This inspection was unannounced and took place on the 17 and 18 July 2017.

St Thomas (to be referred to as the home throughout this report) is a nursing home which provides nursing and residential care for up to 72 people who have a range of needs, including those living with epilepsy, diabetes, cancer, sensory conditions such as hearing and slight loss as well as people receiving end of life care. The home provides specialist support to those living with dementia. At the time of the inspection 59 people were using the service.

The home comprises a large two storey building which is set around a central courtyard and garden area which offers seating and shaded areas for people, relatives, visitors and staff to enjoy. It also provides areas of interest such as a pond with ornate metalwork to keep the pond safely enclosed and planting areas with flowers and trees for people to cultivate and enjoy. On the ground floor the home has living accommodation with communal areas including lounges and dining rooms. The ground floor is linked by adjoining corridors which are open to allow people to move freely around the home and the courtyard is accessible to all. The first floor comprises of living accommodation and a hairdresser and barbers area. The first floor is accessible by a lift allowing people access. 69 bedrooms have ensuite toilet and handwashing facilities and three rooms have ensuite shower rooms. Communal bathrooms and accessible toilets are available on both floors. On the ground floor a chapel provided people with the means to meet their spiritual needs and a linked coffee shop area enabled the chapel to also be used as a meeting point for people and their visitors.

The home did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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. The current general manager had been employed at the home in May 2017 and was in the process of becoming registered with the CQC.

People using the service told us they felt safe. Staff understood and followed guidance to enable them to recognise and address any safeguarding concerns about people. People's safety was promoted because risks that may cause them harm had been identified and guidance provided to staff to help manage these appropriately.

People were supported by sufficient numbers of staff to meet their needs. The provider was able to adapt their staffing levels appropriately when required in order to meet changes in people’s needs.

Recruitment procedures were fully completed to ensure people were protected from the employment of unsuitable staff.

People received their medicines safely; nurses were responsible for managing medicines and had received the appropriate training to enable them to complete their role safely. Medicines were stored, administered, disposed of and documented appropriately.

Contingency plans were in place to ensure the safe delivery of people's care in the event of adverse situations such as a fire or flood which may result in the loss of living accommodation. These were accessible to staff and emergency personnel such as the fire service, if required to ensure people received continuity of care in the event of an on-going adverse situation which meant the home was uninhabitable.

People were supported by staff who received appropriate training enabling them to meet people’s individual needs. Staff received regular supervision to ensure they were supported in their role.

People, where possible, were supported by staff to make their own decisions. Staff were able to demonstrate that they complied with the requirements of the Mental Capacity Act 2005 when supporting people. Records clearly documented that where people lacked the c

This inspection took place on the 25, 26 and 28 July 2016 and was unannounced. St Thomas’s provides residential and nursing care for up to 67 older people, including people living with dementia. The accommodation is arranged over two floors built around an internal courtyard. At the time of our inspection there were 64 people living at the home.

A registered manager was in post at the time of our inspection. 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 service is required by a condition of its registration to have a registered manager.

The provider had a staff dependency tool in place, however we could not be assured that there were always sufficient staff deployed to safely meet the needs of the people living at the home. The registered manager had made some environmental changes to enable people to have more freedom to move around the home. This had been well received by staff and relatives. However, some further evaluation was required to ensure that staff were always effectively deployed to support people to make the most of this freedom, by ensuring that they were safe, had opportunities for social interaction and that their care needs were met.

The registered manager had made other changes during the past year to develop and improve the service. Some of these changes needed time to bed in to ensure they could be sustained, for example the post falls protocol which had recently been introduced.

Staff told us that there was an open culture at the home and they felt able to talk to the management team about any concerns. Processes were in place to enable people and relatives to provide feedback to the registered manager through residents and relatives meetings. However not all relatives felt they had been listened to if they raised concerns.

Staff did not always demonstrate an understanding of how to deliver good care to people living with dementia. While they were kind and caring towards people when they did interact with them, they sometimes missed opportunities to engage with people and ensure that they were getting the social interaction and stimulation they needed. There was also a lack of activities provision at the time of the inspection. The registered manager was in the process of recruiting a new activities co-ordinator and assistant. The provider had recognised the need to improve the experiences of people living with dementia and was undertaking work around this.

