Langford Park

Langford Park is a 'care home' registered to provide accommodation, nursing and personal care support for up to 35 older people; people living with dementia; and younger people with a physical disability. At the time of this inspection there were 31 people living there, supported over 3 floors. Langford Park is set in rural parkland close to the city of Exeter.

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

There had been 3 unsuccessful managerial appointments in 3 years. The service was being managed by the provider, supported by the clinical lead and quality assurance lead, pending the recruitment of a new manager. The management team had continued to develop and embed the systems and processes introduced by the previous manager. This was largely confirmed in feedback received from people, relatives and the staff team. One member of staff commented, “Langford have made lots of changes and there is more support from the management team and the nurses. I think we are at a very good place and all working together as a team better.”

The management team promoted a culture of openness and honesty. They were open and transparent during the inspection. They demonstrated their commitment to reflecting and learning when things went wrong and sharing this knowledge with staff to improve the quality and safety of the service. The majority of staff told us they felt well supported both personally and professionally. They were passionate about their role.

There was a robust and effective quality assurance programme in place. This meant the provider had already identified the majority of issues we found at the inspection and was taking action to address them. Where issues had not previously been identified, the provider took immediate action in response to our feedback.

We found improvements were needed to care plans to guide staff in the cleaning of equipment and recognising signs of infection. The management team acted immediately, and this information had been added to care plans before the end of the inspection. Overall, we found the management of risk had improved, with better recording and well trained and competent staff. The staff team worked in partnership with external health and social care professionals to support people. A robust pre-admission process was in place to ensure any new placements were safe and well planned, after issues had arisen following the admission of people with very complex needs.

People felt safe living at Langford Park and there were enough staff to meet their needs. The provider took action during the inspection to stagger staff breaks, to ensure communal areas were adequately staffed at all times. Last minute sickness had been a challenge, but this had been addressed by the management team and improved over recent weeks. Staff were recruited safely, and safeguarding processes were in place to help protect people from abuse. One person said, “It’s okay, they are all nice. They make sure you are clean, make sure you are comfortable.”

There were systems in place to ensure the safe administration of medicines, although some improvements were needed in relation to the recording of topical medicines administration; the storage of oxygen cylinders and protocols for the use of ‘as required’ medicines. Immediate action was taken to address these issues.

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

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

Rating at last inspection and update

The last rating for this service was requires improvement (published) 25 May 2022.

Why we inspected

This inspection was prompted in part due to concerns received about the management of risk, and staffing. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well led sections of this full report.

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

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

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

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

Follow up

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

Langford Park is a 'care home' registered to provide accommodation, nursing and personal care support for

up to 35 older people; people living with dementia; a learning disability and younger people with a physical disability. At the time of this inspection there were 23 people living there.

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

Since the last inspection the provider had been working to improve the quality and safety of the service. They had commissioned an external consultant and continued to work with the local authority quality assurance and improvement team. Failings in the service had been identified and the provider had been working to address them. However, progress had been hampered by two unsuccessful managerial appointments in two years and the impact of the Covid 19 pandemic. A new momentum had been created by the new manager, who was in the process of introducing new systems and processes, and a clearer structure with more effective monitoring and accountability. However, these changes had yet to be fully established and embedded. The manager told us, "I feel the home is safe and well led now. It wasn't three weeks ago, but we are getting the systems and processes in place."

Improvements had been made to the management of risk; but further improvements were needed. There were gaps in recording related to the repositioning of people at risk of skin breakdown, nutrition and hydration and the safety of bed rails. Not all staff had completed their mandatory training, which meant their knowledge and skills were not up to date. The manager was aware of these issues and was addressing them. They had also identified that risks related to the environment had not been managed since the last inspection, including the maintenance of equipment and emergency plans. Measures were now in place to minimise these risks, with systems to monitor them regularly.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, further consideration was needed related to the use of images on social media for people without capacity to consent.

People told us they felt safe living at the service. One person said, “I love Langford Park. I like the company. Its more than safe.” Staff knew people well and had a good understanding of their needs and risks. People told us they were kind and caring. They felt respected and included in decisions. Risks associated with people's care had been assessed and guidance was in place for staff to follow. Care plans were detailed, person centred and reviewed regularly. People had been referred appropriately for support from external health care professionals. There were improved systems in place to ensure information about any changes in people's needs was shared promptly across the staff team. A member of staff told us, “There is good information sharing. It feels more structured. You know what you are dealing with.”

People received their medicines safely, and in the way prescribed for them. The provider had systems to manage safeguarding concerns, accidents and infection control.

Overall relatives were extremely positive about their communication with the home in relation to their family member. They told us they had contributed to their care plan and been kept informed about their well-being. They valued being able to access the ‘relatives gateway’ on the computerised care planning system, and view the support being given to their family member in real time.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of Safe and Well Led the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

•Model of care and setting maximises people’s choice, control and independence

Right care:

•Care is person-centred and promotes people’s dignity, privacy and human rights

Right culture:

•Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives

The service’s vision and values centred around the people they supported. The organisation’s statement of purpose documented a philosophy of maximising people’s life choices, encouraging independence and people having a sense of worth and value. Our inspection found that people were encouraged to lead rich and meaningful lives in line with their individual preferences and interests. This location may not be ideal for some people who would want to access the local community independently. However, people’s independence and participation within the local community was encouraged and supported. The manager recognised that accessible communication and staff knowledge of people with a learning disability could be improved, and made a commitment to do so.

