About the service: Tynwald is a residential care home that was providing personal care to 25 older people, some who were living with dementia, at the time of the inspection.

People’s experience of using this service:

• The provider could not be assured that people had received all their medicines due to an error in their electronic system. We have made a recommendation about managing this.

• Not all equipment had been maintained as wheelchairs were not serviced.

• The provider had failed to identify any learning from falls by analysing these for any trends.

• Enough suitably recruited and trained staff were deployed to meet people’s needs. However, there had been feedback from people there wasn’t enough staff. We made a recommendation that the provider uses a dependency tool in the main report.

• The provider had not ensured that feedback and auditing was used to make improvements.

• Monitoring records for people’s food intake and weight monitoring where they were at risk of malnutrition needed improvement as they were not always completed or completed accurately. The failure to ensure complete records and effective quality assurance systems was a breach of regulation.

• Systems were in place to protect people from abuse.

• The provider promoted a good quality of life for people. People were happy living at the home and were supported to access the healthcare they needed.

• Care was person centred, achieved good outcomes and people were offered choice and involved wherever possible.

• Feedback from people, relatives and staff was positive.

• The provider was responsive to feedback at our inspection and has put a new management structure in place to support the necessary improvements.

• On the day of our inspection we spoke to the new manager who was in the process of registering as the current registered manager was not available.

More information is in the full report.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published on 16 May 2018). This service has been rated Requires Improvement at the last two inspections.

Why we inspected: This was a comprehensive planned inspection based on the previous rating.

Follow up: We will continue to monitor this home and plan to inspect in line with our reinspection schedule for those services rated Requires Improvement.

This inspection took place on 18 and 19 December 2017 and was unannounced.

Tynwald Residential Home 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. Tynwald Residential Home accommodates up to 26 older people in one adapted building.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was last inspected in August 2016 when it was rated as ‘Requires Improvement’ overall. Four breaches of Regulation were identified during that inspection. These related to person-centred care planning, management of risks; including those associated with medicines, lack of efficient oversight and auditing and staff training which was not sufficiently specific to the needs of service users. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) Safe, Effective, Responsive and Well-led to at least good.

At this inspection improvements had been made in some areas, but there was more work to do to ensure that shortfalls were appropriately addressed.

Not all risks had been properly assessed and minimised; including those relating to medicines, external doors being left open and the proper use of air mattresses.

There were enough trained and competent staff on duty to meet people’s needs. Staff received regular supervision sessions. Safe recruitment processes were operated to make sure only suitable applicants were employed to work with people.

Staff knew how to recognise and report abuse or discrimination and provider policies underpinned staff training. Accidents and incidents had been properly recorded and actions taken to prevent reoccurrences were documented.

The service was clean and hygienic and equipment and utilities were routinely safety checked.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were treated as individuals and staff encouraged people to be themselves. The provider had an equality and diversity policy in place.

People’s health and well-being was monitored and a range of professionals supported staff to keep people well. Meals were varied and plentiful and people said they enjoyed them. People were encouraged to drink plenty and had access to jugs and carafes of drinks, aside from tea and coffee rounds.

Staff were kind, caring and considerate and took account of people’s privacy and dignity when supporting them.

A range of innovative and interesting activities were available and people said their needs for social stimulation were met. People and relatives knew how to complain and had confidence that the staff and registered manager would listen and act on any concerns.

Staff knew people very well and care planning prioritised people’s wishes and preferences.

Auditing had improved since our last inspection, but was more effective in some areas than others.

Feedback was routinely sought from people and there was evidence that it had been acted upon.

The registered manager was visible and approachable and understood their responsibilities to inform CQC of particular events and the provider had displayed the rating awarded at our last inspection; which is a legal requirement.

This is the second consecutive time the service has been rated Requires Improvement.

We have recommended that the provider and registered manager implement regular, more detailed checks on medicines; including creams

This inspection took place on 17, 18 and 19 August 2016 and was unannounced.

Tynwald Residential Home is registered to provide personal care and accommodation for up to 26 people. There were 23 people using the service during our inspection; who were living with a range of health and support needs. These included; diabetes, dementia and some people who needed support with their mobility.

The service is a large detached house situated in an elevated residential area overlooking Hythe, with large communal lounge and dining area, a solarium, quiet lounge and an enclosed sun terrace. A large well-kept garden with a veranda, patio and seating areas is located to the rear of the property. Accommodation is provided over two floors, a passenger lift and stair lifts provide step free access to each floor.

Tynwald Residential Home is run by The Alice Butterworth Charity, established to provide a residence or home for people who either live or have ties to Hythe town or surrounding district. The operation of the service is overseen by a committee of voluntary trustees

A registered manager was in post. A registered manager is a person who has registered with the care Quality Commission to manage the 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.

Tynwald Residential Home was last inspected in May 2014, where no concerns were identified. At this inspection we found improvement was required in some areas where some regulations were not being met.

