The inspection took place on 10 April 2017. It was unannounced. At our previous inspection in August 2016 we found breaches of six of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were to do with providing care and treatment in a safe way, operating effective systems to manage risk and quality, maintaining sufficient staffing levels, providing care and support that met people’s needs, meeting the requirements of the Mental Capacity Act 2005, treating people with dignity and respect, managing risks to people’s safety and welfare, and treating people with dignity and respect. The provider sent us an action plan and other records describing how they intended to meet the requirements of these regulations. At this inspection we found the provider had made sufficient improvements in some areas to meet the requirements of the regulations, but there were still concerns in other areas.

This service has been in special measures. Services that are in special measures are kept under review and inspected again within six months or soon after. We expect services to make significant improvements within this time frame. During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

Tiled House is registered to provide accommodation, personal care and nursing care for up to 29 older people who may be living with dementia or a learning disability. At the time of our inspection there were 14 people living at the home.

Accommodation was on two floors, both of which were partly occupied. Shared areas included two shared lounges and a dining room. Access to a decked area and the secure garden was from the dining room.

There was no registered manager in post at the time of this 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. Following this inspection we received an application to register from the manager in post.

Although improvements had been made with respect to the safety, maintenance and cleanliness of the home, we found some examples where appropriate standards of hygiene and cleanliness were not maintained in relation to fixtures and fittings in shared bathrooms. When we pointed these out to the manager they took action to resolve them on the day.

The provider had arrangements in place to protect people from other risks to their safety and welfare, including the risks of avoidable harm and abuse. Staffing levels were sufficient to support people safely. Recruitment processes were in place to make sure the provider only employed workers who were suitable to work in a care setting. There were arrangements in place to store medicines safely and administer them safely and in accordance with people’s preferences.

Staff were aware of the importance of consent but the provider did not always put into practice the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards where people were unable to consent.

Staff received appropriate training and adequate supervision to maintain and develop their skills and knowledge to support people according to their needs. People were supported to eat and drink enough to maintain their health and welfare. People were supported to access healthcare services, such as GPs and specialist nurses.

Care workers had developed caring relationships with people they supported. People were able to take part in decisions about their care and support and their choices were respected. Staff respected people’s independence, privacy, and dignity.

Care and treatment were based on plans which took into account peop

This inspection took place on the 11, 12 and 15 August 2016 and was unannounced. During our previous inspection on 27 and 28 October 2015 we found two regulatory breaches in relation to the unsafe management of people’s medicines and unsafe recruitment practices for the employment of staff. Following the inspection, the provider wrote to us to say what they would do to meet these legal requirements by December 2015. During this inspection we checked whether the provider had completed their action plan to address the concerns we had found. We found the provider had made the required improvement in their recruitment practice. However, we identified that improvement actions from the previous inspection remained outstanding and further improvements were required to ensure the management of medicines was safe and met the requirements of the regulation.

Tiled House provides accommodation and nursing care for up to 29 older people, most of whom are living with dementia. The home is in the village of Shawford, near Winchester. People have access to gardens.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered person’. 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 previous registered manager left the service on 11 March 2016. A new manager was appointed in March 2016 and they have applied to us for registration.

The provider had not made the improvements required from our previous inspection to ensure the proper and safe management of people’s medicines. Not all people had guidance for the use of ‘as required’ medicines to ensure they received the appropriate treatment when required. We identified some errors in the recording of people’s medicines and not all medicines were safely stored. People’s medicines were not always administered in a safe way to prevent errors. Medicines incidents and errors were not always identified and acted upon to protect people and ensure the safe management of their medicines.

People’s individual risks were not always managed safely. A wound management plan was not in place for a person with a wound and the wound had not been fully assessed, checked or treated due to the lack of communication by staff to each about this. People were not always assisted to transfer safely by staff using the correct equipment or support. The correct equipment was not always available to meet people’s individual moving and handling needs in line with their assessed needs. Risks to people were not always fully assessed or acted upon to mitigate the risk and guidance on how to support people to minimise risks was not always followed. This meant people were at risk of inappropriate or unsafe care and treatment.

At our last inspection we made a recommendation about the prevention and control of infection. At this inspection we found other evidence that showed the appropriate standards of hygiene and cleanliness to prevent the risk of infection were not adequately maintained. The provider’s system for checking and ensuring infection control practices were followed to minimise risks to people was not robust enough to protect people from risks associated with infection control.

The environment was not maintained to a safe and appropriate standard. This meant people could be at risk of accidents and incidents because they were exposed to ineffective safety and security practices.

There were not always enough staff deployed to monitor people’s safety and meet the needs of people in their rooms and in communal areas of the home. Records showed the staffing levels were not always at a safe level as determined by the provider. Not all staff had completed the training as required by the provider to ensure they could provide pe

During our visit we saw that people were being treated with dignity and respect and people's independence was encouraged. People were spoken to in a respectful way. People we spoke to told us that the staff were easy to talk to, approachable and helpful, and that their privacy was respected whilst they were supported to maintain their independence. One person told us "I really like it here, the staff are friendly and are always interested in talking to me." Another person said "they always play games with me which I like."