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

Rating at last inspection and update: The last rating for this service was requires improvement (published 07 September 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted in part due to concerns received about the management of risk; staffing levels; support with personal care and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from these concerns.

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 not changed from requires improvement based on the findings of this 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 comprehensive inspection, by selecting the ‘all reports’ link for Langford Park on our website at www.cqc.org.uk.

Follow up

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

Langford Park is a 'care home' registered to provide accommodation, nursing and personal care support for up to 35 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 31 people living there.

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

The new manager and provider were in the process of improving and developing quality assurance processes, however they were not yet fully established or embedded. This was evidenced by the issues we identified during the inspection related to medicines administration, risk management and staff knowledge and skills.

People were at risk because the systems for ensuring medicines were stored and administered safely were ineffective. The manager and provider expressed their commitment to promptly addressing the concerns raised.

Systems to monitor and manage risks did not always keep people safe. Staff had not maintained their knowledge and skills, which undermined their ability to provide safe care. There were no systems in place to monitor the effectiveness and safety of some equipment.

The service had not consistently submitted statutory notifications, which meant legal requirements had not been met.

The service was experiencing significant difficulties with staffing and recruitment. This was impacting on care provision and the staff team, although the provider was confident the service was safe. The provider had taken action to minimise risks by requesting support from the local authority, suspending new admissions and working with a wide range of staffing agencies. They had also increased the number of staff on shift and were proactive in addressing persistent staff absence and sickness.

The provider had endeavoured to keep families informed about issues related to COVID-19 using emails and videos posted on social media. However, relatives had mixed views about communication with the home related to their family member. None had been involved in developing or reviewing their family members care plan. Some told us they were kept well informed about the welfare of their family member and others felt this was lacking. The manager was introducing a resident of the day programme to better involve and engage people and their families.

There were effective systems in place to protect people from the risk of abuse. Concerns were escalated appropriately to the local authority, and investigations completed as required. Lessons learnt from accidents and incidents were used to prevent reoccurrences. Staff were recruited safely.

There were processes in place to keep people safe from the spread of COVID-19,

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.

The provider and management team led an open, transparent and person-centred service which helped people and staff feel valued and supported. They were committed to continuing to learn and improve, responding immediately to feedback given during the inspection and undertaking to address any concerns raised.

Staff were positive about the improvements introduced by the new manager and the way the service was being managed. The service improvement plan showed that progress was being made. One member of staff told us, “[Managers name] is communicating with everybody more broadly. It’s less of a hierarchy than it was with the previous manager. We are now more of a team.”

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

Rating at last inspection (and update)

The last rating for this service was good (published 5 November 2020). There were no breaches of regulation. The service has now deteriorated to requires improvement.

Why we inspected

We received concerns in relation to staffing levels and the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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.

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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the safe 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 Langford Park 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 the management of risks; the management of medicines; the failure to submit statutory notifications 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Langford Park is a 'care home' registered to provide accommodation, nursing and personal care support for up to 35 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 32 people living there.

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

On coming into post in June 2020 the registered manager had identified failings in the management of the service and quality assurance processes. Action was being taken to address these failings. However, the issues we found related to recording and documentation showed they were not yet fully effective or embedded. In addition, the service had not met its regulatory requirements to notify us of certain events as required by legislation since the new manager came into post.

There was an open, transparent and positive culture at the service. Staff told us they felt valued and part of a dedicated team. They were excited about the progress being made and future direction of Langford Park.

The new manager and provider had reviewed the quality assurance programme and made changes to make it more effective. A service improvement plan was in place. Changes already in progress included the strengthening of the leadership team and a review of staff roles and responsibilities; improved communication; staff induction, supervision and training; investment in the environment and the replacement of equipment which was no longer fit for purpose.

Improvements to the quality and consistency of care plans had continued since the last inspection. Care plans were reviewed regularly, and when people’s needs changed. Since coming into post the registered manager aimed to include family members and the resident when possible in the planning of their care, which hadn’t always been the case previously.

People told us, and records showed, staff numbers had fallen below safe levels at times, however we were reassured that this was no longer the case, following a successful recruitment programme. Robust recruitment systems were in place.

The nursing team had been expanded and was now better supported with clinical oversight from the registered manager. There were safe systems in place for the administration of medicines, which meant people received their medicines as prescribed.

There had been a focus on staff training, including the development of a team leader training programme and specialist training to equip staff to meet people’s complex needs.

People were safe living at Langford Park. Staff were working closely with external health and social care professionals to identify and manage risks to people. The provider had good systems to manage safeguarding concerns, accidents, infection control and environmental safety. The service was clean and there were effective processes to prevent the spread of infection.

The service had continued to develop and provide a programme of activities for people, working within the restrictions of the Covid-19 precautions in place. People were supported to maintain contact with friends and family.

People and their relatives told us they knew how to make a complaint and were confident they would be listened to and action taken.

