Tabley House

Tabley House is a residential care home providing personal and nursing care to 51 people at the time of the inspection. The service can support up to 59 people in one adapted building across two separate units, each of which had separate adapted facilities.

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

People and their relatives were unanimous in their praise for the management team, staff and the standard of care provided. Comments included, “This is a fabulous place I'm so lucky to be here." A visiting relative said, “they [staff] are excellent in everything they do.”, Another described the excellent care (their relative) had received, with dignity, excellent clinical care, and liaison with their doctor but all in a homely and welcoming atmosphere."

Risks to health, safety and welfare, of people who lived, worked and visited the home were identified and managed safely.

Safeguarding systems, policies and procedures ensured people were safe and protected from abuse.

Medicines were safely managed, and systems were in place for reporting accidents and incidents and learning from them.

We were assured by the additional measures in place to help prevent the spread of COVID-19. Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic were assessed and managed. Staff followed good IPC practices.

Safe visiting was supported and enabled. Visitors were invited to take rapid COVID-19 test just before their visit, were provided with appropriate personal protective equipment as in accordance with government guidelines and best practice.

There were sufficient numbers of suitably trained and experienced staff on duty and safe recruitment procedures were followed.

Staff presented as well trained, caring professionals. They were engaging and showed skill and sensitivity in the way they responded to people.

The management team and staff were clear about their roles and responsibilities and they promoted a positive, person-centred culture.

Staff worked well together as a team, and there was good partnership working with others to meet people's needs. A visiting doctor who was the home’s clinical lead in the local Primary Care Network praised the management and staff teams for providing exemplary care and told us how they had worked in partnership to ensure people’s health care needs were met.

Effective systems were in place for checking on the quality and safety of the service and making improvements where needed.

Rating at last inspection and update

The last rating for this service was good overall (published 13 November 2018), with requires improvement in the well led area. There were no breaches of regulation, but improvement was needed to embed quality assurances systems.

Why we inspected

Our routine monitoring undertaken in August 2021 identified that the service had improved significantly on leadership and governance previously rated as requires improvement. 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. Please see the safe and well led sections of this full report.

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 remains the same Good. However, the rating for Well led has improved to Good. 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 Tabley House on our website at www.cqc.org.uk.

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.

We found the following examples of good practice.

People told us that they felt safe and well cared for and made positive comments about the staff including, “Staff are very good and always respectful” and “The home is lovely it meets my needs well.”

Relatives of people who lived at the home told us how they had been supported and kept informed throughout the COVID19 crisis. They told us that managers and staff had helped them maintain contact with their relatives via, Zoom meetings, Video calls and telephone calls.

A visiting doctor praised the management and staff for the way they had managed throughout the COVID-19 crisis advising us that the standard of care, communication, and respect they have for people and their wishes and needs was outstanding.

At the time of the inspection visits inside the home were only allowed in exceptional circumstances such as end of life. At such times special arrangements would be made, sensitive to the needs of the person and their visitors to ensure the safety and wellbeing of all concerned.

The provider had acquired a purpose-built visiting pod which was located directly outside the home at the front entrance. The visiting pod was heated, ventilated, and fitted with internal screen and intercom to afford safe visiting. Arrangements were being made to recommence visiting in the visiting pod in the week following our inspection. In the interim people could keep in touch with their relatives by phone and video calls.

All visitors were offered a lateral flow device (LFD) test for COVID-19 and were asked to complete a health screening form, had their temperature checked and were provided with PPE to wear throughout their visit.

Whole home testing was in place for people, and staff.

Staff had benefited from training, support and guidance on infection control including COVID-19 and demonstrated skill and confidence in the way they carried out their duties and responsibilities.

Staff had access to PPE and there were PPE ‘stations’ situated at various locations around the home.

The home was clean and free of malodour throughout. Enhanced cleaning schedules had been introduced and monitored closely by senior staff to reduce the risk of transmission of COVID-19.

Tabley House was previously inspected in March 2018. During the inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to: person centred care (Regulation 9); safe care and treatment (Regulation 12); safeguarding service users from abuse and improper treatment (Regulation 13); fit and proper persons employed (Regulation 19); consent (Regulation 11); good governance (Regulation 17); and staffing (Regulation 18).

