This inspection visit took place on 06 April 2017 and was unannounced.

At the last inspection on 28 January 2015 we asked the provider to take action to make improvements because we found breaches of legal requirements. This was in relation to person centred care, consent and capacity, safe care and treatment, safeguarding service users from abuse and improper treatment, nutrition, staffing levels and governance of the home. The provider sent us an action plan saying they would meet the legal requirements by 06 July 2015. During our inspection visit on 06 April 2017 we found these actions had been completed.

Thistleton Lodge Care Home is a large detached property in its own extensive grounds. It is easily accessible and there is ample car parking space for visitors. There is a lift and access for wheelchairs throughout. The service can accommodate a maximum of 54 people and specialises in providing care for people who live with dementia. At the time of our inspection visit there were 50 people who lived at the home.

There was a registered manager in place. 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 who lived at the home told us they were happy with their care and liked the staff who looked after them. One person said, “The staff are brilliant and we get the best care possible.”

We observed staff providing support to people throughout our inspection visit. We saw they were kind and patient and showed affection towards the people in their care.

We saw people who lived at the home were clean and well dressed. They looked relaxed and comfortable in the care of staff supporting them.

People who lived at the home and their visitors told us they enjoyed a variety of activities which were organised for their entertainment. One person who lived at the home said, “They are always organising something for us to do. There is never a dull moment.”

Staff knew people they supported and provided a personalised service. Care plans were organised and had identified the care and support people required. We found they were informative about care people had received. They had been kept under review and updated when necessary to reflect people’s changing needs.

Risk assessments had been developed to minimise the potential risk of harm to people during the delivery of their care. These had been kept under review and were relevant to the care provided.

We found people had access to healthcare professionals and their healthcare needs were met. We saw the service had responded promptly when people had experienced health problems.

The service used innovative methods to ensure care was provided in a way that was responsive to people's needs. For example, staff on night duty wore pyjama type uniforms to help orient people to place and time.

People who were able told us they were happy with the variety and choice of meals available to them. We saw regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration.

The service had sufficient staffing levels in place to provide support people required. We saw staff members could undertake tasks supporting people without feeling rushed. People who lived at the home told us staff were responsive to their needs.

We looked at the recruitment of four recently appointed staff members. We found appropriate checks had been undertaken before they had commenced their employment confirming they were safe to work with vulnerable people.

Staff spoken with and records seen confirmed a structured induction training and development programme was in place. Staff received regular training and were knowledgeable about their roles and responsibilities. They had t

The inspection took place on 28 January 2015 and was unannounced, which meant the provider did not know we were coming to inspect. The last inspection of this service took place in June 2014 when we found no breaches of the Regulations.

Thistleton Lodge is a large detached property in its own extensive grounds. It is easily accessible and there is ample car parking space for visitors. The home provides care for up to 54 people with differing needs. There is a lift and access for wheelchairs throughout. The service provides care for people living with dementia. The service was supporting 46 people at the time of our inspection.

The home had a registered manager in place. 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 and their relatives we spoke with all told us that they or their relative was safe and looked after well. However, our observations found that staff were stretched, and had found it difficult to provide effective care and support at busier times of the day to people living with dementia.

We found that the registered person had not protected people against the risk of insufficient numbers of staff deployed throughout the service.

We saw that robust recruitment procedures were in place and required background and identity checks had been carried out on all staff. This helped to ensure that as far as possible, staff were safe to work with vulnerable people.

We looked at procedures around medication and observed that people received their medication in a safe manner, when it was required.

People we spoke with and their relatives felt staff had sufficient knowledge to provide safe and effective care. We found the home had a good induction process for new staff which covered all mandatory training with suitable knowledge checks. Refresher and more advanced training were also available. We have made a recommendation about staff training on the subject of dementia.

We found that staff supervision and appraisal was not formally recorded and were reactive rather than proactive. The staff supervision processes did not help to identify and address any shortfalls in knowledge.

Staff had not received appropriate training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides legal protection for people who may not have the capacity to make some decisions for themselves, whilst DoLS provides legal safeguards for such people who may have restrictions placed on them as part of their care plan. We saw evidence of restrictive practices without authorisation. People in the areas of the home for those who were living with dementia were unable to exit the premises unaided or unattended and were, for the most part, under continuous supervision from staff.

We found that the registered person had not ensured that staff understood their responsibilities with regard to gaining consent from the people in their care with regard to the MCA. Peoples’ liberty was being restricted without authorisation and there was no record of the discussions which took place to decide whether this was in the person’s best interests.

We saw that people received enough food and drink with plenty of choice and variety on the residential unit. However, people who lived in Oak View were not offered a choice of what to eat or drink at lunchtime. Information contained within the care plans showed that people’s weights and fluid intake were routinely recorded. Where concerns were highlighted, the records showed that referrals were made to the relevant professionals for help and advice.

We visited all areas of the home during our inspection and found it to be a clean, bright welcoming environment. However, more could be done to make the environment more ‘dementia friendly’ for people who were living with dementia. We also found storage heaters in the home were very hot to the touch, which could have resulted in injury to a person if they came in contact with them.

We found that the registered person had not protected people against the risk of unsafe or unsuitable premises.

Everyone we spoke with told us that the staff were friendly, helpful and caring. We were told staff displayed kindness and respected peoples dignity and respect. Our own observations throughout the inspection confirmed what people had told us.

Care plans we looked at were person centred, however, they lacked information about people’s life histories, which would give staff more insight into how they would like to be cared for. Pre-admission assessments were completed before people moved to Thistleton Lodge which allowed the service to understand if they could meet an individual’s needs. These plans were reviewed on a regular basis and changes made where appropriate. However, we found little evidence that people or their relatives were regularly involved in these reviews.