The service was committed to ensuring people received the support they needed at the end of their lives to have a comfortable and dignified death

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 1 November 2019). There were no breaches of regulation. The service has now improved to good.

Why we inspected

We undertook this focused inspection to check the quality and safety of the service, as there had been two previous ratings of requires improvement and one of inadequate. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which were rated requires improvement at the previous inspection.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this 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 coronavirus and other infection outbreaks effectively.

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

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.

Langford Park is a 'care home' registered to provide accommodation, nursing and personal care support for up to 35 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 24 people living there.

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

Significant improvements had been made in all aspects of the management of the service since the last inspection. However, systems to monitor the quality of the service were still to be fully established and embedded to demonstrate sustainability.

A comprehensive quality assurance programme had been introduced, and a review of job roles and responsibilities was improving monitoring and accountability. There was an open, transparent and positive culture at the service. Staff told us they felt valued and part of a dedicated team.

Care plans showed people and their relatives were consulted about their care preferences. They were detailed, and person centred, however, improvements were required to ensure their consistency and accuracy. Documentation relating to risks, and risk management, had improved since the last inspection, and work was ongoing to ensure this was sustained.

People were safe living at Langford Park. Action had been taken to improve the safety and security of the premises. Staff were recruited safely, and safeguarding processes were in place to help protect people from abuse.

People were now supported by suitably trained, competent and skilled staff. This meant their healthcare and nutritional needs were met. External professionals were complimentary about how the service worked in partnership with them.

A newly recruited activities co-ordinator was developing a person-centred activities programme,

to reduce people's anxiety and depression and maintain cognitive functioning. This included building greater links with the local community and outside world, through holding a parent and toddler group at the home and sending and receiving postcards from people living in participating care homes.

People were supported to take their medicines as prescribed and other risks to their health and wellbeing were managed safely. The provider had good systems to manage safeguarding concerns, accidents, infection control and environmental safety.

Staff were caring and kind. They knew people well and had developed positive and meaningful relationships with them. People were respected, included in decisions and their privacy and independence promoted. The registered manager was proactive in ensuring that an equality, diversity and human rights approach was firmly embedded at the service. They reminded staff of the impact of language in the culture of the home, for example talking about people as tasks to be completed.

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

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

Rating at last inspection (and update)

The last rating for this service was Inadequate (published 13 March 2019)

This service has been in Special Measures since 11 March 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.

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

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.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 35 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there.

At inspections in 2016 and 2017 the service was rated as Requires Improvement. We inspected the service in January 2018 and found that improvements had been made, therefore the service was rated Good. However, at our inspection in August 2018 we found that the improvements had not been sustained and the service was again rated Requires Improvement overall. Aspects of the management and recording of people's medicines required improvement. People did not always have the opportunity to engage in activities and social stimulation, and were at risk of becoming isolated and depressed as a consequence. Significant changes in the management structure and staff team had undermined the quality and safety of the service. New staff had not received the induction, training and supervision required to do their roles safely and there were concerns about poor recording, decreasing standards of personal care and housekeeping, and a lack of clarity around roles and responsibilities. We found breaches of the regulations related to person centred care; safe care and treatment; staffing and governance and served a requirement notice.

Following the inspection further concerns about the safety of the service were raised. Langford Park became the subject of a whole home multiagency safeguarding investigation in December 2018. Whole service investigations are held where there are indications that care and safety failings may have caused or are likely to cause significant harm to people. These concerns meant the local authority, with the agreement of the provider, placed a suspension on any further local authority placements at Langford Park. The provider also voluntarily agreed not to admit privately funded people to the home during this period. Improvements to the safety and quality of the service meant the whole home safeguarding process was concluded on 26 February 2019 and the placement suspension lifted. The service continues to be monitored and supported through the local authority ‘Provider Quality Support Process.’

Before the inspection we received concerns about the management and governance of the service. We carried out an unannounced focussed inspection of this service on 7 and 8 January 2019 to look into those concerns. We did not look at all the previous breaches and will report on those at the next comprehensive inspection.

While there had been some improvements, several issues identified at the inspection in August 2018, and in an audit completed by the provider in October 2018, had still not been addressed in January 2019. This included recording, risk assessing and training, for example in manual handling. The provider’s failure to address these concerns meant people had experienced harm, such as pressure area damage, and continued to be at risk of harm.

This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Langford Park on our website at www.cqc.org.uk can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Langford Park on our website at www.cqc.org.uk.

There was no registered manager at the service as the previous manager had resigned since the last 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. The providers operations manager was the acting manager pending the recruitment of a new manager.

At the inspection in August 2018 we found that although the provider had a comprehensive governance framework in place, this had failed to ensure the quality and safety of the service. At this inspection carried out in January 2019 we found this was still the case. People living at Langford Park had not been asked for their views of the service so were unable to contribute to the provider’s quality monitoring. Monthly audits, including medication, care plans, staffing, accidents and incidents and safeguarding had not been completed, although the provider was aware of this in October 2018. This meant people were at risk because the provider did not have a clear understanding of the issues compromising people’s safety and had not taken action to address them.

