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Inspection carried out on 15 March 2017

During a routine inspection

Tyspane is a large, purpose-built, two storey building set in its own gardens and grounds in Braunton, North Devon. The home provides nursing and personal care for up to 69 people and is also registered for the treatment of disease, disorder and injury. On the first day of our visit there were 62 people living at the home, with three of those people receiving respite care. One person was receiving care at the local hospital.

At the last inspection in January 2015, the service was rated Good.

At this inspection we found the service remained Good.

People said they felt safe and cared for in the home. There were sufficient, suitably qualified staff to

meet people’s needs. The provider was needing to use agency staff where additional staffing was required. There were robust recruitment checks in place.

People were protected from the risks of abuse as staff understood and carried out what they needed

to do when they identified a concern.

There was a safe system to ensure the safe management of medicines at the service. Medicines were administered by registered nurses and care practitioners who had been trained regarding medicine management and had their competency regularly checked.

People’s needs and risks were assessed before they were first admitted to the home and these were

reviewed on a regular basis and when a change in their needs was identified. There were environmental risk assessments which ensured the premises were safe.

Staff had the skills and knowledge to support people appropriately. They received regular supervision and appraisals to support them with their performance and future development. New staff undertook a thorough induction when they started working at the service

People were supported to have a balanced and variable diet. Where people had specific dietary requirements these were catered for.

People had access to health professionals. A Physiotherapy worked at the home each Friday and a physiotherapist assistant was provided at the service to provide on going support to people with their physical mobility needs.

Staff were very caring and kind. They treated people with respect and dignity at all times. There was a friendly atmosphere at the home and a strong ethos from the registered manager and all staff regarding it being the people’s home and a privilege to be able to spend time with them.

The registered manager and deputy manager had been undertaking the six steps end of life programme to further improve end of life care at the service.

There were four designated activity staff to support people to engage in activities that they were interested in, on an individual and group basis.

People knew how to make a complaint if necessary. They said if they had a concern or complaint they would feel happy to raise it with any member of staff without any worries about repercussion. There had been two complaints since our last inspection which had been responded to in line with the provider’s policy.

There was a registered manager in post who was very active within the service. They led by example and had a high level of expectation of the staff to deliver good quality care.

The provider had several assurance systems in place to assure themselves the service was running safely. These included monitoring visits from the quality team, health and safety and monthly visits from the regional operations director. There were systems in place where the registered manager input data onto the provider’s computer system which could be analysed at the head office.

Inspection carried out on 7 and 9 January 2015

During an inspection looking at part of the service

The inspection took place on 7 and 9 January 2015 and was unannounced.

The service was previously inspected in July 2014 when we found consent to care and treatment was not always sought. During this inspection we found improvements had been put in place which meant these concerns had been addressed. At our last inspection, we also found the home had not safeguarded people who used the service from the risk of abuse. The provider submitted an action plan which identified how they were going to address these concerns. This included obtaining guidance from the local authority, improving the recording of alleged abuse and providing staff training. At this inspection we reviewed the action plan and found the actions had been completed.

Tyspane is a large, purpose-built, two storey building set in its own gardens and grounds. The home provides nursing and personal care for up to 69 people and is also registered for the treatment of disease, disorder and injury. .

Most people had moved into the home on a long-term basis, but the home also provides short term respite care for a maximum of one person at time, with respite stays usually of up to three weeks. At the time of our inspection, there were 63 people living at the home, one of whom was staying at the home for respite care.

Tyspane had a registered manager who had come into post in June 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.

There was a friendly and relaxed atmosphere in the home with staff showing care and consideration to people throughout the visit. People said they thought staff were “very good” and a relative described how the home gave them “peace of mind” as they felt there relative was well cared for.

Since the registered manager had taken over in June 2014, a programme of redecoration and refurbishment had been implemented, which people said had made the home a much more comfortable and pleasant place to live in. Improvements had also taken place in working areas such as the laundry which staff said had been “really good”.

Staffing levels were calculated on the level of need. Staff supported people with an easy, unrushed manner with a pleasant demeanour. Staff said they were supported by the registered manager and senior staff and received training, regular supervision and annual appraisals.

The home provided a variety of activities for people both in the home and on trips out. People were involved in deciding what activities would be offered. People said they enjoyed going out, cooking, quizzes and “pampering” such as manicures and having their hair done.

People’s needs and risks were assessed before admission to the home and these were reviewed on a regular basis. Care plans were developed to address the needs taking into account people’s preferences. Staff undertook capacity assessments and where there were concerns about people’s ability to make decisions, they worked with other professionals. This included considering whether an application for a Deprivation of Liberty Safeguards (DoLS) authorisation needed to be made.

Health and social care professionals said staff were responsive to people’s needs and involved them when they had a concern.

The registered manager supported staff to understand the vision and values of the home. There were systems in place, including audits, which allowed them to monitor the quality of care provided. Where this identified areas where improvement was needed, the manager worked with staff to deliver the improvements. People and their relatives were also involved in identifying how the home could improve and care could be enhanced. This included regular meetings where they were able to make suggestions for activities they would enjoy doing, enhancements to the décor and changes to the food and drink offered.

