The inspection took place on 25 April 2017 and was unannounced. The service was last inspected on 10 November 2015 and was rated as Requires Improvement.

Service to the Aged is a nursing home for up to 60 older people, it provides nursing care to people of the Jewish faith so they can continue to practise their faith and be a part of their local community. Some of the people living in the home have dementia; the home has a dedicated Alzheimer’s unit. At the time of the inspection 56 people were living in the home.

We completed a comprehensive inspection on 16, 18 and 19 February 2015 where we found breaches of regulations relating to staffing, staff training, and consent. We carried out a further inspection on 10 November 2015 and found that improvements had been made to address these breaches of regulations.

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.

Medicines were managed safely by staff trained to administer them and safeguarding procedures and records were robust.

Risk assessments were reviewed and incidents were analysed to see how they could be learned from to reduce the risk of them happening again.

The home was free from odour and clean and staff were using infection control equipment appropriately.

The home had in house physiotherapists to help people mobilise and exercise. Referrals were made in a timely way for health needs and nurses were knowledgeable and confident.

Staff fed back the training could be more classroom based. We saw evidence that staff were supported through supervisions, appraisal and regular staff meetings at all levels.

The principles of the MCA were being followed but some staff lacked knowledge in this area which identified a training need.

People said the food could improve. The registered manager had listened to this and people were going to meet with the caterers to make suggestions.

People said they were happy in the home and staff were kind and caring and respected their dignity and privacy. Relatives told us they thought the care was consistently good.

Activities were regular and well attended and provided a range of mental and physical stimulation.

Care files were person centred and captured needs well. People and relatives said they knew how to complain and complaints were recorded and responded to in line with the provider’s policy.

Robust audit systems were in place and the management team were passionate about improving care standards. Relatives and people fed back to us that they had seen an improvement in the home over time.

We made a recommendation that the home provide additional training to staff in the area of consent and MCA.

We carried out an unannounced comprehensive inspection of this service on 16, 18, and 19 February 2015. Breaches of legal requirements were found in the areas of staffing, staff training and obtaining consent. The provider wrote to us to say what they would do to meet legal requirements in relation to all the breaches. We undertook this unannounced focused inspection on 10 November 2015 to check that the provider had followed their plan and to confirm that they now met legal requirements in those areas. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Service to the Aged on our website at www.cqc.org.uk.

Service to the Aged, known as Sage, is a nursing home for up to 60 older Jewish people. Most people who live there have a diagnosis of dementia and many also have significant needs relating to their health. Sage is a purpose-built home located on a main road in Golders Green in London, close to shops and transport. Each person has their own bedroom with en suite bathroom and there is a large communal lounge and dining area on the ground floor with a patio and terrace people can use.

There were 52 people using the service when we inspected. The service operates according to orthodox Jewish principles. It is operated by a charity with a board of trustees and a management committee. The charity does not operate any other services.

There was a registered manager in post. A registered manager is a person who has registered with CQC 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 found that Sage had a very open and welcoming atmosphere and was a real part of their local community. Visitors were encouraged and there were plenty of opportunities for religious and other activities.

Appropriate action had been taking place in respect of reducing the number of agency staff, a number of new staff had been recruited, and the provider also had a strategy in place for on-going staff recruitment and retention to the service.

New systems had been introduced in relation to staff training and supervision, and staff told us they were happy with the training and support provided.

Staff showed a good understanding of the Mental Capacity Act 2005 (MCA) and the implications of this legislation. Staff we spoke with in relation to their work with people, who lacked capacity, were all able to explain the principles of the MCA and how they might apply them.

We found that that appropriate Deprivation of Liberty Safeguard applications had been made for all people using the service who lacked capacity to consent to remaining in the home

Overall, we found that the provider had addressed the breaches of regulations.

We carried out an unannounced comprehensive inspection of this service on 16, 18, and 19 February 2015. Breaches of legal requirements were found. We served enforcement warning notices on the provider in respect of three breaches that had the greatest impact on people, in the areas of good governance, nutrition and hydration and managing risks. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to all the breaches. We undertook this unannounced focused inspection on 31 July 2015 to check that the provider had followed their plan in respect of the warning notices and to confirm that they now met legal requirements in those areas. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Service to the Aged on our website at

www.cqc.org.uk

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Service to the Aged, known as Sage, is a nursing home for up to 60 older Jewish people. Most people who live there have a diagnosis of dementia and many also have significant needs relating to their health. Sage is a purpose-built home located on a main road in Golders Green in London, close to shops and transport. Each person has their own bedroom with en suite bathroom and there is a large communal lounge and dining area on the ground floor with a patio and terrace people can use.

