Tower Bridge Care Centre

Tower Bridge Care Centre is a residential care home providing personal care to up to 128 people. The service provides support to people aged 65 and over, including people living with dementia. There were 112 people living in the home at the time of the inspection.

People’s experience of using this service and what we found

The provider was still not consistently mitigating risks to people’s health and safety. People had personalised risk assessments in place for different areas of risk, but nutritional care plans did not always contain information about people’s needs and there were no dementia care plans for people to ensure their dementia needs were fully met.

The provider was not always managing people’s medicines safely. People were usually getting their medicines as required and the provider usually kept accurate records of administration. However, we identified one example where a medicated cream was signed for as given when it was not and staff reported internet connectivity issues which delayed their recording of medicines administration.

The provider conducted a range of audits, but these did not identify some of the issues we found at the inspection.

The provider ensured there were enough staff on duty to support people and they had conducted appropriate pre-employment checks before hiring new staff. The provider was meeting the requirements of the Mental Capacity Act 2005 (MCA).

The provider followed good infection prevention and control practises. Notifications of significant events were sent to the CQC as required. The provider ensured lessons were learned when things went wrong.

Staff gave good feedback about their experiences of working for the service and people and their relatives gave mostly positive feedback about the service overall.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (27 October 2022).

This service has been in Special Measures since October 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

At this inspection, we found although the provider had made some improvements, they remained in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has improved to requires improvement. This is based on the findings at this 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

Enforcement and recommendations

We have found breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tower Bridge Care Centre is a residential care home providing personal care to up to 128 people. The service provides support to people aged 65 and over, including people living with dementia. There were 114 people living in the home at the time of the inspection.

People’s experience of using this service and what we found

People’s medicines were not managed safely. There were significant and widespread issues with the ordering, storage and administration of people’s medicines. Staff were administering some medicines without having the appropriate training to do so and people were often missing their medicines due to issues with ordering. These incidents were often not reported and although managers knew about the issues, they had not been rectified by the time of our inspection.

The provider was not always following the principles of the Mental Capacity Act 2005. Where people required decision specific mental capacity assessments and best interest processes to be followed due to needing their medicines to be administered covertly, we found this was not being done.

Although the provider scheduled enough staff to provide people with care, they did not always ensure there was cover when staff called in sick. The service was understaffed on two floors of the building during the first day of our inspection.

The provider had clear risk assessments and support plans in place, in areas such falls or skin integrity. However, we found people’s turning charts were either not being filled in or were not being filled in after people were repositioned.

We were not always assured that the provider was preventing and controlling infection including by ensuring the cleanliness of premises.

Managers and staff were not always clear about their roles as numerous issues had been identified with medicines management and responsibilities for managing those issues were not clear. We found there was a lack of structure in responsibilities and accountability for reporting issues and securing improvement among clinical staff.

Suitable systems were not in place to learn and improve care. The provider was completing audits in a number of areas, including medicines management, but these did not identify the issues we found.

The provider was not promoting a positive culture as staff told us they felt under-appreciated and sometimes felt overworked. The provider did not always work effectively with other professionals. Issues that had been identified with the pharmacy had not been resolved.

The provider engaged with people and their relatives in the running of the service, but did not always effectively engage with staff.

The provider had appropriate systems in place for managing and acting on allegations of abuse.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 June 2021).

At our last inspection we found a breach of the regulations in relation to safe care and treatment. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection, we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to a number of safeguarding allegations. As a result, we undertook a focused inspection to review the key questions of Safe and Well-Led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have found breaches in relation to safe care and treatment, consent, staffing and good governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is inadequate and the service is therefore in special measures. This means we will keep the service under review and will re-inspect within six months of the date we published this report to check for significant improvements.

If the registered provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question, we will take action in line with our enforcement procedures. This usually means that if we have not already done so, we will start processes that will prevent the provider from continuing to operate the service.

For adult social care services, the maximum time for being in special measures will usually be 12 months. If the service has shown improvements when we inspect it, and it is no longer rated inadequate for any of the five key questions, it will no longer be in special measures.

