St Michaels Court

St Michael’s Court is a nursing home providing personal and nursing care to up to 86 people. The service provides support to older and younger people, some of whom may be living with dementia, a physical disability or sensory impairment. At the time of our inspection there were 38 people using the service.

The care home accommodates people across three separate floors, each of which has its own facilities, for example, dining room and lounges.

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

Medicines management required improvement. There was poor medicines administration practice seen and poor guidance in the records on how people would like to take their medication.

There was a lack of staff training with staff not receiving all required training. There were also no competency assessments to check staff’s understanding or spot checks to review care delivery.

There were times when the service appeared to be short of staff so the care provided was task-focussed more than person centred. People spoken with acknowledged at times there could be a shortness of staff in the mornings and around meals times, which could mean a wait.

The management oversight of the service needed improving and audits developed to monitor the quality of care and environmental issues to drive improvements.

People had choice about what they would like to eat and had enough. There were concerns people were not consistently being offered sufficient fluids.

Most staff were clear about escalating safeguarding concerns. People felt safe living in the service. They said, “Yes, I’m happy. I do feel safe. It’s because I don’t have to worry about anything.” They were complimentary about the choice of food and its availability.

People said they received their medication on time and there was not a long wait for pain relief. People said staff noticed if they were not feeling well and contacted the GP. They said they had visits from a chiropodist, physiotherapist as well as the hairdresser.

People spoken with said they felt the home was clean and staff wore appropriate personal protective equipment (PPE) when providing care to them and during the pandemic.

The manager was new and responded to our inspection in a positive way and was open about the shortfalls. There had been a lack of reporting of incidents to Safeguarding and CQC. However, since the new manager has been in post this has been addressed and these are now being completed appropriately and in a timely manner.

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

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

Rating at last inspection and update

The last rating for this service was Good (report published on 12 May 2021).

Why we inspected

We received concerns in relation to the management of medicines and care of people who lived in the service, staffing, and environmental safety issues. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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

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

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective 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 St Michael’s Court 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 treatment, staffing support and training and governance at this inspection.

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.

St Michaels Court is a care home providing personal and nursing care to up to 88 people. There were 29 people living at the service at the time of the inspection.

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

People were supported to lead purposeful lives, engaging with their families and the local community. Whilst adjustments had been made due to the restrictions of the COVID-19 pandemic, measures had remained in place to ensure meaningful relationships and people’s overall health and wellbeing was maintained.

People received their medicines as prescribed and were supported to have creams applied to their skin when required.

People received personalised care, tailored to their individual needs and preferences, and staff supported people and their relatives to be involved with decisions relating to their care. People’s privacy and dignity was upheld through the approaches taken by staff as well as in relation to the care environment, as people each had access to their own bedrooms with ensuite bathroom facilities.

The dining experience for people offered a choice of foods, which was well presented and encouraged people to have further helpings or try alternatives if they had changed their mind once the meal had been given to them. Staff supported people to maintain healthy food and fluid intakes, including through the use of snacks, and making people hot drinks during the night to help them relax and maintain their comfort.

Relatives repeatedly told us they felt comfortable speaking with staff, and would raise any concerns if they had them, with the registered manager. Relatives told us they were confident that any concerns or questions were always looked into and answered in a timely way. Relatives confirmed they were kept well informed of any changes in people’s health or wellbeing, and we identified examples of where relatives worked alongside staff to support people’s care needs.

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

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

Rating at last inspection and update

The last rating for this service was Inadequate with breaches of regulations (report published on 12 November 2019). As an outcome of the inspection, the service was placed in Special Measures. We also requested an action plan from the service on how they were going to make improvements.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations. This service has been in Special Measures since the 29 January 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

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.

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

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.

St Michaels Court is a residential care home providing personal and nursing care to 37 people, some of whom may be living with dementia. The service can support up to 86 people. The accommodation comprised a purpose-built property over two floors.

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

Poor leadership, management and governance of the service continued to impact negatively on the provision of care. Systems and processes designed to identify shortfalls and to improve the quality of care were not always effective. While some improvements were noted since the last inspection in May 2019, on-going concerns were raised on this inspection. This is the third time in ten months that this service will be rated inadequate overall.

People were exposed to potentially harmful situations due to poor risk management practices. Some risks to individuals were not assessed, and if they were, measures identified to mitigate these risks were not properly documented or followed. Medicine management was unreliable and had deteriorated, despite recent input and advice from a local support agency.

