Norman Hudson Care Home

Norman Hudson Care Home is registered to provide residential and nursing care for up to 42 people. At the time of the inspection there were 27 people living in the home, the majority of whom were living with dementia. The home is situated across 3 floors, with communal areas on the ground floor.

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

We were not assured medicines were administered as prescribed and robust recording was not in place. Medication running balances did not always match stock held, ‘as required’ medicines were missing protocols and the medication fridge temperature was operating outside a safe range. The missing protocols were put in place between days 1 and 2 of our inspection. The provider’s audits had identified some, but not all the issues we found on inspection.

Staff were unable to describe safe and appropriate action would be taken in the event of an emergency requiring evacuation. The provider told us they would address this with staff. It was not clear how an unsuccessful fire drill had been followed up in January 2023. Safeguarding records, complaints, accidents and incidents did not show how events the provider had marked for further investigation had been followed up. Staff understood safeguarding responsibilities and both people and their representatives said they were protected from harm.

The nominated individual told us they did not produce visit reports as this oversight came from ‘Gold Command’ (quality assurance) meetings. The provider told us these meetings were documented in emails, but did not present these records. An action plan for previous inspection findings was shared with us. Daily walkarounds were not fully effective and the allocation of ‘chart champions’ had not improved daily recording. Some items of lifting equipment had not been thoroughly examined as required by the Health and Safety Executive.

Electronic and paper based care planning systems were in the home, but staff were not enabled to access the electronic records, which were the most up-to-date. This was partly addressed during our inspection as the provider printed the electronic records. IT equipment needed to make the electronic care planning system operational was due to be installed shortly after our inspection. Electronic care plans were sufficiently detailed records.

The recording of people’s dietary needs was not consistent. People had a positive mealtime experience as staff worked hard to offer people a range of options, which was particularly important where people initially refused what they were offered. Relatives told us they were kept up-to-date around key developments in their family member’s health.

Some caring interactions had improved at this inspection. We saw examples of kind interactions, but other examples were seen where staff were not fully skilled. Dementia training which the provider had arranged with the local authority had to be delayed in February 2023 due to unforeseen circumstances and was rearranged for May 2023. People said the staff were caring and relatives said they had observed improvements. People were more meaningfully engaged with a programme of activities. Activities were also sourced externally and people enjoyed this provision.

Feedback from relatives was generally positive. However, they provided mixed feedback about the responsiveness of the provider’s communication, whilst also saying they felt well informed about incidents in the home. The provider acted openly with relatives around shortfalls found at our previous inspection. A culture review completed by a consultant in December 2022 highlighted concerning issues around the provider’s management of the home. A new management team had been introduced, although further changes were expected in the months after our inspection. The provider said they would ensure there was a suitable handover to the new management team.

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. However, we have asked the provider to investigate the control people have over morning and night routines. We have made a recommendation about the use of best interests decisions, as needed, for this aspect of people’s care.

Work had been carried out to improve the living environment and this was ongoing, as some work still needed to be done. Ideas for improvements to the premises were shared by the provider, which included plans to make the home more dementia friendly.

Infection control measures were not robust at this inspection. The premises were found to be cleaner, but some equipment in the home needed a deep clean.

There was an improved skills mix of staff on day and night shifts. Shifts were fully staffed in line with people’s assessed needs. Staff files demonstrated the provider carried out safe recruitment checks. Staff were receiving an improved level of formal support through induction, high training completion levels and examples of supervision for some, but not all staff.

We identified two incidents at this inspection which should have been reported to the Care Quality Commission. We have dealt with this outside the inspection process.

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 3 February 2023).

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 some regulations. However, we found the provider remained in breach of regulation concerning people’s safety and systems to ensure sufficient oversight of the service.

Why we inspected

The inspection was prompted due to concerns identified at our last inspection in December 2022 around safeguarding, management of risk, premises and equipment, staffing arrangements, staff recruitment and leadership in the home. A decision was made for us to inspect and examine those risks. We carried out an inspection which looked at all five of our key questions.

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 the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to requires improvement, based on the findings of this inspection. We have found evidence the provider still needs to make improvements. Please see all sections of this full report.

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

You can read the report from our last inspection, by selecting the 'all reports' link for Norman Hudson Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and governance of the home.

