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Inspection carried out on 22 January 2020

During a routine inspection

Dalton Court Care Home is registered to provide personal and nursing care for up to 60 people. At the time of our inspection 55 people were living at the home. The home supports people who have needs associated with ageing and may be living with a dementia related illness.

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

Since the last inspection the newly formed senior management team and staff team had turned the service around to ensure people received consistent and effective care and treatment. The provider had improved its systems for monitoring older adult services and greater scrutiny and support had been given to the home. Significant improvements were seen at this inspection. Relatives told us how pleased they had been with the improvements. One person summed this up by saying, "I feel confident now to leave my relative. They are in safe hands.”

People were safe and protected from abuse and avoidable harm. Risk assessments helped protect the health and welfare of people. People received their medicines when they needed them from staff who had been trained and had their competency regularly checked. The service was providing safe and consistent staffing levels. Infection control was well managed and the home was clean and free from hazards.

Staff were well trained and supported for their role so that they could meet people's assessed needs. People's rights were protected as the staff team understood their responsibilities under the Mental Capacity Act. People told us they enjoyed meal times and were offered a variety of good quality meals. People's health and nutritional needs were being well met. The home worked effectively with external healthcare professionals.

People’s equality and diversity was respected by a caring staff team. People told us they judged the staff team to be caring and respectful. Staff gave people their time and understood this was important in supporting people’s well-being. They knew the importance of encouraging people to maintain their independence, wherever possible.

The staff team knew people well. They planned and provided care to meet people’s needs and to take account of their preferences. People's views about the quality of care and any complaints were used to make improvements. People had a wide range of organised activities and entertainments to chose from. Relatives were made welcome and included as part of the care team.

The home was being well-led by the registered manager, who was described by staff as being very supportive, approachable and set high standards. Everyone we spoke with told us they would recommend the home and were ‘delighted’ with how the home had improved. Team morale was high, staff felt valued and enjoyed working at the home.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 18 December 2018). We needed to be assured improvements were fully embedded and would be sustained. We made a recommendation in relation to the safer recruitment of staff. We found no breaches of the law.

Why we inspected

This is a planned re-inspection because of the issue highlighted above.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 4 December 2018

During a routine inspection

Dalton Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 for people with both nursing care and personal care. The home can accommodate up to 60 people. At the time of our inspection 47 people lived at the home. One of the units specialised in providing care to people living with dementia.

Since the last inspection a new manager had been appointed and they had applied to become the registered manager with us, CQC. 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.

This unannounced inspection took place on 4 & 18 December 2018. We carried out this inspection to check people were receiving safe care and treatment and to see what improvements had been made following our previous inspection of 4 July 2018.

The findings of previous visits, December 2017 and 4 July 2018, led us to rate the home as inadequate on both occasions and the home was placed into our special measures. 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.

We had serious concerns about the providers ability to run the home in a manner that was safe and to meet people’s needs. We took the ratings history of the service into account and we judged it necessary to take higher legal action following the July 2018 inspection in order to protect people. To check that this was still the right course of action we carried out this inspection of 4 December 2018.

On this inspection, 4 December 2018, we looked at all the areas where the home had breached the regulations and other areas to ensure that we carried out a fully comprehensive inspection. We did make a recommendation in relation to the safer recruitment of staff.

The breaches the service had not met at the last inspection included: meeting people’s health and welfare needs; record keeping; responding to safeguarding; managing risks; staffing levels and staff training; assessing and monitoring the quality of service and not having a registered manager.

The overall findings and outcome of this inspection, December 2018, was that there had been significant improvements across all areas and the home was no longer in breach of the regulations and was no longer in special measures.

The provider, had after the last inspection, ensured that support had been made available to assist the home in meeting safe standards of care through improved quality monitoring and input from senior managers within the organisation. The new senior team, consisting of a newly appointed home manager, deputy manager, unit leader of the dementia unit and a new operations manager, had made significant improvements in the running of the home.

People living in the home and their relatives all told us they had seen a lot of improvements and everyone we spoke with said they felt safe and well cared for.

We found that people’s care needs were being better met. This was because people were being more thoroughly assessed when they came to the home and the care plans to meet their needs were much more detailed to accurately reflected their needs. These improvements were particularly evident in supporting people who were at risk of falling; those at risk of developing pressures sores; and people at the end stages of their life.

