This comprehensive inspection took place on 5 July 2018 and was unannounced. We last inspected this service in May 2017 where it was rated ‘Requires Improvement’ overall and ‘Requires Improvement’ in the Effective and Well-led key questions. Following the previous inspection in May 2017 we identified two breaches of regulation, corresponding to regulation 11, need for consent, and regulation 17, good governance. During this inspection in July 2018 we found that sufficient action had been taken to improve on these areas. However, we identified some different concerns, relating to medicines.

Teignbridge House is a ‘care home’. 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. Teignbridge House accommodates up to 24 people in one adapted building. At the time of our inspection there were 22 people living in the home.

The service had a registered manager. 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 our inspection an incident had occurred involving the lack of window restrictors on a bedroom window and a person had been injured. During this inspection we looked at the actions taken to minimise the risks of similar incidents taking place. We found the provider had taken steps to ensure other people living in Teignbridge House were protected from similar risks.

All the people living in the home needed help from staff to take their medicines. When reviewing people’s medicines, we found a number of inconsistencies between the number of tablets people had in stock compared to the numbers recorded. This meant it was not possible to tell whether people had been taking their medicines as prescribed by their doctor.

We found records were not always accurate. For example, we found some falls people had experienced had not been recorded in the accident book or the falls diary. People’s care plans were highly detailed however, and contained lots of clear guidance and information for staff on how best to support people.

Although action had been taken to implement improvements following our previous inspection in relation to the monitoring of the service, we found concerns remained as issues relating to medicines had not been identified. This meant the service was still in breach of regulation with regards to good governance.

We found the systems in place to manage the laundry in the home were not effective. People’s clothes were regularly getting lost or mixed up with the laundry of others. Complaints had been made by people in the home and by relatives. The registered manager told us they were in the process of reviewing the systems in place to manage this and were going to be allocating specific hours for staff to oversee this and ensure these issues were dealt with.

Action had been taken to ensure staff understood the Mental Capacity Act 2005, the principles of the Act and how to apply these. We found people were involved in all aspects of their care and their consent had been sought prior to any care being delivered.

Recruitment procedures were in place to help ensure only people of good character were employed by the home. Staff underwent Disclosure and Barring Service (police record) checks before they started work. Staff knew how to recognise possible signs of abuse in order to protect people. Staffing numbers at the home were sufficient to meet people’s needs. Staff had the competencies and information they required in order to meet people’s needs. Staff received sufficient training as well as regular supervision and appraisal.

The people who lived i

This inspection took place on 18 May 2017 and was unannounced. The service was last inspected on 5 February 2015 when it was rated as Good.

Teignbridge House Care Home Limited provides personal care and support for up to 24 people. There were 22 people living at the home at the time of this inspection. Teignbridge House cares for older people including people living with dementia. If people needed support with any nursing care needs this was provided by the local community nurses.

There is a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. The registered manager is also the registered provider of this service. 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 provider did not have effective systems in place to monitor the service and ensure the service ran smoothly. Some management tasks had been delegated to senior staff, such as staff training, care planning and reviews. However, the provider did not regularly monitor these to ensure all tasks had been completed safely and effectively. For example, when staff had completed training this had been recorded by a senior member of staff on individual training matrix. The provider did not have systems in place to check that staff had received training and were competent in areas they had identified as essential. After the inspection we spoke with the provider and the senior member of staff and they took prompt action to improve their training matrix, identify gaps in training and put in place a plan to ensure essential training topics are completed in the near future. However, the lack of a robust quality monitoring system meant there was a possibility the provider may fail to identify staff training needs in the future.

We found that some staff had not completed training on topics such as the Mental Capacity Act 2005 and did not have the knowledge or information necessary to ensure that the service was working within the principles of the MCA and that people’s best interests were met with the least restrictions possible. The provider did not have an effective quality monitoring process to help them identify areas where they were failing to meet current legislation. The provider had received advice in the last year from the local authority Quality and Improvement Team (QAIT) to help them draw up their own service improvement plan. However, the plan had not been regularly reviewed or updated and therefore was not fully effective.