We have made recommendations about ensuring best interests decisions are in place where needed and assessing how best to support people living with a mental health diagnosis.

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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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.

Norman Hudson Care Home is registered to provide residential and nursing care for up to 42 people. At the time of the inspection there were 29 people living in the home, the majority of whom were living with dementia. The home is situated across 3 floors, with communal areas on the ground floor.

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

There was instability and ineffective leadership in the home, particularly with regard to clinical risks and oversight of people’s nursing care. There was a lack of management ownership and accountability within the service. None of the management team had a robust and complete overview of risks in the service. Quality assurance checks were not effective, consistent or robust enough to accurately identify or drive improvement in the service.

People were not always safe. Some relatives shared concerns about how safe their loved ones were living at Norman Hudson. We identified continued concerns around how risks to people were assessed and monitored. Risks to individuals were not identified accurately, and there were not adequate systems in place to ensure actions were taken to mitigate the risk of harm. There were no systems or clear communication in place to ensure people's health was monitored when they were ill or had specific health conditions. Systems and processes were not securely in place to ensure the safe management of medicines.

Fire safety matters, which had been a serious concern at the last inspection, had not all been addressed. Not all staff were confident with emergency evacuation procedures or equipment, and there was limited evidence of fire drills having been carried out.

There were insufficient checks carried out to ensure staff were suitable to work in the home. Staffing levels were adequate on the days of the inspection, although people and relatives told us the home was not always well staffed. There was poor deployment of staff with the appropriate skills and experience to meet people’s needs. Staff told us they completed e-learning training, although they could not all recall what they had done or when and there were gaps in the training matrix. Staff supervision had recently been scheduled and completed for a small number of staff, although some staff could not remember having had a supervision meeting and no appraisals had been completed.

Infection control practice remained an area of concern. Staff mask usage was a continued concern at this inspection, qualified nurses were not always bare below the elbow and there were some malodours and equipment in need of thorough cleaning.

People did not have adequate daily opportunities to be purposefully engaged and occupied. Many of the people at Norman Hudson were living with dementia and needed support and reassurance. Staff lacked the skills and abilities to communicate effectively with people who were upset or anxious, and although they remained in their presence, there was little attempt to reassure anyone or involve them in activities and conversation. People were seated for long periods of time in chairs with nothing to do or seated directly underneath a loud nurse call system during a film. The provider told us they were actively recruiting for activities staff.

Some improvements had been made to the living environment and the décor in the home as well as some new furniture. However, some fixtures and fittings were not safe or secure, such as toilet seats, radiator covers and drawers. Equipment such as tray tables and footstools, were in short supply. Improvements were still needed to make the home more dementia friendly and to ensure living spaces were accessible. We have made a recommendation that the provider seeks relevant expertise in making the home more dementia friendly, and to consider how communal areas in the home could be better utilised.

The recording of people’s care and support was inconsistent, inaccurate and incomplete. Care plans were in the process of being transferred from paper to electronic records, but information was not always sufficient for staff to know how to care for people’s individual needs. Records in relation to food, fluids and repositioning were inconsistent. Staff did not always know why they were recording and therefore lacked understanding of how to identify and report concerns. There was no systematic review of people’s daily notes to ensure people were receiving adequate care. People’s weights were not consistently recorded and there was conflicting information in the records we reviewed.

Mental capacity assessments and other related documentation had been completed. People were not always supported to have maximum choice and control of their lives because everyday decisions were made for people, without always asking them. Some staff understood how to support people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff worked with healthcare partners where they were involved to meet people’s needs. However, people did not always have their health needs reviewed routinely, such as for the risks associated with diabetes.

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 3 September 2022)

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 the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about safe recruitment, safeguarding, management of risk, and leadership in the home. A decision was made for us to inspect and examine those risks.

We undertook a focused inspection to follow up on specific concerns which we had received about the service and to follow up on action we told the provider to take at the last inspection. We inspected and found there was a concern with how people’s needs were being met, so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of caring and responsive.

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 the service can respond to COVID-19 and other infection outbreaks effectively.

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

Following the inspection visit, the provider arranged a ‘gold command’ leadership structure to attempt to address the areas identified. We continued to receive information of concern, with continued themes of poor culture and insufficient management of risks. Consequently, we were not assured risks were being mitigated.

