Weston Park Care Home

Weston Park Care Home (Weston Park) is a care home providing personal and nursing care for up to 103 people across three units. One unit specialised in providing care for people living with dementia.

People’s experience of using this service and what we found

Recruitment was now more robust, and improvements had been made to the management of medication. Governance was now more effective with robust systems in place to identify any areas of improvement needed.

Improvements had been made in respect of people’s nutrition. Our previous visit had found that action taken in response to weight loss and the recording food/fluid intake had not been consistent and had left people at risk. These had now improved.

People felt safe living at Weston Park and felt well supported by the staff team. They felt cared for and had their needs met. Relatives commented that standards of care had dramatically improved. Where relatives had issues relating to their relations care they felt listened to and were confident that the registered manager would address them.

People were generally happy with the care they received. They believed that the registered manager was committed to ensure that quality of care for all was improved and sustained. The registered manager had been transparent following the rating from our last report and, following that, had outlined a commitment to improve.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 24 February 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 24 February 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to good. This is based on the findings at this inspection.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Weston Park on our website at www.cqc.org.uk.

Weston Park Care Home (Weston Park) is a care home providing personal and nursing care for up to 103 people across three units. One unit specialised in providing care for people living with dementia. Waterside Unit provided support to people for rehabilitation on discharge from hospital, however the provider had decided to cease contracting admissions to that unit. There were 72 people using the service at the time of the inspection.

People’s experience of using this service and what we found

The provider had identified the need for improvement in medication management, however sufficient action had not been taken to ensure systems to manage and administer medicines were always safe and effective. Some people had not received their medicines as prescribed and stocks were not well managed. Powders prescribed to thicken some people’s drinks were not always administered as prescribed and were not always safely stored increasing the risk of avoidable harm from accidental ingestion.

Safe recruitment procedures were not always followed. The required pre-employment checks were not always carried out to assess the fitness and suitability of staff employed.

The provider’s governance and quality assurance systems were not sufficiently robust to ensure quality, support continuous learning or to drive/sustain improvements within the service.

Although we observed there were enough staff on duty to meet people’s needs during the inspection, we found that staff were extremely busy and we observed little other interaction between people and care staff.

The service relied heavily on agency staff and was experiencing increased difficulty in securing consistent and reliable agency workers. Retention of staff had been an ongoing challenge and there had been a number of changes to management since the provider had registered with the Care Quality Commission (CQC). During the inspection the provider confirmed that a further restructure of the senior management team had taken place.

Some staff were unclear about people’s dietary needs and the support people required. Not all staff had a hand-held device to access information about people’s care and support needs, individual’s risks and safety alerts. Whilst staff could access other staff members’ devices, our observations indicated staff were not always doing this. There were significant gaps in recording of care and support delivery. People spoke negatively about the food served. The manager provided an action plan regarding meeting people’s nutritional needs and confirmed that menus were being reviewed. Actions in response to weight loss had not always been taken in a timely manner.

Changes to government guidance relating to visiting arrangements within the home had not been implemented. However, following discussion with the manager, they confirmed that changes were to be implemented, and current guidance followed. Not all staff had completed the training required for their role.

During the inspection the provider advised that there had been a restructure to the senior management team to provide increased oversight within the units. Support from an external consultant had been increased and an action plan was shared.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 09 September 2020) and there was a breach of regulation in relation to the safe use of medicines. The service has previously been rated requires improvement at five inspections and inadequate at one. The provider submitted an action plan following the last inspection to show what they would do and by when to improve.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We received an increase in safeguarding concerns including in relation to the management of medicines, leadership and governance. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. Ratings from previous comprehensive inspections for caring and responsive key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we found that not enough improvement had been made or sustained and the provider remained in breach of regulation 12 (safe care and treatment). We also identified breaches in relation to regulations 17 (good governance) and 19 (fit and proper persons employed) at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Weston Park Care Home (Weston Park) is a care home providing personal and nursing care for up to for up to 103 people across three units with one unit specialising in providing care to people living with dementia and one specialising in supporting people requiring rehabilitation following discharge from hospital. There were 51 people using the service at the time of the inspection.