Following the last inspection, the registered provider was placed into special measures by CQC. The registered provider was asked to complete an action plan to confirm what they would do and by when to improve the five key questions we ask. They are: is the service safe, effective, caring, responsive and well led. At this inspection we found that the registered provider had taken action to address the breaches identified at the last inspection and made enough improvements to be taken out of special measures.

Tabley House is a ‘care home’ run by Cygnet Health Care Limited. The care home is registered to provide accommodation to adults with nursing and personal care needs.

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.

The care home accommodates up to 59 people across two units, each of which have separate adapted facilities. One of the units specialises in providing care for up to 12 people living with dementia. At the time of the inspection 35 people lived in the care home.

The care home had a registered manager. 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 registered manager was present throughout the four days of our inspection and was supported by their regional operations director and deputy manager. The management team were helpful and transparent throughout the inspection process and demonstrated a commitment to ensuring the continuous improvement of the service.

There was a warm and caring environment in the care home. We observed that staff were responsive to the needs of people living in the care home and that people were treated with dignity and respect.

Information on people's assessed needs and the support they required and received from staff had been recorded on an electronic records management system. This included risk assessments and other supporting documentation. Additional records had been established to enable staff to record the delivery of care contemporaneously. For example, when recording fluid and nutritional intake or when a person had been assisted to reposition. Care plans had been fully reviewed since our last inspection and the registered manager was in the process of meeting with people living at the care home and their representatives where necessary to confirm that people had been involved and were in agreement with the information recorded.

People were supported to attend healthcare appointments and staff liaised with people's GPs and other healthcare professionals as necessary to maintain people's health or support them at the end of life. We observed that a GP visited the care home on a regular basis to ensure the healthcare needs of people were monitored and reviewed.

Policies and procedures had been developed to ensure staff were aware of their roles and responsibilities for ordering, storing and administering medication. The registered manager was in the process of reviewing staff competencies and transferring to a local pharmacist to improve the efficiency of the service.

People were offered a choice of nutritious and wholesome meals that were provided in dining areas that offered a pleasant environment for people to socialise and eat their meals.

A programme of group and individualised activities was in place which included both on and off-site activities. The activities programme was in need of further review to demonstrate how the social, recreational and leisure needs of people living with dementia were met.

Systems had been established to ensure that staff working in the care home had been appropriately recruited and to safeguard people from abuse or harm. Following our last inspection, the registered manager arranged for a full review of all staff personnel files to be undertaken to ensure all necessary records were in place.

A complaints policy and procedure had been developed and people's views, concerns and complaints were listened to and acted upon.

There were sufficient staff on duty to respond to people’s care and support needs and the registered manager was in the process of recruiting to outstanding staff vacancies. Staff had access to regular supervision and completed induction, mandatory and service specific training to help them understand their roles and responsibilities. Progress in completing training was kept under review.

Staff understood the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Since our last inspection, the registered manager had taken action to ensure mental capacity assessments had been reviewed and completed where there was reasonable belief that a person living in the care home lacked capacity to make specific decisions. Where people did not have capacity, and could not give consent, we saw documentary evidence that specific decisions had also been made in people’s best interests and were the least restrictive option.

The registered provider had developed a range of management information and quality assurance systems to enable oversight and scrutiny of the service. This involved seeking the views of people who used the service and their representatives. Governance and quality assurance systems were in the process of being updated at the time of our inspection to improve oversight, accountability and drive continuous improvement. This was work in progress and will therefore require time to be fully implemented and embedded into practice.

This service had been in special measures. Services that are in special measures are kept under review and inspected again in six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

Tabley House 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.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

On the first day of our inspection, the registered manager was on annual leave, so the deputy manager assisted us with the inspection. On day two of the inspection, the registered manager had returned to work and participated fully in the inspection.

We looked at the care records belonging to six people. We found their needs and risks were not always properly assessed or managed. There was not always adequate information on how to meet people’s needs and to provide their care in the way they preferred. Some of the risk management strategies in place were inadequate and did not provide staff with sufficient guidance on how to manage people’s risks and keep them safe.