Although many of the issues had been highlighted at the inspection in August 2018 and through their own auditing processes, the provider and operations manager told us they had not been aware of the extent of the difficulties at Langford Park until the previous manager had left. They said they had learnt from their mistakes and were committed to identifying and addressing all of the issues as a matter of urgency. This work had started before the end of the inspection and improvements were being made, with the support of the local authority. Quality Assurance processes were to be more robust and would involve people, relatives and staff. Work was planned to rebuild the confidence of staff and ensure they were valued and well supported. The recruitment of a new manager was in progress.

The service was not always safe. Although staff, including agency staff, told us they had a good understanding of people’s needs, risk assessments and documentation did not consistently support staff to recognise the risks and keep people safe. Risk assessments had not always been completed or were inaccurate. They did not consistently contain the guidance staff needed to keep themselves and others safe. People were not always referred appropriately to external health professionals. Care plans and guidance provided by external health professionals was not always evident in people’s records for staff to refer to. The monitoring of risks was not consistently documented, which meant it was not always possible to see whether people had received the support they needed to keep them safe. Information about safeguarding concerns was not consistently escalated, or action taken to keep people safe.

Action was being taken to address these concerns. A new handover system had been introduced a week earlier to ensure information about risks was shared effectively across the staff team. The operations manager had begun to review all the risk assessments and care plans to update them and ensure their accuracy before the end of the inspection. Action was also being taken to improve recording and documentation, and ensure staff had the training required to use the computerised care planning system effectively. Safeguarding processes were being improved.

People were at risk because staff did not have the skills, knowledge or support to care for people safely. New and agency staff told us they had not been given a formal induction when they came to work at the service. Training deemed mandatory by the provider had been completed by only 43 per cent of staff at the time of the inspection. Staff had still not received the support and supervision they needed to enable them to support people safely. This had impacted on the quality of the service and the safety of people living there. The provider and operations manager had begun to address these concerns through the development of a new induction process which all staff would complete. Staff had begun to complete their mandatory training on line and further practical training was planned. Supervision, including clinical supervision for the nurses was being organised.

People were at risk because they did not consistently receive the support they needed to eat and drink safely. Staff were not always following care plans, and were giving people food which put them at risk of choking. Where people were thought to have capacity to choose to eat food which put them at risk, there was no evidence that the risks had been discussed with them or their capacity assessed in this respect. Records did not show they had been re-referred to the SALT (speech and language therapy) team for advice and guidance. The operations manager acted immediately to address these concerns by referring people to the SALT team and ensuring staff had a clear understanding of how to support people safely with nutrition and hydration.

The electronic system for medicines administration was potentially unsafe due to problems with the computer network. This meant there was a high risk of medication errors. The provider had rectified this before the end of the inspection.

There was inadequate security at the premises which put people at risk because visitors could enter the building without being vetted. This was our experience on arrival at Langford Park. We immediately made the provider and manager aware of this security risk, and before the end of the inspection they had taken action to prevent recurrence.

Staffing rotas, and our observations on the day of the inspection, showed there were sufficient staff available to meet people’s needs. However, the perception of many of the people we spoke to and staff was that there were not enough staff and people’s needs were not always met in a timely manner, particularly at night. One person, who needed two members of staff to transfer, told us there were not always two staff available when needed, so they had to spend long periods of time in bed. The acting manag

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there.

At inspections in 2016 and 2017 the service was rated as Requires Improvement. We inspected the service in 2018 and found that improvements had been made, therefore the service was rated Good.

However, at this inspection in August 2018, we found that the improvements had not been sustained. Aspects of the management and recording of people’s medicines now required improvement. Care plans did not consistently contain the guidance staff required to administer medicines safely, and when required. A member of staff was wearing a tabard to indicate they were doing the drugs round and should not be interrupted, but was undertaking other tasks. The manager was aware of the concerns and at the time of our inspection additional training in medicines administration had been arranged. In addition, a new clinical lead had been employed, along with two new nursing staff.

People did not always have the opportunity to engage in activities and social stimulation. Although some activities did take place, there was no activities programme. People told us they were bored and lonely. Two relatives told us their family member was becoming increasingly depressed and withdrawn because they were not receiving the support they needed to stimulate their mind or participate in activities. The manager was aware of this concern and action was being taken to address it. Two new activities co-ordinators were being recruited to work alongside the existing activities co-ordinator. The importance of interaction with people was being emphasised to staff.

Significant changes in the management structure and staff team had undermined the quality and safety of the service. These changes were intended to improve the service and provide better consistency, however at the time of the inspection they were not fully embedded. Many of the new staff had not worked in a care home before. They had not received the induction, training and supervision required to do their roles effectively. There were concerns about poor recording, decreasing standards of personal care and housekeeping, and a lack of clarity around roles and responsibilities. The provider had identified these issues through their quality assurance processes, and developed an action plan to address them. Emergency staff meetings had been held with clear guidance given to staff about expectations and the action required.

People told us they felt safe. Regular health and safety checks were undertaken at the service. There were effective infection prevention processes in place, the home was compliant with fire regulations and a programme of refurbishment was in progress. People were protected from the risk of abuse through the provision of policies, procedures and staff training, and an effective recruitment process.