People in the home had better protection from abuse. The provider had ensured that all staff had been given training and now recognised the signs o

Inspection carried out on 3 July 2018

During a routine inspection

Dalton Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

The home provides accommodation for people with both nursing care and personal care. The home can accommodate up to 60 people. At the time of our inspection 53 people lived at the home.

This inspection took place on 3, 4 & 12 July 2018 and was unannounced.

There was no registered manager in post at the time of our 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. An interim manager had been in post since the departure of the previous registered manager in December 2017 and had made an application to CQC to become the registered manager.

Our last inspection in December 2017 was a focused inspection to check that breaches in legal requirements found on the last full comprehensive inspection of July 2017 had been met. We found that the breaches and the warning notice had not been met and we found further cause for concern with new breaches on the focused follow up inspection of December 2017.

The overall rating given in December 2017 for this service was ‘Inadequate’ and the service was placed in ‘special measures’. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, we will inspect again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame.

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.

At this inspection July 2018 we identified continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). Three new breaches were found: Regulation 13 (Safeguarding service users from abuse and improper treatment); Regulation 16 (Handling complaints); and Regulation 11 (Need for consent).

The service has now been rated inadequate once again for the second time in 6 months. Where we take higher levels of enforcement action we will publish full details once all relevant representation timescales have elapsed.

While we did find that the provider and interim manager had made improvements in areas that had been prioritised by them, we found that the initial pace of improvement had not been sustained and other important areas were still giving cause for concern. These were that people did not always receive safe care and treatment that met their changing needs. There were not always sufficient numbers of staff on duty to meet people’s needs. People with needs that were complex and challenged the service were not being supported by staff with the appropriate skills and training.

Risks to people were still not being well managed. Risk assessments were not being carried out when a person's needs changed so that care plans were still relevant and people received person centred care and safe treatment from staff.

The management of falls within the service was poorly managed and not in line with current nationally recognised good practice. While some auditing of falls risks for the service as a whole was no

Inspection carried out on 22 November 2017

During an inspection to make sure that the improvements required had been made

We undertook a focused inspection of Dalton Court Care Home on 22 & 24 November and 21 December 2017 and 2 January 2018. The first visit to the service on 22 November 2017 was unannounced. We told the provider that we would return to the service for the other days so that we could check on progress and well-being of people in the home.

At our previous comprehensive inspection of this service on 18 & 21 July 2017 breaches of legal requirements were found. One of these breaches Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Person centred care, had been made at a previous inspection in March 2016, and was a continued breach.

We issued a warning notice for the service to meet this regulation by 30 September 2017. This was because people who used this service did not have care or treatment that had been personalised specifically for them; important information was missing from the care plans; and people’s medicines were not being managed safely.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements as set out in the requirements of the warning notice. This report covers our findings in relation to those requirements, and other concerns found during this focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dalton Court Care Home on our website at www.cqc.org.uk.

The service had a registered manager in post and they had been in post since September 2016. 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.

On the first day of the focused inspection, 22 November 2017, we found that the warning notice had not been met and there was a continued breach of Regulation 9 Person centred care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that little progress had been made to meet the warning notice and there were new areas of concern identified. We immediately notified the provider who took swift action, and across the other subsequent visits we saw how the provider’s actions were leading to improvements in the service.

We found assessments of people’s needs were still not being carried out to cover all areas of the person’s support needs. There was little evidence of person centred care planning. This included end of life care planning and care plans. Some people living with dementia had not had a life story history undertaken. This is essential in the delivery of recognised national best practice for people living with dementia.

The registered manager had not been effectively managing new admissions of people to the home. Pre-admission assessments carried out lacked detail and were not always accurate. As a result we judged the service was accepting people with complex health needs without sufficient numbers of skilled and trained staff to meet people’s needs.

At our last inspection in July 2017, we had found the provider had failed to protect people against the risks associated with the unsafe use and management of medicines. At this inspection, while there had been some improvements we found that medicines were still not managed safely.

Risks to people were not being well managed. We identified that risk assessments were not being carried out when a person’s needs changed so that care plans were still relevant and people received person centred care and safe treatment.

