Tamara House provides care and accommodation for up to 26 older people some of whom are living with dementia. At the time of the inspection there were 25 people living in the service.

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.

Some of the people who lived in the home had limited communication therefore we spent time observing some people. Other people were able to tell us their experiences of living in Tamara House.

At the last inspection, on the 27 and 28 April 2016 the service was rated Good overall. We carried out this inspection because we had received information of concern. This information stated safeguarding issues were not always being investigated or reported to the local authority and CQC as required. Concerns also included allegations that people who had fallen did not receive prompt medical assistance; people were being put to bed fully dressed and without suitable night attire and that medicines, in particular medicines that required additional security, were left in the kitchen for night staff, who hadn’t received the necessary training, to administer. The information of concern stated that staff were unable to access food and drink from the kitchen overnight, which meant people who required or requested additional food and drinks were unable to have any. We heard there could be a lack of infection control management, possibly soiled sheets being put through a normal wash, at normal temperature and being placed back on people’s beds unclean; also that the kitchen was unclean, with dead flies left lying around and people not having water jugs in their bedrooms. Concerns were raised that call bells were not left within people’s reach to call staff for assistance, staff not receiving adequate training and commencing work without completed security checks in place; and staff working extra hours due to shortages of staff.

In response to these concerns we undertook a focused inspection on the 13 September and changed this to a comprehensive inspection and visited on the 18 and 19 October as we needed additional information to assure ourselves that people remained safe.

We spoke to the local authority safeguarding team as this information/complaint had been forwarded to them as a safeguarding alert and we requested the outcome of their investigation. They confirmed they had visited the service and reviewed some care plans for people. They were satisfied the care plans held relevant information including completed risk assessments and evidence of referrals to appropriate healthcare professionals when needed. The safeguarding lead confirmed they had met with the provider and registered manager and concluded the meeting was open and transparent. They stated they were reassured over the concerns raised. For example they felt reassured that people were able to obtain food and fluids at any time, the premises were clean and people remained safe.

On the first evening of our inspection there was a potential risk to people in the event of a fire. This was because there was no information given to staff, who were not completely familiar with the service, relating to the fire processes and procedures of the home. However both care workers were experienced in care and one of them stated they knew people well enough to know how they would need to be supported in an emergency.

During the next inspection on 18 and 19 October, the registered manager, who had not been available during the focussed inspection explained night of 13 September, had been an emergency situation and rather than use agency staff who did not know the service, they had used someone who had worked there previously alongside

This inspection took place on the 27 and 28 April 2016 and was unannounced. Tamara House provides accommodation for up to 26 older people who require support in their later life or are living with dementia. There were 24 people living at the service when we visited.

Accommodation is arranged over two floors, there are stairs and a lift to get to the upper floors. The home has 26 en- suite bedrooms, 25 of which have their own shower. There are also shared toilets, bathrooms and shower facilities. On the ground floor there is a large dining and living area and access to a patio garden.

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.

At the last inspection on 22 December 2014, we asked the provider to take action to make improvements to the accuracy of their care records and to the way they assessed and monitored the quality of the service. In addition, they did not have a registered manager in place. The provider sent us an action plan which explained how they would address the breaches of regulations. During this inspection we found these issues had been fully addressed.

People were relaxed and comfortable at the service. People told us they were happy at the service and with how their needs were being met. We observed positive and caring interactions between people and staff.

Care records were detailed and personalised to meet people’s needs. People were involved as much as possible in their care planning. People’s risks were monitored and managed well.

People had their medicines managed safely and received their medicines as prescribed. People were supported to maintain good health through regular access to health and social care professionals such as GPs and speech and language therapists.

People were kept safe from discrimination and abuse. Staff had undertaken training on safeguarding adults. They demonstrated a good knowledge of how to report and describe what action they would take to protect people from harm.

People had their needs met by staff who were trained and had the correct skills to carry out their roles effectively. Safe infection control practices were followed.

People were kept safe by suitable numbers of staff who had been safely recruited to their roles.

People were encourages to live active lives. Activities were meaningful and reflected people’s individual preferences and interests.

People were supported to maintain a healthy and balanced diet. People enjoyed the meals offered and had access to drinks and snacks as they wished. People were involved in planning the menus.

There was a system in place to receive, investigate and manage complaints and people and relatives said they felt confident to raise concerns if necessary.

People spoke highly of the registered manager and said they were approachable and took an active role in running the service.

There was an effective quality assurance system in place to monitor the service and to drive improvements.

This was an unannounced inspection which took place on 22 December 2014.

Tamara House provides accommodation for up to 26 older people who require support in their later life or are living with dementia. There were 22 people living at the home when we visited.

