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St Marks Court Requires improvement

The provider of this service changed - see old profile

Reports


Inspection carried out on 3 November 2021

During an inspection looking at part of the service

About the service

St Mark’s Court is a residential care home providing personal, nursing and dementia care across three units. There were 38 people living at the service at the time of the inspection. The service can support up to 60 people.

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

The service was not always well-led. Audits had not always been effective in identifying inconsistencies with care planning, meaning people were at risk of receiving care that was less than good. Most staff were not confident with the electronic care planning system, however additional training was underway.

The service was not always safe. Some risk assessments lacked detail and were not always consistent. Staff did not always record risk-reducing actions, so it was at times unclear whether these were carried out or not.

The building was safe with regular maintenance checks in place.

There was a positive culture within the home and people and relatives gave good feedback about the care. People and their representatives were involved in decisions about the service. Staff had a good relationship with visiting professionals.

There were enough, suitably trained staff available to meet the needs of the people living at the service. Medicines were managed safely and audits were carried out. People were safeguarded from abuse. One person said, “I feel very safe living here.” Lessons had been learnt from incidents.

We were assured by the infection prevention and control practices within the home.

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

Why we inspected

We received concerns in relation to the lack of understanding of the electronic care planning system and pressure area care. 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 improvement. 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 St Mark’s Court on our website at www.cqc.org.uk.

Inspection carried out on 19 March 2021

During an inspection looking at part of the service

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom are living with dementia. There were 51 people living there at the time of this inspection.

We found the following examples of good practice.

Systems were in place to help prevent people, staff and visitors from catching and spreading infection. Staff had closely considered how to support people to maintain relationships whilst keeping safe. For instance, dining tables had Perspex screens, which let people still sit together and chat over meals but reduced the potential to spread infections.

There was enough PPE, such as aprons, gloves and masks, which staff were seen to use. Staff had undertaken training in putting on and taking off PPE and the manager routinely checked staff compliance with the guidance.

Staff and people were tested regularly for COVID-19. A COVID-19 vaccination programme was in place.

People who used the service told us they found the staff were very supportive. The manager explained how the activity co-ordinator had been organising visits, including window visits and video calls, to help people maintain family connections.

The activity co-ordinator told us they were aware the people who used the service missed singers coming into the home. Therefore, the service had organised an event called ‘St Marks has talent,’ where staff and people performed and received awards. They had also arranged for singers to perform virtual entertainment for people’s birthdays.

The provider employed ‘speak and listen’ staff who spent time with people who may be more isolated.

We observed positive interactions between staff and people.

Further information is in the detailed findings below.

Inspection carried out on 12 December 2019

During a routine inspection

About the service

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom are living with dementia. At the time of our inspection there were 42 people using the service.

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

Since the last inspection the provider and registered manager had continued to make improvements to the operation of the service. Staff were deployed effectively, and this had led to a positive impact on people's quality of life. Staff discussed how the introduction of a floating staff member had supported them to fully meet people's needs and ensure people remained safe.

Staff were making a difference to people’s wellbeing by working well as a team, and by sharing the same values and principles.

Medicine management was being reviewed and measures had recently been put in place to reduce the potential for errors to occur.

A one-page assessment document had been fully introduced and these were detailed. The registered manager and provider recognised that having more information about people's life history would assist staff understand people's cultural differences and experiences.

At times support plans contained assessment information rather than clearly defining the interventions staff were to use. The evaluations and reviews had not assisted staff to critically consider if the interventions work and show how their dedicated and skilled work had led to very positive outcomes for people. The provider was in the process of reviewing the care documentation to see how this could be enhanced.

There was some variability in the quality of capacity assessments and ‘best interests’ decision records, which the registered manager was resolving.

The activity coordinators had been extremely effective in their role and had developed a wide range of events. They had made sure people had a life with meaning. The activities coordinators had secured a range of grants and been undertaking projects which had led to real community integration. Staff had recently started to put together ‘scrap’ books with people that contained photos and memories of their lives.

The registered manager and staff demonstrably showed people were valued and respected. Staff created a warm and friendly environment. Relatives and visiting professionals reported that staff were superb, fantastic, extremely friendly, kind and caring. Staff actively engaged people in discussions, and we heard lots of friendly banter.