There were 47 people using the service when we inspected. Due to issues that had been identified by the service and the local authority before our inspection, the service was not admitting anyone new when we inspected. The service operates according to orthodox Jewish principles. It is operated by a charity with a board of trustees and a management committee. The charity does not operate any other services.

There was a new ‘Matron Manager’ in post and she was in the process of being registered with the Care Quality Commission. A registered manager is a person who has registered with CQC 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 found that Sage had a very open and welcoming atmosphere and was a real part of their local community. Visitors were encouraged and there were plenty of opportunities for religious and other activities.

Appropriate action had been taking place in respect of pressures ulcers, timely referrals were made to relevant healthcare professions and there were risk assessments in place that were updated regularly.

The kosher kitchen of the service provided food that was appetising and always freshly prepared and cooked. We found that improvements had been made to ensure people were supported to eat and drink enough to meet their needs. This included people who needed a lot of support to eat and those who received nutrition and hydration through a percutaneous endoscopic gastrostomy (PEG) tube.

The matron manager had made a number of improvements that the service needed to improve the care and support provided to people, including improved quality monitoring audits.

Overall, we found that the provider had addressed the three breaches of regulations that had resulted in us sending warning notices.

We will undertake another unannounced inspection to check on all outstanding legal breaches identified for this service.

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This was a follow up inspection to check compliance with regulations relating to management of medicines. At our 9 January 2014 inspection, we judged that the provider did not protect people using the service against risks associated with the unsafe use and management of medicines. This was because of concerns we identified regarding medicines administration, storage and recording. For example, we saw omissions in people’s medicines administration records (MAR) sheets and saw that “enteral feeds” (used to administer medicines or nutrition directly to a person’s stomach) were stored in people’s rooms.

Shortly after our inspection, the provider sent us an action plan in response to the concerns we identified and when we inspected again on 6 March 2014, we saw that improvements had been made. For example, MAR sheets we looked at had been completed and there were no enteral feeds stored in people’s rooms.

This was a responsive inspection, carried out in response to concerns we received about care and welfare of people using the service; and management of their medicines.

We saw evidence that people’s care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People using the service appeared well cared for and were dressed appropriately, frames and wheel chairs were carefully labelled with the owner’s name and we saw notices on some residents’ doors advising staff on the resident’s preferred manner of room entry i.e. “knock and wait.”

Peoples' feedback on care and support provided was generally positive. One person remarked “they look after me very well. I am spoilt” whilst another person commented “it’s an extremely difficult job to run a place like this. They [staff] do very well.” However, one person told us that care staff were rough when assisting with dressing.

We saw there were not appropriate arrangements in place for recording the administration of medicines. We found omissions in the records were made when medicines were given to people. There was also no guidance for staff in the administration of medicines that were required on an “only when needed basis.” Medicines were not kept safely, or being stored securely for the protection of people who use the service. We saw that a medicines refrigerator, situated in a service user lounge, was not locked.

We spoke with four people using the service. They told us that staff were caring and treated them with dignity. One person remarked that staff were, ”very nice and very kind” whilst another person told us, “staff do their best.”

When we inspected on 21 June 2013, we looked at provider records and saw that some staff were overdue mandatory training. We asked the provider to take action. When we inspected on 3 October 2013, we saw that some mandatory training sessions had now been delivered. When we inspected in June we also saw that the provider did not have a performance appraisal system in place for the Registered Manager. We asked the provider to take action. When we inspected on 3 October 2013, we saw that the Registered Manager had had an appraisal meeting in September 2013.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. After our October 2013 inspection, we were sent a copy of the provider’s 2013 Resident Survey. We saw that that 83% of the 31 respondents agreed with the statement “do you feel that the nursing and care staff treat you with respect?”

During our inspection, we observed care being delivered and saw that staff were attentive, patient and communicative. The provider told us that approximately 90% of people using the service had varying degrees of dementia. We looked at provider records and saw that a range of activities were offered including bingo, quizzes and outings. One person we spoke with told us that the home also offered daily group exercise activities. Another person told us that they occasionally delivered lunchtime piano recitals to other people using the service.

