We carried out an unannounced comprehensive inspection on 24 October 2018.

Tamar House Nursing Home is a care home with nursing for up to 21 people. On the day of our inspection there were 18 people living at the service. It specialises in care for older people who are living with dementia or have a physical disability.

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.

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.

The inspection was the service’s planned comprehensive inspection. We have received notification of an incident following which a person using the service died. This incident is subject to an investigation and as a result this inspection did not examine the circumstances of the incident.

At the last inspection on 27 June 2017, the service was rated Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated good:

We met and spoke with most of the people living in the service during our visit. However, some people were not able to fully verbalise their views, so staff used other methods of communication, for example pictures. Others could tell us about the care and support they received. Due to people’s needs we spent time observing people with the staff supporting them.

People lived in a service where the provider’s values and vision were embedded into the service, staff and culture. Staff, relatives and professionals said the registered manager was approachable and had made many improvements since being in post. Staff said the registered manager was involved in the day to day running of the service. One professional commented; “It is always a pleasure to go to Tamar house, the staff are professional, caring, friendly and approachable.” One staff member said; “It’s a lovely home and I cannot think of anything that would improve it. I think the people that live here really like being here.”

People remained safe at Tamar House. People who were able to told us they felt safe living there. One person said; “Yes I feel safe, I always have someone to help me.” A relative said; “Yes, I do. If they (their relative) can’t live at home this is the next best place.”

People received their medicines safely from suitably trained staff. People were protected by safe recruitment procedures to help ensure staff were suitable to work with vulnerable people. People, relatives and staff agreed there were sufficient staff to keep people safe. Staff said they were able to meet people’s needs and support them when needed.

People’s risks were assessed, monitored and managed by staff to help ensure they remained safe. Risk assessments were completed to enable people to retain as much independence as possible. Robust systems were in place to assess risks and ensure measures were put in place to further reduce those risks to protect people.

People lived in an environment that was clean and hygienic. Parts of the environment had been refurbished, taking into account people’s needs.

People received care from a staff team who had the skills and knowledge required to effectively support them. Staff had completed safeguarding training. Staff without formal care qualifications completed the Care Certificate (a na

The inspection took place on 6 June 2016 and was unannounced.

Tamar House Nursing Home provides care and accommodation for up to 21 people. On the day of the inspection 17 people were living at the care home. Tamar House Nursing Home provides care for older people who may live with a dementia or physical difficulty. The home is on two floors, with access to the upper floors via a passenger lift. There are shared bathrooms, shower facilities and toilets. Communal areas include a lounge, dining room and outside patio area.

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 our last inspection on 22 and 24 April 2015 we told the provider to take action to make improvements to how people’s care was recorded, how the Mental Capacity Act 2005 (MCA) was implemented, and how people’s consent in respect of their care was obtained. During this inspection we looked to see if improvements had been made and we found that action had been taken.

People told us they felt safe living at the service. People were protected from avoidable and harm and abuse because staff knew what to do, if they were concerned someone was being abused or mistreated. People were protected from risks associated with their care, and the environment was assessed to ensure its safety. People told us there were enough staff to meet their individual needs. People received their medicines safely, and were supported at the end of their life to have a comfortable and dignified death.

People received care from staff who had received training and support to meet their needs. People’s consent to their care had been sought and their human rights were protected by the Mental Capacity Act 2005 (MCA) and the associated deprivation of liberty safeguards (DoLS). People were supported to eat and drink enough and when concerns were identified action was taken to contact relevant health professionals. People told us they had access to their GP and staff were prompt in calling them.

People told us staff were kind and caring. Staff showed kindness towards the people they cared for. People’s views were sought to ensure they were involved in decisions about their own care. People’s privacy and dignity was respected.

People received individualised care, and had care plans in place to provide guidance and direction to staff about how to meet their needs. People told us they would feel confident about speaking to the registered manager if they had any complaints. People’s complaints were investigated and used to make improvements to the service.

People and staff had confidence in the management and leadership of the service. The registered manager kept her own training up to date and felt supported by the provider. The registered manager was aware of her legal obligations to notify the Commission of significant events, such as expected and/or unexpected deaths. There was a culture of honesty and openness which reflected the requirements of the duty of candour.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

This is a summary of what we found-

Is the service safe?

At the time of this inspection the service was safe.

People told us they felt safe living Tamar House Nursing Home.

We found Tamar House Nursing Home to be clean and there were no unpleasant odours.