People’s experience of using this service and what we found

Some people did not always receive their medicines as prescribed and there was no evidence of appropriate follow up. Staff’s competency to administer medicines had been checked, however we identified that staff required additional training in the use of the electronic medicines management system (EMAR). Although we found no evidence of harm, this placed people at increased risk of harm.

The recording of care interventions at the time they took place had improved and we found no evidence of harm, further improvement was required to ensure that records could be relied upon. Following the inspection, the registered manager provided us with an action plan detailing the measures taken/to be taken to address these issues.

Quality assurance systems were in place, and on the whole effective. We noted that improvement was required in terms of medicines audits and of real-time recording, as noted above, however two additional managerial roles had been introduced to support the registered manager which would address this.

People we protected from abuse by staff who had received training and understood their responsibilities. People and relatives told us they felt they/their relative was safe living at Weston Park. Risk assessments were carried out and regularly reviewed to protect people from avoidable harm. Accidents and incidents were recorded with managerial oversight to capture learning to prevent re-occurrence. There were clear procedures to prevent and control the spread of infection. The service had managed the impact of the COVID-19 pandemic well. There were sufficient staff to meet people’s needs although staff on one unit were observed to be busy. We discussed this with the registered manager who confirmed during the inspection that staffing levels had been increased in line with revised dependency calculations.

There was a positive atmosphere within Weston Park. Staff and relatives spoke unanimously about the significant difference that the new registered manager had made since their appointment in terms of staff morale, staff knowledge, person-centred care and quality of care. The registered manager had overseen the opening of a new unit during a pandemic period which had been extremely successful.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update) -

The last rating for this service was Requires Improvement (Published 20/01/2020) and there were breaches of regulation. The service has been rated requires improvement or inadequate at the last five consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that not enough improvement had been sustained and the provider remained in breach of regulation 12, however sufficient improvement was made and they were no longer in breach of regulations 17 and 18.

Why we inspected

We undertook this focussed inspection to check whether the Warning Notices we previously served in relation to Regulations 12 (safe care and treatment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this focussed inspection and remains Requires Improvement.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Weston Park Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified a continued breach of regulation 12 (safe care and treatment) in relation to safe management of medicines at this inspection.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Weston Park Care Home is a care home providing personal and nursing care to 55 people aged 65 and over at the time of the inspection. The service can support up to 103 people. Weston Park Care Home accommodates people across two separate floors. Each floor provides care and support to people with different needs, including residential and nursing care. There are two further units which are currently unoccupied.

People’s experience of using this service and what we found

Governance and quality assurance systems did not effectively identify and address concerns. Audits and systems had identified some areas for improvements. However, some of the issues we found at the inspection had not been identified by the provider’s own governance systems. Records were not always complete and accurate.

Risk assessments were carried out. However, where people were at risk of pressure ulcers developing, staff had not always followed measures identified to reduce this risk. Systems in place to monitor nutritional risks such as weight loss, were not always effective, timely action was not always taken to reduce further risk.

Medicines were not always managed safely at the home. We identified issues in relation to staff following correct procedures to administer medication covertly (Hidden in food or drink), safe storage and ensuring an effective supply of medicines. The registered provider could not demonstrate that all staff responsible for the administration of medication, were competent to do so.

There were not always enough staff adequately deployed on duty to meet people’s needs in a timely way. The management team had focused on the recruitment of new staff and the use of agency staff had reduced. We saw that procedures had been followed to ensure that staff were recruited safely.

Overall, people were well treated by the staff and their dignity and privacy was respected. However, people also told us that staffing levels and unfamiliar staff sometimes had a negative impact on their care at times.

People were supported by staff who had received appropriate induction and training. The management team had focused on providing further training. Supervision sessions with staff had been carried out but not as frequently as required by the provider and action was being taken to address this.

The management team had undertaken a review of the safe management of nutritional risks and were undertaking regular observations in the dining rooms. Records had been reviewed and the chef had undertaken further training. People were generally positive about the food available and had seen improvements.