We found staff were committed to delivering a service which was person-centred. 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.

Staff took steps to safeguard vulnerable adults and promoted their human rights. Incidents were dealt with appropriately and lessons were learnt, which helped to keep people safe. External professionals were involved in individuals care when necessary. The GP and community nurses visited at least once per week and routinely checked how people were feeling.

Staff had received a wide range of training and checks were made on the ongoing competency of staff. Appropriate checks were completed prior to people being employed to work at the service.

The cook had received a range of training around meeting people's nutritional needs. Staff were encouraging people who were under-weight to eat fortified foods. A range of menu choices were available.

The registered manager had acted on concerns and complaints and had taken steps to resolve these matters. They actively promoted equality and diversity within the home.

The service was well run. The senior managers and registered manager carried out lots of checks to make sure that the service was effective. The registered manager constantly looked for ways to improve the service. They continually researched information about best practice and ensured staff practice remained at the forefront in introducing new guidance.

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

Rating at last inspection

Requires improvement (report published 10 September 2019).

Why we inspected

This was a planned inspection based on the rating at the last inspection.

Follow up

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

Inspection carried out on 9 July 2019

During an inspection looking at part of the service

About the service

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom are living with dementia. At the time of our inspection there were 30 people using the service.

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

A registered manager had been in post for the last two months. The provider’s regional manager and quality team had supported them to identify shortfalls and to make positive improvements to the operation of the service. However, these changes were not fully embedded and further time was required for the provider and registered manager to be assured that these were effective.

To ensure people’s safety in the event of an emergency a range of improvements were needed around fire risk management. The registered manager confirmed they would organise this training and develop an evacuation plan.

The provider’s dependency tools did not assist staff to provide safe staffing levels. The regional manager and registered manager took this up with the quality manager and immediately increased the staffing levels. Despite this increase, we saw that on a morning the staff on the nursing unit could not support everyone to have a drink. The registered manager agreed to look at the deployment of staff during this time.

Staff were revisiting risk assessments, and these were in the process of being improved. Risk assessment for dehydration did not consider underlying physical conditions, which led to an inaccurate risk profile. The regional manager immediately discussed this with their quality team who reviewed the tool and supplied a new version that needed to be tested to determine if it was effective.

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. However, the policies and systems in the service did not support this practice, as the documentation was inaccurate and was confusing.

Staff completed monthly physical health checks but when this indicated a change or deterioration we could not establish what action was taken or understand the results. The registered manager undertook to revisit staff competency to use this tool.

The registered manager had reviewed medication practices and made improvements, but further work was needed. As required protocols were variable in content, and stock control needed to be reviewed for controlled medicines.

The staff were in the process of changing all 30 people's care records to mirror the new style records that were more informative. The registered manager had introduced new templates such as concise person profiles, pocket size cards detailing risks for individuals and communication plans. The registered manager had also introduced a system of using colour coded dots on people's door to assist staff see at a glance how much support people needed in the event of an emergency.

Equipment was appropriately maintained, and checks were routinely completed. A new treatment room with air conditioning had been created on the nursing unit. The service was clean and tidy.

Recruitment was effective, but the provider needs to ensure enough space was available for people to record their full employment history. Staff training, and supervision were being completed. The provider and registered manager constantly monitored the effectiveness of the courses. This oversight had led them to change the training provider and staff reported that the new courses were far more informative.

Tools were in place and staff ensured people were encouraged to eat a balanced diet. The cooks were very knowledgeable. The cook had received training around how to support people who were underweight or needed adapted diets. Staff were now closely monitoring food and fluid uptake for people and knew who was at risk of becoming dehydrated or losing weight.

Staff told us that the registered manager and regional manager were approachable and closely listened to their views. They were positive about how the service was now being operated and felt morale had significantly improved.

The provider had a system in place for overseeing the service and had identified gaps in practice and put action plans in place. However, the recent frequent changes to the manager and the regional manager being needed elsewhere had impeded progress in meeting these goals.

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

Rating at last inspection and update

Requires Improvement (report published 11 December 2018) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve the governance arrangements and meeting MCA principles. Although the service had started to improve in the Key Questions we reviewed and no breaches of regulation were identified further improvements were needed.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. 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 not changed. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Marks Court on our website at www.cqc.org.uk.