The management of falls within the service was poorly managed and not in line with current nationally recognised good practice. We found a similar lack of action and recording for people at risk of developing pressure sores.

Staff also lac

Inspection carried out on 18 July 2017

During a routine inspection

This inspection took place on 18 and 21 July 2017. The visit to the service on 18 July 2017 was unannounced. We told the provider that we would return to the service on the 21 July 2017.

We last inspected the service on 20 June 2016 when the service was found to be in breach of three regulations. Requirement notices were issued. This was because people’s medicines were not being managed safely and procedures for obtaining consent to care and treatment did not always follow current legislation and guidance. Also, people who used this service did not have care or treatment that had been personalised specifically for them and important information was missing from the care plans of some people.

The registered provider gave us an action plan setting out how what they were going to do to improve and the timescales to carry out the improvements. During this inspection we reviewed the action taken by the provider to meet the requirement notices. We saw that some improvements had been made. Some breaches in the regulations identified in June 2016 had been addressed but some still remained.

We found that there was a continued breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A requirement notice had been issued at the last inspection on 20 June 2016. This was because some people who used this service still did not have care or treatment plans that had been personalised specifically for them. We found this was still the case for some people, including personalised advanced care planning for end of life care and to manage medication changes. This placed people at risk of receiving care or treatment that did not meeting their individual needs or expectations.

We found that improvements had been made to the management of medicines but this was not consistent across both Daffodil and Orchard units. Orchard unit demonstrated some good practice whereas Daffodil unit lacked effective oversight to sustain good practice. Similarly audit systems had been improved and were in place for medication and care plan reviews however Daffodil unit did not apply them with the clarity and effectiveness of other parts of the service.

During the first day of the inspection on 18 July 2017 we asked for further information and assurances from the registered manager of the safe handling of medicines on Daffodil unit. This was to mitigate the risks associated with the medicines management that we had found on that day. This information was provided and on the second day of our inspection 21 July 2017 we saw that appropriate action had been taken to mitigate the immediate risks to people in respect of medicines management and greater oversight in place. However improvement was required to continue and embed this.

We found a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the registered provider had not ensured that the systems in place were effective to make sure the nutritional and hydration needs of people were accurately recorded and monitored. A requirement notice was issued.

We found that the registered provider had met Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. This was because the service had improved procedures for obtaining consent to care and treatment and the practices were in line with current legislation and guidance.

We have made the following recommendations following the inspection 18 and 21 July 2017:

We have made a recommendation that the service seek advice and guidance from a reputable source on support and training for nursing staff on the use of audits and monitoring of practices to help ensure a consistent level of medicines monitoring within the home.

We have made a recommendation in relation to the development of head injury protocols within the home.

We have made a recommendation in relation to continuously reviewing staffing levels in line with changes

Inspection carried out on 20 June 2016

During a routine inspection

This inspection took place on 20 June 2016 and was unannounced.

We had previously carried out an unannounced comprehensive inspection of this service between 14 December 2015 and 07 January 2016. Nine breaches of legal requirements were found. We judged that this service was “Inadequate” and Dalton Court was placed in special measures. We issued seven requirement actions and two Warning Notices.

Requirement actions were issued as people who used this service did not receive respectful and dignified care or appropriate treatment that met their needs and reflected their preferences. People were at risk from the risks of infections and contamination, of having unlawful restrictions placed on their liberty and at risk as their nutritional and hydration needs were not met. People who used this service did not receive their care and support from people who had the skills, competence and experience to do so safely. The management of the service was not open and transparent, with no clear lines of accountability in place. The registered provider sent us an action plan to show how they would ensure compliance with these parts of the regulation.

We issued two Warning Notices because the registered provider was not complying with Regulation 17 – Good Governance and Regulation 18 – Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A Warning Notice tells a registered provider or a registered manager that they are not complying with a regulation.

We undertook an unannounced focused inspection on 4 May 2016 to check that the requirements of the two Warning Notices had been met. We found that the registered provider had complied with the requirements of the Warning Notices.

Our unannounced inspection on 20 June 2016 was a full comprehensive inspection. We found improvements had been made. Some breaches in the regulations identified in December 2015 had been addressed but some still remained.

We have made the following recommendations:

We have made a recommendation in relation to risk assessing whether staff were safe to work with vulnerable people.

