Archived: Swiss Cottage Care Home

Swiss Cottage is a residential care home providing personal and nursing care to up to 85 people. The service provides support to older people, some of whom are living with dementia. The home consists of 4 units, of which 2 were used. At the time of our inspection there were 30 people using the service.

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

People were not always protected from abuse and improper treatment. People did not always receive safe care as individual and environmental risks were not always well managed. Learning could not always occur from incidents and accidents or when people experienced emotional distress due to a lack of reporting. There were shortfalls in infection prevention and control. Topical medicines and thickening agents were not always safely managed. There were enough staff deployed, however they did not always work effectively to meet people's needs. Relatives felt staffing levels had improved. People were able to receive visitors without restriction.

People were not supported to have maximum choice and control of their lives, and staff did not support them in the least restrictive way possible and in their best interests. Although, the policies and systems in the service supported this practice, they were not always operated effectively.

People did not always have their health needs met or well monitored and were at greater risk of weight loss due to unmet nutrition needs. Food was not always appetising, and people were not always offered choice and variety in what they ate. Staff had received training and supervision, but this had not resulted in safe practices.

People were not always treated with dignity and respect. For example, personal information was displayed on people's walls, which informed passers-by of confidential information about their needs. People's gender preferences about who supported them with personal care were not always upheld.

Records showed people's hygiene preferences were not maintained. Care plans did not always contain person-centred information about people’s past histories and preferences. People did not receive regular support to take part in meaningful activities.

Systems and processes continued to be ineffective and did not ensure people received a quality service. The provider did not always follow their own policies relating to areas such as infection prevention and control, falls management and safeguarding. There was not an effective system to review and ensure care plans were accurate. The provider had not submitted all required notifications to CQC. However, relatives were kept up to date. People, relatives and staff felt the registered manager was approachable.

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 22 February 2023). The provider completed an action plan and we had continued to impose conditions on their registration at this location. At this inspection we found the provider remained in breach of regulations. This service has been in Special Measures since 11 September 2021.

Why we inspected

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

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.

Enforcement

We have found breaches in relation to people’s safety, safeguarding, person-centred care, dignity and respect, nutrition, handling complaints and good governance.

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 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 of 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.

Swiss Cottage is a care home providing personal and nursing care up to 85 people. The service provides support to adults with long term conditions, most people were living with some form of dementia. At the time of our inspection there were 41 people living at the home. The home was split over three floors, but the provider had recently closed the first floor.

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

We found people were still not safe at the home. For example, people who had specialist diets and who were at risk of choking. Whilst the managers acted when we raised these concerns, they required us to direct them as to what action they should take. We later had assurances of the work they had completed to reduce these risks, but we found there was still further work to be completed to make people safe.

The provider and managers auditing systems were not present or effective at meaningfully assessing the standard of care at the home and identifying if action was needed to be taken to make improvements. There were continued issues around the care of people who had poor skin integrity, effective care planning and providing a meaningful social experience.

The cleaning regime and maintenance at the home was not effective, with stained flooring and equipment, some rooms were tired in appearance and some communal spaces were cold. Staff were not following correct procedures for the safe disposal of their personal protective gloves.

Staff were not always respectful of people’s bedrooms and their privacy. Some people still felt bored and some said the planned social events did not interest them. Other people spoke positively of the social events, which was an improvement from previous inspections.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People spoke well of the food and drinks, but the dining experience was limited and those who needed support to eat were not always supported well at these times.

There was positive feedback received about end of life care at the home, but further work was needed in the planning and recording of this care for individuals.

Relatives and people felt safe at the home. One person told us, “Yes I do feel safe.” A relative said, “At the moment I think that [name of relative] is safe because they [care staff] are all keen and are always being proactive, they [staff] always phone us up if there are any issues.” Another relative told us since their relative moved to the home their health has significantly improved, they said, "I now have my [name of relative] back."

Relatives spoke well of the managers and staff at the home. They had worked hard to make improvements to people’s experience of care, but we had not seen significant, sustained and embedded improvements.

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 27 May 2022). The provider completed an action plan and we had continued to impose conditions on their registration at this location. At this inspection we found the provider remained in breach of regulations. This service has been in Special Measures since 11 September 2021.

Why we inspected

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

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.

Enforcement and Recommendations

We have identified breaches in relation to promoting people’s safety, how person centred the care experience was, restrictive practices to people's freedoms, and how effective the leadership was at this time.

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 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.

Swiss Cottage is a care home providing personal and nursing care to 49 people. The home is divided into three areas and set in woodlands. Most people who were living at Swiss Cottage were living with some form of dementia. The service can support up to 85 people.