Risks to people's safety had been identified, managed and reviewed. These included potential hazards in the environment and risks when people were supported by staff to move or transfer. They also included an assessment of the risk to people of falls, weight loss, choking and the development of pressure sores. Staff knew what action they needed to take to manage risks and keep people safe.

People were supported by staff who had been trained in safeguarding and were able to recognise the signs of abuse. Safeguarding policies and procedures were in place and staff knew what to do if they had any concerns.

Recruitment procedures were in place to ensure that people were protected from the risk of employment of unsuitable staff. New staff followed a period of induction to ensure that they had the necessary skills and confidence to fulfil their role.

People were protected from the unsafe administration of medicines as there were clear processes and procedures in place for the safe receipt, storage, administration and disposal of medicines which nurses followed.

The provider had a programme of mandatory training to ensure that people had sufficient skills and understanding to meet people’s needs effectively. There was a system in place to ensure that tr

We inspected with an expert by experience from Age UK. We spoke with five residents, six visitors, five staff and the registered manager. People told us that they or their relatives were involved in planning their care and support. We saw that appropriate people were involved in making decisions. People were offered choices and encouraged to make decisions.

Care and treatment was well planned but staff did not always follow the guidance. People’s needs had been assessed. However because staff did not always follow the guidance these needs were not always met.

People were able to have food and drink when they wanted it. Drinks were left in people’s reach and adapted cups were used so that people could drink independently. We observed that the food looked appetising and people’s nutritional needs had been considered. Staff ensured that people unable to feed themselves were given full assistance and their diet was closely monitored.

Staff were supported by management and offered appropriate professional development. All staff we spoke with recognised that recent staff changes had presented a challenge but most felt things were heading in the right direction.

There was process in place to identify and monitor the risks to the health, safety and welfare.

We saw that people were being supported by staff thoughout our visit and there was always a member of staff in one of the communal areas of the home. We spoke with two people who lived at St Thomas and one person’s relative. People told us that staff were very quick to come to them when they used the call bell. One person said they felt there “could always be more staff”. We spoke with four staff members who said there was a good team that worked hard. However they all felt there were insufficient members of staff to spend enough ‘quality time’ with people.

During our visit of 13th June 2012 we found that improvements were required to provide adequate nutritional support. Improvements were also required for the appropriate storage and safe handling of medicines. On our visit we saw that improvements had been made in both these outcome areas.

Most people who lived at St Thomas were not able to tell us in any detail about what they thought about the care and support they received. To help us to understand the experience of people who could not talk to us, we used a specific way of observing care called the Short Observational Framework for Inspection (SOFI).

We observed that staff related to people in a friendly and respectful way. People were given choices about their daily routines. Visitors told us that they were consulted and kept informed about the wellbeing of their relative. We found however that the provider had not always made appropriate arrangements for obtaining medicines to ensure that people were receiving their prescribed medication.

Relatives told us that the food was good and we observed that people were given a choice of food and drink. We found however that people who were particularly at risk of malnutrition were not always monitored consistently. This increased the risk that staff would not take appropriate action to maintain these people’s health.

People were supported by a caring staff team.

People who live at St Thomas’s were generally unable to tell us what they thought about the care and support they received. We used a specific way of observing care to help to understand the experience of people who could not talk with us. Most people we saw appeared to be well supported by the staff. People that were mobile around the home had less consistent supervision.

The inspection took place on 22 and 23 June 2015 and was unannounced. St Thomas provides residential and nursing care for up to 72 older people, including people living with dementia. At the time of our inspection 53 people were living in the home.

The home consisted of four units situated on two floors built round an internal courtyard. Two lifts and stairs provided access to all floors. At the time of our inspection one lift was out of action, but people were able to access both floors using the second lift. People were protected from harm by the use of keypads on exit doors between floors and units. The reception area was manned by a receptionist during office hours, and a walkie talkie was provided for visitors to contact staff when the reception was unmanned.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The registered manager had left the service in January 2015. Appropriate actions had been implemented to ensure the home was well managed. The provider had deployed an experienced registered manager from another of their homes to manage St Thomas as an interim measure. They are referred to as the temporary manager in this report. A dedicated manager for this home had been in post for three weeks at the time of our inspection. They had started the process to apply for the registered manager role with the CQC. They are referred to as the new manager in this report.