People chose how to occupy themselves in the service. We observed that people were spending time in the communal areas watching television and interacting with each other in the dining room. During our inspection we observed people spending time in the garden sunbathing and singing along to music. We observed staff spending the majority of their time with people who used the service, playing bingo, talking about their family and playing cards. They frequently checked on them to ensure they were alright when spending time on their own.

We saw staff supporting people to make their own choices about what they had for lunch and what activities they took part in. Staff knew exactly how each person communicated which meant people's wishes were understood and respected.

During our inspection we saw that staff interacted and communicated with people in an appropriate and respectful manner. Staff carried out their duties but stopped to speak with people and spend time answering their questions or checking if they needed anything. We heard staff giving people choices, such as where they wanted to sit or the kind of drink they would like. One person told us, "We have things here to amuse us." They went on to say "If this is a care home this is good."

We observed that staff worked in ways that respected people’s privacy, dignity and independence and this was also confirmed by the people we spoke with who used the service. For example, a person told us that staff were always polite and helpful. “I can do things for myself and I do. They have to help some of the others a lot.”

Staff received appropriate professional development. We saw training records that showed staff had received training in a number of subjects which were relevant to the people they cared for at this service. This included subjects such as dementia, safeguarding vulnerable adults, diabetes, communication and the Mental Capacity Act 2005. Regular agency staff had been included in any training organised by the provider.

During our inspection we used the Short Observational Framework for inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of those people who could not talk with us. During our visit, we observed that not all staff interacted and communicated with people in an appropriate and respectful manner. We observed staff walking into the lounge and having no interaction with people.

We were supported on this inspection by an Expert by Experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

During our visit we spoke with four people who use the service. We were also able to talk with the relatives of three people.

People felt able to express their views about the service. They were able to discuss any concerns they may have with the registered manager.

“If I had a complaint I would go to the manager and she would help me, I don’t have anything to complain about, I am well looked after.”

Overall people were happy with the staff and the care they received. However we had concerns around staff training in some areas.

One relative told us, “There is a huge changeover of staff – and I think a lot of them are agency staff.” One person told us “Once or twice I have had to tell the manager about some of the staff and how they react with the people who live here.”

We also gathered evidence of people’s experiences of the service by reviewing the responses to a recent survey of people and their relatives.

One response was “It would be nice to be informed of any activities so family could attend.”

Another response was “Staff always treat Mum with respect, are always kind, gentle and supportive.”

The inspection took place on 27 and 28 October 2015 and was unannounced.

Tiled House provides accommodation and nursing care for up to 29 older people, most of whom are living with dementia. The home is in the village of Shawford, near Winchester. People have access to gardens.

Tiled House has 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.

Recruitment practices were not safe. Before a member of staff was recruited, relevant checks such as identity checks, obtaining appropriate references and Disclosure and Barring Service (DBS) were completed, however the provider did not obtain a full employment history for all staff recruited. There was a risk that staff may be unsuitable for the role.

Some improvements were required to medicines management to ensure staff were able to identify when people might require pain relief. Medicines were administered in a caring and professional manner. The provider used protocols for people who required pain relief such as paracetamol. These gave clear guidelines to staff about when and how often this type of medicine should be given for individual people. However, pain assessments were not in use in the home. We have made a recommendation in relation to pain assessment.

Protocols were not in place for medicines, other than pain relief, which needed to be administered ‘as required,’ describing to staff how and when the medicine needed to be administered. Therefore there was a risk that these medicines may not be administered appropriately due to a lack of clear guidelines.

Communal areas of the home were clean and smelled fresh, however we found four bedrooms which contained a strong malodour. This stemmed from the mattresses on people’s beds which were stained. The mattresses identified were all replaced before the end of the inspection. We have made a recommendation in relation to infection control.

Staff had completed safeguarding training and were able to explain to us how they protected people from abuse. The safeguarding policy was available for staff to review and staff knew where it was kept and where to find relevant telephone numbers for reporting any concerns people had experienced abuse.

A range of tools were being used to assess and review people’s risk of poor nutrition or skin damage. There were specific risk assessments for each person in relation to falls, nutrition, moving and handling and mental health and cognition. Support plans were written for people in relation to each identified risk.

There were enough staff on duty to meet people’s needs. Staffing levels were calculated by the provider which took into account the number of people using the service and their dependency level. This was reviewed and updated regularly and the registered manager told us she was able to increase or decrease staffing levels over and above the calculated level, if this was necessary. From observation, we saw there were enough staff to meet people’s needs and staff took their time assisting people without rushing them. They also used the time supporting people to socially interact with them rather than just ‘completing a task.’

The high use of agency staff in the home was mitigated by actions taken by the registered manager to ensure agency staff had the right skills, experience and qualifications to meet people’s needs. Actions included training agency staff and using regular agency staff.

Staff had received appropriate training to meet people’s needs. Records showed that staff had received training in key areas such as infection control, first aid, moving and handling, food hygiene and health and safety. Clinical training was provided for trained nurses. Recently nurses had completed training in wound care, mouth care, diabetes and venepuncture (the process of obtaining intravenous access to people’s veins in order to take samples of people’s blood for analysis).