The staffing arrangements for the service were unstable due to a very heavy reliance on agency staff. Recruitment systems did not operate effectively to ensure staff were recruited safely and new staff were not always properly inducted before starting their first shift. Effective training and support to ensure a good standard of staff competency was lacking.

People did not always receive personalised care. New members of agency staff were sometimes unfamiliar with people’s care needs and staffing pressures meant they were unable to respond to individuals as required. Care records did not promote personalised care delivery due to the fact they contained inconsistent or inaccurate information. End of life care planning continued to be particularly weak.

People were provided with support to ensure they ate and drank enough. Record-keeping and oversight of these areas of care was not always at the required level though and placed people at risk of harm. People were able to access and benefit from appropriate health care support, but effective and timely care was not always guaranteed.

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

There had been an improvement in the provision of group activities and entertainment, and people we spoke with were mostly happy with their care. Staff cared for people with kindness and respect and the premises in which people lived were well suited to their needs.

Rating at last inspection and update

The last rating for this service was Inadequate overall (report published 26 June 2019) and there were multiple breaches of regulation. Prior to this, the service was rated as Inadequate overall (report published 29 January 2019) and in breach of multiple regulations. Since January 2019, we have met with the provider and received monthly action plans, which were reviewed as part of this inspection. At this inspection not enough improvement had been made and the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the very high reliance on agency staff at the home. A decision was made for us to inspect and examine those risks as well as other aspects of care provision.

Enforcement

We identified breaches in relation to safe care and treatment, consent, staffing, recruitment, person-centred care and governance at this inspection.

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

Follow up

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.

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

People’s experience of using this service:

Although there had been some made, further improvements were still needed to ensure people received good quality, safe care at all times.

There had been a high turnover of management staff since our last inspection resulting in a lack of consistent leadership and support for staff.

Improved quality checks had been implemented, but not yet embedded and sustained.

The service was not always safe. Improvements had been made in risk assessments, for example around pressure care, however some risks were still not mitigated fully. Further improvements were required around some areas of medicines records.

There had been some improvements in the availability of staff, but overall there remained a lack of enough staff available to support people.

People had improved access to healthcare professionals, however, recommendations were not always followed and care plans not always updated.

People continued to receive care that was not always individualised and met their preferences. However, there were some improvements in the provision of activities for people to engage in.

Medicines were not always being managed safely at the home.

Staff supported people to maintain their privacy, however at times people felt upset because they had not received support to use the toilet in a timely way.

Improvements had been made in safeguarding people, and management staff were aware of their responsibilities to investigate and report concerns.

There had been improvements in the provision of enough food and drink for people, and this was well-recorded by staff.

People were more involved in their care, as well as families, where appropriate.

Improved recording around people’s mental capacity meant it was clear what decisions had been made in people’s best interests.

Staff worked well as a team and felt more supported by the management team.

This service is rated Inadequate overall, and therefore 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.

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.

Rating at last inspection: The previous inspection took place on 12 December 2018, rated as Inadequate overall, and in all key questions. The report was published 29 January 2019. The service was in breach of Regulations 9, 10, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Registration Regulations 2009. We met with the provider following this inspection and requested an improvement plan. They kept us updated regularly of their progress on this plan. Improvement plans were reviewed as part of this inspection.

Why we inspected: Services placed in special measures are inspected within six months of the publication date of the report to determine if sufficient levels of improvement have been made. However, we received further complaints and concerns about the service and carried out an urgent inspection.

Follow up: We will continue to monitor the service according to our schedule for returning to locations rated Inadequate.

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

St Michaels Court is a care home with nursing for up to 86 people, some of whom may be living with dementia. 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 is a modern building over three floors. At the time of our inspection there were 71 people living within the home.

There was not a registered manager in post at the time of this 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. There was a manager in post who told us they had been there for two months, however this manager was no longer in post on the second day of our inspection visit.

Our last comprehensive inspection was carried out in August 2017, and we found that the service was rated as ‘Good’ overall.At this inspection we found that the service had deteriorated with widespread serious concerns and was rated ‘Inadequate’ in all areas. There were also seven breaches of regulations of the Health and Social Care Act 2008, and one breach of CQC Registration Regulations 2009.