People’s capacity was not assessed in accordance with Mental Capacity Act 2005. There was no evidence of any best interest meetings and some of the care practices at the home were restrictive and institutionalised. For example, some people had bed rails in place, their bed heightened so they could not get in them and one person was placed in a recliner chair during the day to prevent them from getting up unsupervised. These types of decision under the MCA are considered restrictive practices, as they restrict people’s liberty or freedom of movement. Despite this the MCA had not been followed to ensure these practices were in the person’s best interests and legally consented to.

Medicines were not safely managed. Stock levels of people’s boxed medications were incorrect and medication could not be accounted for. There was no robust system in place to record the administration of people’s thickening medication or to check the correct amount of thickener had been added to people’s drink to prevent a choking or aspiration incident. We saw that one person's thickener was used for other people in the home who had not been prescribed it. Staff lacked sufficient guidance on the application of prescribed creams and other topical medications.

During our visit, the majority of feedback from the people and relatives we spoke with about the food on offer was positive. When we checked some people’s care records however we saw that their nutritional needs were not always met in a safe way. This was because some people’s special dietary requirements were not always catered for and some people received an unsuitable or insufficient diet for their needs. Catering staff lacked sufficient information about people’s special dietary requirements and lacked an understanding of the importance to cater for these needs. Referrals to the dietician in support of people’s needs had not always been made to ensure people were protected from the risk of malnutrition.

Staff were not always recruited in a robust way and staffing levels were insufficient to meet people’s needs. As a result people experienced falls and incidents due to a lack of adequate supervision. This was because some people who required close monitoring and supervision often fell when staff were not present to supervise them appropriately. In addition records showed that people did not always receive the care they needed to meet their needs in accordance with their care plans. Staff training for permanent staff was satisfactory but agency staff lacked evidence of a suitable induction into their job role. The manager failed to ensure agency staff had sufficient information about people’s needs and the service in order to provide safe and effective care. Some staff lacked sufficient knowledge of people’s moving and handling needs to ensure people were supported correctly and in a safe way.

The manager and staff at the home had not always recorded accident and incidents adequately or taken appropriate action to safeguard people against future risks. Incidents of a safeguarding nature had not always been identified, responded to or referred appropriately to the local authority and CQC. There was little evidence some of these incidents had been properly documented or investigated by the manager to protect people from risk.

Some people’s ability to be independent was hindered by the environment. The environment was not dementia friendly. There was no adequate signage within the home to help people find their way around and no contrasting colour schemes to help people differentiate between different areas of the home. There were also some repair and maintenance issues within the home needed to be addressed. Safety checks on the home’s equipment had been undertaken appropriately.

There was a complaints policy in place. Two people told us that their complaints had been satisfactorily dealt with. During the inspection one person's relatives told us they had concerns about the care their loved one received. We spoke about these concerns directly with the manager and deputy manager. They later withdrew this complaint. Most of the people we spoke with felt the service was well-led. We found evidence to the contrary.

There were no effective systems or processes in place to ensure that the service provided was safe, effective, caring, responsive or well led. Audits were undertaken but they were ineffective in identifying the issues found during the inspection. The provider did not play an active role in the service and had not undertaken any effective checks on the service to ensure it was safe and satisfactory. This meant the service was not well led.

After our visit, we asked the manager and provider for an urgent action plan on how they were going to ensure immediate and significant improvements were made. An improvement action plan was submitted and is in progress. This assured us that some of the risks and concerns we had identified during our inspection were being addressed immediately. Referrals were also made to the local safeguarding authority and other health and social care professionals to protect people from risk and to ensure they received the support they needed.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special

measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the providers registration.

We spoke to one relative who said; "Staff meet her needs, we would not be here otherwise." Another relative said; 'She can choose whatever clothes she wants, and there is a great choice of meals.'

We looked at four care plans for people living at the home. We saw that care plans were detailed and well ordered.

We saw that staff were very patient with people who took a long time to eat. One staff member told us 'It is important to me that if I am helping someone, I do so from start to finish.'

We asked about staff appraisals and were told that these were structured to meet organisational and individual needs as well as promoting high standards of care within the home.

We were shown a number of risk assessments and audits of various areas within the care home including; building maintenance, infection control, people's weight, equipment, medications, training and staff surveys.