Archived: Acacia Court

We found the following examples of good practice.

Relative's provided really positive feedback and were appreciative of the manager and staff's support in helping them maintain contact with their family members. Comments shared included, "We couldn't be happier, the manager has helped us to safely meet our relative and its just so reassuring" and "They have maintained contact with us throughout this pandemic, nothings too much trouble, we know they are safe and well looked after."

The provider has built a summer house/pod especially for visitors to the service.

Staff were provided with current infection prevention and control (IPC) guidance and the registered manager worked effectively with them to ensure they followed correct IPC procedures. . Staff completed IPC training and the registered manager was arranging further updates.

Well stocked and clearly signed personal protective equipment (PPE) stations were located around the service. Staff were observed using correct PPE when carrying out their duties.

People told us staff always wore the correct PPE and they felt safe whilst living at the service. Relatives were very positive and felt assured their family members were safe and well cared for.

Staff told us they felt safe at work and well supported by the registered manager and senior staff.

Further information is in the detailed findings below.

There were 27 people in residence at the time of the inspection.

The home was last inspected in March 2018 and was rated ‘Requires improvement’. The inspection had been a ‘focused’ inspection which looked at a previous breach of regulations concerning safe management of medicines. We found the provider still required further improvements and remained in breach as medicine processes were still not being safely followed. We found a further breach of regulations as we were concerned that appropriate person-centred care was not always being provided; some people living with dementia were not being suitably supported.

On this inspection we found standards and improvements had been made in both areas and the service was now meeting the regulations of the Health and Social Care Act 2008 [HSCA]. We have rated the service as Good.

At the last inspection we found the environment needed to be more stimulating for the people who were living with dementia. On this inspection we found that some improvements had been made, such as easier access to the garden via an external lift, more signage and more easily accessible information on display to help orientate people living with dementia. There was more homely arrangements of furniture to aid social interaction and help people to be more comfortable in their living environment. We found there could be further improvements and we discussed these.

We saw written care plans were formulated and reviewed regularly. We saw that people and their relatives were involved in the care planning and reviews were held. This evidenced individualised care for people.

We found the failings regarding medication administration had been addressed. We now found medicines were administered safely. Medication administration records (MARs) were clear and met best practice. People received their medicines consistently.

A registered manager was 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 management and overall governance was stable. The registered manager was a consistent and positive lead in the home and had been effective in building a positive staff team and ensuring a consistent approach to care.

Staffing numbers ensured people’s care needs were consistently met. Feedback from staff, people using the service and visitors was positive in that staffing levels were consistently maintained to ensure safe standards of care.

People’s nutritional intake was supported appropriately. Meal times were seen to be a relaxed and enjoyable experience for people. People’s nutritional state was very well monitored.

Staff told us there were good systems in place to support them in their work such as training and supervision.

Observations and feedback from people and their relatives evidenced people’s dignity was protected and maintained.

Staff were motivated to provide meaningful activities and a consistent programme of social activities continued to be developed. These included external entertainers and therapists on a regular basis.

People’s risks regarding their health care were being adequately assessed and monitored. There was good referral and liaison with community health care professionals who worked with the home to help ensure people’s health care needs were met. The feedback we received from visiting professionals was positive.

We looked at how staff were recruited and the processes to ensure staff were suitable to work in the home. We saw checks had been made so that staff employed were suitable to work with vulnerable people.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. All the staff we spoke with were clear about the need to report any concerns they had.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made and decisions made in the person’s best interest.

There were people being supported on a Deprivation of Liberty [DoLS] authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found these were being monitored by the registered manager of the home.

We observed staff interacting with the people they supported. We saw how staff communicated and supported people. People we spoke with and their relatives told us that staff had the skills and approach needed to ensure people were receiving the right care.

A complaints procedure was in place and people, including relatives, we spoke with were aware of how they could complain. There were records of complaints made and the provider or registered manager had provided a response to these.