Tower Bridge Care Centre is a residential care home providing nursing and personal care for up to 128 people aged 65 and over, including people living with dementia and people who have nursing and end of life care needs. There were 117 people living in the home at the time of the inspection.

Tower Bridge Care Centre has four floors that supports people over five units. Each unit has separate adapted facilities.

People’s experience of using this service and what we found

People and their relatives were positive about the kind and caring attitude of the staff team and were confident with the level of support received. One relative said, “It’s really good care, I am very pleased, they are lovely people and are looking after them well. I have no complaints and couldn’t be happier, it has taken a lot of stress off my shoulders.”

People and their relatives told us they had been well supported during COVID-19 and the staff team had helped them to stay in touch with each other due to visiting restrictions. One relative said, “Staff take the phone through to them and they are always glad to see them. I can tell by the interaction between them they are treated with dignity and respect.”

The provider worked in line with current guidelines to support safe visiting. We saw they had been flexible and understanding during visits at the end of people’s lives. One relative praised the emotional support and kindness given to them and their family member at a difficult time.

Health and social care professionals involved in regular multidisciplinary meetings with the home spoke of a positive relationship across the staff team. They felt staff had a good oversight of people’s needs and were regularly contacted for advice and support.

Staff were positive about the support from the senior management team and the newly appointed clinical lead. However, there had been no permanent registered manager since January 2021, which had impacted on the management of the service.

Where the provider had identified areas for improvement across the home, plans were being implemented and had not been fully addressed at the time of the inspection. Our records showed the provider had not always notified us about incidents that occurred across the service in a timely manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 21 April 2020).

Why we inspected

The inspection was prompted in part by notifications of recent incidents, which included how the provider managed an incident of a missing person and an incident related to staff misconduct. A decision was made for us to inspect and examine those risks.

As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Enforcement

We have identified a breach of regulations in relation to safe care and treatment. You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and commissioning authorities to monitor progress. If we receive any concerning information we may inspect sooner.

Tower Bridge Care Centre accommodates people in one building across four floors, with each person having their own bedroom and en-suite bathroom. Two floors are for people living 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 living in the early stages of dementia. There were also communal living and dining rooms, a main kitchen, smaller kitchenettes on each floor and external access to a garden so visitors did not need to enter the home.

We found the following examples of good practice.

¿ There were robust protocols in place for visitors upon entry, with temperatures taken and a questionnaire to be completed, which included the infection control guidelines to be maintained during the visit. A personal protective equipment (PPE) station had been set up in the entrance foyer, with important information displayed on the wall, PPE to put on and dispose of safely and hand sanitiser available before entering the home.

¿ Socially distanced garden and bedroom visits were taking place, via an appointment booking system for set times and limited numbers of visitors at one time, to avoid potential infection transmission with other visitors.

¿ Where people’s relatives were unable to visit, people were supported to stay in touch with them with via phone and video calls. Video call sessions were booked to ensure devices were available, with staff also using their own mobile phones to help facilitate calls where people did not have their own devices.

¿ Posters were displayed throughout the home to provide advice and top tips for staff to help them communicate more effectively with people whilst they had to wear a face mask. Staff had requested support from health and social care professionals and had worked closely with one health and social care professional for a strategy on supporting people living with dementia when they walked with purpose and how infection risks can be reduced.

¿ The home had implemented innovative use of technology to improve communication and keep staff updated. Three communication groups to share updates via WhatsApp had been set up, for the whole home staff team, the senior management team and also a healthcare professional chat group, facilitated by a geriatrician which received positive feedback in the local media. The registered manager said having this support and advice had been invaluable during the peak of the pandemic.

¿ The provider had set up a confidential staff helpline to provide advice, emotional and wellbeing support, which was available 24/7. This was displayed across the home to remind staff further support was available if needed.