We have made a recommendation about the management of complaints.

We found breaches of the following Regulations:

Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used this service did not have care or treatment that had been personalised specifically for them. This placed people at risk of receiving care or treatment that did not meeting their individual needs or expectations.

Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. Procedures for obtaining consent to care and treatment did not always follow current legislation and guidance. This meant that people who used this service were placed at risk of receiving care or treatment that they had not agreed or consented to.

Regulation 12 of the Health and Social Care act 2008 (Regulated Activities) Regulations 2014 because people were not protected from the risks of receiving unsafe care, treatment and avoidable harm. Additionally, medicines were not managed safely and people were placed at risk of receiving their medicines not as their doctor intended.

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

Dalton Court Care Home (the home) is operated by Amore Elderly Care Limited, a unit of the Priory Group. Dalton Court is registered to provide accommodation for people who require personal and/or nursing care. The home can accommodate up to 60 older people and people with complex health care needs. Accommodation is provided in single, en-suite rooms over two floors, with the upper floor accessible via stairs or passenger lift. There is a separate unit at the home that provides accommodation for people living with dementia.

The home does not currently have a registered manager. A registered manager is a person who has registered with the Care Quality Commi

Inspection carried out on 4 May 2016

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service on 14 December 2015. Breaches of legal requirements were found and we issued two Warning Notices. A Warning Notice tells a registered provider or a registered manager that they are not complying with a regulation.

We issued two Warning Notices because the registered provider was not complying with Regulation 17 – Good Governance and Regulation 18 – Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focused inspection to check that the registered provider had complied with the requirements of these Warning Notices.

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 (Dalton Court Care Home) on our website at www.cqc.org.uk

We could not improve the ratings for Safe and Well Led from inadequate because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

This focused inspection took place on 4 May 2016 and was unannounced.

Dalton Court Care Home is a purpose built nursing home for up to 60 older people and people with complex healthcare needs. It is divided into two units: one for people with dementia on the top floor and the ground floor accommodation for people with mobility and health issues.

All bedrooms have ensuite toilet and shower facilities. There are a variety of communal lounge and dining areas and pleasant gardens for people to access if they wish.

At the time of this inspection the service did not have a registered manager.

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.

The registered provider had appointed a new manager for the home. During this inspection of the service the new manager told us that they had made an application to become a “registered manager”.

We found that the registered provider had met the requirements of the warning notice in relation to the concerns about the staffing levels at the home.

One of the people who used this service told us; “The staffing is much better now. There are lots of them about and they (staff) are lovely. There is new management and they are very nice and friendly too.”

Another person said; “Staff seem to have more time now. They are all very nice although there has been a lot of people come and go.”

The staff we spoke to also commented on the improved staffing levels and support they were receiving. One person told us; “We have more time to give people the time and care they need. It’s much more relaxed here now.”

We found that the service had recruited more staff and that there was less reliance on staff coming to work at Dalton Court from other homes within the organisation. We checked a sample of the recruitment records of recently employed staff. We found that proper checks had been carried out by the registered provider to help ensure only suitable people had been employed.

We found that the registered provider had met the requirements of the warning notice in relation to the concerns about the way in which quality and safety were managed at the home. However, there remained some areas where further improvements still needed to be made.

For example, we reviewed a sample of care records that belonged to some of the people who used this service. Whilst we could see that some work had been carried out to help improve the accuracy and detail of these records, there was still a significant amount of work to be done on them to ensure people received the standard of support and care they needed.

The new manager and senior staff at the home were able to p

Inspection carried out on 14 December 2015

During a routine inspection

The inspection took place over three days; 14, 18 December 2015 and 7 January 2016. The inspection was unannounced.

This provider is in special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

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 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.

Dalton Court Care Home is registered to provide accommodation for people who require personal and/or nursing care. The home can accommodate up to 60 older people and people with complex healthcare needs.

Dalton Court Care Home is operated by Amore Elderly Care Limited, a unit of the Priory Group.

Accommodation is provided in single, en-suite rooms, over two floors, with the upper floor accessible via stairs or passenger lift. There is a separate unit at the home that provides accommodation for people living with dementia.

There is a registered manager in post at the home.