The management structure within the home was clear and supported the home with clear Iines of accountability and responsibility.

There were systems in place to get feedback from people so that the service could be developed with respect to their needs and wishes.

The registered manager was aware of their responsibility to notify us [CQC] of any notifiable incidents in the home.

Acacia Court is a ‘care home’, registered to provide personal care for people living with dementia. The care home is registered to provide support to 27 people. At the time of the inspection there were 22 people living at the home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home provides accommodation over three floors. The home itself comprises of two large detached houses which are joined together by an extension. There is a large lounge area; a dining area, a spacious garden to the rear of the property and a car park is available at the front of the property.

There was a registered manager in post at the time of the 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.

At the previous comprehensive inspection which took place in August, 2017 the home was rated as ‘Requires Improvement’. Breaches of legal requirements were found in relation to ‘Safe Care and Treatment’. After the comprehensive inspection, we asked the registered provider to submit an action plan which outlined how they were addressing the breach in regulation which we identified.

This inspection was carried out to ensure improvements had been made to meet the legal requirement. The team inspected the service against three of the five questions we ask about services: is the service safe, effective and well-led?

No risks, concerns or significant improvement were identified in the remaining ‘Key Questions’ through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these ‘Key Questions’ were included in calculating the overall rating in this inspection.

During this inspection, although we found a number of improvements had been made, the registered provider still remained in breach of ‘Safe Care and Treatment’ and a breach of regulation was identified in relation to 'Person Centred Care'. This is the second consecutive time the service has been rated 'Requires Improvement'. We will check this during our next planned comprehensive inspection.

We reviewed systems which were in place in relation to medication management. We found that although improvements had been made there were still areas which needed to be addressed. Topical creams (medicated creams) were not being consistently recorded on medication administration records (MAR’s), room temperatures where medicines were stored were not being recorded and there was no evidence of actions being taken following errors identified in medication audits.

People who are living with dementia need to be supported by living in an environment that is dementia friendly. The environment needed to be more stimulating for the people who were living with dementia.

You can see what action we have told the registered provider to take at the back of the full version of the report.

At the previous inspection we recommended that the registered provider explored quality assurance systems and developed ways of assessing and monitoring the quality and standard of care being provided. During this inspection although improvements were identified, quality assurance systems failed to identify and address concerns found during the inspection.

We have made a recommendation in relation to quality assurance systems.

There was evidence to suggest the home was operating in line with the principles of the Mental Capacity Act, 2005 (MCA). When able, people must be involved in the decisions which need to be made in relation to the care and treatment which is provided. We reviewed documentation which demonstrated how people were supported in the least restrictive way possible and the necessary deprivation of liberty safeguard (DoLS) applications had been submitted to the local authority.

Care plans and risk assessments were regularly reviewed. Records contained relevant and up to date information. It was evident throughout the course of the inspection that staff were familiar with the needs of the people they were supporting.

Accidents and incidents were being recorded and staff were familiar with the reporting procedures which needed to be followed. Although, we did identify that that accident and incidents were not being reviewed and trends were not being analysed. We discussed this with the registered manager at the time of the inspection who agreed that a system needed to be implemented, to effectively monitor for any patterns or trends.

The registered provider’s recruitment processes were reviewed. Staff records were organised and comprehensive. All staff had suitable references and disclosure and barring service (DBS) checks in place.

Staff received regular supervisions and annual appraisals. Training was regularly provided and staff expressed that they were supported with their learning and development.

The day to day support needs of people living at Acacia court were being met. Appropriate referrals to external healthcare professionals were taking place and guidance and advice that was provided was being followed. This meant that people’s overall health and well-being was being safely and effectively supported.

We found the environment to be clean, well maintained and free from any odour. There was a cleaning rota in place and staff were complying with the necessary infection control policies which were in place.

Health and safety processes were in place to monitor, assess and improve the quality and standards of the home. This meant that people were living in a safe and well maintained environment.