People’s capacity to make decisions had not been formally assessed, and staff did not have sufficient information or training to ensure they followed the principles of the Mental Capacity Act 2005. After the inspection a senior member of staff told us they were booked to go on a training course provided by the local authority in the near future and they planned to complete mental capacity assessments for people living in the home after they have completing the training.

There was a warm and welcoming atmosphere. People told us they were happy living in the home. Comments included “People seem so happy here”, “I couldn’t be happier anywhere than I am here”, and “Absolutely perfect!” A visitor told us “I would say it is almost exceptional. Very caring staff. Regular staff. They don’t have lots of staff changes. I am really impressed with this care home.”

People told us they felt safe. They told us there were enough staff to meet their needs and ensure routines ran smoothly. Call bells were answered promptly. Staff turnover was low and staff recruitment records showed that staff were carefully checked to ensure they were suitable for the post before they began working in the home.

Risks to people’s health and safely had been assessed, regularly reviewed, and measures had been put in place to minimise risks where possible. Treatment and

This inspection took place on 5 February 2015 and was unannounced.

Teignbridge House Care Home Limited provides personal care and support for up to 24 people. There were 21 people living at the home, one person was in hospital. Teignbridge House cares for older people including people living with dementia. Some people at the home required nursing intervention and this was provided by the local district nursing team.

The service had a registered manager in place, who was also the provider of 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.

Throughout the inspection there was a calm, friendly and homely atmosphere. People appeared relaxed and happy. People and health care professionals spoke highly about the care and support Teignbridge House provided.

People were supported to maintain a healthy balanced diet. People told us they enjoyed their meals and did not feel rushed. One person said, “Good choice offered.”

Care records were comprehensive and detailed people’s preferences. People’s communication methods and preferences were taken into account and respected by staff. People’s risks were considered, well-managed and regularly reviewed to keep people safe. Where possible, people had choice and control over their lives and were supported to engage in activities within the home and outside where possible.

People were protected by safe recruitment procedures. Staff put people at the heart of their work. Staff were kind, compassionate and gentle in their interactions with people. Strong relationships had been developed and practice was people focused and not task led. The service had an open door policy, relative and friends were welcomed and people were supported to maintain relationships with people who mattered to them.

Staff were supported with an induction and ongoing training programme to develop their skills and competency was assessed. Everyone we spoke with felt there were sufficient staff on duty. People told us “There are enough staff, I ring a bell and they come.” A staff member commented; “Every day is different, some busier than others but yes there are enough staff.”

The provider and staff had sought and acted on advice where they thought people’s freedom was being restricted. This helped to ensure people’s rights were protected. Applications were made and advice sought to help safeguard people and respect their human rights. Staff had undertaken safeguarding training, they displayed a good knowledge on how to report concerns and were able to describe the action they would take to protect people against harm. Staff were confident any incidents or allegations would be fully investigated. People told us they felt safe.

People knew who to contact and how to raise concerns and make complaints: “I’d go to the desk and talk to staff”; “I’d speak to the manager, they’d sort it quickly”; “I don’t have any complaints – if I did I’d talk to […] (provider)” and “I have nothing to complain about, I’m very happy here.” People told us they had not needed to make a complaint but the management team were visible and approachable and would deal with any concerns promptly. We saw that complaints which had been made had been recorded and investigated in accordance with the home’s policy. Learning from complaints incidents was used to drive improvements.

People and staff described the management as very supportive and approachable. Staff talked positively about their jobs and took pride in their work. People told us “It’s first class here”; “It’s excellent, I love it here – it is well-run; I’m well-fed, they help me when needed, they polish my shoes and do my washing!” Staff confirmed “Yes- it’s well-run, a nice atmosphere, they trust you to do the job”; “There isn’t a blame culture here – we work together, share the responsibility for improving things.”