There were systems in place to ensure risk assessments were comprehensive, current, and supported staff to provide safe care while promoting independence. The computerised care planning system, accessed by staff using handheld computers, ensured that information about people’s risks was shared efficiently and promptly across the staff team. This meant staff had detailed knowledge of people’s individual risks and the measures necessary to minimise them.

Care plans were person centred and provided clear guidance for staff which enabled them to meet people’s needs according to their preferences. They had not always been formally reviewed in line with the provider’s own policy, however they had been updated as required and the information therefore remained current.

Staff had a clear understanding of the process for managing and reporting accidents and incidents and were using it effectively. Information was reviewed and analysed by the management team, and action taken where required, to prevent reoccurrence.

Staff promoted people’s independence and treated them with dignity and respect. They were familiar with people’s history and backgrounds, respected their choices and acted in accordance with their wishes. People were accepted for who they were regardless of their sexuality, faith or culture.

People were supported to make choices about their day to day lives, for example how they wanted their care to be provided and how they wanted to spend their time. The service ensured people and their advocates where appropriate, were fully consulted and involved in all decisions about their lives and support. Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA. This meant people’s legal rights were protected.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS provide legal protection for those vulnerable people who are, or may become, deprived of their liberty. They had made appropriate applications for people they had assessed that required to be deprived of their liberty to the local authority DoLS team.

People had sufficient amounts to eat and drink and received a balanced diet. Care plans guided staff to provide the support they needed. The service worked with the speech and language therapists (SALT) team, to meet the needs of people with swallowing difficulties. People spoke positively about the food and choices available.

Staff made prompt referrals to relevant healthcare services when changes to health or wellbeing had been identified. The service worked closely with health and social care professionals to ensure people’s health needs were met. We spoke to visiting health professionals during the inspection who spoke positively about the responsiveness and effectiveness of the service.

The service was moving towards specialising in end of life care. People were often discharged to Langford Park from hospital at short notice. The service worked closely with health and social care professionals to ensure people’s needs and preferences were understood and met, and they and their families were supported at the end of their lives.

The Accessible Information Standard is a framework put in place making it a legal requirement for all providers to ensure people with a disability or sensory loss can access and understand information they are given. Although we were given some examples of good practice in this respect, and there was a specific policy in place, there was a lack of consistency in care plans to guide staff. The manager advised they would make the necessary improvements to ensure compliance with the Standard.

People knew how to make a complaint and told us they had confidence in the complaints process. The provider was using the complaints policy effectively to address some concerns raised by family members.

Despite the management team being highly visible at the service and staff telling us they were well supported, there was not always effective monitoring and accountability to help ensure the ongoing quality and safety of the service.

People, relatives and staff were invited to express their views of the service through satisfaction surveys, interviews and at meetings. The information from the quality assurance processes was used to drive improvements at the service.

We found four breaches of the regulations. You can see the back of the full report to show what action we have told the provider to take.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 32 people living there.

At an inspection on 18 and 22 February 2016 the service was rated as ‘requires improvement’ in all key questions and ‘requires improvement’ overall. We found no breaches of regulation. At the inspection on 06, 07 and 23 June 2017, significant improvements had been made. The service was rated ‘requires improvement’ in ‘safe’ and ‘well-led’, and ‘good’ in the other key questions. However we found breaches of the regulations related to safe care and treatment and good governance. The service was again rated ‘requires improvement’ overall.

We undertook an unannounced focused inspection of Langford Park on 15 and 22 January 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our inspection on 06, 07 and 23 June 2017 had been made. We inspected the service against two of the five questions we ask about services: “Is the service safe?” and “Is the service well led?” We found significant improvements had been made and these two key questions were now rated good. No risks, concerns or significant improvement were identified in the remaining key questions through our ongoing monitoring or during our inspection, so we did not inspect them. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection.

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.

The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. They had acknowledged the areas in which the service needed to develop and improve, and had been proactive in making this happen. This had led to improvements in the quality and safety of the service. A relative confirmed, “There has been a gradual but firm process of improvement. My concerns have evaporated. It’s being properly managed”.

There were now effective quality assurance systems in place to help assess the safety and quality of the service, and identify any areas which might require improvement. The findings of the audits contributed to a service improvement plan, with clearly defined actions, responsibilities and timescales. The views of people, their relatives, and staff were actively sought to ensure the service was run in the way they would like it to be.

People told us they felt safe. Improvements to systems for the administration of medicines had been made, which meant people now received their medicines safely according to their individual needs and preferences. A computerised medicines administration system minimised the risk of errors and allowed the management team to monitor medicines on a daily basis. Regular medicine audits and spot checks were carried out by the provider.

There were now effective infection prevention processes in place, and a robust system to ensure that pressure relieving mattresses were at the correct setting for the person’s weight, to minimise the risk of skin breakdown.

There were systems in place to ensure risk assessments were comprehensive, current, and supported staff to provide safe care while promoting independence. The computerised care planning system, accessed by staff using hand held computers, ensured that information about people’s risks was shared efficiently and promptly across the staff team. This meant staff had detailed knowledge of people’s individual risks and the measures necessary to minimise them. People were protected from the risk of abuse through the provision of policies, procedures and staff training, and an effective recruitment process.