We reviewed the range of policies and procedures. Policies and procedures were all up to date, contained the relevant information and were available and accessible to staff. Staff were able to discuss specific procedures and processes with us during the inspection.

The registered provider was aware of their responsibilities and had notified CQC of events and incidents that occurred in the home. The registered provider ensured that the ratings from the previous inspection were on display within the home, these were also available for the public to review on the provider website, as required.

Acacia Court is a care home service, registered to provide accommodation and personal care for people living with dementia. The care home is registered to accommodate up to 27 people and at the time of the inspection there were 25 people living at the home.

The home is a purpose built facility with accommodation located over three floors. The home itself comprises of two large detached houses which are joined together by an extension. There is a large lounge area; a dining area, a spacious garden to the rear of the property and a small car park is available at the front of the property.

At the time of the inspection there was 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.

During the comprehensive inspection which took place in April 2016, we found the registered provider was not meeting legal requirements in relation to safe care and treatment and nutrition and hydration. As well as not meeting the requirements in relation to the registered provider’s duty of candour with respect to the information they were providing to the Care Quality Commission (CQC). The home was rated as 'requires improvement' overall and was served with a statutory warning notice in relation to medicines safety.

Following the inspection in April 2016 the registered provider submitted an action plan which outlined how they were improving the standards of care and quality of service. We conducted a focused inspection in December 2016 to ensure that they were meeting all legal requirements.

The provider had made improvement regarding the administration and storage of medicines which meant that the concerns which were highlighted in the statutory warning notice had been met.

At the last focused inspection we found that the provider was not always following best practice in relation medication management. During this inspection we found that concerns still remained in relation to medication processes and systems which were in place.

The provider remained in breach of this regulation.

We observed the environment of the home and found that improvements were needed in a number of areas. The environment needed to be more stimulating for the people who were living with dementia. There was evidence of some attempt to provide dementia friendly areas but further work needs to be applied.

We have made a recommendation in relation to dementia friendly improvements.

At the last focused inspection we found that the provider was not meeting the requirements needed to support the overall governance of the service. During this inspection we found that the medication audit systems had improved and they were identifying the majority of errors which were occurring, monthly quality assurance audits were taking place by the provider and we saw evidence that health and safety audits, maintenance audits and care plan audits were being completed and responded to in a timely manner.

The provider was no longer in breach of the regulation in relation to good governance. However, we have made a recommendation in relation to quality assurance.

The home operated within the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). We were provided with information in relation to mental capacity assessments, processes which needed to be in place to make decisions in a person’s best interest and ensuring people were supported to have maximum choice and control of their lives. We were provided with evidence to suggest that people were supported in the least restrictive way possible and staff were aware that all 25 people who were living in the home had mental capacity assessments in place and DoLS applications had been submitted to the local authority.

Accidents and incidents were recorded in an accident and incident record book, which were then reviewed on a monthly basis. A monthly analysis was undertaken to mitigate the risk of such accidents and incidents occurring again in the future.

The day to day support needs of people living in the home were being met. An external healthcare professional we spoke with on the second day of the inspection was positive about the level of care and support which was being provided.

We observed staff providing individual support to people in a compassionate, kind and caring manner. Staff could explain the different levels of support which needed to be provided, specialist dietary needs of some of the people they were caring for, as well as likes, dislikes and preferences.

There was no dedicated activities co-ordinator in post however we were informed that different members of the staff team would ensure that there were different activities arranged for each day of the week. The range of different activities was varied, creative and encouraged people to get involved.

It was evident throughout the inspection that improvements had been made to care plans and risk assessments but further improvements were still needed. Staff were familiar with the most up to date care needs of some of the people we discussed and it was evident that the communication systems which were in place were proving to be an effective and useful source of reliable information. Communication systems ensured that staff were made aware of any significant changes which had occurred to a person’s care plan and any risks which needed to be managed.