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

People spoke well of the care staff. They said they found them caring and kind. One person said, “It does feel a bit like family here in some ways.” Another person said, “There are some nice girls here, they are all very good and I feel safe with them.” One person’s relative said, “They (staff) do genuinely care for (relative) here, it has improved recently.” Another also said, “I think they (management) needed that kick up the bum from last time, they (staff) have been top banana.”

Since the last inspection we found improvements had been made, in relation to managing people’s specialist food needs, skin and pressure care, and responding to those people who may have left the home in an unsafe way. Staff said communication had improved. Most staff were motivated to want to improve people’s experiences of living at the home, to give them enjoyment and pleasure whilst living at the home.

Despite this we found there were still issues with the home. The provider and management team had not created a person-centred culture at the home. Staff were willing to spend time with people and help them to have a social life, but they did not have the time to do this. People told us they were bored, and staff told us people were not interested in the traditional “activities” such as bingo. Some staff had shown independent initiatives to change this, but this was not across the whole home, nor was it led by the managers and provider.

We also found this person-centred aspect of care was missing with food and drinks. Some people did find the food ok, but most did not like the choices. Assessments had not been completed to ensure people were getting their favourite foods and drinks. We were told there were now drinks and snacks available at night, but the provider was not checking this.

Relatives had been complimentary of the care their loved ones had received when they were at the end of their life. Although we did find shortfalls with the planning of end of life care.

Protecting people from potential harm and abuse had improved. But there were still shortfalls in the management systems to respond to bruising and injuries sustained in the hospital or the home. Investigations were not always completed when they should have been. When some people’s needs were changing, we were not confident action was being taken to reduce these risks. Actions were taken when something happened, but there was also no consideration or investigation to consider if these events could have been prevented.

The management and provider’s audits were not effective at identifying the shortfalls and issues we found. The audits completed to test the quality of the service did not always evidence what the person doing the audits, had done. Nor had they taken the opportunity to test aspects of the care provided when something happened. There was still not a culture of embracing lessons learnt and sharing these with the staff.

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

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

Rating at last inspection and update: The last rating for this service was inadequate (published 24 May 2021). 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.

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

Why we inspected

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

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.

You can read the report from our last inspection, by selecting the ‘all reports’ link for Swiss Cottage 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 safe care and always protecting people from harm, not providing person-centred care and how well led the home was.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Swiss Cottage is a care home providing personal and nursing care to 73 people. Most people were living with some form of dementia, some were receiving end of life care. The service can support up to 85 people.

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

One person’s relative said, “I don’t feel [my family member] is safe.” Another person’s relative told us the same. One member of staff said, “We are pushed to the limit, everyone has their breaking point.” We asked one person if there was enough to do to keep them happy and fulfilled. “No, staff are mostly nice, but they don’t have time.”

People’s safety was not being protected and promoted. Two people living with advanced dementia had left the home when it was not safe for them to so and had gone missing. There were failures in the security of the building and processes in place to alert staff and those in charge this had happened. Staff were not updated, and lessons were not always learnt when this and other incidents had happened before.

When people had potentially experienced harm, robust measures were not followed to promote their safety and rights. Safeguarding alerts and referrals to the local authority were not raised when they should have been. People’s property in the home often went missing. Systems were not effective in securing people’s property.

Staff told us there was not enough staff to always meet people’s care needs. Most falls were unwitnessed by staff. Staff did not respond when fire exit alarms were sounded. Staff did not spend time with people to talk, give them comfort, and promote their mental and emotional well-being. Internally arranged events to promote people’s interests, were not taking place at the home. The environment was not homely or comforting. One relative said, “The home is very clinical, it looks a bit tired.”

There was ineffective leadership at the home. Staff did not feel listened too. When they raised issues with the manager, they said nothing changed. The manager of the home and provider were not effectively testing the quality of the care provided. The manager and provider were not looking at people’s experiences to see if improvements were needed. The manager and provider no longer saw the clear shortfalls in people’s care in terms of promoting people’s safety and seeing what people’s daily lives were really like.

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 good (published on 26 January 2018).

Why we inspected

We received concerns in relation to staffing levels, medicines, people not receiving personal care, staff not responding to a possible head injury, and clothes going missing. As a result, we undertook a focused inspection to review the key questions of safe, responsive 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 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 inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe, responsive and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Swiss Cottage 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care, staffing, person centred care, and the leadership 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.

Following our previous comprehensive inspection in February 2017, we gave this location an overall rating of ‘Inadequate’ and was therefore placed into ‘special measures’. We carried out a focused inspection in May 2017 to check they had met legal requirements. We found a number of breaches continued.