Staff had a regular supervision meeting with the registered manager and an annual appraisal. Areas for improvement were discussed during staff appraisals. All staff told us they respected the registered manager and felt supported in their role. Staff were knowledgeable about people’s needs and how to support them. Staff said they knew about people’s needs from handovers, care plans, risk assessments, people themselves and their families.

We saw that care was delivered in line with people’s wishes. People chose where they wanted to sit to eat their lunch. We saw that staff were very patient with people while they took time to decide and then supported them to sit in the place of their choice.

1. We checked whether the provider was acting in accordance with the requirements of the Mental Capacity Act 2005 (MCA). The MCA is a law that protects and supports people who do not have the ability to make decisions for themselves. We found that staff had received training and were able to describe some of the key principles. Mental capacity assessments had been undertaken which were decision specific.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. We found that the registered manager understood when an application should be made and was aware of a Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. Relevant applications had been submitted and staff were aware of which people were subject to a DoLS.

People were supported to have sufficient to eat and drink and maintain a balanced diet. Drinks were readily available throughout the day and staff encouraged people to drink. Fruit squash and water was available all day and we saw staff regularly pouring drinks for people. No one was without a drink within easy reach at any time. A tea trolley came round during the morning serving tea, coffee, biscuits and yogurts. We saw staff encouraging people to eat and drink.

The meals offered were home cooked, freshly prepared and nicely presented. There was a choice of two main courses and a vegetarian choice. There were also a hot pudding with an alternative of fruit. People were encouraged to have second helpings.

Staff were aware of any special diets or people’s dietary preferences. The chef showed us a list of people’s special diets which was kept in the kitchen. She said she was aware of people’s likes and dislikes. Care plans included risks assessments in relation to each person’s risk of choking or malnutrition and there were plans in place to address any identified risks. Staff explained that they ensured people received sufficent to eat and drink by encouraging fluids and checking monitoring charts.

People were supported to maintain good health through access to ongoing health support. A GP visited every Tuesday but also came on other days if people were ill. Records of GP visits were recorded within people’s care plans ensuring that all staff were aware of the advice given by the GP.

We observed staff interacting with people in a kind and compassionate manner. They responded promptly to people who were requesting assistance and they did so in a patient and attentive way. We also noted a considerable amount of warm and friendly exchanges between staff and people which were, when people were able, reciprocated in the same manner. Staff were cheerful and the atmosphere in the home was relaxed. People seemed calm and contented.

Staff spoke with people while they were providing care and support in ways that were respectful. We observed that people were addressed with their chosen names. Staff ensured people’s privacy was protected by ensuring all aspects of personal care were provided in their own rooms

People’s care plans included a ‘This is me’ record which gave a brief life history. It included what name people liked to be known as, the places they had lived, their school, job, hobbies and interests. This enabled staff to really get to know people and understand what was important to them. People were involved in decisions about their care and were offered choices in all aspects of their daily life.

Most people required a high level of support to meet their care needs. Staff and the registered manager told us they encouraged independence whenever this was possible.

People’s care plans included the range of all expected risk assessments and care plans. For example in relation to skin care, mobility, communication and medication. These were evaluated regularly and showed they had all been reviewed recently. The provider had well organised records and the guidance provided for staff in order that they met people’s needs was detailed and comprehensive. The records were written well and provided step by step information for staff to enable them to provide appropriate care that met people’s needs.

The registered manager told us they were recruiting for an activities co-ordinator, as there was no-one in post at the moment. However, all the staff were aware of the importance of stimulus and mental exercise for people. Staff involved people in playing games of with soft balls, and a game of rope-quoits. Some people had jigsaws; some were reading newspapers or magazines. Most people were wide awake and involved with whatever was happening.

People, staff and relatives were aware of how to complain or raise a concern but most people said they had not had need to do so. All said they would approach the registered manager, who they felt would listen and respond appropriately.

The registered manager was required, by the provider, to work two day shifts providing nursing care. This meant she was only available in a management role for three days a week. Without support from a deputy or an administrator, this was insufficient and meant the service breached regulations which may not have happened had the registered manager been able to carry out her management role on a full time basis. The registered manager told us she worked extremely long hours in an attempt to fulfil her clinical duties as well as her registered manager role but was unable to carry out all the tasks she would like.

There was a positive and open culture within the home. All staff were highly complimentary about the registered manager. She was extremely well respected as a leader. Staff said they were actively encouraged through meetings and appraisal to give feedback about the service.

The home had a registered manager in post who was aware of her responsibilities both regulatory and to the home. Relevant notifications had been submitted to the Care Quality Commission (CQC). There was high visibility of the registered manager ‘on the floor’ and positive interaction between the registered manager, people and staff.

Policies and management arrangements meant there was a clear management structure within the home.

The quality of the service was closely monitored through a series of audits including care plan, catering, medication and night time audits. Quality assurance audits were carried out by the provider. As a result action plans had been drawn up and all actions completed.

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