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 staff worked very hard, sometimes working extremely long shifts, to try and meet the needs of the people who used this service. Their role was very task orientated with little time for staff to interact on a personal level with people who lived at Dalton Court.

We found that staff had not completed or updated essential aspects of their training, for example moving and handling training, basic life support and first aid.

We observed and people told us, that their experience of care, treatment and support was task orientated rather than in response to their needs as individuals. Staff were aware of some of the individual needs and choices of the people they supported but they were unable to effectively and consistently respond to them due to the lack of staff at the home.

Care plans relating to people’s wishes when they came to the end of their life contained little information about preferences and choice.

We saw that staff were very busy responding to call bells throughout the day. There were times when people who used this service we

Inspection carried out on 14 May 2015 and 15 & 19 June 2015

During a routine inspection

We visited the home on 14 May, 15 and 19 June 2015. We also met with the provider on 25 June 2015. The inspection was unannounced and in response to concerns and information received by the Care Quality Commission (CQC).

Dalton Court Care Home is registered to provide accommodation for people who require personal and/or nursing care. The home can accommodate up to 60 older people and people with complex healthcare needs. Dalton Court Care Home is operated by Amore Elderly Care Limited, a unit of the Priory Group.

Accommodation is provided in single, en-suite rooms, over two floors, with the upper floor accessible via stairs or passenger lift. There is a separate unit at the home that provides accommodation for people living with dementia.

There is a registered manager in post at the home. 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 our inspection of this service we found:

Information recorded in care records contained gaps. For example, pre-admission assessments had not been fully completed or left blank, particularly in the areas relating to people’s mental health, well-being and personality profile.

This is a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were placed at risk of receiving care and support that was not personal or centred around their individual needs and wishes. You can see what action we told the provider to take at the back of the full version of the report.

We found that the provider did not meet the requirements of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Appropriate assessments of people’s capacity to make decisions had not been carried out. People who used this service had their liberty restricted because they were not freely able to leave the home if they wished. Where people lack the ability to make decisions about their lifestyle, the MCA and DoLS require providers to submit applications to a ‘supervisory body’ for authority to restrict people’s liberty.

We also found examples of incidents that had not been reported to social workers and CQC. These were potential allegations of abuse and should be referred under the Local Authorities Safeguarding procedures and a notification submitted to CQC.

This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people who used this service were deprived of their liberty and were not protected from abuse or improper treatment. You can see what action we told the provider to take at the back of the full version of the report.

We looked at the way in which people’s medicines were handled and managed at the home. We found that medicines were not managed safely and care plans relating to the management of medical conditions were poor. The records and care plans with regards to the administration of topical medicines such as creams and ointments were poor. The management of “when required” medicines such as pain relief and sedatives was not robust. This meant that staff did not have clear guidance to help make sure people received the correct treatment, as their doctor had prescribed and at the time they needed it.

Everyone who used this service had a plan of their care and support needs. Not everyone was aware that they had a plan and whilst some staff saw care plans as a valuable source of information, others relied on their own knowledge to support people with their care needs. Care plans and records had not been maintained to provide an accurate and up to date account of people’s care and support needs. There was confusing and contradictory information recorded about people’s care needs. Staff had told us that communication was poor and this meant that they may not always be up to date with changes in people’s care needs.

These are breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People did not receive their medicines in a safe way or as prescribed. People were placed at risk of receiving inappropriate care, particularly when their needs changed. You can see what action we told the provider to take at the back of the full version of the report.

The service did have a complaints procedure in place, the details of which had been made available to people using the service and their relatives. However, we found that the process had not been operated effectively and some of the people we spoke to during our visit felt that they had not been listened to or that their concerns had been addressed.

This is a breach of Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because although people were able to raise concerns, they were not confident that they would be taken seriously or that action would be taken to resolve them. You can see what action we told the provider to take at the back of the full version of the report.

Monitoring audits regarding the safety and quality of the service had been undertaken. The samples we were shown during our visit to the home were of variable quality and content. The staff we spoke to at the home told us about concerns regarding staff morale, poor management of work rotas and a “bullying” style of management. Staff also told us that communication was poor and that the “management was unapproachable.”

This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The audits were not robust and failed to identify important breaches in compliance with the regulations. Incidents were not routinely reviewed to help mitigate any risks and ensure people who used this service were safe. You can see what action we told the provider to take at the back of the full version of the report.