There was a formal complaints policy in place and people we spoke with were familiar with how to make a complaint. The complaints process was visible throughout the home as well as being available in each of the bedrooms. During the time of the inspection there was one on-going complaint which was being investigated. The complaint was being investigated in accordance with the provider’s policy and had been responded to an effective and timely approach.

Staff we spoke with were positive about the support which the manager was providing. The people we spoke with, the relatives and an external healthcare professional felt that the home offered a safe, compassionate and friendly environment.

There was a range of different up to date policies and procedures available for staff. When we discussed policies and processes which were in place, staff were familiar with policies such whistle blowing, safeguarding, equality and diversity and medication policies.

Four staff personnel files were reviewed during the inspection and we saw that recruitment was safely and effectively managed. Processes which were in place demonstrated how effective recruitment practices were carried out. This meant that all staff who were working at the home had suitable and sufficient references and disclosure and barring system checks (DBS) in place.

We received positive comments about the food which was provided throughout the course of the inspection. The home tried to establish preferences, likes and dislikes from the outset in order to provide people with their own choices. People we spoke with as well as relatives expressed how that standard of food was “Brilliant”.

This inspection was to follow up on concerns that were identified at our last inspection in April 2016 and to check if the provider had made improvements.

At the last inspection on 5 April 2016 we found breaches of the HSCA 2008 (Regulated Activities) Regulations 2014 in relation to , Safe care and treatment, , meeting nutritional and hydration needs and , the providers ‘Duty of Candour’ with respect to information they supplied to us. We also found medicines were not being managed safely.

We told the provider to take action to improve and, with respect to medication safety, we served a statutory Warning Notice.

Following the inspection in April 2016 the provider wrote to us to say what they would do to improve. We undertook a focused inspection on the 13 December 2016 to check they now met legal requirements.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Acacia Court' on our website at www.cqc.org.uk'

Acacia Court is a care home which provides personal care and accommodation for up to 27 people living with dementia. It comprises two large detached houses joined by an extension. The accommodation includes a large lounge, a spacious dining area and a large garden to the rear of the property. There is parking to the front of the building. Twenty seven people were living at the home at the time of the inspection.

There was 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.

We found that improvements had been made regarding the administration and storage of medicines so that the concerns highlighted in the Warning Notice had been met. However, the provider was not always following best practice in relation to the recording of topical medicines [creams] and updates for staff did not include a record of competency checks to evidence they were safe to administer medicines. The staff carrying out the medication administration was not given protected time, in line with the providers policy, which increased the risk of errors occurring.

We told the provider to take action to make further improvements.

At the last inspection we found people were at risk because sufficient arrangements were not in place to ensure people's weight was checked on a regular basis. On this inspection we found improvements had been made and the breach was now met. People had their nutritional and hydration intake monitored and were weighed on a regular basis. Referrals were made to the relevant health care professionals when weight loss was identified, for example the dietician or SALT (Speech and Language) team when weight loss was identified.

At the last inspection we were concerned that Information provided to an external stakeholder regarding a potential safeguarding concern was inaccurate; the provider was found to be in breach of their ‘Duty of Candour’ to provide open and accurate information. On this inspection we found improvement had been made and this breach was now met. Notifications were submitted to CQC by the registered manager. Safeguarding incidents were reported to the local authority safeguarding team. The registered manager displayed a good knowledge regarding the importance of providing necessary information to statutory bodies.

We looked at aspects of the overall governance [management] of the service and we were concerned that the issues we highlighted for further action had not been identified or monitored effectively. Monthly and weekly medication audits were completed but did not always identify issues or errors. Further, audits carried out by the provider had not been completed since June 2016. We could not see issues identified from the audits had been improved or rectified as an action plan had not been drawn up to demonstrate this.

You can see what action we asked the provider to take at the back of this report.