Inspection carried out on 20 June 2014

During a routine inspection

A single 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 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:

Is the service safe?

We found the service was not always safe. However people who lived at the service told us they felt safe. One person said "The staff are excellent and can�t be faulted". Another person said "The staff are lovely". People and relatives told us they felt they could speak with the staff and manager and that they were �very approachable.�

We found that the home was not meeting current practice standards for DoLS (Deprivation of Liberty Safeguards), and did not act in accordance with legal requirements where people lacked the capacity to consent to care and treatment.

People who used the service were not always protected from the risk of abuse because the recording of safeguarding incidents did not allow for a robust cycle of the process to be recorded. This meant it was not clear if the provider responded appropriately to any allegation of abuse. It may also have made it difficult to prevent abuse from happening again in the future.

On the day of our inspection we met seven people who were supported by the service and they looked happy and relaxed. They told us that the support they received made them feel reassured. A relative we spoke with said the support their relative received gave them ��peace of mind��, and that staff always seemed very attentive and approachable.

Care and support was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw comprehensive assessments of need were done before a person received support. We saw the manager did regular audits on medication, infection control, health and safety, and professional practice to make sure care and support were being delivered safely by the staff.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. The manager and training co � ordinator told us that DoLS training forms part of the safeguarding course and that the relevant staff have been trained to understand when an application should be made, and how to submit one.

However, it was noted during the inspection that potentially restrictive practices were used regularly by the home. For example the use of alarmed and monitored internal and external doors, floor and bed pressure pads, and bed sides. The use of these methods had not been formally assessed or documented in relation to whether they may result in a deprivation of liberty for people living there. This meant it was unclear if people who used the service were protected against the risk of unlawful or excessive control or restraint because the provider had not made suitable arrangements.

Is the service effective?

This service was found to be effective because people told us the service supported them to live their lives in a way that suited their personal needs and maintained their quality of life. Some relatives told us there were times when they felt more staff were needed, such as weekends and bank holidays, but on the whole were very happy with the care and support provided. People told us they felt the support they received was good, and one said �There are plenty of staff and you don�t have to wait for help if you ring the bell.�

The training co � ordinator, manager, and staff told us the provider arranged a range of relevant training and support to help staff meet the needs of the people they supported. Training records confirmed this and showed specialist training such as catheter care, epilepsy, nutrition, and CPR had been delivered. This meant staff were enabled to provide safe and effective care to people.

A relative we spoke to told us that told us �My relative is well looked after.� Another told us �It�s wonderful here, I have no complaints.� People and their relatives told us that if they were unhappy with something, they felt confident they could talk to staff or the manager and it would be sorted out quickly. This showed people�s views were listened to and the service was effective at dealing with any concerns or issues.

Is the service caring?

We found the service was caring. For example, we observed staff treated each person as an individual with dignity and respect. People told us that all of the support staff were very kind and ��It�s a lovely place to live��. A relative told us that the longer standing members of staff were very skilled at caring for their relative with limited communication, and this familiarity made them feel their relative was well cared for.

During the inspection we heard and saw staff speaking respectfully with people who lived at the service. We also saw staff using different forms of communication, such as showing people the lunchtime meal options, so people could make their own decisions. This showed that people were communicated to in a way that enabled them to make their own decisions.

Is the service responsive?

We found the service was responsive because people�s needs were thoroughly assessed by the service before they received support. The deputy manager told us most people would trial the service for up to three months and during this time a fuller assessment and care planning would take place. This meant people had the opportunity to see if they were satisfied with the service and their needs and preferences were fully understood.

We saw people's care was planned and delivered in line with their individual preferences. Each person�s care plan was formally reviewed every six months, and changes made if necessary. We saw people�s support needs were also re-assessed every month to ensure they were happy with the support they were receiving and it remained appropriate. This showed the service was responsive to people�s changing needs.

People told us they were able to make choices regarding what time they received their support. The staff we spoke with demonstrated a good understanding of each person's support needs and preferences and how they should be met. This meant people were able to retain control over their daily activities and were supported by skilled staff who were responsive to people�s needs.

Is the service well led?

We found the service had the potential to be well led following a period of several management changes. The new manager had been in post for three weeks at the time of the inspection and was in the process of registering with CQC. She had previously been registered manager in another service. During the inspection she displayed a clear and extensive knowledge of managing a similar size home previously for fourteen years. She was aware of the weaker areas of practice highlighted by the inspection and expressed a determination to prioritise and address these as soon as possible.

There was a clear staffing structure in place with clear lines of reporting and accountability. Staff said they felt well supported by colleagues and the new manager appeared to taking early action to improve the home. They said they now felt they could report any issues or concerns to the manager in the first instance, which they hadn�t previously. The manager said they were able to contact their regional operations manager for advice or support whenever needed. This showed that appropriate support was available for all staff.

The quality of the service was monitored through regular contact and meetings with people and their representatives, audits, staff supervision, and monthly monitoring visits by a senior manager from the provider.