Some of the care plans we looked at contained DNACPR (do not attempt cardiopulmonary resuscitation) forms. We found little evidence to confirm that these decisions had been lawfully made in the best interests, or with the consent of, or proper consultation with the people they related to.

This is a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People had not been properly consulted about their wishes with regard to their end of life care and support. You can see what action we told the provider to take at the back of the full version of the report.

We observed the service of two mealtimes at the home and looked at samples of people’s nutritional assessments and records. We found that people either were not supported appropriately with eating and drinking or that staff had failed to complete their nutritional records accurately.

This is a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were placed at risk of malnutrition and dehydration. You can see what action we told the provider to take at the back of the full version of the report.

We found that the home was not always adequately staffed, particularly during the night shift. People who used the service and staff working at the home told us about the low staffing levels experienced at times.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the provider had not ensured sufficient numbers of staff had been deployed in the home in order to effectively meet the needs of people who used this service. You can see what action we told the provider to take at the back of the full version of the report.

We checked the information we held about this service and compared this with the accident and incident records kept at the home. We found that the provider and registered manager had failed to notify CQC of serious events and allegations that had occurred or been made at the home.

This is a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. It is a requirement of the Care Quality Commission (Registration) Regulations 2009, that the provider must notify the Commission without delay of allegations of abuse, accidents or incidents that had involved people who used this service. This is so that we can monitor services effectively and carry out our regulatory responsibilities.

The staff we spoke to during our visit to the home told us that they did not have the skills and knowledge to safely support people who may display distressed or aggressive behaviours. We have made a recommendation that the service finds out more about training for staff, based on current best practice, in relation to the specialist needs of people living with dementia.

The people we spoke to during our visit to the home all told us that they felt safe living at Dalton Court. They told us that the staff looked after them well. However, people also said that they had noticed the nursing and care staff at the home were much busier and had less time to chat now. A relative described the staff as “fantastic” but was concerned about the numbers of staff leaving.

We noted at mealtimes that there were plenty of food options for people to choose from. We saw that the food was presented attractively and that there was fresh fruit and home bakes available for snacks.

The home was generally clean, tidy and fresh smelling. We spoke to the housekeeper during our visit to the home and were provided with information about the cleaning schedules and infection control protocols in place. These were well managed and when necessary, appropriate specialist advice had been sought.

CQC met with the provider as part of this inspection of the service. The provider had taken our concerns seriously and started to take immediate action to address the issues identified at the inspection. Additional support has been provided at the home in the form of a peripatetic manager to help and support the registered manager carry out her role and bring about the required improvements to make the service safe.

The overall rating for this provider 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.

Inspection carried out on 9 June 2014

During a routine inspection

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

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

� Is the service caring?

� Is the service responsive?

� Is the service safe?

� Is the service effective?

� Is the service well led?

This is a summary of what we found:

Is the service caring?

We carried out a short observational framework inspection (SOFI) in the dementia unit during this inspection. SOFI is a "tool" designed to help inspectors record their observations during an inspection of a service, particularly where people have cognitive or communication impairments and cannot verbally give their opinions of the service they receive.

Our observations saw warm and positive interactions between people who used this service and staff. The scenario we observed involved people who used the service participating in a singing and musical activity. Some people were more able than others but staff ensured inclusion for everyone. People with limited communication and cognitive skills were seen to respond with warm smiles.

We saw staff helping people to eat their lunch too. Staff were kind and attentive, explaining the content of the meal to people and encouraging them to eat and drink. We did not observe staff rushing or trying to deal with too many people at once.

One of the people who used this service told us, �The care staff are kind and very nice to me. I prefer to stay in my own room most of the time but they (staff) do take me outside in my wheelchair for walks.�

A relative we spoke to told us that they had previously experienced poor care in a different home. They said about Dalton Court, �I am very happy with the care and support here. My relative has settled very well. The staff are very good and often have a laugh and a joke, all the things my relative loved to do when they were well.�

We did receive one comment from a relative who was concerned about the numbers of staff on duty at �peak times� such as first thing in the morning. They told us that, �Staff seem to rush and things are overlooked sometimes.�

Is the service responsive?