We had previously recommended improvements to the way the service followed the principals of the Mental Capacity Act 2005 [MCA]. The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. We found improvements had been made. Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority for each of the people living at the home. Mental capacity assessments were completed when specific decisions needed to be taken.

We found improvements had been made so that care records contained behavioural risk assessments to enable staff to support people in a consistent way. People with long term health conditions had care plans in place and information about the condition for staff to support them.

Incidents and accidents were completed and reported correctly. The registered manager analysed all completed forms each month for any common themes or trends.

Acacia Court is a care home which provides personal care and accommodation for up to 27 people living with dementia. It comprises two large detached houses joined by an extension. The accommodation includes a large lounge, a spacious dining area and a large garden to the rear of the property. There is parking to the front of the building.

Sixteen people were living at the home at the time of the inspection.

A registered manager was in post and had been working at the home since 2010. They were not managing the service at the time of the inspection. A registered manager from one of the provider’s other services was managing Acacia Court in their absence.

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 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.

As the overall rating for Acacia Court was ‘Inadequate’ at the last inspection the home was placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in Special Measures will be inspected again within six months and this inspection was undertaken within that timeframe to establish if sufficient improvements had been made. Adequate improvements had been made therefore the home has been taken out of Special Measures.

Although some improvements had been made to medicines management since the last inspection, we found that the management of medicines was still not robust. Further improvements needed to be made, including auditing of medicines, monitoring of fridge temperatures and clear documentation regarding variable doses of medicines, recording allergies and documentation of the destruction of Controlled Drugs.

Recruitment processes had improved and were effective in ensuring that new staff were suitable to work at the home. Staff had completed the training they required to fulfil their role and training records confirmed this. Staff told us they were receiving regular supervision and had received an annual appraisal of their performance. Records confirmed this.

Staffing levels had improved since the last inspection. Families who were visiting at the time of the inspection told us the staffing levels were better and there were enough staff on duty at all times. Through observation, we concluded there were enough staff to meet people’s needs. There was a member of staff in the lounge at all times during the inspection.

Some improvements had been made in relation to seeking people’s consent to care and treatment. Although the service was mainly working within the principles of the Mental Capacity Act (2005), there was still some scope for improvement in relation to undertaking mental capacity assessments. We made a recommendation about this.

The restrictions in place to maintain people’s safety was done so lawfully and in accordance with Applications to deprive people of their liberty had been submitted to the Local Authority.

Improvements had been made in relation to safeguarding people from abuse. Safeguarding concerns were being appropriately reported to the Local Authority. Staff could clearly describe how they would recognise abuse and the action they would take to ensure any concerns they had were reported. Training records confirmed the staff team was up-to-date with training in the safeguarding of vulnerable adults. Staff were aware of the whistle blowing policy and said they would not hesitate to use it.

Improvements had been made to the environment and arrangements to monitor and check the premises were more robust. The privacy of people’s bedrooms was ensured as people had locks for their bedroom doors, which meant other people could not access their rooms. Some action had been taken to ensure the environment was dementia-friendly, including signage on doors and the use of colour to distinguish rooms.

People and families were satisfied with the quality of the food and the choice of meals available. We noted from the care records that alternative arrangements had not been put in place to check the weight of people who refused to or could not use a scale.

Families told us that the recreational activities had improved but were still limited to certain times. They said more needed to be done to occupy people during the day. Families said that their relatives would benefit from direct access to the back garden.

Improvements had been made to individual risk assessments and care plans but further work was needed to ensure that care plans included sufficient detail for staff to understand how to manage individual in a consistent way.

Audits or checks to monitor the quality of care provided had been developed further and were more robust. However, were not effective as they had not picked up on issues we identified. These included the medicines audit and care plan audits.

Confidential information was now being stored in a secure way because the manager’s office had been reconfigured so was no longer used by visitors to access a person’s bedroom.