Follow up

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

Inspection carried out on 24 October 2018

During a routine inspection

We inspected St Mark’s Court on 24 October 2018. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting.

St Marks Court is a ‘care home’. People in care homes receive accommodation, nursing and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom have dementia. At the time of this inspection 50 people used the service.

We last inspected the service in September 2017 and found the service was not meeting our expectations. We rated St Mark’s Court as Requires improvement overall and in four domains. We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care and treatment and good governance.

We found that the provider was failing to submit notifications, which is an offence and we issued a fixed penalty notice. The provider paid the £1250 fine and has subsequently sent in notifications.

The service has not had a registered manager since June 2017. 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. Over the last year the provider had recruited three managers and one person had applied to be the registered manager but left the service before the process was completed. At the beginning of September 2018, a new manager had started working at the service.

At the last inspection we highlighted concerns around how people were supported with their mobility. Staff needed to ensure that they adopted the correct moving and handling techniques. Moving and handling equipment needed to be appropriate for each individual and stored appropriately. Accidents and incidents were monitored but we found improvements were needed with how the information was analysed and used to assess risks of falls and injury. We found that the provider was changing the systems they used for monitoring the service and in the transition period the systems in place had not picked up the issues we identified.

At this inspection we found that although the provider had been working to resolve these issues and improvements had been made, the instability in the management had led to a continuation of issues.

We found that the provider was introducing new training programmes but not all staff were up to date with mandatory training. New staff had not received moving and handling training, the catering staff had not renewed food hygiene level two awards and the provider needed to ensure there were sufficient qualified first aiders to cover 24 hours every day. Staff had not completed regular supervision sessions but the new manager was re-introducing these.

There were not enough staff on the unit for people living with dementia during the mealtimes to ensure people ate sufficient food. Also, staff on this unit did not fully recognise when people were at risk of malnutrition or take proactive measures to encourage people to consume sufficient nutritious foods and maintain their weight. Catering staff were not always alerted to people’s dietary needs and had not been support to understand how to create foods that were suitable for people at risk of losing weight.

The regional manager discussed how they had recently reviewed staffing levels and these were to be increased both during the day and overnight. They were in the process of recruiting staff to fill these newly created vacancies. Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

The provider was planning to complete a full refurbishment of the service and some decorative works had commenced on the nursing unit. Priority needed to be given to refurbishment to the unit for people with dementia, as this was malodorous. The settees in lounges needed replacing, as these were sagging and low. We heard that since the new manager had started to work at the service repairs were being completed, for instance a bath that had been broken for over six months had been fixed.

Safeguarding and whistleblowing procedures were in place. Staff reported concerns but the previous manager had not dealt with these effectively. A complaints process was in place and the new manager was checking with relatives and the people that used the service that any issues raised had been acted upon. We found no records to show the previous managers had investigated incidents or what lessons had been learnt.

We reviewed the systems for the management of medicines. We found that people were administered medicines safely but the oversight of these needed to be improved. The treatment room temperatures exceeded 25°c, in part because one of the air conditioning units had been broken for a number of months and the other treatment cupboards were small. This meant that some items would be stored above the recommended temperature.

Staff understood the principles of the Mental Capacity Act 2005. We discussed how staff needed to demonstrate that decisions were made for people in their ‘best interests’ and complete effective capacity assessments.

The new manager and regional manager were taking steps to review the service to ensure that they were aware of all concerns, these had been thoroughly investigated and actions were taken to resolve them.

Staff knew the people they were supporting but the care records lacked information about people’s lives and were not always person-centred, as we could not establish basic information about how to support individuals. We discussed this with the regional manager who explained that the provider had identified these deficits in the care records and was in the process of improving them.

People we spoke with told us they felt safe in the home and that staff made sure they were kept safe. Staff respected people’s privacy and dignity. We found a range of activities were available.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to the need for consent and good governance. You can see what action we told the registered provider to take at the back of the full version of the report.

Inspection carried out on 3 August 2017

During a routine inspection

We inspected St Mark’s Court on 3 August 2017. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting. We also visited the service on 4 September 2017, to seek information about the actions the new manager had been taking since taking up post two weeks earlier.