The overall rating for the service has not changed from inadequate, based on the findings of this inspection.

We have found evidence the provider needs to make improvements. Please see all sections of this full report.

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

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

Enforcement and Recommendations

We have identified breaches in relation to people’s care and support, safety, staff suitability, and management of the home 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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

Norman Hudson Care Home is registered to provide residential and nursing care for up to 42 people. At the time of the inspection there were 39 people living in the service, the majority of whom were living with dementia. Care is provided across three floors and the service has two units known as 'Aspley' and 'Pennine'.

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

Risks to people had not been adequately managed. Fire safety was a serious concern at this inspection. Following our visit to the service, we made a referral to West Yorkshire Fire and Rescue and wrote to the provider to seek immediate assurances about people’s safety.

Airflow mattresses which help to protect people’s skin were not set correctly. Infection control practice was poor as used incontinence pads were seen throughout the home. Staff mask usage was a concern at our last inspection and further examples of these not being worn correctly were seen at this inspection.

Staffing levels were not adequate to meet the needs of people. We observed occasions where people needed assistance and they had to wait for extended periods. Staff rotas showed shifts were not fully staffed.

Some improvements had been made to the living environment, but this did not fully address concerns found at our last inspection. We identified new concerns relating to the safety and comfort of the living environment.

The management of the home was poor. Quality checks the provider completed showed the home performed well, but our inspection findings were considerably different. Quality assurance checks were not found to be effective. There was a lack of lessons learned and continuous improvement.

Staff recorded what people had to eat and drink several hours after they had this, meaning there was a risk the recording was not accurate. The management of people’s weights needed improvement.

Evidence of formal support for staff through supervision and appraisal could not be provided. People did not always receive care which helped them maintain their dignity.

Relatives felt people were protected from the risk of abuse. People received their medicines as prescribed from staff who were assessed as trained and competent. The recruitment of staff was found to be done safely. Staff worked with healthcare partners to meet people’s needs.

Mental capacity assessments and other related documentation had been completed.

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 requires improvement (published 13 July 2021) 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 the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, risks to people’s safety, infection prevention and control and staff communication. A decision was made for us to inspect and examine those risks.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection. Following our inspection, we worked with safeguarding partners, commissioners and health professionals to ensure close monitoring of this service.

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

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

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to staffing levels, managing the risk of cross infection, reducing risks to people, the living environment and the effectiveness of quality checking.

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 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

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.

Norman Hudson Care Home is registered to provide residential and nursing care for up to 42 people. At the time of the inspection there were 39 people living in the home, some of whom were living with dementia. Care is provided across three floors and the home has two units known as ‘Aspley’ and ‘Pennine’.

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

Observations were made of staff wearing masks inappropriately on several occasions. The premises were mostly clean, although we found aspects of the home which required maintenance. Fire risks were mostly well managed, although the fire risk assessment had not been carried out by a competent person.

Events which the registered provider was expected to report to us had not been notified in some instances. We have dealt with this outside the inspection process.

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. However, the systems in place had not identified that four applications to legally restrict people’s freedom needed to be made. This was done following our inspection.

One person had not received access to healthcare which they needed. The registered manager had made a referral for this, but action had not been taken to follow this up.

The recording of people’s dietary intake required improvement. This was dealt with following the inspection. It was unclear whether diabetic foods were being offered. Recording of people’s weights showed these were appropriately managed.

Quality assurance systems included audits, senior management visit reports and satisfaction surveys. However, these checks had not always identified the issues found at this inspection. Team meetings were being held regularly and staff received ongoing support from the registered manager who they spoke about positively.

Relatives we spoke with told us people living in this home were safe. There were sufficient numbers of staff on duty. Medicines were safely managed by a team of people who were trained and assessed as competent. We have made a recommendation about recording variable dose medicines and time specific administrations.

We witnessed kind interactions between people living in the home and staff who displayed compassion and protected people’s dignity. Feedback about the quality of care we received from relatives was mixed.

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 Good (published 23 March 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing levels, medicines management, infection control, access to healthcare and premises and equipment. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

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

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

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 monitor the service.

We have identified breaches in relation to infection control, risk management, premises and equipment and governance.

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.

At the last inspection, the service was rated Good.

