We inspected Barchester Tower on the 11 and 14 May 2017. This was an unannounced inspection

Barchester Tower provides personal care and accommodation for a maximum of 22 older people living with dementia. There were 12 people living there at the time of our inspection, one person was on respite (holiday) for a short stay. Most people were not able to express themselves verbally due to their health needs.

There was 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.

At a comprehensive inspection in November 2015, the overall rating for this service was requires improvement with two breaches of regulation: regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by November 2016.

During our inspection on 11 May 2017, we looked to see if improvements had been made.

At this inspection we found that considerable improvements had been made. We could see that action had been taken to improve people’s safety and the audits demonstrated that there was a commitment to continuously improve. However there were still some areas of medicine and cleaning practices that needed further embedding in to practice to ensure peoples continued health and well-being.

The provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed including those for accidents and incidents, care plans, medicines and health and safety. However there were certain areas that still need to be progressed further to ensure that the audits identified issues such as cleanliness of furniture and wear and tear of carpets.

Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service and relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

Care plans reflected people’s assessed level of care needs and were based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking and moving and handling. For example, pressure relieving mattresses were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and leg ulcers. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. There were systems in place for the management of medicines and people received their medicines in a safe way.

People were encouraged and supported to eat and drink well. One person said, “Tasty and there’s always a choice.” There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. People were advised on healthy eating and special dietary requirements were met. People’s weight was monitored, with their permission. Health care was accessible for people and appointments were made for regular check-ups as needed. Food and fluid charts were completed when necessary and showed people were supported to have a balanced diet.

Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them. People we spoke with were very complimentary about the caring nature of th

We spoke with three of the 13 residents at the inspection. Due to high levels of communication difficulties we used a variety of other methods to assess the quality of the care at the home. These included observation and looking at written records. We also spoke with the provider, registered manager, deputy manager and a new care worker. After the inspection we spoke with an external social care professional.

People we spoke with said or indicated that they liked living at the home. We saw that staff spoke regularly with everyone and always asked before providing care and support. We looked at people’s care plans and saw that their needs had been assessed and regularly reviewed with guidance for staff.

We saw that staff worked with other professionals and services. We were told by a social care professional that the home provided good information when requested and responded to advice and guidance.

We found that equipment was suitable and well maintained. There were quality monitoring systems in place and these were recorded.

Some people we spoke to were able to tell us that they enjoyed living at Barchester Tower, and were happy. We were told “everyone is very nice” “I am really happy I’m here” and “the food is always very good

The inspection was carried out on 23 and 24 November 2015 by one inspector, a specialist advisor and an expert by experience. It was an unannounced inspection. The service provides personal care and accommodation for a maximum of 22 older people living with dementia. There were 11 people living there at the time of our inspection and a further two people on respite for a short stay. Most people were not able to express themselves verbally due to their health needs.

There was 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.

Staff were trained in the safe administration of medicines, however medicines protocols for PRN and topical creams were not in place and people’s medicines were not always administered in line with prescribed guidelines.

People were not always protected from the risk of cross infection. Hand wash facilities were not available in all toilets and bathrooms. Cleaning schedules required additional detail to enable effective monitoring and to ensure all areas of the home were regularly cleaned.

The premises were cluttered in places. This could pose a slip or trip hazard to people. Robust protocols were not in place to monitor the safety of the environment and address any shortfalls.

All fire protection equipment was serviced and maintained. However personal emergency evacuation plans were not in place for two people recently admitted to the home to support their safe evacuation from the premises in the event of a fire.

Robust protocols were not in place to manage people’s pressure area care, weight, nutritional and pain management needs. There was a lack of adequate communication with some health care professionals around people’s health care needs.

The lack of adequate protocols to monitor people’s health needs; the lack of adequate communication with health care professionals; the lack of robust protocols to ensure the premises are safe and free from the risk of infection are breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The registered manager carried out audits to identify how the service could improve. However they had not identified shortfalls we found during the inspection to continuously improve the quality of the service and care.

The registered manager sent annual satisfaction questionnaires to people, their relatives or representatives, however it was not always recorded what action had been taken in light of people’s feedback.

Failure to adequately assess, monitor and improve the quality of the service is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Funding arrangements were not in place for all people. We have made a recommendation that people are provided with the personal items they need until funding can be agreed.

People gave us mixed feedback about the food and drink available to them. The dining experience was not adequately adapted to the needs of people living with dementia.

We have made a recommendation about consulting people to ensure their food and drink preferences are met and to ensure that the dining experience meets the needs of people living with dementia.

We have made a recommendation about seeking specialist dietary advice to support optimum cognitive function for people living with dementia.

During lunchtime we observed people’s walking frames had been placed out of people’s reach. It was not clear whether people had consented to this practice. This practice could potentially reduce people’s independence and restrict their freedom of movement.

We have made a recommendation about obtaining consent from people to remove their mobility aids to ensure people have lawfully consented to this restriction.

We have made a recommendation that ‘All About Me’ documents are completed to support effective handover with external health professionals in the event people are admitted to hospital.

We have made a recommendation that suitable signage and environmental items of benefit for people living with dementia are provided in line with current guidance.

We have made a recommendation that meaningful activities are developed and implemented for people living with dementia.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns.

There were sufficient staff on duty to meet people’s needs. There were safe recruitment procedures in place which included the checking of references.

Staff communicated effectively with people, responded to their needs promptly, and treated them with kindness and respect.

People were involved in their day to day care. People’s care plans were reviewed with their participation and relatives were invited to attend the reviews and contribute.

People were able to spend private time in quiet areas when they chose to. People’s privacy was respected and people were assisted in a way that respected their dignity.

Personal records included people’s individual plans of care, life history, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

Staff’s training was renewed annually, was up to date and staff had the opportunity to receive further training specific to the needs of the people they supported.

All members of care staff received regular one to one supervision sessions and were scheduled for an annual appraisal to ensure they were supporting people based on their needs and to the expected standards.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood when an application should be made and how to submit one.

The registered manager notified the Care Quality Commission of any significant events that affected people or the service.