People were treated with dignity and respect. We spoke with people who lived at the care home they told us staff were, “kind, considerate, nothing is too much trouble for them” and “they look after me”.

Care plans were personalised to the individual and gave comprehensive information about how the person wanted their care and support to be provided.

There was a safe and robust recruitment process in place which ensured people who lived at the care home were not placed at risk.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DOLs) which applies to care homes. The home considered the impact of any restrictions put in place for people that might need to be authorised under the Deprivation of Liberty Safeguards. The legislation regarding DOLs is part of the Mental Capacity Act 2005 (MCA) and requires providers to seek authorisation from the local authority if they feel there may be restrictions or restraints placed upon a person who lacks capacity to make decisions for themselves. At the time of our inspection the home had not made any applications to restrict people’s liberty under DOLS.

We found that people’s care plans contained risk assessments to support staff to reduce and prevent a risk to the person or to themselves.

Is the service effective?

At the time of this inspection the service was effective.

People’s health and care needs were assessed and individual care plans were in place to guide and direct staff to meet a person’s health and social care needs.

Is the service caring?

At the time of this inspection we found the service to be caring.

People who lived at Tamar House Nursing Home told us staff were kind and caring. Comments included, “very kind and helpful”, “they look after me” and “they know exactly what I need”

During our inspection we found staff to be attentive to peoples care needs.

We found staff engaged in friendly conversation with people.

Is the service responsive?

At the time of this inspection we found the service to be responsive.

We found in people’s care records that staff involved external health care professionals such as GP’s, speech and language therapists (SALT), and psychiatric nurses (CPN’s) to support people with their changing care needs.

During our inspection we observed staff to respond to people’s need when requested.

The manager carried out an annual quality survey to assist in recognising where improvement was required and we saw the manager took action to address any shortfalls.

Is the service well-led?

At the time of this inspection we found the service to be well-led.

The service had a manager who was registered with the Care Quality Commission.

It was clear from our observations that the manager and provider were actively involved in the care and support of people who lived at Tamar House Nursing Home.

Staff we spoke with told us they enjoyed working at Tamar House Nursing Home, the staff we spoke with had worked at the home for many years. Staff were complementary of the manager and told us that she was “approachable” and “supportive”.

We found the manager had effective systems in place to monitor the quality of the service being provided. We found the monitoring or medication and the environment required improvement.

We (the Care Quality Commission) carried out this inspection following information of concern raised with us.

We talked with six people who lived at the home. They all told us that they were happy with the service provided by Tamar House. They told us, “I am happy here, I have everything I need” and “You would go a long way to find a better place than this. “

People told us that staff treated them kindly and with dignity and respect at all times.

We spoke with three staff who said that they felt supported in their role and that they had sufficient training in all areas to help them do their jobs well. They told us that the manager was approachable and accessible both during the week and out of regular work hours to support them if needed. Supervision and appraisal were not regularly provided by the manager to support and ensure the development of good staff practice.

Staff demonstrated a good understanding of signs of abuse and explained the actions they would take to raise any concerns they may have.

The environment, care planning and medication were all monitored to develop the service being provided. The monitoring of care records had not been effective to ensure they were updated and relevant to each person.

Records relating to people’s care were not sufficiently detailed and personal to ensure that people’s choices and preferences would be met for areas including personal care and communication.

We (the Care Quality Commission) carried out this inspection to follow up on three compliance actions made at our inspection 31 October 2012.

We talked with one person who lived at the home, they told us that they were warm, comfortable and felt well looked after.

Most staff had worked at the home for many years. The nurse in charge told us that they had worked at the home for years and "loved every bit of it ".

We looked at the records for four people; records were seen to be accurate and fit for purpose. Since our last visit initial care plan records had been developed as a learning experience and staff confirmed this had been a positive development.

We saw that the areas of the home previously identified as needing repair or renovation had all been addressed and a maintenance plan put into place to monitor areas previously seen to be non compliant.

We looked at the systems in place to monitor the quality of the service. We found that auditing systems were in place and efforts had been made by the registered manager to monitor the service and address any problems found. We saw that systems to monitor the environment and care planning had been developed to ensure that all areas and aspects of care were part of an ongoing monitoring plan.

We (the Care Quality Commission) carried out this inspection as part of our scheduled inspection programme.

We talked with eight people who lived at the home. One person told us, “I am very lucky, they are all very kind and I feel safe”, another person said “I am definitely treated with dignity and respect, they couldn’t be nicer”. Other people told us that the food was of a good standard and that they had choices about how they spent their day. We spoke with two visitors to the home who were complementary about the care the home provided.