At that inspection we found that people’s risk assessments were in place for each person. We found that some work had been completed but was yet to be audited and signed off by the manager. The risk assessments we reviewed as part of this inspection showed some improvements in the details contained within the documents but work was still required in this area to ensure every person had current, detailed assessments in place to reduce the risk of them coming to harm. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that medicines were not managed safely. On the residential unit, we found stock carried over from one month to the next was not always recorded. This made it difficult to maintain an accurate record of overall stock of individual medicines for each person. While boxed and liquid medicines were dated to show the date they were opened, this was not the case for inhalers. The records for one person who was prescribed a specific medicine did not include any details of the correct procedure to ensure this medicine was administered safely and as prescribed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People had not been involved in the development of their care plans. They did not accurately reflect people’s current needs and lacked personalisation. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Activities provision was poor and did not support people to maintain their interests and hobbies. People cared for in their bedrooms were isolated, with little to do other than watching television. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.

The service did not provide appropriate food to people with specific dietary needs and support offered to people at meal times was poor and not in line with their care plans. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We identified a significant lack of training and supervision for staff. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Although the ratio of staff to people had increased, the deployment of staff was not meeting the needs of people using the service. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that, although improvements had been made in some areas, continuing breaches were identified in relation to medicines management, staffing, the way in which people's food and hydration needs were met and in the provision of a person centred service. We saw that the provider had plans in place to further improve the service and was monitoring this work to ensure it was completed to a good standard and in a timely manner. However, this work was not completed

at the time of the inspection. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.

You can read the report from this comprehensive inspection by selecting the 'all reports' link for Swiss Cottage on our website at www.cqc.org.uk.

We carried out this unannounced comprehensive inspection on 30 and 31 October 2017, to see if the provider had made the necessary improvements to meet these breaches of regulations.

This service has been in 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. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

There was a registered manager in post.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People using the service felt safe. Staff had received training to enable them to recognise signs and symptoms of abuse and felt confident in how to report them.

People had risk assessments in place to enable them to be as independent as they could be in a safe manner. Staff knew how to manage risks to promote people’s safety, and balanced these against people’s rights to take risks and remain independent.

There were sufficient staff, with the correct skill mix, on duty to support people with their needs. Effective recruitment processes were in place and followed by the service. Staff were not offered employment until satisfactory checks had been completed.

Medicines were managed safely. The processes in place ensured that the administration and handling of medicines was suitable for the people who used the service.

Staff received an induction process and on-going training. They had attended a variety of training to ensure they were able to provide care based on current practice when supporting people. They were supported with regular supervisions and appraisals.

People were supported to make decisions about all aspects of their life; this was underpinned by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Staff were knowledgeable of this guidance and correct processes were in place to protect people. Staff gained consent before supporting people.

People were able to make choices about the food and drink they had, and staff gave support when required to enable people to access a balanced diet. There was access to drinks and snacks throughout the day.

People were supported to access a variety of health professionals when required, including opticians and doctors, to make sure they received continuing healthcare to meet their needs.

Staff provided care and support in a caring and meaningful way. They knew the people who used the service well. People and relatives, where appropriate, were involved in the planning of their care and support. Care plans reflected people’s assessed needs.

People’s privacy and dignity was maintained at all times.

People were supported to follow their interests and join in activities if they chose to.

People knew how to complain. There was a complaints procedure was in place and accessible to all. Complaints had been responded to appropriately.

Quality monitoring systems were in place. A variety of audits were carried out and used to drive improvement.

We undertook this unannounced focused inspection on 12 May 2017 to check they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Swiss Cottage Care Home on our website at www.cqc.org.uk.

The service is a nursing home and provides accommodation and personal or nursing care for up to 84 people with a range of needs including those associated with dementia and with life limiting health conditions. At the time of our inspection there were 47 people living at the home. The service consists of three units ; one supporting people with non- nursing needs, one for people with nursing needs associated with dementia and a third for people with nursing needs related to other primary health conditions.

The service did not have a registered manager. The previous registered manager had left the service in October 2016. A manager had been appointed a few weeks prior to the inspection in February 2017, but left the service shortly after the inspection before becoming registered. At this inspection we found a new manager had been in post for five days and had started the process of applying to become the 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.

Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, but these were not always sufficiently detailed. Medicines were not managed safely in the residential unit because carried forward stock was not always recorded and some medicines were not dated to indicate when they had been opened. Some medicine protocols were not completed fully.

Staff were not deployed effectively to provide for people’s needs. People reported that some staff did not meet their needs effectively. A programme of training for staff was in the process of being implemented to address the shortfall in staff skills and knowledge.

A service wide review of care plans was underway, although new care plans had not been implemented yet. People and their families did not feel involved in the planning or review of their care. However, some care plans looked at showed more personalised information than at the previous comprehensive inspection. The requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met.