We last inspected the service on 6 May 2015 and found the service was meeting our expectations. We rated St Mark’s Court as ‘Good’ overall and all in five domains.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom have dementia. At the time of this inspection 42 people were in receipt of care from the service.

The home has not had a registered manager since June 2017. 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 provider had recruited a person to be the registered manager and they started working at the service in the middle of August 2017.

During our observations of care within the service, we identified concerns related to how people were supported with their mobility. Staff needed to ensure that they adopted the correct moving and handling techniques. Moving and handling equipment needed to be appropriate for each individual and stored appropriately. We raised concerns around specific practices and the quality manager informed us they would review this and submit safeguarding alerts immediately. We observed that equipment such as slings were stored in a pile on the floor, which was unhygienic. Also equipment such as wheelchairs were identified by numbers rather than the person’s name so it was difficult for staff to find the item for the individual who had been assessed to use it.

Accidents and incidents were monitored but we found improvements were needed around how the information was analysed and used to assess risks of falls and injury. We found that the provider was changing the systems they used for monitoring the service and in the transition period the systems in place had not picked up the issues we identified.

Safeguarding and whistleblowing procedures were in place. Staff reported concerns but needed to take ownership for reporting matters to the local safeguarding team. They also needed to ensure recommendations made by safeguarding teams were implemented, such as making sure people were supported to change their position in chairs regularly throughout the day.

A complaints process was in place and any concerns were investigated by the regional manager or the quality compliance team. However people told us that at times when they raised issues they received no feedback and action was not taken to rectify their concerns.

People’s care records were cumbersome, extremely difficult to navigate and we often found it difficult to get a sense of the person’s needs. The lack of a detailed written assessment had contributed to the difficulties around developing the care records as an effective working tool. Staff needed to improve the accuracy of their recording when monitoring peoples' fluid intake.

People told us they felt the care staff did a good job. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were protected.

We found a range of activities were available on the ground floor which people from elsewhere in the service accessed. When we visited a pet therapy session was taking place with a pony and the staff had been breeding chickens. The chickens were kept in the bar area of the home, which was away from the main areas of the service. They were reaching maturity so needed to be moved outside and despite staff best efforts, such as ensuring they were cleaned daily they were malodourous and this meant people were not accessing this area. There was a risk assessment in place, which highlighted and mitigated any risks around existing chest conditions were exacerbated by exposure to chicken feathers and the associated dust.

People we spoke with told us they felt safe in the home and that staff made sure they were kept safe. Staff respected people’s privacy and dignity.

People who used the service and the staff we spoke with told us that there were enough staff on duty to meet people’s needs.

We reviewed the systems for the management of medicines and found that people received their medicines safely.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care and treatment and good governance. You can see what action we told the registered provider to take at the back of the full version of the report.

Inspection carried out on 6 May 2015

During a routine inspection

We inspected St Marks Court on 6 May 2015 and the visit was unannounced. We last inspected the service in November 2014. At that inspection, we found breaches of legal requirements in five areas; consent to care and treatment, record keeping, staffing, supporting staff and assessing and monitoring the quality of service provided. We asked the provider to take action to make improvements and they told us they would be fully compliant with the regulations by 30 April 2015. On this visit we found improvements had been made in all of the regulations that had been previously breached and the registered provider was now meeting current regulations.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care and support is provided for older people, some of whom have a dementia related condition. At the time of the inspection there were 33 people living at the service.

The service had a registered manager who had been in post since December 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People using the service told us they were well cared for and felt safe at the home and with the staff who provided their care and support. The home was clean, tidy, well maintained and no unpleasant odours were evident in any part of the home.

Staffing levels were sufficient to meet people’s needs and employment procedures ensured that appropriate recruitment checks were undertaken to determine the suitability of individuals to work with vulnerable adults.

Improvements had been made to the management of medicines. Medicines records were accurate and complete, and medicines were managed safely. People’s medicines were stored securely.

Staff recruitment procedures ensured that appropriate recruitment checks were carried out to determine the suitability of individuals to work with vulnerable adults. Security checks had been made with the Disclosure and Barring Service (DBS). DBS checks help employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

Staff members had a good understanding of safeguarding adult’s procedures and knew how to report concerns. A whistleblowing policy and information was available for staff to report any risks or concerns about practice in confidence to the provider.