Accommodation is arranged over two floors, there are stairs and a lift to get to the upper floors. The home has 26 en-suite bedrooms 25 of which have their own shower. There are also shared toilets, bathroom and shower facilities. On the ground floor, there is a large dining and living area, and access to a patio garden.

The service is required to have a registered manager but no registered manager has been in place since August 2014. 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.

We last inspected Tamara House in August 2014. At that inspection we asked the provider to take action to make improvements to the care and welfare of people, staffing, supporting staff and the assessing and monitoring of the quality of service. The provider sent us an action plan which explained how they would address the breaches of regulations. During this inspection we found improvements had been made.

People told us there were not always sufficient numbers of staff to meet their needs. However, the additional staff had and continued to be recruited and the rota confirmed improvements to staffing numbers. The manager supported staff by providing training opportunities, however, staff had not always been provided with training opportunities to meet people’s individual needs. Recruitment procedures protected people, as the provider carried out the necessary checks to determine whether staff were suitable to work with vulnerable people.

People did not always receive care which was personalised to their needs, for example care plans and risk assessments were not individualised and did not give clear direction to staff about how to meet a person’s needs. Which meant care may be provided inconsistently. People were not involved in creating and reviewing their own care plan and consent to their care plan had not always been obtained. People should be involved in their care plans to help ensure the care being provided by staff is in line with their wishes and required needs. Staff were aware of people’s individual nutritional needs, however, documentation relating to this was not descriptive of the care required and not reflective of the care being delivered. The manager was in the process of re-designing people's care plans to ensure the necessary information was documented.  People had access to health care services and services were contacted in a timely manner. People’s needs were met in an emergency such as a fire, because they had personal emergency evacuation plans in place.

Although, staff received training and were required to pass a written exam in respect of the Mental Capacity Act (MCA) and Depravation of Liberty Safeguards (DOLS) staff appeared  to not fully understand how these legislative frameworks protected people to ensure their freedom was supported and respected.  On one occasion an application in respect of DoLS had not been made. The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. When people are assessed as not having the capacity to make a decision, a best interest decision is made involving people who know the person well and other professionals, where relevant. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty.

People were protected from avoidable harm as staff could identify the signs of abuse, and knew the correct procedures to follow if they thought someone was being abused. People were supported by staff who promoted and showed positive and inclusive relationships. Staff were kind and caring in their interactions with people. People’s independence and social life were promoted, however, people told us they were not given opportunities to go out on social trips.

People were encouraged to be actively involved in the running of the service and people’s views were obtained and used to facilitate change. The manager took into consideration feedback from external health and social care professionals to enable learning and improvement to take place.

People’s medicines were managed well; however, the auditing system to check if improvements were required was not effective.

The provider and manager worked well with external health and social care professionals, and promoted a positive culture that was inclusive to people, staff and visitors. However, the quality monitoring systems in place did not always help to identify concerns and ensure continuous improvement.

We found a number of breaches of regulations. You can see what action we told the provider to take at the back of the full version of the report.

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-

Before our inspection we received some anonymous information of concern about the service. The areas of concerns related to staffing numbers on afternoon shifts, staff training and the induction process for new staff. As part of our inspection we looked at the concerns which had been raised.

Is the service safe?

At the time of our inspection we did not find the service to be safe.

There were not enough qualified, skilled and experienced staff to meet people’s needs. We looked at the home’s care rota for the month of July 2014 and found that the number of care staff did not consistently meet the provider’s own required staffing levels. We were concerned to find that the numbers of care staff working at the weekend was particularly poor.

People we spoke with who lived at Tamara House told as that they did not feel there were enough staff. People shared their experiences and observations with us which included people receiving a delay in their call bells being answered, a delay in their breakfast being served and support with care.

Is the service effective?

At the time of our inspection we did not find the service to be 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. However, improvement was required as care plans did not always give clear direction and guidance to staff about how to meet a person’s care needs.

People were cared for by staff who were not supported to deliver care and treatment safely and to an appropriate standard. We saw from the provider’s training records that some staff had not received training relating to their role. It was a concern given staffing shortages that rotas could be effectively managed to ensure staff working on each shift held the necessary skills.

There was a system in place to provide staff with supervision. Supervision is a formal process to help discuss working practices and addresses any improvements or ongoing training that may be required. Supervision processes were in place at Tamara; however, we saw from documentation that it was difficult to establish the frequency of when supervision was carried out. The administration of supervision documents was chaotic.

Is the service caring?

At the time of this inspection we did not find the service to be caring.

We observed good interactions from staff when speaking with people and supporting them.

People we spoke with told us they were generally happy living at Tamara House. Comments included, “I’m looked after alright”, “on the whole very good “and “The staff are very good what we got, they can’t always do what they would like to do”.

We spoke with people about the staff who supported them, although people told us they were happy and felt safe living at Tamara House, some comments included “I know they are busy, some of them have awkward tones”, “some of them are lovely, they get their off days” and “they are all very good, they do what they can”.

