit them on the same chair. I had to stop them and clean it myself first” Another person said “I have seen others being taken away [to get changed] and chairs not cleaned and then another person goes and sits in it.” They also said they had needed to point out to staff that someone had been incontinent. However, this was not everyone’s experience and one person told us that they were completely satisfied that their relative was helped to the toilet when needed and as far as they were aware they were helped to have a bath regularly as they always appeared clean. They said “the level of care shown to X has transformed my family’s life” and that there was an “emphasis on normality of life”.

One person told us that they were concerned about the number of falls people using the service had. They said their relative had twice fallen and been injured since being in the home. They felt that they had not been given a satisfactory explanation about how the falls had happened or what would be done to stop it happening again. Another person told us that their relative had fallen in the home, but they were satisfied that the service had told them what action they were going to take to help keep the person safe.

People told us that they had some choices about the care they were provided with. They said they could choose whether they wanted to join in with the social activities in the home and had a choice of drinks throughout the day. However, most people told us that they did not have a choice of meals and one person said ‘’we have a choice whether to eat it or not’’.

People using the service said they thought the home was kept “reasonably clean”. They told us they were happy with their rooms and the facilities available. Visitors to the home, including health professionals, told us that they had noticed an unpleasant odour in the entrance hall.

People told us that they were aware of staff shortages in the home, but said that sometimes staff from the office would come and help people to eat their meals at lunchtime. Visitors told us that they did not feel there were enough staff as they had no time to spend with people to sit and talk with them. One person told us that they had noticed the use of agency staff had increased recently.

One person told us that they thought it was good that the staff had a good grasp of English and so there were no language barriers between them and the people that use the service.

A single adult social care inspector carried out this inspection. 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, visitors and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is it safe?

Care was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw care plans that were sufficiently detailed to allow staff to deliver safe and responsive care. People told us they were happy with the care and support they received. A person who used the service said, "The carers do their work brilliantly, they are kind and patient and the nursing staff are wonderful. I think this is the only place that enables me to be as happy as I am.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had been submitted, proper policies and procedures were in place. Relevant staff were trained to understand when an application should be made and how to submit one.

We looked at the staffing levels and staff skills and experience and found that there were sufficient suitably trained staff to meet the people’s needs at Tusker House at this time. We however had received mixed comments from people and visitors about the staff provision before our inspection which was acknowledged by the management team. We were told, "We have recently changed shift patterns to overlap the times when it is busy, and this has addressed the staffing issues."

Systems were in place for staff to learn from incidents, accidents and near misses

Is it effective?

People had their needs assessed and individual care plans were devised. Before anyone joined the service, a pre-admission assessment took place.

Care plans were detailed and provided personalised information which enabled care staff to provide care and treatment which was individual to that person.

People maintained good health. The service worked closely with GPs, care coordinators and the local authority.

Systems were in place to monitor, assess and improve the quality of the service. Feedback was regularly obtained from people who used the service and their relatives.

There was a clear complaint policy and procedure in place that ensured complaints were handled and resolved appropriately.

Care plans were personalised and included information on the person’s life history and identity. This allowed for staff to provide care that was personalised and appropriate to that person.

We saw that there were systems in place to support staff. A member of staff said, “I love working here. It’s easy-going and a real family atmosphere. I can talk with [the manager], their door is always open.”

Is it caring?

Staff spoke with compassion and kindness for the people they supported.

People were supported by committed and attentive staff. Observations of care found that people were treated with dignity and respect. We were told, “[My relative] receives very good care here. Everyone is so friendly and approachable.”

Staff demonstrated a good understanding of the care needs of people who used the service.

People were encouraged to treat the service as their own home.

People were treated with dignity and respect.

It is responsive?

People told us that they felt happy and confident approaching staff with any concerns.

The staff we spoke with understood and respected people's choices and decisions.

People had their needs assessed and support from external health professionals' was sought where necessary.

Where's people's health had rapidly deteriorated we saw that the service took appropriate action.

People had access to activities which we saw they enjoyed and responded to.

Is it well-led?

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. Quality and compliance audits were regularly conducted. Where it was required, responses to the audits findings were developed and these were recorded.

Staff we spoke with had a clear understanding of why they were there and what their roles and responsibilities were.

The service had a business continuity policy in place. This made sure that each service had a plan in place to deal with foreseeable emergencies. This would reduce the risk of people's care being affected in the event of an emergency such as flooding or a fire.