This inspection took place on 22 and 27 September 2016 and the first day was unannounced. The service was last inspected on 8 August 2013 when it met the requirements that were inspected. On the first day of inspection there were 22 people living at the service.

Garden House is registered to provide accommodation and personal care for up to 30 people. It is situated in the seaside town of Torquay. Garden House does not provide nursing care. Where needed this is provided by the community nursing service.

A registered manager was employed 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Prior to the inspection the registered manager had completed a Provider Information Return (PIR). This is a form that asked the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR contained very little information and told us there were no plans for future improvement. The registered manager assured us that in future the PIR would include more useful information.

People received individualised personal care and support delivered in the way identified in their care plans. People’s care plans contained information staff needed to be able to care for the individual. Care plans were reviewed regularly and updated as people’s needs and wishes changed. However, information on the main care plans was not always updated following the review. The registered manager was taking action to address this.

Care plans did not contain individual activity plans to ensure people had meaningful activities to promote their wellbeing. Information about the person’s life, the work they had done, and their interests was limited so could not be used to develop individual ways of stimulating and occupying people. This meant there were limited opportunities for social interaction between staff and people living at the service. However, there were some regular activities for people to participate in. These included visiting musical entertainers and ‘pet therapy’.

Not everyone living at Garden House was able to tell us about their experiences. Therefore we spent some time in the main lounge and 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 to us. We saw good interactions between staff and people living at the service. However, the interactions were often limited to offering personal care. The registered manager had plans to improve the level of stimulation and interaction available for people.

People’s needs were met as there were sufficient staff on duty. During the inspection we saw people’s needs were met in a timely way and call bells were answered quickly. However, care staff told us around supper time could be very busy as they had to serve supper as well as help people eat. The registered manager told us they were looking to change rotas so that care staff did not have to serve supper.

People’s needs were met by kind and caring staff. Not everyone was able to tell us about their relationships with staff. However, we saw that people were relaxed and happy in staffs’ presence. One visitor told us “I know they (staff) care for [relative]” and “I can’t have [relative] home, but this is the next best thing”. People’s privacy and dignity was respected and all personal care was provided in private.

People’s privacy was generally respected. People were discreetly assisted to their own bedrooms for any personal care. Staff knocked on people’s bedroom doors and waited before they entered. When they discussed people’s care needs with us they did so in a respectful and compa

We visited Woodland House to follow up on concerns we identified at the previous inspection.

We found that improvements had been made to the management of medication. We found that medication was available to people when they needed it. Nursing staff had completed the Medication Administration Record sheet after each dose was given.

We observed that records were accurate, kept securely and could be located promptly when needed.

On the day of our inspection 15 people lived in the home. During our inspection, we spoke with one person who lived in the home, four relatives, one visiting healthcare professional, three care workers and one domestic. People who lived in the home had dementia and when we spoke with them they were not always able to tell us about their experiences.

During our inspection visit we observed that interactions between people who lived in the home and staff were good and showed staff respected people at the home. We asked relatives about the quality of the care provided at the home. They commented "the staff are excellent, they know X’s needs” and “things are going very well”. Care plans contained enough information for staff to follow so they knew how to meet people's needs.

Medication had been stored safely. However, we found shortfalls in medication management. This meant we were not able to evidence whether people received their medicines at the times they needed them, in a safe way.

We observed there were enough experienced care workers on duty at the time of this inspection visit who knew the needs of the people who lived in the home. People received consistent care.

The home had a comprehensive quality assurance system to assess and monitor the quality of the service. Relatives told us "I’ve never had any real complaints, the odd grumble has always been put right” and “I’m happy with things”.

We observed people's care as a way of understanding their experience. We saw that staff were attentive, kind and respectful. They worked with people in a way that suited their needs and helped them to experience feelings of well being. People were supported to make choices, for example in relation to what time they got up and what they ate.

People had their mental and physical health needs met. Staff observed people’s behaviour as a way of monitoring their physical health and made referrals to health care professionals. We saw that where recommendations had been made that staff followed this advice. Staff had the knowledge and skills to safeguard people from abuse. They were employed in sufficient numbers. We have asked the provider to note that the staffing levels will need to be kept under review. This was because the home was undergoing an upgrade and refurbishment and occupancy levels were lower than normal. We saw records showing that new staff were being recruited.

Staff received training, supervision and annual appraisals to ensure they had the skills to meet people’s needs.

Systems for assessing quality and managing risk were in place however action identified by the provider had not yet been fully implemented.

Some records relating to people’s care needs were not up to date, or detailed enough to ensure that care was provided consistently, and as planned by nurses. Some records did not accurately reflect the support being provided.

Because of the mental health care needs of people at Woodland House we were unable to ask people what they thought about life in the home. We spent time watching the care that was provided and what reactions people had to the staff.

We noted that all interactions were not provided in a respectful way and that any time spent with people was often limited to when personal care was provided. Observations of interactions between staff and people were mixed. We saw four examples of personal care being provided with no interactions given. These people appeared anxious and called out in distress. However, we also saw examples where mutual respect and affection were shared. One example resulted in a person's anxiety being reduced through quietly spoken words of reassurance and touch.

One relative said their family member always appeared comfortable with all members of staff at the home when they visited the home.

The healthcare people received was good. Relatives spoken to agreed with this and said they felt their family members health care needs were cared for very well. People had their dietary needs met well.

We saw that although physical health care needs were met, people did not have their mental healthcare needs met to the same standard, despite people in the home having end stage and severe dementia type conditions. We found that the care provided did not show that people’s preferences and choices had been respected.

We spoke with the provider during the visit. They showed us an audit carried out the week before our visit. It showed the provider had also observed a lack of meaningful care or programme of activities for people with dementia. They had written an improvement plan which included education for staff in dementia care, changes in routines and plans to improve choice for people at the home. There was no evidence that these changes had been introduced at the time of our visit. The improvement plan had included changes to the environment which were in progress during our visit.

We found that staffing levels were not always adequate at peak times of the day, resulting in people being placed at risk. Once this had been fed back to the organisation, additional staff had been found. The provider had also requested a change of staffing to make sure male and female ratios reflected the mix of people in the home.

A relative told us that the provider and previous managers have tried to set up relative support groups and hold relative meetings but these have not been successful, due to lack of interest. However, this relative said they had been pleased to be involved in any changes at the home and was often asked for input about his relatives care and care within the home. They gave an example of being included in the recent plans for improving the environment and décor at the home.