People usually had access to healthcare as needed, however, at times there had been a delay in staff reporting and asking specialist health care professionals advice when people's needs changed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported to have choice and control over their care. Work was being undertaken to review people’s care needs in consultation with them and their relatives. Care plans were in place which included person centred information, however care plans did not always reflect people's changing needs.

People were supported to take part in activities and their spiritual needs were considered.

A new operations director and operations manager had been appointed just prior to this inspection and had identified some of the issues raised at this inspection. They appeared knowledgeable and were receptive to feedback given at the inspection. After the first day of the inspection they sent us a detailed action plan that indicated that steps were going to be taken to address the concerns identified.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 26 July 2019) and there were breaches of regulation. This service has been rated requires improvement for the previous four consecutive inspections. The provider completed an action plan after the last inspection to show what they would do and by when to improve. We also met with the provider and the local authority to discuss the action the provider needed to do to improve to good. At this inspection enough improvement had not been made/ sustained, and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part by the notification of a specific incident and this incident is subject to a police investigation. As a result, this inspection did not examine the circumstances of the incident, but examined any further risk.

Enforcement

We have identified breaches in relation to safe care and treatment, insufficient staffing levels and the governance of the service, at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Weston Park Care Home is a residential care and nursing home providing personal and nursing care to 59 people aged 65 and over at the time of the inspection. The service can support up to 103 people.

Weston Park Care Home accommodates people across two separate floors. Each floor provides care and support to people with different needs, including residential and nursing care. There are two further units which are currently unoccupied.

People’s experience of using this service and what we found

People and their relatives were generally satisfied with the care they received at Weston Park. People told us they were supported by staff who were kind and caring in their approach. Whilst people were treated with dignity and their privacy respected, we found aspects where care could be improved further.

Changes in the leadership team and staffing meant that improvements were not fully embedded to provide consistently safe, effective and high-quality personalised care. The service’s rating therefore has not changed overall. We noted however that while there continued to be issues, we also found areas where improvements and progress had been made.

People and staff raised concerns about the consistency of staff and high usage of agency staff. The provider aimed to arrange consistent and familiar staff however this was not always possible. People and staff told us agency staff could impact on the care provided and did not always have full knowledge of people’s needs.

We have made a recommendation about the deployment of staff.

Risk assessments were carried out, however, actions to reduce aspects of risk had not always been followed, especially in relation to the management of skin conditions. Some further risk assessments were required and the management team ensured these were put in place straight away. Further work was needed to ensure systems were robust and all safeguarding issues were reported appropriately.

Overall medicines were managed safely, however we found shortfalls in relation to the storage of thickeners and the administration of topical creams and ointments. This was addressed straight away with the staff and records were updated.

People were supported overall to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, we found at times staff were focused on competing tasks and care was not always provided in a person-centred way.

The provider had implemented a new electronic recording system. There were many advantages to the system, however this had yet to be fully embedded. Some staff did not know how to use the system or where to find information and needed further support. Care plans had been re-written and were detailed and reviewed on a regular basis.

The regional manager was temporarily managing the service and a new permanent manager had been appointed.They were driven to make the necessary improvements and were taking action. However, progress had been inconsistent since the last inspection. Recent quality audits had been successful in identifying and addressing health and safety issues, but had not identified all the issues highlighted at this inspection.

Staff told us they felt more supported in recent weeks and able to approach the management team with concerns or issues. People and their relatives were asked for feedback about the service and complaints were dealt with as per the provider’s policy.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 June 2018) and there were three breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider had rectified one of the breaches. However, we found two continued breaches of regulations. The service remains rated Requires Improvement and has been rated Requires Improvement twice and inadequate once at the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating. This inspection also followed up on action we told the provider to take at the last inspection. We have found evidence that the provider needed to make further improvements. Please see the safe, caring, responsive and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report. During the inspection, the manager evidenced steps they had already taken to make improvements and reduce risk for people going forward.

Enforcement

We have identified breaches in relation to the safe care and treatment of people and the governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Weston Park was previously inspected on 3, 4 and 5 October 2017. During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 related to: staffing; training; recruitment of staff; safeguarding service users from abuse and improper treatment; records; medicine management; seeking consent in accordance with the Mental Capacity Act 2005; providing person centred care and governance arrangements. We also found a breach of the Care Quality Commission (Registration) Regulations 2009 as the registered person had not always notified the Commission of incidents or allegations of abuse.