People told us there were sufficient numbers of staff to keep them safe and meet their needs. Staff had time to sit down and spend quality time with people, and interacted with them in a calm, unhurried way.

The previous inspection of the home was carried out on 18 and 22 February 2016. At that inspection the service was rated as ‘requires improvement’ in all domains and ‘requires improvement’ overall. We found no breaches of regulation. At this comprehensive inspection in June 2017 we found significant improvements had been made, however additional areas of concern and breaches of regulation meant further improvements were needed to ensure people’s safety. The service has therefore again been rated ‘requires improvement’ overall.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there, with one new person moving in on the day of the inspection. 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.

When we last inspected in February 2016, a whole service multiagency safeguarding process was underway to protect people's safety and well-being. The local authority safeguarding team, the commissioning team and the Quality Assurance and Improvement Team (known as QAIT) had been closely monitoring the home with regular visits, and providing training and support to help the provider and management team establish effective care and management systems. While we found significant improvements in the management and quality of the service, it was too soon at this stage to determine whether they would be sustained, and some improvements were yet to be implemented. This comprehensive inspection in June 2017 was carried out to check whether the improvements made had been sustained, and the service was now providing safe and effective care to people.

At this inspection we found that although there were systems in place to ensure people received their medicines safely, they were not always effective. For example, the member of staff doing the drugs round was distracted by the need to answer the door to visitors and provide support to other members of staff, which meant medication was administered late to people. Guidance had not been sought from the pharmacist on the safest method for administering covert medicines, in line with the service’s covert medication policy. Medication requiring disposal was observed on top of a cupboard in the nurses’ office, when regulations state that medication requiring disposal should to be stored in a tamper proof container and locked away. One person had three opened tubes of the same cream in use, one of which had no recorded expiry date.

During the inspection we found that the management of clinical waste was not safe, which put people at risk due to the potential for the spread of infection. Two open bags of waste, including used disposable gloves, were left on the floor in the laundry.

At the last inspection in February 2016 we found that improvements were needed in relation to the assessment of risk, particularly related to falls and accident and incidents. At this inspection we saw there were now effective systems in place to assess and minimise risks, supported by a new computer based care planning system. However, further improvements were needed to ensure staff had the information they needed to keep people safe, specifically related to the safe use of pressure relieving mattresses.

At the last inspection the provider did not have adequate systems in place to monitor and review the quality of care and ensure the service continued to meet people’s needs effectively. At this inspection we found a comprehensive system of audits was now in place. However, further improvement was required to ensure people’s safety with regard to medicines administration, infection control and the use of pressure relieving mattresses. Following the inspection the provider sent us an updated service improvement plan which showed that these issues were being addressed.

People were supported to maintain good health and had access to healthcare services; however staff did not consistently follow guidance from healthcare professionals. This related to people being supported to follow exercise programmes and the provision and use of recommended equipment such as pressure cushions. We have made a recommendation that the registered manager and provider take further steps to ensure they work more effectively with health professionals, seeking support and further training from an appropriate source.

People and health professionals expressed concern about staffing levels and told us staff were, “rushed off their feet”. The registered manager acknowledged that recruitment and retention of staff had been an issue, but provided reassurance that there were enough staff deployed to meet people’s complex needs and to care for them safely. There had been a successful recruitment drive, and they told us, “We are almost fully staffed now, and have an excess of nurses”. They planned to “over employ” saying, “I’d rather over employ than be in a situation where we are left in the lurch”.

The home was managed by a person who was registered with the Care Quality Commission as the registered manager for the service. They, along with the provider were committed to the improvement and development of the service and had commissioned an external consultant to mentor them and turn Langford Park into a home which provided “outstanding care for residents” where people want to work”. There had been significant changes across the service which had had a positive impact. A health professional told us, “Our team feel privileged to have worked with Langford Park over the last 18 months. We were part of the original safeguarding enquiry and as a result we have been able to experience the improvements made first hand”.

When we last inspected in February 2016 we found that staff had not been receiving regular individual support and supervision. At this inspection we found staff now received regular individual supervision and an annual appraisal, and they told us they felt well supported.

At the last inspection concerns were expressed that, although the physical care was good, staff weren’t always as thoughtful as they could be, for example leaving people without their hearing aids and glasses. At this inspection we found there had been significant improvements. A new ‘values framework’, had been developed which encouraged staff to deliver ‘outstanding care’ with kindness and compassion. People and their relatives told us staff were caring and thoughtful. One person said, “They are so obliging…‘I am so impressed with this place, and they all seem to go that extra mile”.

When we last inspected in February 2016 people and their relatives told us there had been a large turnover of staff, which had made it difficult for them to build relationships with the staff who supported them. At this inspection we found the service had been proactive in helping people and staff build relationships, for example by displaying staff photographs in the main entrance so that people would know who they were and ensuring people were supported by a consistent staff team.