At the last inspection on 22 and 26 September 2014 we asked the provider to take action to make improvements to ensure that effective measures were in place to address concerns we identified. We found concerns with regards to the management of identified risks to people’s health and welfare, and cleanliness and hygiene in the home. Sufficient staff had not been employed to support people’s needs at all times, and staff had not been appropriately supported through training and supervision to provide people with effective care. At this inspection we found the improvements required had been made.

The provider had taken steps to ensure risks specific to each person had been identified, and actions taken to reduce the risk of harm. The home was clean, and people and others were protected from the risks of cross contamination and health care-associated infection because staff maintained safe hygiene standards.

Staffing levels were sufficient to meet people’s identified needs. Staff had the skills and understanding to meet people’s identified needs effectively. Although staff training had not met the provider’s identified requirement for 85% completion rate, actions were in place to ensure this target would be met by the end of June 2015. Measures were in place to ensure people’s safety was not affected whilst training was refreshed.

Staff had not had the opportunity to attend regular formal reviews of their roles and responsibilities. The new manager had started a programme of supervisory and appraisal meetings. To ensure staff were supported whilst awaiting formal individual meetings, the provider had created opportunities for staff to raise concerns or discuss their development through regular team meetings and the management’s open door policy. Staff told us they felt supported by team leaders and managers.

On the first day of our inspection we found recruitment checks had not been sufficiently robust to protect people from unsuitable staff. When we raised concerns regarding employment gaps and evidence of good conduct with the new manager, they took immediate action to address the shortfalls, and ensure people were not placed at risk of harm.

Appropriate measures were in place to ensure people were not at risk of abuse. Staff understood and followed the process to identify and report safeguarding concerns.

Medicines were stored and administered safely. Nurses followed safe protocols to ensure they identified any risks associated with medicines. Checks ensured medicines were stored safely and accounted for.

Risks affecting people’s health and the home’s environment had been identified, and appropriate measures taken to ensure people, staff and others were not placed at risk of harm. Regular checks and services ensured equipment and fittings remained safe. Staff were trained on the actions to take in the event of an emergency such as fire.

Staff understood and supported people to make decisions about their health and wellbeing. They understood the process of mental capacity assessment and best interest decision-making if the person was assessed as lacking capacity to make specific decisions. Where people’s liberty was judged to be restricted, the temporary manager had followed the requirements of the Deprivation of Liberty Safeguards to lawfully restrict people’s freedom for their own protection.

People were encouraged to eat and drink sufficiently to meet their nutritional needs. Dietary preferences and needs were understood and met. People at risk of malnutrition and dehydration were supported to maintain their nutritional health. Training was being delivered to ensure all staff understood the importance of maintaining accurate records of people’s daily intake.

People were supported to maintain their good health through effective liaison with health professionals, such as the GP and dietician. Documentation was cross referenced to ensure staff were aware of and followed health professionals’ guidance.

People were supported to develop and maintain friendships in the home. Staff treated people with respect and kindness. They involved people in decision making and conversations, and promoted their dignity and privacy. The provider’s values, including recognition of people’s individuality, and promoting independence, respect and dignity, were displayed in the way staff interacted with and supported people.

People’s needs and wishes were documented and reviewed regularly. Staff understood how to communicate effectively with people. They understood gestures and vocalisations used by people unable to verbally explain their care needs. Activities were planned but flexible to encourage people’s participation. The local community was welcomed into the home, and a minibus provided opportunities for people to travel outside.

Relatives said staff were responsive to concerns raised, and kept them informed of changes to people’s needs, and changes in the home. Events such as meetings and social gatherings provided relatives with the opportunity to raise and discuss concerns. Complaints were addressed in accordance with the provider’s policy.

Staff described managers as approachable, and were confident that the new manager would continue to drive improvements in the home. Staff felt valued, and spoke with pride of their achievements. They had opportunities to suggest improvements, and were involved in the evaluation of new practices.

The temporary and new managers led by example, using their experience and knowledge in dementia care to guide and inform staff. This ensured people experienced care that met their diverse and individual needs. Audits carried out by the managers and regional quality team had identified areas for improvement. An action plan held managers accountable for progress and completion. Learning was shared to drive improvements across the provider’s portfolio of homes.