Tower House is a residential home registered to provide personal care for up to 12 older people with a range of conditions. On the day of our inspection 11 people were living at the service.

At the last inspection, the service was rated Good.

At this inspection we found the service remained Good.

Why the service is rated good:

There were sufficient staff to meet people's needs. Staff were not rushed in their duties and had time to chat with people. Where risks to people had been identified risk assessments were in place and action had been taken to manage the risks. People received their medicines as prescribed.

People continued to receive effective care from staff who had the skills and knowledge to support them and meet their needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the procedures in the service supported this practice. People were supported to maintain good health. Various health professionals were involved in assessing, planning and evaluating people's care and treatment.

The service continued to provide support in a caring way. Staff were kind and respectful and treated people with dignity and respect. People benefited from caring relationships with staff. People were involved in decisions about their care needs and the support they required to meet those needs.

The service continued to be responsive to people's needs and ensured people were supported in a personalised way. Staff understood people's needs and preferences. People's needs were assessed to ensure they received personalised care. There was a range of activities for people to engage with.

The service was led by a registered manager and deputy manager who promoted a service that put people at the forefront of all the service did. There was a positive culture that valued people, relatives and staff.

We carried out an unannounced comprehensive inspection of this service on 18 and 20 November 2014 at which a breach of legal requirements under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 was found. We served three warning notices around the provision of medicines management, staff training and induction and around the non-application of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Compliance actions were also made around assessing and monitoring the quality of service provision, and care and welfare or people who used the service.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches and submitted an action plan. We undertook a focused inspection on the 2 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Tower House’ on our website at www.cqc.org.uk’

Tower house provides accommodation for up to 12 people who require support with their personal care. The home mainly provides support for older people. There were 10 people living at the home at the time of our inspection.

Tower House has 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.’

At our focused inspection on the 2 June 2015, we found that the provider had made significant improvements and had followed their plan which they had told us would be completed by December 2014. We found all legal requirements had been met.

Management of medicines had greatly improved in the service. Clear care plans, guidance and risk assessments were now in place around the use of prescribed and non-prescribed medicines. Regular audits were now in place to identify any shortfalls in the management of medicines.

Fire safety had greatly improved in the service. The deputy manager had accessed resources such as the local fire officer and training to ensure people were protected against the risks associated with the potential of a fire. Staff had all been retrained in fire safety and clear guidance was in place on what to do in the event of a fire.

All staff had been retrained in all areas deemed ‘mandatory’ by the provider. Staff were now provided with the knowledge and skills to undertake their roles effectively. The deputy manager also ensured staff’s competency was assessed alongside training. A new induction policy and procedure was in place to ensure any new staff were supported and trained in their roles in a time efficient manner.

Staff knowledge of MCA and DoLS had greatly improved. At the time of this inspection, no people were subject to a DoLS. Staff and the deputy manager were able to explain their roles and responsibilities around MCA and DoLS and were able to provide examples of when this would need to be applied. All staff had been retrained in MCA and DoLS. One staff member told us this had greatly improved their confidence.

The service had made considerable improvement since the last inspection to ensure they were working in line with the required regulations. The deputy manager had utilised outside resources and had implemented new audits and quality monitoring checks to ensure there was good governance of the service.

During our inspection we found the provider had put measures in place to improve the recruitment, interview and selection process. Existing staff recruitment files were reviewed to ensure they recorded satisfactory explanations for any gaps in employment histories and health checks had been completed. This was to ensure that people who use the service were not placed at risk of being cared for by staff who were not suitable to provide their care and treatment.

During our inspection we observed a clean environment throughout the home. People who use the service and relatives we spoke with told us the home was kept clean and tidy. People were protected from the risk of infection because guidelines published by the Department of Health about infection prevention and control had been followed.

The provider had put measures in place to ensure staff received appropriate training and professional development. This was to enable them to deliver care and treatment to people safely and to an appropriate standard. A system of staff supervision and appraisal was in place to support workers.

The provider had put measures in place to ensure that users of the service were safeguarded against the risk of abuse by identifying and responding appropriately to incidents involving allegations of abuse. People who use the service told us they felt safe and trusted staff. One person told us “They (staff) are so kind.”

People we spoke with told us they were happy living in the home. They told us they felt safe, cared for and listened to by staff. They described the home as comfortable with a family atmosphere.

One person said, “I like to stay in my room, staff come in to see me often, and sit and talk to me”. Another person said, “They will always cook something else for me if I don’t like what is on the menu”. We found from our observations that people were not always treated with dignity and respect.

We spoke with staff and looked at people's care plans and supporting documents. We found that peoples care plans detailed people’s needs and associated risks and had detailed how to meet those needs whilst minimising identified risk.

The provider had not always ensured staff received appropriate professional development or support to deliver care and support to the people who live in the home.

We found people and their relatives did not have opportunities to contribute their views about the quality of the service. We found the provider did not have any system for monitoring services provided to be confident people were being well cared for and safe.

People gave very positive comments about the home and the support they were provided with by staff. Comments included, “I am happy here” and “I get the help that I need.” They told us that they obtained medical support and were assisted to medical appointments. One person stated that they had not been involved with development of their care plan.

We were told that people thought there were always enough staff on duty, day and night. People told us that staff were quick to respond to calls for assistance. Other comments were,”Staff lovely, I cannot fault them,” and “They are most kind.”

The inspection took place on 18 and 20 November 2014. Tower House is situated in the small village of Shiplake and provides accommodation for up to twelve older people. During this inspection, the home was providing care to 11 people within the service.

Tower House has 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.’

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We found the service was not safe. Poor medication practices were undertaken which potentially placed people at risk of harm. We found expired medications within people’s rooms. Where people required the use of PRN (“as required”) medication, these were not offered in line with their prescriptions. People did not have medication care plans in place and no medication audits were undertaken by management. There was a high use of non-prescribed medication which staff and management were unaware of which could potentially impact on people’s prescribed medication.

People told us they felt there were enough staff to meet their needs. Staff were visible and promptly answered people’s call bells and requests

The last fire risk assessment undertaken within the service was dated October 2010. The providers fire drill procedures stated “Fire drills to be practiced every 6 months by day staff and every 3 months by night staff.” Three new staff members confirmed they had not undertaken a fire drill since the commencement of their employment. For one staff member, this was six months ago. We were not provided with evidence that fire drills had taken place. Recruitment checks were not always adequate as gaps in staff employments histories were not explored to ensure their suitability to work within the service.

One staff member received no fire safety training, Infection control training, first aid training, food hygiene training, health and safety training or COSHH training since the commencement of their employment six months ago. We were told this staff member did not administer medication. We found this staff member was administering medication, including controlled drugs without any formal training. We found the provider was not following their training policy. We also found no formal induction procedure or policy in place for new staff members.

We found staff and management were not aware of their roles and responsibilities around the use of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The application of this legislation ensures people are not unlawfully deprived of their liberty through restrictive actions.

People were very positive and complimentary about the staff and management of the service. Staff were patient when working with people, and working at a pace which suited the person. People also told us staff were very respectful and allowed them to be as independent as possible.

The manager and deputy manager had a “hands on” approach and were involved in providing care and counted as members of staff working on the floor. Staff were positive about the fact that the manager and deputy manager were always available and visible. The deputy manager undertook some audits within the home to monitor the quality of care within the home, for example, infection control audits and kitchen audits, however we found no medication audits in place, no training audits in place, and the manager had not identified that fire safety was not to an acceptable standard. When information was requested to evidence which checks and audits were undertaken, these were not always documented or recorded.