Information related to an adult safeguarding concern had been shared with the local safeguarding that was not accurate. A process was established to manage and monitor accidents, including a process for analysing accidents on a monthly basis. The analysis was limited as it focussed on falls rather than the full range of incidents that occurred at the home.

A procedure was established for managing complaints. Families we spoke with were aware of what to do should they have a concern or complaint.

The provider was informing the Care Quality Commission (CQC) of all the events CQC are required to be notified about.

You can see what action we asked the provider to take at the back of this report.

Acacia Court is a care home which provides personal care and accommodation for up to 27 people living with dementia. It comprises two large detached houses joined by an extension. The accommodation includes a large lounge, a spacious dining area and a large garden to the rear of the property. There is parking to the front of the building.

Twenty three people were living at the home at the time of the inspection.

A registered manager was in post and had been working at the home since 2010. 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 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 the staffing levels were not sufficient to ensure people were being monitored at all times was. The staff duty rotas for October 2015 through to the first week in December 2015 showed a clear variation in staffing levels that did not reflect what staff said the staffing levels should be. Frequently the registered manager was working within the care staff numbers. You can see what action we told the provider (owner) to take at the back of the full version of this report.

People told us they felt safe in the way staff supported them. Staff we spoke with were clear about adult safeguarding. The majority of the staff team had not received training in adult safeguarding. We found five recorded incidents that should have been reported to the Local Authority as safeguarding concerns but had not. You can see what action we told the provider to take at the back of the full version of this report.

Medicines were not always managed in a safe way. We observed a topical medicine (cream) in a person’s bedroom was not stored securely. The medication reference book available for staff to use was out-of-date. The fridge temperatures were not always within the acceptable range. Medicines given by hiding them in a person’s drink or food was not done in line with the Mental Capacity Act 2005. The medication policy was not in accordance with good practice national guidance for managing medicines in care homes.

Recruitment practices were not robust. The home was short staffed so staff from the provider’s other homes locally were helping out. We were able to account for all of these staff except one person who had worked two shifts in October 2015. Therefore we were unable to confirm how the person had been recruited and whether they were suitable to work with vulnerable. You can see what action we told the provider to take at the back of the full version of this report.

A whistle blowing policy was in place and staff said they knew what whistle blowing was and would not hesitate to report any concerns.

Staff were receiving regular supervision and an annual appraisal. Training the provider required staff to complete was not up-to-date. For example, only 38% of staff had completed training in dementia care. Few staff had received food hygiene training. You can see what action we told the provider to take at the back of the full version of this report.

Arrangements to monitor the safety of the environment and equipment were not rigorous. For example, hoists and hoist slings were not being thoroughly examined in accordance with Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). New window restrictors had been fitted following a serious incident but these were not in accordance with national guidance on window restrictors in care homes. The environment had not been designed, adapted or decorated to support the independence and orientation of people living with dementia. You can see what action we told the provider to take at the back of the full version of this report.

Appropriate referrals had been made to the Local Authority to deprive people of their liberty. Staff had received awareness training in relation to the Mental Capacity Act (2005). The way in which mental capacity assessments had been developed was not in keeping with the principles of the Mental Capacity Act (2005). The completed mental capacity assessments we looked at were generic in nature and did not identify the decision the person was being assessed as needing to make. You can see what action we told the provider to take at the back of the full version of this report.

People and families we spoke with were satisfied with meals. People said they had access to drinks and snacks throughout the day.

People had access to health care when they needed it, including their GP, dentist, optician and community mental health service. A visiting healthcare professional told us the registered manager and staff were approachable and responsive.

Risk assessments and care plans were not being revised as people’s needs changed. For example, a person had a care plan in place indicating they were at risk to falls even though the person was no longer mobile. You can see what action we told the provider to take at the back of the full version of this report.

People’s privacy was not always maintained. Some people liked to walk about and to go in and out of other people’s bedrooms. This was an on-going issue and we found a person asleep on another person’s bedroom during the inspection. You can see what action we told the provider to take at the back of the full version of this report.