The service had an open and transparent culture. The provider had set values that were respected and adhered to by staff. Staff felt listened to and were encouraged to share any concerns they had so issues were promptly dealt with. The staff worked closely with external agencies such as the local authority to raise issues and seek advice promptly when required.

People’s opinions were sought formally and informally. Audits were conducted to ensure the quality of care and environmental issues were identified promptly. Accidents and safeguarding concerns were investigated and where there were areas for improvement, these were shared for learning.

People’s medicines were managed safely. Medicines were managed, stored, given to people as prescribed and disposed of safely. Staff were appropriately trained and confirmed they understood the importance of safe administration and management of medicines.

People lived in a home that was clean and hygienic. The premises were well maintained and comfortable.

People had access to healthcare professionals to make sure they received appropriate care and treatment to meet their health care needs such as district nurses and GPs. Staff acted on the information given to them by professionals to ensure people received the care they needed to remain safe.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who lived in the home told us they felt safe and were well treated by staff. When asked if they ever had been treated badly or witnessed anyone else being treated badly, one person said "All the staff are lovely. There isn't one problem at all. If there was I can approach any of the care staff". We observed staff talking to people in a patient, friendly and supportive manner throughout our inspection.

People were protected from abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening. All staff had completed safeguarding training as part of their induction.

Personal emergency evacuation plans were available for each person. We found that the home was set to respond to emergencies without delay and there was clear protocol set out. This meant the disruption to people's care and welfare would be minimised.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which applies to care homes. The Deprivation of Liberty Safeguards is in place to protect people's human rights. The Registered Manager said they had not needed to submit a Deprivation of Liberty Safeguards application to-date. However, the Registered Manager was aware of when an application should be made and knew where to go if an application was required.

We saw there were robust systems in place to assess and check appropriate and safe care was being delivered. These included daily and monthly internal audits. These audits included monitoring checks on the safety and maintenance of the home.

Is the service effective?

We observed people decided where and how they spent their time. People who lived in the home expressed their views and were involved in making decisions about their care. We spoke with five people who lived in the home. They told us they were able to make their own daily living choices such as meals and activities.

One person told us "We always get a choice of meals and you can ask for an alternative if you like". Another person said "You can have company or privacy as you like. You can watch TV with others in the lounge, or sit quietly in the other lounge or watch TV in your own room".

One person told us "When I first came here they asked me in detail what I liked, this is as close to home life as you can get. Just without the chores". They added "I'm very lucky to be here and enjoy my life".

We looked at three care plans and saw that the plans detailed people's preferences regarding personal care routines, food, interests and social activities. Records showed that people or their representatives had been involved in developing the care plans. The Registered Manager said they had regular discussions with each individual and updated the care plans on a monthly basis. This helped them to plan ways of supporting people to improve their quality of life. One person said "I don't need to look at my care plan; it's so personal you just tell the staff and they always fit in with your preferences".

Is the service caring?

People were supported in promoting their independence and community involvement. They told us they regularly went out into the community either with their family members or with support from the staff. People went out for walks, shopping, coffee, the garden centre and trips to places of interest.

One person said "We have little trips out, but it's your choice you can stay home if you want. There's no pressure, just whatever makes you happy".

We saw that attention was paid to people's appearance including their hair and nails. All clothes worn by people were clean, smart and reflected people's individual styles. This showed that staff recognised the importance of helping people to look their best. All staff spoken with told us how they ensured people's privacy, dignity and independence. People who used the service told us staff offered them choices and help when needed.

One person told us "I was living alone and I'd reached a point where my relatives were my daily carers." They added "Since my move here I'm very satisfied with the staff supporting me and my relatives just come to enjoy my company."