We took enforcement action and we rated the service as 'Inadequate' and placed it into Special Measures. Following the inspection, the provider formulated an action plan and sent us updates in response to the breaches and concerns we had identified. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have 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. At this inspection the overall rating for the service is ‘Requires Improvement’

At this inspection, we found that the provider was taking action to address the previous concerns we had raised. Further improvements were still required and the provider remained in breach of Regulations 12, 13 and 17 of The Health and Social Care Act 2008 (Regulated Activity) Regulations 2014 in relation to management of risk, safeguarding and good governance. We considered however, that sufficient action had been taken to meet the further breaches identified at the last inspection.

Weston Park 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.

Weston Park accommodates up to 103 people across four separate units, each of which have separate adapted facilities. Two of the units had been temporarily closed and there were 58 people living at the home during the inspection.

At the time of the inspection there was no 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. A new manager had been appointed in January 2018 and had made an application to register with CQC.

Overall people, relatives and staff told us that they had seen improvements to the service. People were generally positive about the support they received.

There remained some concerns that staff did not always follow safeguarding procedures in a robust manner. We found that some improvements were being made to manage risks more safely, however there remained some gaps in the effective implementation and evaluation of risk assessments.

At this inspection we found that the usage of agency staff had reduced significantly. There had been a period of recruitment including a new chef, head housekeeper, a nurse and care staff. Managers had taken a lead on recruitment, which focussed on quality to fill staffing gaps and was on-going. There were sufficient staff to meet people's needs and provide personalised care and support with activities. There was a new management team in place including the home manager, quality assurance manager and two unit leads. There had been a focus on the organisation and allocation of roles within the staff team, however there remained some inconsistencies in the oversight of staff skill mix.

Recruitment and selection of staff was carried out safely with appropriate checks made before new staff started working in the home.

We saw that accidents and incidents, along with any pressure ulcers and weight loss or gain were monitored. At this inspection we made observations and saw that call bells were accessible to people. We saw other examples where equipment had been used to help manage potential risks such as sensor beams, low beds and crash mats.

There were no records of fire drills carried out at the service. The provider assured us that fire drills and evacuations incorporating night staff would be undertaken as soon as possible and a system was implemented to ensure that the management team had oversight of these drills.

We found that staff needed further guidance to ensure that The Mental Capacity Act 2005 (MCA) was applied robustly. Improvements had been made and staff now carried out mental capacity assessments and these were decision specific. However, we found some examples where the principles of the MCA had not been followed.

Since our last inspection, the provider had focused on staff training and had updated training records to evidence the training completed by staff. There was a significant improvement in the number of staff who had undertaken mandatory e-learning. A new training induction had been introduced. We received assurances from the provider and manager that this was work in progress which they would continue to focus on. Staff supervisions and appraisals was being implemented but needed to be embedded.

The provider had employed a new chef, who was knowledgeable about people’s dietary needs. We saw that she took time to speak with people to seek feedback about the food and choices available. We found that people's nutritional needs were being monitored. However, we noted that whilst there had been some improvements in the recording within daily charts, there remained inconsistencies and charts had not always been fully completed.

We found that the new management team were focused on the quality of the care provided. We saw examples where the management team had tackled and addressed areas of concern and this was an on-going process. People were complimentary about the way they were treated by staff and told us they were treated with dignity and respect.

The service had received a number of compliments. We reviewed relatives’ comments received within letters, about the improvement of the home. During the inspection a number of relatives actively sought out inspectors to share their positive feedback about the service.

Previously we found that daily charts had not always been completed in accordance with people's care plans. On this inspection we found that staff were aware of the importance of accurate and up to date record keeping but identified gaps in recording that could put people at risk. We were advised that nurses and unit leaders were actively monitoring the completion of charts on a daily basis, however we found that this remained insufficient.

Since our last inspection we saw that a significant number of the care plans had been re-written. Overall we found improvements to the information recorded, which in most cases was detailed and person centred. We saw that people’s wishes and preferences were respected.