We spoke with two care workers: one of whom who had been in post for two years, the other recently started. The longer serving care worker was able to outline symptoms of abuse. They told us that they were scheduled for safeguarding training in July 2013. The provider may wish to note however, that the newer care worker was not able to demonstrate an understanding of safeguarding issues. They told us that they would also be attending safeguarding training in July 2013.

Shortly after our inspection, we were sent a staff training spread sheet. This showed that some staff were overdue mandatory training in accordance with the provider’s policies. We were also sent a training schedule and advised that by December 2013 all staff would be up to date regarding mandatory training.

People told us what it was like to live in this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) Inspector joined by an Expert by Experience; people who have experience of using services and who can provide that perspective. 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 to us.

People told us that they were given choices about the food and drink provided at the home, and that their cultural needs were being met. We were told by the manager that they often have volunteers from the local Jewish school who sit and talk to people living at the home and provide concerts.

People and their relatives told us that staff were always polite and they did not feel rushed. Staff knocked on doors before entering people’s rooms and they were treated with dignity and respect.

People who use the service told us they felt safe at the home, were involved in their care

and could talk with the manager or other staff if they had a worry or concern. There were effective systems in place to ensure that people were protected from abuse, and they received the nutrition and health care they needed. Peoples' records were stored securely.

This unannounced inspection took place on 16, 18 and 19 February 2015. Our previous inspection of 6 March 2014 found that the service had made improvements to the way they managed medicines. Our inspection before that took place on 9 January 2014 and we found the service met standards relating to care and welfare of people who use services.

Service to the Aged, known as Sage, is a nursing home for up to 60 older Jewish people. Most people who live there have a diagnosis of dementia and many also have significant needs relating to their health. Sage is a purpose-built home located on a main road in Golders Green in London, close to shops and transport. Each person has their own bedroom with ensuite bathroom and there is a large communal lounge and dining area on the ground floor with a patio and terrace people can use. There were 53 people using the service when we inspected. Due to issues that had been identified by the service and the local authority before our inspection, the service was not admitting anyone new when we inspected.

The service operates according to orthodox Jewish principles. It is operated by a charity with a board of trustees and a management committee. The charity does not operate any other services.

When we visited there was a manager registered with the Care Quality Commission (CQC), however we found that the registered manager was no longer working for or associated with the service and so we have taken action to remove their registration. A registered manager is a person who has registered with CQC 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. When we visited there had been a new manager in post for five weeks.

We found that Sage had a very open and welcoming atmosphere and was a real part of their local community. Visitors were encouraged and there were plenty of opportunities for religious and other activities.

However, people were not always supported safely with care that met their needs. Three people had acquired serious pressure ulcers at the service in the months preceding our visit and we found that the service did not take appropriate action to prevent and treat these. We also found that people’s care records were confusing, untidy and information was difficult to find. As the service had a high rate of agency staff use and did not ensure that agency staff were made aware of people’s individual needs, this meant that people did not always receive safe and effective care.

Staff employed by the service underwent a robust procedure to check they were appropriate people to work with people in need of support before they started work. However, they were not always appropriately supervised and areas of training and development need were not always addressed. Staff told us they did not feel well-supported by managers but were hopeful that improvements would be made by the new matron manager.

The kosher kitchen of the service provided food that was appetising and always freshly prepared and cooked. However, we found that people were not always supported to eat and drink to meet their needs. This was particularly evident for people who needed a lot of support to eat and those who received nutrition and hydration through a percutaneous endoscopic gastrostomy (PEG) tube.

People were safeguarded from the risk of abuse and staff knew what to do if they had concerns. However, we found that the service did not always seek appropriate consent from people before providing care and treatment including for the end of their life. Staff and the matron manager knew what to do if they believed a person needed to be deprived of their liberty for their own safety.

Medicines were managed appropriately and safely. Emergency procedures were in place in the service, however first aid kits were not routinely checked and were incomplete.

The newly-appointed matron manager recognised that the service needed to improve the care and support provided to people, as did the person appointed by the management committee of the board of trustees to oversee the day-to-day operation of the service. They recognised that previous systems for checking the quality of the service had not been effective. Plans were in place, and support provided to the matron manager, to improve these.

We found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report.