Staff had opportunities to update their skills and professional development. Staff demonstrated an understanding of the Mental Capacity Act (MCA) 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We spoke to the registered manager around one staff file where employment dates had not been recorded in the recruitment process. This was acted on and completed by day two of our inspection.

Care records contained clear information covering all aspects of people's individualised care and support and staff had a caring approach to working with the people who used the service.

Staff were confident in supporting people with medicines and knew people well.

There was a clear management structure and staff clearly understood their roles and responsibilities. There was an open and transparent culture in which staff felt valued and able to approach the registered manager. Staff told us they felt valued and enjoyed their job. The management team continued to improve and work with relatives at the home if they had any concerns or complaints. The home had received many compliments in relation to the care and support they provide.

Further information is in the detailed findings below

When we inspected Norman Hudson Care Home in June 2014 we found the service to be in breach of regulations 17(Respecting and involving people who use services), 9 (Care and welfare of people who use services), 11 (Safeguarding people who use services from abuse), 13 (Management of medicines), 22 (Staffing) and 10 (Assessing and monitoring the quality of service provision) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We judged that people who used the service experienced poor care that had a significant impact on their health, safety or welfare or there was a risk of this happening. The matter needed to be resolved quickly. As a result of this the Commission made a decision to set compliance actions in relation to these regulations. This meant that we told the provider they had to make improvements.

In addition to this, and because of a history of non-compliance with regulations the Commission took the decision to take further enforcement action against the provider. This action was taken under regulation 9 (Care and Welfare) and regulation 11 (Safeguarding people who use services from abuse).

The provider made representations against this enforcement action and has kept the Commission informed of the actions they have taken to achieve compliance with the regulations.

This visit was made to see if the provider had achieved compliance with the regulations under which the enforcement action was taken.

This inspection was made over two days. On the first day two Adult Social Care Inspectors, an Expert by Experience and a Specialist Advisor went to the home and one Adult Social Care Inspector returned on the second day.

We looked at care records for five people and observed care. We spoke with two people visiting their relatives and eight people who lived at the home. Not all of the people we spoke with were able, due to complex care needs, to tell us about their experiences.

We spoke with ten members of staff including the nurse in charge and the registered manager. The registered manager is also the Nominated Individual for the service.

We found that improvements had been made and that people who lived at the home were receiving the care and support they needed. We also found that systems were in place to make sure people who lived at the home were safe.

Visiting relatives said:

'I can't fault the care that they give now, it has improved. (my relative) is well looked after in terms of their health"

'I think (my relative) is more settled generally, things have improved lately. I can see it in the other residents too.'

'I think that the staff have the skills to keep people safe'

'Things have improved in the last six months. I used to think that there was a bit of an atmosphere but this has definitely got better. I think they have separated some of the residents and made another lounge. This has helped to improve things.'

All of the people the Expert by Experience spoke with said they felt safe living at the home.

We looked around the premises, observed staff interactions with people who lived at the home, observed lunchtime and looked at records. There were 28 people living at the home at the time of our inspection.

It should be noted that the person named as manager on this report is no longer employed at the service. The new home manager is currently applying to become the registered manager for the home.

When we visited Norman Hudson Care Home in February 2014 we found the care and welfare needs of people who lived at the home were not being met. We asked the provider to make improvements. We also found that procedures were not in place to keep people who lived at the home safe. We issued a warning notice to the provider in this regard. We went back on this visit to check whether improvements had been made.

Before this visit we had received information of concern about care and welfare of the people living at the home, staffing levels, and staff training and competencies. We looked at these areas during our visit.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

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

Is the service safe?

Staff did not respond appropriately when we told them about an incident we had observed where one person who lived at the home hit another person. Medicines were not managed safely and the provider had failed to make sure appropriate procedures had been followed during an outbreak of diarrhoea and vomiting. We found that staff did not always demonstrate respect for people who lived at the home.

Is the service effective?

We found the health and wellbeing needs of the people who lived at the home were not always met. Poor organisation and deployment of staff meant that people did not always have their needs met in a timely fashion. One relative told us that due to poor communication from the home and problems with the care and support their relative received they were looking for a new care home.

Is the service caring?

We saw some staff supporting people in a kindly and respectful manner. However we saw other staff not being respectful of the privacy and dignity needs of the people who lived at the home. We saw that the provider had failed to ensure people's comfort when the heating system was broken and people were living in an uncomfortably warm environment. Some visitors we spoke with told us they were happy with the care their relative received.