The home had two activities coordinators, one on each of the units. There was an activities programme and entertainment available. They explained to us that under the new management there was now a bigger focus on activities.

The provider had a complaints policy and procedure in place, which was on display in the reception at the home. At our last inspection we found that the system for recording and responding to complaints was insufficient. At this inspection we found that improvements had been made.

Quality assurance systems needed to be more robust. Whilst the management team advised us that a schedule of audits was in the process of being embedded to help monitor and improve the quality and safety of the service provided, the systems needed to be strengthened further

We found that improvements had been made to the leadership of the service. The provider had recruited a new management team including a quality assurance manager and had also employed the services of a specialist consultancy agency with a view to making the necessary required improvements.

Staff commented on improvements and their confidence in managers, unit leads and seniors. A schedule of audits was in the process of being embedded to help monitor and improve the quality and safety of the services provided.

There was no 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. Two managers had been running the home and were responsible for separate units; both had resigned from their posts. One had already left and the other was due to leave during the week of the inspection. Neither of these managers had registered with CQC. The registered provider had employed a new manager who had been in post for one day when we undertook the inspection. The manager told us that she intended to apply to register as soon as possible.

At this inspection we found that the provider had taken action to meet the requirement meeting people’s nutritional needs and consent to care. However, we still had concerns relating to the safe care and treatment of people, how people were cared for, how people were protected from abuse and harm, staffing, consent to care and the governance of the service. The provider had not taken the necessary actions to meet the requirements. We also found further breaches during our most recent inspection. Following this inspection, we are taking further action against the provider for repeated and serious failures to meet the regulations. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

People could not be assured that appropriate action was taken when there was an allegation or concerns of abuse or avoidable harm. Risks associated to people's health and care needs had not always been appropriately assessed, monitored and reviewed. Staff did not always follow the guidance where risk assessments had been completed. This impacted on people's safety and welfare.

Recruitment procedures had not always been followed robustly and there was a risk that the systems in place did not ensure that suitable people were employed. We found that systems to ensure that there were sufficient staff on duty were not always effective, because there were occasions when staff absences could not be covered. There was a high usage of agency staff and some people said that agency staff weren’t always as familiar with people’s needs. The provider told us that recruitment was a priority.

People's medicines were not managed or administered in a safe way. People did not always receive their medicines as prescribed and thickener was not always administered correctly.

Staff had received some induction and training, but not all staff had received adequate training. Records could not evidence that staff received appropriate supervision and appraisal.

Previously, we found that people’s nutritional needs were not being met effectively. At this inspection we found that some improvements had been made and we received some positive feedback from a visiting dietician. However further improvements were still required regarding the standard of the food provided.

Further improvements were required to ensure that The Mental Capacity Act (MCA) was always followed where necessary.

Whilst individual staff were mostly kind and caring to people, we saw instances where people's dignity and privacy was not respected.

Whilst some people spoken with were positive about their support and treatment this was inconsistent. We were concerned that people did not always receive care and support which was responsive to their individual needs and staff did not always follow the guidance identified within people’s care plans. Work had been undertaken to review people’s care plans however we found that the plans had not always been reviewed regularly and were not updated in response to people's changing needs.

People told us that the level of activity had recently reduced and we were advised this was due to staff holidays. There had been two new members of staff recruited to the activities team. There were some positive developments and ideas in progress, which involved the community.

The provider had a complaints procedure, however appropriate records of complaints had not been maintained.

The registered provider did not have effective auditing systems or processes, which assessed monitored and drove improvement in the quality and safety of the services provided for people. The service had not made sufficient improvement since the last inspection. Lack of effective governance or systems meant that patterns of risk were not always being identified or actioned.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

A manager was in post but they were not yet registered with the Care Quality Commission. 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 had previously inspected the home on 12 and 14 July 2016, when it was under a different provider. When the new provider took over the home in September 2016, the deputy manager was subsequently appointed as manager and a number of the staff remained the same. This was our first inspection since the location had been re-registered with us.