Medicines were not stored below the maximum temperature; some medicines were not accounted for properly which had not been identified.

Hot water temperature checks to safeguard against scalding were not sufficiently detailed.

Planning and delivery of training had not ensured a continuous learning process to ensure staff had the skills and knowledge to support the people they cared for.

Elements of care planning did not fully establish some people’s needs or reflect their wishes about how they wanted to be supported.

Auditing, for the purpose of identifying shortfalls in the quality and safety of the service provided were not wholly effective or fully developed; some records were incomplete.

Deprivation of Liberty Safeguarding authorisations had been applied for where people were unable to consent to restrictions in place.

People’s health needs were well managed and referrals to outside healthcare professionals were made in a timely way.

There were enough staff to meet people’s needs. People were supported by enthusiastic staff and volunteers.

Staff were caring, compassionate and responsive to people’s needs and interactions between staff and people were warm, friendly and respectful.

People enjoyed their meals, they were supported to eat when needed and risks of choking, malnutrition and dehydration had been adequately assessed and addressed.

People commented positively about the openness of the management structure and were complimentary of the staff and registered manager.

We found a number of 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.

At the time of our inspection, there were 22 people using the service.

During our inspection we gathered evidence that helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection; speaking with people using the service; speaking with the staff supporting people, and to a visiting healthcare professional. We also looked at records.

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

Is the service safe?

We observed that people were treated with respect and dignity by the staff. People we spoke with during our inspection told us they felt safe in the home.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. An application that we reviewed had been appropriately submitted. This meant that people were being safeguarded as required.

The service was clean and hygienic. Domestic staff cleaned the home following a regular and deep cleaning schedule. We saw that staff wore aprons and washed their hands before providing care.

Training and supervision of staff was in place and staff were qualified to carry out their roles.

Is the service effective?

People’s individual health and care needs were assessed and care was given that met their needs.

Care records were detailed and contained care plans and risk assessments that were regularly reviewed, along with records of daily care given. People told us that staff made sure their needs were met. Records we looked at included notes from visits by professional clinicians.

We found people were involved in making choices about their care. People told us that they felt well looked after in the home. They were able to choose from a range of activities and could choose to spend time in their own rooms or in the communal areas of the home.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. One person told us, “I am quite happy”. People told us that the staff were friendly and caring. One said, “The staff are very good”.

People’s preferences, interests, and needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People could participate in a range of activities. Regular residents’ meetings were held at which people could share their views with the staff and management of the home.

People and staff told us that they felt comfortable to speak out if they were unhappy.

Is the service well-led?

The service worked well with other agencies and services to make sure people received care that met their needs. A visiting healthcare professional told us that they had a good rapport with the management and staff at the home.

People we spoke with told us that they felt well cared for in the home.

We found that staff employed in the home were well supported and had training available to them. This ensured that staff were appropriately qualified to undertake their roles.

At the time of our inspection, there were 24 people using the service. We spoke to five people who used the service, two visiting relatives and a visiting healthcare professional to the home. People told us that they were happy with their care, staff treated them with respect and had a good understanding of their individual needs. One person told us "staff understand my needs; it's a good place".

Care records were detailed and contained care plans and risk assessments that were regularly reviewed. People told us that staff made sure their healthcare needs were met and care records included notes from professional clinicians. A relative told us " there couldn't be a better place; has given us peace of mind".

All the people we spoke to who used the service told us that they felt safe and would know what to do if they had any worries or concerns. One person stated that they "feel able to talk to people; they are ready to listen".

The home undertook regular audits of the premises and there was a formal complaints procedure that people could use if they needed to.

We found that there were enough staff employed in the home who had a good understanding of their roles and responsibilities. They were able to provide appropriate care and support to the people who used the service according to their individual needs, including a range of planned social activities and events.

People living at the home, relatives and visitors all commented on how good the care was. People told us they were happy with the care and support they received at Tynwald Residential Home.

People living at the home, visitors and relatives told us that they thought the home was clean and tidy.

People told us that that they were treated with respect, kindness and dignity. Individual preferences concerning food were met, reviewed and changed if necessary.

People had the freedom of choice over how and where to spend their day in the home and were actively involved in the planning of the care they received.

We observed that people who used this service were very relaxed and comfortable within the environment. They interacted well with the staff who worked with them and staff encouraged their independence.

People living at the home, relatives and visitors all commented on how good the care was. People told us they were happy with the care and support they received. One person said “I think it is very pleasant, staff are lovely, all lovely”. Other comments received were “I love it, lovely home”, and “It’s the best one I have ever been in. When you walk in all you smell is food cooking”, and “I could not praise it enough”.

People told us that sufficient staff were on duty and staff were kind and caring. People had access to health care such as opticians, chiropodists, doctors and dentists.

People told us the food was very good and had a choice menu with plenty of fresh vegetables and homemade cakes. Comments received were “The food is very good, I am very fussy”, and “I like old fashioned food, they do their best here.”