Is the service responsive?

We saw that work was being planned to support people in meeting their social and recreational needs. However we saw that some people had not had their interests and preferences recorded and for one person they had been recorded but were incorrect. One relative told us that communication from the home was poor. The provider failed to respond immediately to some of the issues we raised over the course of our visits.

Is the service well led?

We saw that the Nominated Individual was working shifts as a nurse at the home to provide leadership and guidance to staff. However we found that not all staff were following the good practice procedures put in place by the Nominated Individual. Audits had failed to identify issues within the home and care records were not being audited to make sure people received the support they needed.

Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken.

In addition we found there were not enough staff available to meet people's needs. We judged that both of these issues had a major impact on people who used the service and issued warning notices to the provider informing them that improvements had to be made.

We also found that people who used the service were not protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We judged that this had a moderate impact on people who used the service, and told the provider to take action.

The provider responded and told us that they had taken action to improve the service. We made this visit, over two days, to see what actions had been taken and to assess improvements in the three areas outlined above.

We found better arrangements were in place to make sure that people received the care and support they needed from staff at the home and other healthcare professionals. However, we found a number of issues relating to the delivery of care within the home and, whilst we felt the provider had taken sufficient action to meet with the warning notice, we have said further improvements were needed.

We found staffing was better organised and recruitment of new staff was ongoing.

We found insufficient action had been taken to protect people who used the service from the risk of abuse.

These were some of the things people who used the service or their relatives told us during our visit:

'Some of the staff are really lovely.'

'My mum really enjoys the food; they have two cooked meals a day.'

'I find my relative's clothing is not folded it is just thrown in the drawers and it's like it on most occasions I look.'

'Recently they have improved up to a point but it's superficial. For example the environment has improved but care hasn't always.'

'You seem to have to ask for everything before it is done.'

'It can be a bit boring sometimes.'

'The food is a bit mundane and there's not a great deal of choice.'

'I have no complaints about the staff or care I receive.'

Many of the people we met during out inspection were unable, due to complex care issues, to tell us about their experiences at the home. In view of this we used other methods to understand the experience of living at the home. These included observation of care and looking at care records. Two of the people we spoke with told us that they often have to wait for staff to assist them in meeting their needs.

We spoke with one person's relative on the telephone who told us that they had concerns about the care their relative received.

We found the service were failing to make sure that people's care and welfare needs were met. This included failure to access to medical attention in a timely manner.

We found that safeguarding procedures were not being followed.

We found there were not enough staff available to meet the needs of the people living at the home.

We found that Statutory Notifications to the Care Quality Commission were not always being made as required under the Health and Social Care Act 2008.

We found that work had been done and systems put in place to demonstrate that staff had respect and consideration of the people who lived at the home. This included looking after people's personal belongings.

We saw that work had begun to redecorate and refurbish several areas of the home including people's bedrooms. This meant that the provider was working toward making sure that the premises were safe and suitable.

One person told us they felt that the staff attitudes towards them were mixed. Some staff they described as very good but said others were not. They told us that their room was comfortable and that the food was good.

A visitor told us that they had seen some nice interactions between staff and people who lived at the home.

We found a number of issues which indicated that staff did not always consider or respect the privacy and dignity needs of the people who lived at the home. This included lack of care and respect toward people's personal possessions and personal space.

We found that maintenance was poor in some areas and in some areas, posed a risk to the safety of the people who lived at the home.

Staff were knowledgeable about how to keep people safe and understood examples of issues that might not be in the people's best interests. There were good processes in place for managing complaints.

There were enough staff available to meet people's physical needs but we saw that staff did not always engage with people to meet their recreational needs.

We made this visit to see if the service had achieved compliance.

We found that improvements had been made and that people who lived at the home were receiving the care and support they needed and that their nutritional needs were being met.

Whilst we were at the home we observed that the staff were very busy and that this had an impact on some aspects of care, in particular the timely administration of medication. Staff told us that this was not always the case but not necessarily unusual.

We spoke with six of the people who lived at the home. These are some of the things they told us:

"Staff are very nice but they are always too busy to spend time with us"

"I am ok but people who need more help sometimes have to wait a long time"

"I'm bored, I need something to do"