The service was not safe. People were not adequately safeguarded from the risk of abuse and staff did not have thorough knowledge of safeguarding procedures. The provider had not ensured that safeguarding incidents had been investigated or reported to the appropriate authorities.

Risks were not adequately recognised, assessed and mitigated. This included risks associated with the development of pressure ulcers and people’s health such as choking or drinking enough, or their health conditions. People’s environment was not always kept safe as they did not always have safe equipment to use.

Topical medicines such as creams for skin care were not administered or recorded as prescribed and some were out of date. Some bottled items were not dated and in one areas of the home, stocks of oral tablets did not add up correctly which meant that people may not have received their medicines correctly. Protocols for some medicines required further clarification for staff around how and when to administer them.

There were not always good infection control practices in place, and some areas of the home and items of equipment that people used were unclean.

There were not enough staff to keep people safe and meet their needs. As a result, people were left unattended and uncomfortable for long periods of time. Staff were not available in communal areas so people could not get assistance when needed.

People were not always supported to drink enough and drinks were not always available to people. There was not always a good choice of food and drinks each day, but some options were not always available to people as the home often ran out of certain foods and drinks.

People were not supported to maintain their wellbeing through the involvement of relevant healthcare professionals and other agencies in a timely manner.

Staff did not always gain consent from people before delivering support and people’s privacy and dignity was not always upheld. There were times when staff supported people to maintain their independence, but not always.

People did not have access to opportunities to follow their hobbies or interests regularly, or engage in occupation or activity.

People and their families were not consulted or involved in the planning of their care. Staff did not always deliver care according to people’s own needs and preferences, and did not always know people’s needs well.

There were meetings for people and relatives, however people did not proactively get asked for their feedback on the service. There was not a plan for improvement in place and the service did not learn from incidents and accidents, to further improve the care provided.

Staff did not feel supported and concerns they had raised about the quality and safety of care provided had not been taken seriously. There was poor leadership in place and not everybody was fully aware of their responsibilities.

Governance systems were not adequate to identify and improve areas where concerns were found.

People’s mental capacity to take particular decisions had been assessed, but there were not always records of people involved in conversations around making best interests’ decisions for people.

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

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.

Our previous inspection in July 2016 identified breaches of three regulations. These regulations related to the provision of person-centred care, safe care and treatment and the governance of the service. This June 2017 inspection found that improvements had been made in all three areas and the provider was no longer in breach of any regulations. The July 2016 inspection had resulted in ratings of ‘requires improvement’ across all areas. This June 2017 inspection resulted in a rating of ‘good’ across all areas.

St Michaels Court provides accommodation for up to 86 people who require nursing and/or personal care. Some people may also be living with dementia. At the time of this inspection 75 people were living in the home.

A registered manager was in post. They were registered as the manager for two of the provider’s homes, with the second home they managed being approximately ten miles away. 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 felt safe living in the home and were cared for by staff that treated them with kindness and compassion. There were enough staff to meet people’s needs, but some people commented that staff did not always have time to chat with them. Recruitment procedures were thorough and people’s medicines were safely managed and administered to them.

Mental capacity assessments had been carried out appropriately. People and those acting on their behalf were involved in discussions and decision making about the care and support received. People were supported to have as much independence as possible. There was good access to health professionals when required.

People enjoyed the food and were offered choices. Staff were well trained and supported by the management team to undertake their roles.

The home was well managed which helped ensure people’s safety and welfare. There were systems in place to receive people’s views and to monitor the quality of the service that people received.

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

We found three 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 this report.

The management of medicines was not consistently safe. People did not always receive their medicines as the prescriber intended. The service had failed to maintain accurate and full records in relation to medicines administration.

People received enough to eat and drink and told us the food was good. People’s nutritional needs were met, although at times they were not positioned in a way that was ideal for eating. People’s hydration needs were not always met, as people were not always supported to drink.

Systems were in place, including staff training, to protect people from the risk of abuse. There were risk assessments that staff followed to help mitigate risks to individuals and their environment.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Although staff did not always have a good understanding of these areas, we found that assessments for people’s mental capacity were thorough and least restrictive methods were used in people’s best interests if they were to be deprived of their liberty.

People’s social needs and personal preferences were not consistently met. There was little time for meaningful interaction with staff and very little provision of activities.