A staff member told us "It is very important to ensure people are treated with respect and treated as individuals." We saw staff demonstrate this during our visit. Another person told us "I spend a lot of time talking with people to find out just what they like and what they are like as a person". This meant people's rights, choices and diverse needs were being met.

Is the service responsive?

We saw strategies for managing risk were incorporated into care plans and these balanced safety and effectiveness with the right of the individual to make choices. All documents were focussed around the needs of that person and what specific issues were going to cause risk, for example falls. These were reviewed monthly or as required. Care plans showed that the person was the centre of the planning, taking into account their mobility, social care and health requirements. Risk assessments outlined how to manage risk so that the level of risk was reduced. For example pressure sore assessments were regularly assessed with appropriate support from the District Nurse as required.

One person told us "I've got everything I need and more here." Another person told us "I don't have any complaint, but would be happy to talk to the staff if I did."

Is the service well led?

Staff were monitored and supervised in their role to ensure they knew how to provide a high standard of care. There were staff meetings, with daily communications during handovers and important information shared with the communication book. Staff told us they felt comfortable raising issues with the management of the home and they were confident they would be listened to and action taken if needed. Staff training was monitored so that any gaps could be identified and training booked. This meant there were processes in place to ensure staff received the support they needed to carry out their roles effectively.

One person told us "This is a lovely place to work, we all get on well with each other and support each other." They added "I'm fully supported and have an excellent manager that I can approach easily with any concerns or suggestions".

We visited Teignbridge House Care Home to follow up on concerns we identified at the previous inspection in October 2013. We found that improvements had been made.

We saw that medication was stored securely. We saw that the medication systems in use meant people had their medicines at the time they needed them and in a safe way.

The provider had carried out appropriate checks to ensure staff were suitable to work in the home. Staff had not started work until the checks were completed.

Care workers received appropriate training so they could carry out their job role effectively. People who live in the home told us care workers were competent and knew how to meet their needs. Comments included “the staff are very good” and “I’m very happy with the staff”.

There were systems in place to monitor the quality of the service provided. People who live in the home told us “nothing could be better” and “there’s nothing to grumble about”. Care workers we spoke with told us “It’s much better now” and “things have improved, we can see the difference”.

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

On the day of our inspection 23 people lived in the home. During our inspection, we spoke with six people who lived in the home, one relative, one visiting healthcare professional, the registered manager, manager, and five care workers. Some 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 observations and conversations, we saw care workers treating people with respect. People told us "the staff are brilliant” and “the staff are very kind”. People who lived in the home told us they were happy with the care they received. Comments included “it’s lovely here” and “nothing could be better”.

Some medicines were not stored safely. We also found issues relating to the administration, recording and disposal of medicines.

Recruitment procedures were incomplete. For example, two care workers had recently started to work at the home before essential checks had been undertaken. We found staff had not completed some areas of training to keep them up to date with current best practice.

There was a basic quality assurance system in place. Concerns which had been identified had not been put right by the service through the use of their monitoring systems. We found records were not kept in a way that protected people's safety and welfare. The care plans were not written in enough detail to ensure that care workers could follow the instructions.

People told us what it was like to live at 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 a practising professional. There were 21 people living at the home during the inspection with one admission expected. The home also offers short term respite care. We spent time with seven people living at the home and spoke to the owner/manager and five staff in depth. We also 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 answer specific questions.

People who lived in the home told us that they were very happy with the way they were looked after. We were told “It’s a very good home, they do well here”. People told us that the owner was “a good man” and “a wonderful chap”. People told us that the staff were good at meeting their health and welfare needs. We were told "I gave it a year and now I am sure that this is the place for me”.

People we talked with told us that they enjoyed the meals provided. One

person said " I eat better than I did when I was at home". Others told us "I get plenty of food and I can order what I fancy".

People who lived in the home told us they felt safe. They said they knew how to raise

concerns and felt comfortable about doing so. One person said “I can’t imagine anyone not feeling looked after here”.