During a check to make sure that the improvements required had been made

We inspected Tyspane on 25 July 2012 and we found the records we sampled did not provide an accurate description of care delivered. We considered this may put people at risk of inconsistent or inappropriate care. The purpose of this report is to explain our findings when we inspected the service on 21 May 2013. These showed the home had improved the way they recorded the care people received. They had taken actions to address the matters we found during our previous inspection and were fully compliant with outcome 21: Records.

Inspection carried out on 21 May 2013

During a routine inspection

We brought forward this planned inspection due to a number of anonymous concerns we received. These included concerns about staffing levels, people's needs not being met and possible unsafe recruitment processes. We found no evidence to support any of these concerns.

During this inspection we spoke with 11 staff and the registered manager. We also spoke with one visiting relative and with nine people about their experiences of living at the home. We spent time observing how care and support was delivered. We looked at some key records. These included care plans, daily records, risk assessments, staff rotas, menus and staff training and recruitment files.

People we spoke with were positive about the staff and the care and support they received. Comments included, ''couldn't ask for better, the staff are all very good.'' ''I I can't find any problems, staff are all lovely. I have never had a problem.''

We observed care and support being delivered in a respectful way, with dignity and independence promoted. We saw that care was well planned and risks were assessed and measures put in place to minimise any identified risks.

Recruitment processes were robust and we found that there were sufficient staff to meet the needs of people currently living at the home.

Systems were in place to review and monitor the quality of care and support provided.

Inspection carried out on 25 July 2012

During a routine inspection

We brought the scheduled inspection forward because we received concerning information about the health and welfare of people at the home. This information suggested that people�s health needs were not being managed appropriately; nutritional and wound care procedures were not being followed which could have put people at risk.

We carried out an unannounced inspection of Tyspane Nursing Home on 25 and 26 July 2012. We focussed on the outcomes for people with regard to health and welfare, nutrition, support and competency of care workers, complaints and record keeping.

We looked at the records of six people in detail; and spoke with seven people about their experiences at the service. There were some people were not able to comment directly on their care so we spent time with them to help us understand what life was like at the home. This meant we spent time observing another four people�s care and interactions with staff to see whether they had positive experiences. To do this we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us about their experiences of care. We used SOFI for one and half hours in the lounge and dining room. At our visit we spoke with 10 staff, two relatives, and the manager.

People told us that they were involved in all aspects of their care and treatment. For example, we were told �They keep me very clean� and �They have met my every need�. We saw that health care professionals worked closely with the home to ensure people�s health was maintained.

People said that they felt safe. For example, one person told us they were looked after by �Brilliant people, who are so nice and very attentive. They treat you like a human being�. We also saw this when we observed people�s experiences. We saw that people were regularly prompted to eat and drink.

We saw that people were occupied with activities and this had a positive effect on their wellbeing. For example, a person told us �A carer came out with me and we went all the way to Barnstaple. It was lovely.� Relatives also remarked about activities, telling us �There�s activities in the lounge every day, outings and other things people can do it they don�t want to join in the group�.

People told us they had confidence in the skills and experience of the care workers. People told us about wound, catheter and tube feeding care and comments included �The nurses are very skilled and follow the hospital regime for doing my dressings�, �They�re always checking my catheter to make sure it�s not overflowing� and �They always flush it (PEG tube) before and after with boiled water every time to check its running through. And they turn it (the tube) so it doesn�t get fast in one place�.

People said that Tyspane was �Homely and a good place to be, which is peaceful and calm� and �This place is exceptional, can�t fault it�. Two relatives told us that communication was �Very good� and one went further by explaining �They were very open� about explaining an incident that had happened.

At this inspection, we made a compliance action about record keeping to ensure that detailed evaluations of care delivered for people was documented. We also made the provider aware of an area that they might improve. This related to feeding people with smaller spoons to avoid the risk of people choking.

Inspection carried out on 8 August 2011

During a routine inspection

During this unannounced visit to Tyspane we spoke to 8 people who live at the home, two visiting relative and to 8 members of staff including the registered manager, nursing and care staff on duty that day.

People who live at the home told us that staff treated them with respect and dignity. Comments included ��staff are all very kind and caring�� �The staff all try hard to make sure I am comfortable and well cared for.�

People who live at the home said that they are involved in making decisions about their care and treatment. One person said in their opinion the manager �really went the extra mile to listen and try and help with making life more pleasant.�

We saw that care and support was well planned and observed staff provided support in a caring and respectful manner throughout different times of the day.

We were told by people living in the home and by staff that we spoke to that there are sufficient numbers of care, nursing and ancillary staff to meet the needs of people living at the home. Several people mentioned the fact that this home provided regular physiotherapy as part of the support that that this really helped to maintain some level of independence and in some cases to build up their strength as part of a rehabilitation plan.

Staff that we spoke to said that in their opinion they had good support, training and supervision to do their job. We saw that training included a range of health and safety topics and some more specialist training.

We saw that the service had good systems in place to ensure that the views of people who live at the home are listen to including any concerns or complaints. People we spoke to told us that they felt confident in voicing their opinion about the service and knew who they could make any concerns known to.

Reports under our old system of regulation (including those from before CQC was created)