At our last inspection, we told the provider to take action to make certain improvements. These included improvements to staffing, safeguarding, consent, good governance and nutrition and hydration. The provider at that time sent us an action plan stating how they would address these issues.

At this inspection, we found that the new provider had started to take action to make improvements but further improvements were still required. We found that improvements were needed to ensure people received consistent support from staff that knew them and their needs well. We also found that improvements were needed to ensure that people received care that was individual to them and responsive to their needs. We had concerns that some people did not have their nutritional needs met safely. People did not always have the opportunity to participate in stimulating activities and we found that people’s dignity was compromised at times. There were also issues with the quality assurance systems within the home. Following the first day of the inspection, we asked the provider to send us an immediate action plan to tell us how they would address the concerns we had identified.

We identified seven breaches of the relevant legislation. You can see what action we told the provider to take at the back of the full version of the report.

People’s views varied on staffing levels, some said there were sufficient staff whereas others felt that staffing was low at times. We found that staff were not always sufficiently deployed. The home was very dependent upon agency staff. The provider and manager told us that the recruitment of new staff was a high priority and they were actively recruiting, but that this was dependent upon appropriate applications being received. There had been high staff turnover and the manager told us they were now focused on the quality of the new staff being recruited. A new management structure was being implemented.

Staff spoken with understood what safeguarding was and knew how to report any concerns within the organisation. We found that the home was clean, well decorated and maintained. The maintenance person ensured that all appropriate checks were carried out and recorded.

During the inspection we found that the principles of the Mental Capacity Act 2005 (MCA) had not been followed to ensure people's rights were always protected. MCA assessments had not always been recorded correctly where necessary and DoLS had not been followed robustly enough.

We found that people did not always receive effective care from staff who had the knowledge and skills needed. Information provided for agency staff was inconsistent and at times insufficient to enable them to meet the needs of people. The provider advised us they were working towards supporting the staff to increase their skills and knowledge. Since the new provider had taken over they told us they were addressing staff induction and training.

The provider had undertaken some refurbishment since taking over the home. The Tatton Unit had been refurbished to a high decorative standard and had been re-opened. Many people’s rooms were nicely decorated and personalised. There was a maintenance programme in place.

People’s views about the food were mixed. Menus had been changed and the provider was focused on making necessary improvements. On the second day of the inspection we found that improvements had been made to the dining experience. However we found that systems for managing people’s nutritional risks were not always effective. Staff were not aware of a person’s specific dietary requirements which meant that the person could have been at risk of choking.

People living at the home and their visitors gave mixed feedback about how caring the service was. We observed that in some cases staff treated people in a kind manner and had developed effective relationships with them. However also we observed interaction between some staff and people who lived at the home which was not effective. We also found at times that peoples’ dignity was compromised. We saw that the management team had already identified areas of practice which needed to be addressed.

Whilst some people told us that staff were responsive to their needs, other feedback received indicated that staff did not always deliver care in a way that was centred around individual needs and preferences. For example concerns were raised about the lack of choice regarding the time a person liked to get up and people’s personal care needs not being met.

We identified a number of issues with the records that were maintained for people. We found that some care plans were not detailed enough to provide staff with the information they needed to deliver effective, responsive care. Work was being undertaken to re-write all of the care plans onto new documentation, in consultation with people and their relatives.

We found that some activities were available to people, but these needed to improve. Staff vacancies had impacted on further improvements. The head of activities had developed a work plan since coming into post, which included a proposal about the actions needed to enable people to follow their interests and improve the activities available.

The new owner and regional manager were closely involved with the current management of the home. They told us they had inherited a significant number of issues but were focused on making the necessary improvements to the home. They have developed an action plan and the recruitment of new staff and implementation of a new management structure had been identified as a priority. Staff supervision meetings and staff meetings were being held.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. Our records indicated that some notifications had been had submitted notifications to CQC in line with CQC guidelines. However we found that we had not received notifications to inform us about any DoLS authorisations made by the supervisory body and the manager was not aware of her responsibility to submit these.

There were some systems in place to monitor the quality and safety of the service. However, some of the quality assurance systems that the provider had put in place were not sufficiently robust, as they did not identify the concerns that were identified on this inspection.