Most of the samples of records that we looked at during our visit were up to date and accurate. For example, where people�s care needs had changed due to hospitalisation or an adverse event in their life, we saw that risk assessments and care plans had been reviewed, updated and amended to reflect the current care and support needed.

At previous inspections we had noted that pureed meals had not been presented appropriately. At this recent inspection we saw that food moulds were used to help make the meal look more attractive on the plate. However, not everyone we spoke to thought the moulds were the most appropriate. For example, mashed potato was served in the shape of a flower. One person thought that although it looked nice, it could cause confusion for someone with dementia.

The provider�s internal compliance manager had recently visited the home and produced a report of their findings. The report identified where improvements had been made since the last assessment and also areas where further improvements were needed. The manager of Dalton Court had used the findings of the report as an action plan to help ensure the required improvements were addressed.

Is the service safe?

There were procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. The Deprivation of Liberty Safeguards are a legal framework, designed to ensure that people lacking capacity who are being cared for or treated by others should be deprived of their liberty only in accordance with the law and where there are no other less restrictive ways of keeping them safe.

Three applications had been made by the home. We spoke to the manager and the deputy manager about the Deprivation of Liberty Safeguards. They understood when an application should be made, and how to submit one.

Records showed that decisions had been made about the end of life care for some of the people who used this service. Records did not include how or why these decisions had been made. It was impossible to tell whether these arrangements had been made with the person's consent and in their best interests.

We found that some areas of the home were not as clean as they should have been. For example tables were stained and sticky. Some of the furniture needed replacing because it was badly stained. The laundry room and the downstairs sluice also required attention to help minimise the risks associated with the control and prevention of infection.

Is the service effective?

People�s health and care needs were assessed with them and with their relatives where appropriate.

Specialists dietary, mobility and equipment needs had been identified in care plans where required. We observed that staff carried out the instructions recorded in people�s care plans.

A relative and a member of staff commented about staffing levels, particularly at busy times such as early morning. We noted that there were a significant number of highly dependent people. We have suggested that the provider reviews people�s needs assessments as well as the planning and delivery of care. This will help to ensure the welfare and safety of people who use this service are supported by sufficient numbers of staff.

Is the service well led?

The service worked very well with other agencies and services to help make sure people received safe and appropriate care. Monthly meetings took place with the managers at the home and external health and social care professionals. We spent some time at one of these meetings during our visit to the home. This facility helped the manager ensure people who used this service received co-ordinated care and were able to access other health and social care services as they needed them.

A member of staff that we spoke with told us of the improvements that had been made at the home since the appointment of the new manager. She noted that staff training and support had improved and that �staffing issues� were getting �sorted out�.

One relative told us that the new manager �is very visible in the home� and that she was also �very approachable.�

Another person said �I would not be afraid to approach the managers or staff at the home in order to raise any concerns I had.�

Inspection carried out on 28 November 2013

During a routine inspection

We found improvements in the way the quality of the service had been assessed and monitored. However, there was room for further improvements as the systems in place had failed to identify some of the issues we found during this visit.

We looked at a wide selection of records including those relating to care delivery and planning, risk assessments, staff supervision, recruitment and quality monitoring.

The staff told us about the increase in staff supervision and that managers now carried out �spot checks on paperwork to make sure it was up to date.�

We saw that care records had been reviewed, updated and generally reflected people�s needs accurately. However, there were concerning shortfalls in the records and support people received with their nutritional requirements.

We found that the people who lived at Dalton Court were generally �happy� with the service and that the staff were �very good, caring and helpful.�

One person told us �I sometimes have to wait for staff to assist me, but they are very good and helpful. They always come as soon as they can.�

Another person said �The staff are very good, they come to help me when I need them. They make sure I always have my call bell to hand so that I can alert them.�

People told us that they knew who to speak to if they were worried or had concerns about something. One of them said �The staff treat me well. They are never unkind, I would say if they were and I would tell the manager.�

Another person said, �I have never had cause to complain about anyone. The staff are lovely and I would tell someone about it if they weren�t.�

The staff we spoke to told us of the �changes and improvements� they had noticed since our last inspection, including staff training, support and supervision from more senior staff. They felt there was �generally� enough staff on duty but there were times that caused them concern. For example, early mornings �when everyone wants to get up and have breakfast�. Staff found this time of day very busy and challenging.

