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Inspection Summary

Overall summary & rating


Updated 7 November 2019

About the service

The Court is a care home that provides accommodation for up to 17 people who need help with their personal care. At the time of the inspection 14 people lived in the home. Most of the people living in the home lived with dementia.

People's experience of using this service

At the last inspection, the provider was rated good. At this inspection, we identified serious concerns with the delivery of people’s care and the management of the service. This meant the rating for the service has deteriorated to inadequate.

During the inspection, the registered manager did not demonstrate they had sufficient oversight of the service and the support people received. They did not demonstrate they understood their regulatory and legal requirements with regards to the service.

There were no adequate or effective systems in place to monitor the quality and safety of the service. This resulted in people being exposed to ongoing risks. For example, people’s care plans were not sufficiently detailed to ensure people received safe and effective care and records showed they did not always receive appropriate support. Professional advice obtained from other health and social care professionals was not always followed and the management of medication required improvement.

People did not always receive a suitable diet and some people did not eat enough to mitigate the risk of becoming malnourished. Weight monitoring was inconsistent which meant that the registered manager could not be assured people maintained a healthy weight. People told us the food and drink on offer was satisfactory. There were no menus for people to choose from however and people did not always get a choice.

People were not supported to have maximum choice and control of their lives. 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 or the application of the Mental Capacity Act 2005 (MCA).

Staff recruitment was unsafe and did not ensure that only fit and proper persons were employed to work in the home. Staff had not completed sufficient training to do their job role and the competency of some staff members to do their job safely had not been checked for some time.

Accident and incidents were not properly investigated to ensure that staff learned from these events to prevent them from happening again in the future. For example, some people had sustained unexplained bruising but there was no evidence that the cause of this has been investigated.

The home’s environment although pleasantly decorated was not dementia friendly to promote people’s independence. There were some activities on offer but on the days we visited, a significant amount of people’s time was spent sat in the communal lounge with the radio or TV on. We saw that some people routinely walked around the home asking if they could go home or if they were due a visitor.

The number of staff on duty was sufficient to meet people's needs. People told us they felt safe with staff and said staff were kind and caring. Relatives confirmed this.

People told us the staff were nice and it was clear from our observations that people felt comfortable with the staff team supporting them. Staff spoken with, spoke with genuine warmth about the people they cared for and knew how to safeguard people from the risk of abuse.

The atmosphere at the home was warm and homely and the premises was clean and adequately maintained. The registered manager was open and transparent during our inspection and acknowledged that significant improvements needed to be made. They displayed a positive and committed attitude to making those improvements in a timely manner.

Rating at last inspection and update

The last rating for this service was good (published 02 December 2017). At this inspection it has declined to inadequate. The provider has now completed an action plan to sho

Inspection areas



Updated 7 November 2019

The service was not safe.

Details are in our Safe findings below.



Updated 7 November 2019

The service was not effective.

Details are in our Effective findings below.


Requires improvement

Updated 7 November 2019

The service was not always caring.

Details are in our Caring findings below.


Requires improvement

Updated 7 November 2019

The service was not always responsive.

Details are in our Responsive findings below.



Updated 7 November 2019

The service was not well-led

Details are in our Well-Led findings below.