We found that the registered person had not ensured people were fully involved in reviewing their written plans of care.

We found the home provided a wide ranging programme of activities for people who lived there. People told us they enjoyed trips out to the local area.

We observed a calm atmosphere within the home on our unannounced arrival. People we spoke with and staff told us the home had an open culture and the management were approachable. Staff told us they enjoyed working at Thistleton Lodge.

We saw that feedback from people their relatives and staff was obtained through surveys and regular meetings. People were able to express their views to improve the service.

We saw that a full range of audits and quality checks were completed by the management of the home in order to check on the quality of service provided and drive improvements where required. Safety checks were completed on equipment and the building itself. However, these checks had not identified the issues we found during our inspection.

We found a significant number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in respect of levels of staffing, meeting peoples’ nutrition and hydration needs, unsafe or unsuitable premises, consent to care and treatment, peoples’ involvement in reviewing the care provided and the operation of systems designed to assess, monitor and improve the quality and safety of the services provided. These also amounted to 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.

We asked if medicines were handled safely. We found that appropriate arrangements were in place for recording and administering medicines. The home manager completed regular audits of medicines handling to help ensure that should any shortfalls arise, they can be promptly addressed. When we visited we saw that there had been a medicines error at the home, this was being investigated by the manager in accordance with the homes policy. The controlled drugs cupboard did not meet with current law but a new one was on order.

When we last inspected this service in October 2013 we identified a number concerns. The provider sent us an action plan which adressed these concerns and told us how, and by when they would make improvements. We carried out this inspection to check that improvements had been made in these areas.

We found the provider had effective systems in place in order to gain consent from people before any care was delivered to them. Where people were unable to make decisions for themselves, the provider acted in accordance with the law and ensured decisions were made in the best interests of people concerned.

People's needs were asessed and used to inform individual plans of care. These helped to ensure that people's needs were met in a way that was safe and which protected them against risks of inappropriate care.

People were not protected against the risks associated with the unsafe use of medicines. The provider did not have effective measures in place to ensure the home's medicines policy was followed at all times.

The home maintained accurate and appropriate records. This helped to ensure that up to date and relevant information about people was maintained so that care and treatment could be planned and delivered appropriately and safely.

We carried out this inspection following concerns raised about the care and welfare of people who used the service.

We found the provider had not ensured staff who cared for people living with dementia had the knowledge and skills required to provide care and support that fully met their needs. We found little evidence that people were involved in the planning of their care as written records were incomplete.

People we spoke with were generally happy with the care and support they received and spoke highly of the staff team and the home in general. We found, however that people's risk assessments and plans of care were not reviewed and updated in line with changes in their needs. This could result in inappropriate or unsafe care being delivered to people.

We found the home did not have suitable arrangements in place for storing, administering, recording or auditing the use of people's medication.

We found records at the home did not always include accurate and up to date information about people who used the service.

People told us:

"I'm happy that staff always ask me and explain what they need to do before they help me with [personal care]."

"I love it here...I wouldn't want to be anywhere else...You wouldn't find anywhere better."

"The staff are fantastic, just like family."

We found that the provider had well trained staff who ensured that consent to care and treatment was gained from people who used the service. Staff at the home were well supported to carry out their role and there was a good team ethos amongst the staff and management. The provider took a person centred approach to assessing people's needs and delivering care, which promoted the health and welfare of each individual. We saw that the care that was delivered to people was of a high standard and people were satisfied with the care and support they received. The registered manager had effective systems in place for monitoring and assessing the quality of care that was provided.

People living at the home and relatives we spoke with all said that staff were respectful. One relative told us ‘’They (the staff) know how (user of the service) can be difficult but they (the staff) accommodate her wishes’’

The relatives we spoke with told us, ''this is the third home my relative has been in and we are more than happy with it.'' One relative said, “If anything changes, I’m always told straight away and it’s much better than where (user of the service) was before.”

The staff that we spoke with understood the signs of abuse and what to do if they had concerns. One member of staff told us they were more than happy to whistle blow they said ‘’I wouldn’t hesitate’’.

The staff we spoke with all told us that they had completed an induction and one told us, ‘’ When I started I spent two weeks working with an experienced member of staff ‘’

One person using the service that we spoke to said ‘’ I have no complaints and would tell the manager if I had’’

One relative said that they were able to express their views about the care, treatment and support their relative received, and that the manager and staff were always happy to listen, and act on issues when problems arose. Several people who live at the home said that they felt safe and that they care were received was appropriate to their needs. One relative said that they believed people’s rights were respected, and that the staff and manager had people’s best interests at heart in everything they did. Several people said that the meals were very nice with plenty of choice. Other people said that they had been able to have some items on the menu changed as some improvements had been needed. One relative said that their relative had needed to have a lot of care and support from the local GP and District Nursing team, and that the staff and manager had done a good job in helping to organise this. People said that they felt safe living at the home, and that they knew who to speak to if they felt they were being ill-treated. One person spoke about a talk they had been to recently regarding abuse. They had found it very useful. People living at the home, and their relatives said that the home is always kept clean and tidy. One relative who was spoken with said that their relative is prescribed a lot of medication and that in her experience there never been any issues with staff giving it at the right time, in the right dosage. People said that the staff are always busy, but willing to help at anytime. Others added that the staff are very kind and caring, have a good sense of humour and are good at their job. People said that the manager and staff do talk to them about the way their care is being provided, and that they have had surveys given to them to complete relating to their views on quality of the service.