The relatives we spoke to during our visit told us that they were �very happy� with the service their relatives received. One person told us that there was, �Good communication� and another said, �The staff phone me if there is a problem with my relative. I don�t mind this I would rather know and if there is something I can do to help, I will do.�

Inspection carried out on 18 September 2013

During a routine inspection

During our visit to Dalton Court we spoke to four of the people that used this service, four relatives who were visiting the home and to seven members of staff. We looked at a sample of nine care and support records belonging to people who lived at Dalton Court.

We looked around all areas of the home during our inspection visit and saw that the home was clean, tidy and generally well maintained and there were no unpleasant odours.

The relatives we spoke to all said that they were satisfied with the care their relative received. They told us that the �staff are excellent� and that relatives received �good care�. One person in particular said, �Our relative is looked after very well and we are kept up to date with what is going on. It is a five star establishment.� However, another person told us, �They never seem to have the same nurses on, there seem to have been lots of changes in staff. This is not good for people with dementia.�

We found that care plans did not provide accurate information about people's care and support needs. Risk assessments, particularly around the management of continence, mobility and behaviours meant that some of the people who used this service did not experience care and support that was safe, appropriate and promoted their dignity. We also found examples where people had not had access to appropriate health care professionals to help them balance the risks and benefits involved in the course of their care or treatment.

We found that the auditing systems in place were not effective and failed to identify the issues found during our inspection of the service.

Inspection carried out on 14 February 2013

During a routine inspection

The home currently had an acting manager and we, the Care Quality Commission, were amending the details as Roseanne Fearon was no longer the registered manager for this home.

We observed that people's privacy and dignity were upheld and staff sought their views to influence the care, treatment and support offered. People we spoke with understood the care and treatment choices available to them and said they were involved in making decisions about their care and support.

People experienced care, treatment and support that met their needs and protected their rights. One person told us, �If I had any gripes I would tell them but we have been very pleased with the home. We knew straight away, the atmosphere was lovely and the staff are very friendly.�

We found the home to be appropriately staffed for the needs of the people living in the home. Staff had received training and support that helped them to carry out their roles.

We saw that the provider had an effective system in place to identify, assess and manage the quality of the care and the environment. This meant, for example, that the home was clean, tidy and well maintained.

Inspection carried out on 29 September 2011

During an inspection to make sure that the improvements required had been made

There were no specific comments regarding medication from people living at the service.

Inspection carried out on 16 June 2011

During an inspection to make sure that the improvements required had been made

On this follow-up visit we were looking to see if people�s needs were being met by the right numbers of staff with the appropriate skills mix. We had also previously been concerned about the way peoples medication was managed.

People were observed getting the care and attention when they needed it, nobody was seen to have to wait for care. People told us that they receive care when they need it and felt confident that the staff knew what they were doing.

On the adult social care audit in May 2011 all people spoken to were positive about the care they received and staff observed had a good rapport with the residents. Residents told them: �you can have anything you want� �staff are very helpful and will do anything you ask�

A family member commented that they were pleased with the care their relative was receiving whilst on respite and �wants for nothing�.

People we spoke to said they had been involved in drawing up care plans, and a relative spoken to also said that they had been asked about permission to give care, treatment and to administer medication of a person who did not have capacity to make these decisions.

When we spoke to people in the home they said they had a good deal of control and felt able to tell staff how they wanted care delivered and how they wanted to spend their time. They could do this in a variety of ways, they said, on a daily basis, by speaking to the manager or if they wished by going to the residents meetings.

Although the way in which medication is handled has improved we found that there were some inconsistencies in practices and procedures that were still putting people at risk. This meant that some people who use the service did not always receive their medicines in a safe way.

Inspection carried out on 9, 14 December 2010

During an inspection in response to concerns

People told us that they were given the opportunity to look round the home and meet staff and other residents. They were also given a brochure on the home and the Priory Group, who run the home.

However, some relatives told us that they had found communication with the home was not as good as they would have expected. They were not always kept up to date about changes to their relatives care or health, or consulted.

People told us that �The staff are all very nice and look after us well�

�I like it here� �I like to eat in my own room�

�Its always lovely and clean� �The food here is lovely and we have plenty of choice