¿ Staff had been able to manage and contain any outbreaks within the home with the processes they had in place. A health and social care professional we spoke with praised the resilience and dedication of the staff team and felt the leadership of the home had been crucial in how the home had coped, especially during the peak of the pandemic.

Tower Bridge Care Centre provides nursing care, respite and accommodation for up to 128 people over four floors. Two floors are for people living 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 118 people using the service.

People’s experience of using this service

People were given appropriate support with their medicines and clear records were kept upon administration. The provider effectively managed risks to people’s health and safety, the risk of infection as well as their risk of being abused. The provider conducted appropriate pre- employment checks before anyone started working at the service and mechanisms were in place to learn lessons when things went wrong.

People were given the support they needed with their nutritional needs. The provider worked effectively with other agencies to give people the care they needed and supported people effectively with their healthcare needs and their end of life care needs.

The provider conducted appropriate checks of people’s needs and choices and incorporated these into a clear plan of their care. Care was delivered in line with current standards. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People’s equality and diversity was respected and promoted and their privacy and dignity was also met.

The provider produced a personalised care plan of people’s needs and supported them to express their views and be involved in making ongoing decisions about their care. The provider had communication care plans in place and used different methods to communicate with people according to their needs.

The home was designed to meet people’s needs and the provider had a varied programme of activities in place to engage people. There was a clear complaints policy and procedure in place which was adhered to and the provider acted in accordance with their duty of candour responsibilities.

Staff were given the support they needed to do their jobs which included an initial induction and ongoing training, supervision sessions and appraisals.

People gave good feedback about the service and care staff told us the culture of the service was positive. Care staff gave us good feedback about the registered manager in particular. The provider engaged people in the running of the service by seeking and acting on their feedback. The provider monitored the quality of the service and took action where improvements were required.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was requires improvement (published 25 February 2019).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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 procedure in place and people told us they felt comfortable raising a complaint where needed.

The provider delivered a range of activities and monitored people’s involvement to reduce the risk of social isolation.

People received appropriate support at the end of their lives.

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.

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 had their choices and decisions respected by staff. The service had a diverse activity plan in place that where possible took into account people’s preferences. People were encouraged to participate in a wide range of activities with their peers. People and their relatives were encouraged to give feedback on activities provided to improve the service provision.

People were aware of how to raise concerns and complaints. The service had a complaints policy available to people. Complaints raised were documented and action taken to seek a positive resolution in a timely manner. All complaints logged were reviewed by the registered manager, to monitor trends and ensure repeat incidents were mitigated.

The registered manager carried out audits of the service to drive improvements. Audits looked at health and safety, staff training, care plans and risk assessments. Where issues were identified, action was taken to address these in a timely manner. Quality assurance questionnaires were sent to people and their relatives to gather feedback on the service.

People told us the registered manager was approachable and listened to people’s ideas. The service had a culture that was inclusive and transparent. People, their relatives and staff told us the registered manager was a visible presence within the service and they could meet with him at a time of their choosing. People benefitted from a service that encouraged partnership working. The service sought guidance and support from health care professionals to enhance the care people received. Records confirmed guidance received was implemented.

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.

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.

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?

During our inspection on 21 May 2014 we found people were not always protected from the risks associated with unsafe medicines management. At this inspection we found that some improvements had been made, however we found further improvement was required around the recording and administration of topical creams. People's medicines were stored securely and for all but one person adequate stocks of medicines were maintained.

However, we found the service did not always have information about when people's creams should be administered and staff had not always recorded when people had received the creams they were prescribed. We observed that people were at risk of not receiving doses of their medicines at the correct time. People were at risk of not receiving medicines safely as prescribed.

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?

During our inspection on 21 May 2014 we found people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate care records were not maintained. Whilst the provider told us they were taking action to address these concerns we found during this inspection that further improvement was required.

People's care records were not kept up to date, and contained inconsistent and conflicting information about people's care and support needs. People were at risk of receiving care that did not meet all their needs.

Is the service well-led?

The registered manager had not ensured that people's care records were kept up to date and did not ensure they were stored securely.

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 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.

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.