At the last inspection we found care plans did not contain information about people’s history and background and people did not always contribute to their development. In addition people were not always consulted about their end of life wishes, and they were not documented in care plans. At this inspection we found people, and their relatives where appropriate, had been fully involved in the development of their care plans and consulted about their end of life wishes. This meant staff and professionals had the information they needed to provide personalised care. They would know what the person’s wishes were for their future care and final days, and could ensure they were respected.

When we inspected in February 2016 we found that there was one activities organiser with limited time available to assess and meet the diverse social care needs of everybody at the home. At this inspection we found there were now two activities co-ordinators in post who supported people to engage in a wide range of activities according to their needs and interests.

A comprehensive induction and training programme meant staff were knowledgeable about their roles and responsibilities, and people’s individual needs. This included specialist training from external health professionals.

Policies and procedures ensured people were protected from the risk of abuse and avoidable harm. Staff told us they had regular safeguarding training, and they were confident they knew how to recognise and report potential abuse. Staff were recruited carefully and appropriate checks had been completed to ensure they were safe to work with vulnerable people.

People had sufficient to eat and drink and received a balanced diet, and care plans guided staff to provide the support they needed.

Staff promoted people’s independence and treated them with dignity and respect. People were supported to make choices about their day to day lives, for example how they wanted their care to be provided and how they wanted to spend their time. The service ensured people and their advocates where appropriate, were fully consulted and involved in all decisions about their lives and support. This meant people’s legal rights were protected.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we

We carried out this inspection in February 2016 to check whether these improvements had been made. Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there. 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 significant improvements in all aspects of the management of the service since the last inspection. There had been input from the local authority safeguarding team, the commissioning team and the Quality Assurance and Improvement Team (known as QAIT) since the last inspection. These professionals had closely monitored the home with regular visits and provided training and support to help the provider and management team establish effective care and management systems. This input had been welcomed and the providers and management team had worked closely and constructively with them to keep people safe and improve the quality of the service. However, it was not possible at the time of the inspection to determine whether there was consistency in the effectiveness of the care, treatment and support people received, or whether this would be sustained, as the changes had been so recent. In addition, some improvements had yet to be implemented.

At the last inspection we identified that risks to people’s safety had not been fully assessed, recorded or reviewed. At that inspection we found staff did not have access to written information about potential risks or the actions they must take to reduce those risks. At this inspection we found improvements had been made and there were systems in place to minimise risks. However further improvements were needed in relation to the assessment of risk, particularly related to falls and accident and incidents.

At the last inspection we found there was no information to show how people had been involved in the planning and review of their care. Since that inspection a new care plan system had been introduced in the home and staff were writing new care plans for everyone. However not everybody we spoke to had been consulted. The new care plans required additional information, especially about people’s history and background. People’s end of life wishes had not been consistently discussed with them or their families and had not been recorded. This meant there was a risk they may not receive the care they and their families wish for at the end of their life.

There had been a large turnover of staff which had made it difficult for people to build relationships with the staff who supported them. One visitor said, “The biggest issue is the turnover of staff. You’re never sure who will be here when you visit”.

At the time of the inspection staff had not been receiving regular individual support and supervision. Managers recognised they had lost confidence during the safeguarding process and were feeling under scrutiny and demoralised. They wanted to provide constructive and positive support to help them feel more motivated and valued. Formal staff supervision was being reintroduced during the week of the inspection in the form of one to one sessions.

There were some organised activities and the activities organiser visited people who were cared for in their rooms. However, this was not sufficient to meet the social and spiritual needs of everybody at the home. The provider and registered manager were taking steps to address this and a health professional reported some progress had been made. An additional activities co-ordinator had been appointed, and it was planned that staff would support people with more ‘person centred’ activities on an individual basis. An ‘activity care plan’ was being developed to identify activities relevant to people and their interests, and direct staff in how to provide them.

At the last inspection the provider did not have adequate systems in place to monitor and review the quality of care and ensure the service continued to meet people’s needs effectively. At this inspection we found new quality monitoring systems were in place to ensure the home ran smoothly. However, these had not yet been fully established and therefore we are not yet fully confident that improvements can be sustained on a long term basis.

At the last inspection we found the service did not always manage medicines safely. At this inspection we found systems were now in place to ensure people received their medicines safely. This was confirmed by a health professional who told us, “They do seem to manage their medication very carefully”.

At the last inspection we found people’s rights were not being fully protected in relation to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. At this inspection we found that improvements had been made. Staff were more familiar with this legislation. Applications had been made for people to be cared for under the Deprivation of Liberty Safeguards where appropriate.

People were protected from the risk of abuse through the provision of policies, procedures, robust recruitment and staff training. The registered manager and provider had worked closely with the local authority, acting promptly and decisively to address concerns and minimise risk.

There were adequate numbers of staff with the knowledge and skills to meet people’s physical needs. Communication systems had improved and staff were kept well informed about any changes to people’s needs through staff meetings and handover sessions between each shift.

The staffing structure in the home provided clear lines of accountability and responsibility. There was always a registered nurse on duty which made sure people and staff always had access to a more senior staff member to oversee people’s health needs and respond to any concerns. Care staff demonstrated a good understanding of people’s physical care needs, and completed charts and daily records recording their interventions in line with people’s care plans.