People told us staff were kind and caring. However, there were several occasions during our inspection where people were distressed and staff did not provide timely reassurance and comfort. We saw that staff did not always interact with understanding of people living with dementia. At times staff interactions were purely task-led.

People’s health needs had been identified, assessed and reviewed on a regular basis. Their care plans were individual to them and accurate, however lacked details of people’s personal interests and history. Staff did not always adhere to care plans.

There were some effective systems for monitoring and improving the service in place, and the registered manager had taken appropriate action in response to any complaints.

There were several areas where audits or observations had not picked up issues with regard to person-centred care and staff competency.

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

During this inspection we spoke with the home's acting manager, three other staff members, three people who lived in St Michaels Court and relatives of two further people. We reviewed six people's care records and other records relating to the management of the service.

This inspection was undertaken to establish whether we could substantiate the concerns raised with us. We reviewed the evidence we had obtained during this inspection and used it to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

We had received information about a medication error that had occurred. During this inspection we identified the incident concerned had taken place in June 2014. We were satisfied that the service had dealt with this appropriately.

We were also able to establish that all staff administering medication had undertaken training and recent competency testing to ensure that they were safe to administer medication to people.

We discussed the potential implications to the service of the recent Supreme Court judgement relating to the Deprivation of Liberty Safeguards (DoLS) with the acting manager. These safeguards form part of the Mental Capacity Act 2005 and make sure that people are looked after in a way that does not inappropriately restrict their freedom. The acting manager was aware of this recent judgement and had sought advice from the local authority on making applications. The local authority had asked them to prioritise applications in the first instance. The acting manager had identified applications in respect of two individuals that were being made.

Is the service effective?

Staff told us that staffing provision was usually adequate to ensure people's needs were met. The service had utilised agency staff more than usual in recent weeks to help cover holiday absence. Most people we spoke with felt that staff numbers were sufficient. One relative told us, 'Staff are a bit more pushed sometimes at weekends, but it's usually fine.'

Is the service caring?

We found that people were treated with respect and consideration by staff. We had received information suggesting that people living with dementia were gotten out of bed at 5:30 a.m. We found that this was not the case on the day of our inspection. We were unable to substantiate this concern that had been raised with us.

Is the service responsive?

We saw that in relation to the complaint we had received, the service had acted promptly to invite the person's family to a meeting so that their views and concerns could be heard. This demonstrated that the service acted promptly when concerns were raised.

Is the service well led?

As a result of the complaint the acting manager was taking steps to improve the admissions process for people moving in to St Michaels Court. This showed that the service learnt from people's complaints and used this information to improve the service people received. This was an indication that the home was well led.

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

The service had made substantial improvements which ensured people were safe from the risk of ingesting harmful substances. People were cared for in accordance with their care plans and systems were in place to ensure this continued.

We found the home to be clean which meant that the risks of infection were minimised. People told us the home was always as clean as we found it to be during our inspection. One person told us, 'They're always cleaning here. See how nice my room is.'

We spoke with the service manager about the Deprivation of Liberty Safeguards (DoLS). They told us they had been in contact with the local authority to enquire whether an application would be appropriate in respect of one person. This demonstrated to us that where there were concerns that the appropriate action would be taken.

Is the service effective?

People we spoke with told us they were happy living in St Michaels Court and they had everything they needed. Staff explained how they communicated with people who were unable to communicate verbally and described how they supported people living with dementia. They were able to tell us about individual's preferences, health requirements, what things worried people and how they alleviated their concerns.

Is the service caring?

People we spoke with were clear that staff treated them or their family members with care and consideration. One person told us that their family member had '.always been treated with great respect.' We found that people were relaxed in the company of staff and noted that staff took time to speak with people's visitors. One person told us, 'It means so much to me that staff here say hello and chat with my family when they come in. It's so nice.'

Is the service responsive?

The service was organised to ensure people's needs were met. People's needs were assessed and reviewed on a monthly basis. Where they changed we found that the service responded promptly and sought appropriate advice from health professionals when necessary. People had requested access to a wider range of denominational services and this had been organised. Information was available in several areas of the home about this. Upcoming meetings were widely publicised throughout the home. We were told that attendance at these meetings was increasing.

Is the service well led?

People we spoke with were keen to tell us how much the service had improved in recent months. We heard nothing but praise for the service managers from people living in the home, their relatives and staff. Staff we spoke with told us that they were proud to work at St Michaels Court.

