This comprehensive inspection took place on 5 December 2017 and was unannounced. At the last comprehensive inspection in November 2015 the service was rated Good. At this inspection we found the service remained Good.

Threshfield Court provides accommodation with nursing and personal care. The service is in the small village of Threshfield, close to Grassington in the Yorkshire Dales. Threshfield Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Threshfield Court accommodates up to 57 people, many of whom are living with dementia in one adapted building that is made up of three units. At the time of our inspection there were 50 people using the service.

People told us they felt comfortable and trusted the staff. Staff had received training to ensure they knew how to recognise and report potential abuse. The service cooperated with the local authority to ensure safeguarding allegations were thoroughly investigated and took appropriate actions to minimise them from reoccurring. Risks to people were identified and monitored to enable trends to be identified and plans developed to help manage them from reoccurring. Staff were recruited safely to ensure they did not pose an identified risk to people who used the service. Medicines were managed in a safe way and checks carried out to ensure staff were competent to administer people’s medication. Sufficient numbers of staff were available to meet people’s needs. There were plans to improve their deployment around the home as part of a forthcoming dementia initiative.

Staff were provided with training and development opportunities to support and enable them to meet people's needs. People were assisted to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible; policies and systems in the service supported this practice. People's medical needs were monitored with input and guidance from health care professionals. People were supported to eat and drink enough to maintain a balanced diet. People were positive about their food and felt there was ample choice and variety of this. Arrangements were in place to ensure people’s dietary intake was monitored with involvement from community specialists when this was required.

People and their relatives were included and involved in decisions about the way their support was provided. People were treated with dignity and respect and staff provided support to promote their independence in a kind and compassionate manner.

People received support that was personalised to meet their needs and were involved in making decisions about how this was delivered. People’s support reflected their wishes and preferences and this was updated and regularly reviewed. People’s diverse needs were respected and a range of activities were provided to enable them to have opportunities for meaningful social interaction.

People, their relatives and staff were positive about the way the service was managed. There was a positive and reflective culture that welcomed people’s feedback, to help the service to learn and develop. A range of systems and procedures were in place to enable the quality of provision to be monitored and assessed to help the service to continually improve.

Further information is in the detailed findings below.

This inspection took place on 3 November 2015 and was unannounced. The last inspection was carried out in December 2013 when the service was found to be meeting the Regulations assessed.

Threshfield Court offers accommodation with nursing and personal care for up to 61 older people, many of whom are living with dementia. The service is in the small village of Threshfield, close to Grassington in the Yorkshire Dales. Threshfield Court is a large detached building with accommodation on three floors and a passenger lift to all the floors. The service currently provides a service to 52 people.

There was a registered manager 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.

People told us they felt safe at the service. Staff were confident about how to protect people from harm and what they would do if they had any safeguarding concerns. There were good systems in place to make sure that people were supported to take medicines safely and as prescribed. Risks to people had been assessed and plans put in place to keep risks to a minimum.

There were enough staff on duty to make sure people’s needs were met. Recruitment procedures made sure staff had the required skills and were of suitable character and background.

Staff told us they enjoyed working at the service and that there was good team work. Staff were supported through training, regular supervisions and team meetings to help them carry out their roles effectively. Staff were supported by an open and accessible management team.

The manager and staff were aware of the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). DoLS are put in place to protect people where their freedom of movement is restricted. The registered manager had taken appropriate action for those people for whom restricted movement was a concern. Best interest meetings were held where people had limited capacity to make decisions for themselves.

People told us that staff were caring and that their privacy and dignity were respected. Care plans were person centred and showed that individual preferences were taken into account. Care plans gave clear directions to staff about the support people required to have their needs met. People were supported to maintain their health and had access to health services if needed.

People’s needs were regularly reviewed and appropriate changes were made to the support people received. People had opportunities to make comments about the service and how it could be improved.