Staff were caring and kind in the way they supported people. They treated people with compassion and respect. They understood people’s preferences and ensured people’s privacy when supporting them with personal care activities. People’s preferences and preferred routines were recorded and displayed in their bedrooms.

Recreational activities were externally facilitated for one hour four days per week. Very little recreational activity happened between these sessions. Occasional trips out were arranged and a trip to a pantomime was taking place on one of the days of the inspection.

A complaints procedure was in place and displayed in each person’s bedroom. People we spoke with and families were aware of how to raise concerns.

The approach to checking and auditing the service was not robust. Medication audits were established but they had not picked up on some of the issues we identified. Care record audits had not taken place for some time, which meant some of the concerns we identified with the care records had not been recognised by the registered manager. You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this location is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in Special Measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

You can see what action we told the provider to take at the back of the full version of this report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives, staff providing support and looking at records.

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

Is the service safe?

People and/or their families were involved in decisions about their care and they were provided with the opportunity to read and sign care plans.

The manager had a system in place to review incidents each month so that lessons could be learnt from emerging themes and patterns.

The home was clean, hygienic and odour free. Measures were in place to ensure the environment was safe and suitable for the people who were living there.

Both people who were living there and staff told us there was enough staff on duty to ensure people's safety.

Effective recruitment processes were established and necessary checks were carried out as part of the recruitment process to ensure staff were suitable to work with vulnerable adults.

The home protected the rights and welfare of the people in accordance with the Mental Capacity Act (2005). At the time of the inspection no Deprivation of Liberty Safeguards applications had been made.

Is the service effective?

People's health and care needs were assessed with them and/or with a family member. People and family members told us staff communicated well about care needs and any changes were discussed with them. Care plans reflected current care needs and included information about peoples' preferences and preferred routines.

Advanced care planning was established for some people and the person's doctor and family were involved in any decisions made.

Arrangements were in place to monitor the safety and suitability of the environment.

Is the service caring?

The people we spoke with told us staff were caring and treated them kindly, and with respect. A person said, 'The staff are lovely. They help you way more than they need to.' Family members we spoke with supported this view. Throughout the day we observed staff prompting and encouraging people, in a kind and respectful way, with their individual needs.

Staff were knowledgeable about people's preferences, interests and diverse needs so care and support was provided in accordance with people's wishes.

Family members told us staff communicated well and involved them in in decisions about their relatives care.

Is the service responsive?

People and family members knew how raise a concern if they were dissatisfied with something. A family member told us the manager was approachable and listened to any concerns or worries they had.

From our discussions with people and family members, and through observation of care records we could see that the approach to care and support was revised as people's needs changed. This was particularly evident with changing health and care needs.

Is the service well-led?

The home had systems in place to regularly monitor the quality and safety of the service provided. Records we looked at demonstrated that action plans were developed to address identified shortfalls in a timely way.

Care records informed us the home worked closely with health and social care organisations, such as the local community mental health team, local GPs and social workers.

Staff we spoke with said they received good quality training and had an annual appraisal.

The people we spoke with were positive about their care and support. They told us they could decide how to spend their day and staff respected their decisions. One of the people we spoke with said, 'I'm free to do as I want. I like to sit here in the lounge. I go into the dining room at lunchtime and sit with my friends. I have a lovely bedroom. The view from my bedroom window is beautiful, just beautiful.'

Equally, relatives were satisfied with the care and support provided at the home. One relative said to us, 'The staff talk to me, especially the manager, if there is any change. I have seen a care plan and I've signed one but not recently.'

People were satisfied with the meals and said they got plenty to eat and drink and had a choice of meals each day.

The care documentation we looked at was individualised and included sufficient detail for staff to understand a person's individualised needs.

Staff told us they were well supported in terms of training. A process was in place for providing staff with an annual appraisal. Sufficient arrangements were in place for monitoring the quality and safety of the service provided.