Activities were provided although these did not meet the needs of some people we spoke with. People and relatives felt there were not enough activities provided and some people felt bored. People were supported to have enough to eat and drink but people with specific dietary requirements did not have their needs met effectively. Support at mealtimes was varied across units with some people having a better mealtime experience than others.

The provider had systems in place to monitor the quality of the service which identified areas for improvement and suggested remedial actions to be taken. Staff were able to contribute to the development of the service through team meetings and understood the visions and values of the service. People and their relatives had opportunities to share their views and make suggestions about how the service could be improved.

During this inspection we identified that there were breaches of a number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The service remains 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.

At the time of our inspection the service provided accommodation for 65 people who need nursing or personal care.

The service did not have a registered manager in post. The previous registered manager had left the service in October 2016, although they had not cancelled their registration. A new manager had been appointed and was in the process of applying to become the 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 home had not been cleaned to an acceptable standard to prevent the risk of infection or provide an environment free from unpleasant odours. Procedures intended to reduce the risk of an acquired infection were not always followed by staff.

People did not always receive their medicines as they had been prescribed and medicines administration records were not always correctly completed. Staff did not always ensure that medicines had been taken when they were signed off as having been administered. Stocks of medicines held did not always correspond with the amount recorded. Protocols in place for medicines administration were inadequate.

There were insufficient staff to respond to people’s needs in a timely way. Staff had not received appropriate training to identify and support people’s needs. Staff performance was not routinely reviewed.

Personalised risk assessments were in place but these were often confusing, contradictory and not updated as people’s physical and mental health needs and the associated risks changed. Care plans were not person centred and people were not involved in the review of these. Documentation was often inaccurate, undated and very difficult to read.

People’s privacy and dignity was not protected. Doors to people’s rooms were routinely left open and people in their beds were exposed to the view of visitors passing their room. People were not always dressed appropriately when they were in communal areas. People had mixed opinions as to the caring attitude of the staff that cared for them.

People also had mixed opinions about the food provided, which did not meet everybody’s nutritional requirements. People were not always supported appropriately to eat their food. People were also not supported to maintain their interests and hobbies. People cared for in bed were isolated and lonely.

The quality assurance system was ineffective. The provider had failed to ensure that appropriate action had been taken to address the breaches in regulations that had been identified during the inspection in August 2016 or to identify further areas for improvement.

During this inspection we identified that there were breaches of a number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

The home provides accommodation, support and treatment for up to 84 people who require nursing and personal care; some of whom may be living with dementia. At the start of our inspection there were 62 people living at the home but this had increased to 65 during the latter part of our inspection. People lived in three units at the home, dependant on their care needs. The first was a residential unit for people who required personal care in which 20 people lived. The second was a unit for people who required nursing care and the third unit accommodated people who required nursing care but were also living with a dementia.

The home had a registered manager in place at the start of our inspection but they left the service after the initial two days of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Following the registered manager’s departure management of the home was overseen by the provider’s Home Support Manager and their Regional Operations Manager. In their absence the home was managed by the recently appointed Agency and Recruitment Co-Ordinator, who had worked at the home for a number of years previously as the deputy manager. They had left the post in February 2016.

People told us that they felt safe at the home because there were people around. However, there were insufficient trained, experienced staff to always provide the care and support people needed at the time they required it. As a result people had to wait for assistance to be provided, be this with personal care or assistance to eat their meals. There were discrepancies with the stocks of medicines held and we were not assured that people had received their medicines as they had been prescribed.

People’s needs had been assessed prior to their admission but there were not always care plans in place to show how all the identified needs were to be addressed. Where they were in place, care plans did not always give staff sufficient information to ensure that the planned care addressed the identified needs of the individual. Similarly the assessments of risks identified as arising from people’s care and treatment had not always been completed. People were not always supported to maintain their interests and hobbies and people who were living with severe dementia were unable to participate in the activities arranged. People who were nursed in their rooms were at high risk of experiencing social isolation.

There was no evidence that people had consented to the care provided or, where they lacked capacity to make or understand decisions, that those made on their behalf had been in accordance with the requirements of the Mental Capacity Act 2005 (MCA).

The recruitment procedures in place gave the provider assurance that the staff recruited were suitable for the posts they applied for. Staff were provided with appropriate induction and on-going training. They were supported by regular supervision and appraisal meetings at which they were able to discuss their performance and training needs. They were encouraged to make suggestions for improvements to the service.

People found the staff to be caring and kind. Staff promoted their dignity and independence and treated them with respect. People and their relatives were aware of the complaints system and complaints had been dealt with in accordance with the provider’s policy.

Although there was an apparently robust quality monitoring system in place this had not always been effective. Records were not always accurate or complete.

During this inspection we identified that there were a significant number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.