We spoke with six staff who all told us they enjoyed working at the home. Many staff had worked at the home for many years. People using the service and staff told us that they felt there were sufficient staff on duty to meet people’s needs.

We looked at the records for four people, met with those people and observed how their care was provided. Whilst care provided met people’s needs, not all records were accurate and fit for purpose.

We looked at the systems in place to monitor the quality of the service. We found that auditing systems were in place and efforts had been made by the registered manager to monitor the service and address any problems found. However, some areas of the home were seen to be in need of repair and reorganisation to ensure the safety of people using the service.

The inspection took place on 22 and 24 April 2015 and was unannounced.

Tamar House Nursing Home provides care and accommodation for up to 21 people. On the day of the inspection 15 people were living at the care home. Tamar House Nursing Home provides care for older people who may live with a dementia or physical difficulty. The home is on two floors, with access to the upper floors via a passenger lift. There are shared bathrooms, shower facilities and toilets. Communal areas include a lounge, dining room and outside patio area.

At our last inspection in June 2014 the provider was meeting all of the Essential Standards inspected.

The service 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.

People told us they were well supported by staff who were kind and caring, one person told us, staff are “lovely…kind… respect me”. Through their interactions, the registered manager and staff showed respect and consideration for people, a member of staff told us, “It’s wonderful… I don’t know one carer who isn’t caring”. People’s friends and families were welcomed by staff. People told us they felt their privacy and dignity were maintained.

People told us they had no concerns but were confident if they did they could speak with the registered manager and with staff. People were encouraged to give feedback about the care and support they received and their feedback was valued and used to make changes. The registered manager shared examples of when improvements had been made following complaints. The registered manager understood the value of feedback and complaints to help improve the service. External health and social care professionals were complimentary about the staff and about the care home.

People felt safe, one person told us “I feel safe and sound”. People were protected from abuse because staff had been trained to recognise abuse, and were confident to whistle blow about poor practice. Staff were confident they would be listened to and any concerns raised would be taken seriously. One member of staff told us, “this is their home and they need to feel safe”. Safe recruitment procedures were in place. People told us there were enough staff. The registered manager regularly reviewed the staffing levels in line with people’s individual care needs to help ensure there were always sufficient and appropriately skilled staff.

People, when appropriate, had been assessed in line with the Deprivation of Liberty Safeguards (DoLS) as set out in the Mental Capacity Act 2005 (MCA) and the registered manager and staff had an understanding of the legal framework. People had not always consented to their care and treatment. Care plans did not always detail information about people’s mental capacity. This meant there was no guidance in place for staff about how to support people who lacked capacity to make day to day decisions about their care and support. The registered manager confirmed action would be taken to address this issue and make changes straight away.

People’s care plans did not always involve the person or detail information about their personal histories to help staff get to know people and help promote engaging conversations. People’s care plans addressed their health and social care needs but they were not always reflective of their current care needs, and did not give clear guidance and direction to staff. The registered manager was responsive to our feedback and by the end of our inspection, had already started to make improvements.

People were protected from risks associated with their care and risk assessments were in place to give guidance to staff about how to minimise associated risks. People’s nutritional needs were met. People were supported to maintain a healthy balanced diet but care plans were not always in place to support this. People were complimentary of the meals and people were offered choices. One comment included, “food is well cooked and presentable.....a good amount and lovely sweet”.

People’s medicines were managed safely. The registered manager had a monitoring system in place. Medicine errors were thoroughly investigated and used as learning opportunities. Nursing staff were expected to undertake training and annual competency assessments. People were supported to maintain good health through regular access to healthcare professionals, such as GPs, social workers, and district nurses.

Staff told us they felt well supported and the registered manager offered and encouraged training opportunities. Staff completed an induction and were given supervision and appraisals to help them reflect on their practice and ongoing development.

The registered manager was knowledgeable about people, and took a hands-on approach to the management of the care home. The registered manager felt supported by the registered provider who visited several times a week and was always available on the telephone.

There were quality assurance systems in place. Incidents were recorded and analysed. Learning from incidents and concerns raised was used to help drive improvements. The registered manager had commenced the annual survey earlier because of the concerns which had been raised. This demonstrated a proactive approach to the management of the care home, and emphasised the value the registered manager placed on feedback to help drive continuous improvement.

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