The service managers carried out regular checks to make sure that people's care and welfare was assured and carried out correctly. Where areas for improvements were identified action was taken and the effectiveness of any action reviewed.

We found that relatives were now invited to a three month review of care records, where their views were documented. People using the service and their relatives were also invited to residents' meetings, where they were able to express their views.

We found that people using the service had an assessment of their needs, detailed care planning and had risk assessments in place to protect them from harm. All of these documents had been updated within the three months prior to inspection to ensure the information was current. A relative we spoke with told us, "Things have improved a lot".

We found that there were now enough suitably qualified and experienced staff on shift to meet everyone's needs. Staff had more time to engage with people and take part in activities. A relative we spoke with told us, "The activities are much better". Another relative told us, "The staff provide a good standard of care".

We found that the service had failed to improve the effectiveness of their audits, and as a result, issues with service provision were not identified.

We found that the service was now investigating complaints effectively and that care records were now written in legible writing and kept securely.

We found that the service had made improvements with care planning; however, some people were still not receiving care and treatment in line with their individual plan. A relative told us, "It has got better, but there is still a way to go".

We found that significant improvements had been made at meal times. People were encouraged to make choices about food, drink and where they would like to eat their meal. However, one relative told us "Breakfast is not always served on time; sometimes you wait until eleven am before it arrives".

We found that the service did not have an adequate system of audit in place to identify issues in quality and the delivery of care. Complaints were not always investigated in line with policy and one relative told us, "I never received an outcome of my complaint."

We found that the service had failed to make improvements with involving people in care planning, and maintaining people's privacy and dignity. We spoke with the relatives of four people using the service. One relative told us, "My mother went to hospital, the hospital said she was dirty". One other relative told us, "Her clothes keep going missing and I’ve found her dressed in another person’s clothes". Another relative told us, "She wants a bath but staff said they don't have time. She hasn't had one in a year".

We found that the service had failed to make sufficient improvements with regard to nutrition and hydration. People were still not given sufficient choice at meal times and people's needs at meal times were not always met.

We found that the service had made sufficient improvements with regard to staffing, having put in place two extra members of care staff so they could better meet the needs of people living in the home.

We found that the service had not made the improvements necessary with regard to record keeping. The service was still not maintaining care records for people that were accurate, fit for purpose and kept securely.

We found inconsistencies in care planning, needs assessments and risk planning which could lead to confusion for staff using people’s records to help them understand individual care requirements. This could result in inappropriate care or treatment being delivered to the individual, which would put them at risk.

We identified major concerns about the way in which the service was managing the pressure care of people using the service. We found that the service was not always putting in place preventative measures to lessen the risk of a person developing a pressure sore. We also found that people's pressure needs were not being cared for in line with what was specified in their care plan.

We spoke with three relatives of people using the service and one person using the service. One relative told us, "There's no continuity of care, staff don't know people well enough to look after them properly". A person using the service told us, "I don't really get cared for as such, I'm left to care for myself really, and struggle". Another relative told us, "I've had to change dressings on my mum’s pressure wounds because they've been dirty. There's no record of when they were last changed".

People told us that the dignity and respect of their relatives was not being maintained. One person told us, "On occasions we have found him dressed in dirty clothing". One other person told us, "I found my dad dressed in someone else's clothes that were too small for him".

We found that care planning was basic and the service was not protecting people from harm through the assessment and planning of care. People told us that they were receiving poor care. Two visiting health professionals told us they felt people were not being well looked after.

We found that people were not being properly supported to make choices about nutrition and hydration. People told us that the food was not of good quality and that menu's were repetitive. People did not have a choice of where they would like to dine.

We found there were not enough staff to meet the needs of people living in the home. Four staff members we spoke with felt that the service was consistently understaffed, as did two visiting health professionals. People living in the home felt there needed to be more staff.

We found that care records were at times incomplete, inaccurate or missing. There was not sufficient information held about people so that staff could sufficiently meet their needs.

We looked at care plans for people specifically those living with dementia situated on the first floor of the building. We selected at random some care plans to check the service had completed assessments of people who lacked capacity and check that appropriate risk assessments had been put in place specifically regarding nutritional needs.

We checked whether improvements to reduce the noise level of the call bell had been put in place and whether regular quality audits had been carried out. We spoke with the manager who provided us with the majority of the information.