People told us that the lack of staff was impacting on the care that they received.

Is the service responsive?

At the time of our inspection we did not find the service to be responsive.

We spoke with people about whether staff came promptly when they rang their call bell. One person told us, “When you want something they sometimes take a while to get it”. Another person told us, “They’re supposed to come up within five minutes to see if you are all right, but it doesn’t happen very often”. One person told us they were concerned that they did not have access to a call bell in the communal lounge.

The provider had a policy in place to manage complaints.

We saw from the complaints folder that a recent complaint had been raised by a relative; we looked at the associated documentation which showed the complaint had been responded to promptly and dealt with effectively by the management of the home. This demonstrated people had their comments and complaints listened to and acted on.

We were told that complaints were discussed as part of residents’ meetings; this demonstrated that the provider valued people’s feedback and was willing to listen to positive and critical comments about the quality of the service delivered at Tamara House. One person who lived at Tamara House told us, “If things aren’t right, I tell them how it is”.

Is the service well-led?

At the time of our inspection we did not find the service to be well-led.

The provider had systems in place to monitor the quality of the service being provided, however, these systems were not always effective in identifying areas which required improvement.

The manager who had been registered with the Care Quality Commission had recently resigned.

It is a requirement of the Health and Social Care Act 2008 that providers inform us of particular incidents when they occur. We found that the provider had been informing us of incidents; however, they had failed to report to us the impact of staffing at the home.

Staff we spoke with told us they felt “supported” however, we received comments that “management could be more supportive”.

People we spoke with were positive about their experience at the home. Comments included “the staff are nice.” Another told us “I like it here.”

Not everyone was able to tell us their experiences of living in the home or if they felt safe. However from our observations on the day of our visit, people appeared happy and at ease in the home. One person we spoke with was able to tell us they felt safe living in the home and with the staff.

There were suitable safe storage facilities for medication including storage for medication which required refrigeration.

Throughout the day we saw that staff were competent and cheerful. There was a relaxed atmosphere and everyone had opportunities to take part in activities according to their abilities and interests.

The home carried out an annual quality survey inviting the people who used the service, relatives and other professionals to respond to a questionnaire. They reviewed the quality of service through a monthly audit of the cleanliness of the home, medication, maintenance, and equipment used.

We carried out an unannounced inspection in response to concerns raised by a whistle blower. At our last visit to Tamara House we found the service was not compliant in eight key outcomes. We looked at five outcomes at this visit. We wanted to know whether the service had made improvements. We found that improvements had been made and the service was compliant in the five outcomes that we looked at during our visit.

There were fifteen people living at Tamara house on the day of our visit. We spoke with nine people who lived at Tamara House. We also spoke with the registered manager, catering manager and six staff members.

We saw that people were offered choices about how their care was delivered and how they spent their time. We observed staff being kind and respectful. One person told us, “it’s very nice here” and another “staff look after me pretty well”.

The care plans were detailed so that staff had enough information to support people to meet their needs in the way that people chose.

People we spoke with were very complimentary about the meals they had. One person we spoke with after lunch told us “The food is very good – I can’t grumble at all”. People’s care records demonstrated a comprehensive assessment of people’s needs.

People told us that they did not have to wait too long for their call bells to be answered and that people were supported with their personal care.

One person told us “cook very good we get good meals" and “best care home around here regards the staff”.

We found staff were not consulting and encouraging people who were confused or had memory loss.

We found care plans were not up to date so necessary changes were not being made to ensure the person was receiving safe and appropriate care and support.

We found people using this service were not always protected from the risk of abuse because staff were not identifying possible abuse and taking measures to prevent it from happening or recurring.

We found there were inadequate systems to assess and monitor the service that people received, or to identify, assess and manage risks to people's health, safety and welfare.

People using the service, who were able, told us:

‘Staff are all very kind, I feel well looked after’

‘They help me to be independent and help me with my stockings when I need it’.

‘If I press the bell they come in five minutes, I was ill recently and they were right there’.

‘This is a home from home’

‘You press the bell and they come, they check you at night, I have caught them a couple of times checking me’

‘There is nothing to complain about here’

‘Rest assured that we are cared for and the staff are well appreciated’.

People told us that they felt able to decide how they spent their time:

‘I can get up when I want and go back to bed when I want’

‘I like to stay in my room and not go to the lounge and that’s ok’

‘I have brought my own furniture and my family do my washing, I prefer that’.

Every person we spoke was complimentary about the standard and choice of food:

‘The food is very good, there is a choice, if I don’t like what there is can ask for a jacket potato’

‘You can spend the day how you like, food is excellent, for breakfast I had a choice of four things’

‘There is a cup of tea whenever you want it’