People’s individual nutritional requirements were assessed and documented to ensure they received a diet appropriate to their needs and wishes. There were sufficient staff to ensure everybody who needed support with eating received it. The recently appointed chef told us they planned to speak with people about their food preferences and offer an increased range of choices.

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

At the time of our inspection there were 35 people living at Langford Park. The summary is based on conversations with 10 people using the service, eight staff supporting them, six relatives, six health and social care professionals, the unregistered manager, observation and a review of a variety of records.

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

Is the service safe?

All of the people we spoke with who used the service told us they felt safe at Langford Park. People told us their care was never rushed, with staff delivering care at the individual's pace. Relatives were confident in the care and support provided. One relative told us, 'I never have to worry about X; I know she is safe and well cared for'. Another relative said, 'It is an enormous relief to have X here. We have no concerns at all'.

Risk assessments had been completed to identify potential risks to people using the service, such as pressure ulcers, falls and nutrition. Where a risk had been identified care plans showed the actions required to reduce these risks. These included the provision of specialist equipment such as pressure relieving mattresses, hoists and walking aids. We found this equipment was in place and used appropriately where needed.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

The unregistered manager reviewed all accident and incident reports to help identify any trends in relation to place, time or activity. We saw that action was taken as a result of accidents, for example falls. This showed us there was evidence that learning from incidents and investigations took place and appropriate changes were implemented.

We saw that systems and equipment within the home were serviced and maintained regularly. This ensured people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises and equipment.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. However, the provider did not operate an effective recruitment process to ensure people were protected from unsuitable staff.

Is the service caring?

People spoke highly of the staff team describing them as 'kind, friendly, compassionate and patient'.

Relatives told us they were happy with the care provided to their family member. Their comments included, 'We are delighted with the care, we have seen improvements in X's overall condition. We can't speak highly enough of the staff, who are patient and kind'; 'Care and attention is good. We couldn't get anything better'; and 'The care here is brilliant. The staff are caring and competent. The best thing we did was to move X here'.

People were supported by kind and attentive staff. Staff spoken with showed they knew people well. We observed staff interacting with people who used the service and saw that they were caring and kind in their approach. Care plans included people's interests, likes and dislikes. This ensured that people's preferences were considered as part of their care.

Is the service effective?

Specialist advice had been sought, for example, regarding people's mental health needs, dietary and mobility needs. The service had a good working relationship with other health and social care professionals and always followed their guidance and advice. The input of other healthcare professionals involved in people's care and treatment ensured people's health and social care needs were met.

Prior to admission to the service a pre-admission assessment was completed for each person and additional information was obtained from other health and social care professionals. This showed that people's health, personal and social care needs were assessed before they moved into the home and helped to ensure the home could meet individual needs.

The unregistered manager ensured there were sufficient staff on duty with the appropriate qualifications, skills and experience required to ensure people's needs were met.

Is the service responsive?

All relatives spoken with during the inspection told us they were pleased with the care, treatment and support their family member received. They said the staff always informed them of any significant changes in their relative's general health. Visiting relatives told us they were always made to feel very welcome when they visited. One relative said, "We are delighted with the care. X has improved greatly since moving to Langford Park'.

Visiting health and social care professionals told us the service was responsive to people's changing needs. All professionals told us the home communicated well with them and that referrals were appropriate and timely. This meant people had access to a variety of health and social care professionals to meet their needs.

People knew how to make a complaint if they were unhappy. People said they would be happy to speak to staff or the unregistered manager and that they were confident any concerns would be listen to and acted on. We saw that complaints and concerns had been addressed promptly and effectively. People can therefore be assured that complaints are investigated and action is taken as necessary.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. Professionals spoken with expressed their confidence in the unregistered manager and staff.

We spoke with staff who were clear about their roles and responsibilities. They felt the unregistered manager was accessible and supportive.

The service sought the views of people who used the service in order to improve. Regular 'residents' and relatives' meetings took place and people felt able to contribute. There was a quality assurance system in place which included an annual satisfaction questionnaire. We found that results were positive and the service acted on suggestions made.

We spoke with five relatives, eight visiting health professionals (including members of the stroke rehabilitation team, dieticians, palliative care nurses and a tissue viability nurse) and the Devon County Council contracts team. Relatives told us, 'X's condition has improved since coming here', 'I am happy with everything so far', 'We like it here. X is settled. It is friendly and welcoming' and 'Things are really good here'.

Visiting professionals told us that the service always referred people appropriately and in a timely way. One physiotherapist told us, 'It appears to be good care and support for people here'. Other comments from professionals included, 'There have been major improvements over the past year or so', 'They (staff) know what is going on for people. They have some fab nurses' and 'They have complex service users but we have no concerns about the care'. Devon County Council contracts officer told us there were no current concerns about the service.

We spoke with six members of staff, including the registered manager. Staff told us they felt well supported and they felt they had access to a good range of training to help them do their job safely and competently.

At this inspection we found that the provider was meeting all of the outcomes we looked at. The service was responsive to people's care and support needs and people told us they felt the staff were caring, and that they felt safe at Langford Park. We received many positive comments about the registered manager. People living at the home, relatives and professionals told us the service was well managed.