There were effective management arrangements in place. The registered manager had a good oversight of the service and was aware of areas of practice that needed to be improved. There were systems in place to look at the quality of the service provided and action was taken where shortfalls were identified.

Concerns were raised with us about a number of aspects which could affect the health and welfare of people using the service. These concerns were around personal care, people not being treated with dignity, hand hygiene, moving and handling, administration of medication and the way people were assisted to eat their meals. The person raising the concerns had also contacted the local authority for them to look at the concerns using their safeguarding processes. We decided to visit the service in the interim, to determine that people were being appropriately looked after and that people were not at risk of harm.

We spoke with some people living at the service and staff about their experiences and noted that at previous visits people have told us they received good care and staff were available when people needed them.

We found that documentation was up to date and reflected the care needs of individuals. We also found that correct procedures were in place around moving and handling, personal care and prescribed medication. We looked at how the service monitors care delivery and what systems were in place to assess the quality of the service people received.

People who used the service, and their representatives, told us they were well looked after. One person said, “The care here is first rate.” We found people were able to choose where and how to spend their time and there were quieter areas for people who preferred a more restful environment. We observed staff were kind and respectful and spoke with people using their preferred names.

We found people’s care and welfare needs were identified and they were given the support they needed to meet these needs. People had access to a range of NHS services including community psychiatric nurses and district nurses.

We observed the meal service at lunchtime, in one communal area and saw people were offered a choice of food. People who needed help or encouragement to eat were given appropriate support.

We found people who used the service were safe and staff were aware of how to recognise and report any concerns about people’s safety and well being.

People we spoke with described the staff as “first class and lovely.” We saw staff were supported to maintain and develop their knowledge, abilities and skills.

There were systems in place to assess the quality of the service people received.

Some people were not able to tell us about their experiences. We therefore used a number of different methods to help us understand the experiences of people. This included observing the delivery of care and speaking to visitors as well as people who lived at Threshfield Nursing home.

Several people who lived at the home were able to tell us about their experience. We also spoke with two relatives who were visiting the home. Everyone told us they were satisfied with the care they or their relative received. People told us that they were treated with respect and were able to make choices and decisions about their care. One relative told us “This is the best home for my relative. He has put weight on. They look after him so well." Another relative said “This home is informal and less regimented than my relatives previous home.”

The service had in place policies and procedures covering safeguarding and the protection of vulnerable adults. Staff were familiar with safeguarding and whistle blowing procedures and knew what to do in the event of abuse being suspected.

Records we looked at confirmed that staff received training in areas such as dementia awareness, infection control and safeguarding. Staff we spoke with told us that they received ‘really good support from the manager’ and that they received useful/appropriate training.

There were a range of effective quality management systems in place to assess and monitor the quality of service that people received.

We visited Threshfield Court on this occasion because we had received some information that the staffing levels in dementia care were not always safe.

We visited the Conistone and Hebden areas of the home. These two originally separated areas had been merged into one providing care for 13 people. We talked to staff and observed the care people were given; we also looked at records that showed us the level of care people received. We saw that staffing levels were currently safe in the home. However we did find that earlier in the year there had been a problem with staffing levels when dependency levels were higher. This meant that staff may not have always been able to give people the care they needed.

We concluded therefore that whilst staffing levels were safe, previously there had been higher dependency levels in the home which could have had an effect on the delivery of care. The provider may find it useful to note therefore that staffing levels should reflect the dependency levels of people receiving care and that these must be reviewed on a daily basis to make sure staffing levels are appropriate.

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 the inspection was part of an inspection programme to assess whether older people living in care homes are treated with dignity and respect and their nutritional needs are met.

The inspection team was led by a CQC inspector, and joined by an ‘expert by experience‘ and a healthcare professional. These are people who have experience of using services and can provide that perspective and professional advise.

People told us that they enjoyed living at the home and that the care they received was good. They said that staff were kind and helpful and skilled at looking after people.

One person said “This is a very good home, I have everything I need the staff are tremendous, they are thoughtful and very caring towards us all.”