Staff were attentive when assisting people and responded promptly to requests for assistance or help. Appropriate risk assessments were in place to ensure risks were assessed and appropriate care and support was identified.

Accidents and incidents which occurred at the home were reviewed and analysed regularly to identify possible trends and to prevent reoccurrences. Duty managers were available out of hours for advice and in the event of an emergency.

People received care from staff who were provided with effective training to ensure they had the necessary skills and knowledge to effectively meet their needs. Staff received regular supervisions and annual appraisals were carried out. All new staff received appropriate induction training and were supported in their professional development.

Improvements had been made in relation to of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Detailed information was available for staff. The requirements of MCA were followed and DoLS were appropriately applied to make sure people were not restricted unnecessarily, unless it was in their best interest.

People were supported to make sure they had enough to eat and drink and their nutritional needs were met to ensure they stayed healthy. They told us enjoyed the food prepared at the home and had a choice about what they ate.

People were supported to have access to healthcare services and referrals had been made to health professionals for advice and guidance. The home provided a suitable environment and was adapted to meet the needs of people living with a dementia related condition.

People spoke positively about living at the home and told us staff treated them well. We observed warm, kind and caring interactions between staff and people. Staff were patient, unhurried and took time to explain things to people clearly. Staff acted in a professional and friendly manner and treated people with dignity and respect. We observed staff supporting people and promoting their dignity. Staff regularly checked on people to see if they needed support or assistance.

People were encouraged by staff to be independent, and maintain hobbies and interests that were important to them. People were supported and encouraged by staff to access their communities. A comprehensive activities and entertainment programme was available. This helped prevent people becoming socially isolated and provided interest and stimulation. People’s relatives were involved in the care and support of their family member. Care records confirmed their involvement in care planning and reviews.

We saw people were asked for their permission before care and support was delivered and they were offered choices. Meetings were held for people using the home and their relatives. Surveys were undertaken and people’s feedback was acted upon.

A complaints policy and procedure was in place. People and their relatives told us they felt able to raise any issues or concerns. Complaints received by the service were dealt with effectively and the service had recently received a number of compliments. Advocacy information was accessible to people and their relatives.

Care plans were regularly reviewed and evaluated. They contained up to date and accurate information on people’s needs and risks associated with their care. Health and social care professionals were involved in the review process where applicable.

The service had a registered manager who spoke positively and enthusiastically about their role. Staff told us noticeable improvements had been made which had resulted in a positive impact in the quality of service provided. Staff also told us the registered manager was supportive and approachable.

Management regularly checked and audited the quality of service provided and made sure people were satisfied with the service, care and support they received.

Up to date and accurate records were kept of equipment testing. Other equipment and systems were also subject to checks by independent assessors or companies.

Care staff we spoke with told us the management team was approachable and supportive. We received positive feedback from people, their relatives and staff about the management team and how the service was managed and run.

Staff meetings were held regularly. Staff were asked their opinions in an annual satisfaction survey and were satisfied and very positive about their work.

Inspection carried out on 6 and 10 November 2014

During a routine inspection

This inspection took place on 6 and 10 November 2014 and was unannounced. This meant the staff and the provider did not know we would be visiting. We last inspected St Marks Court on 17 and 21 July 2014.

At the last inspection we found the provider was not meeting all the regulations we inspected. We found people’s care and treatment was not always planned in a way that  ensured their safety and welfare; the service had not always taken steps to provide care in an environment that was adequately maintained; there were not enough qualified, skilled and experienced staff to meet people’s needs; staff did not always receive appropriate training and suitable appraisal and supervision arrangements were not fully in place; the systems the provider had in place to monitor the quality of service people received, were not effective, or undertaken on a regular basis. An action plan was received from the provider which stated they would meet the legal requirements by 30 September 2014. At this inspection we found improvements had not been made in relation to three of the five breaches and there were two further breaches of legal requirements.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom are living with dementia. At the time of our inspection there were 45 people living at the home. Accommodation at the home is arranged over three floors. The ground and first floor being dedicated to providing accommodation and care for people requiring general nursing needs and residential care. The second floor is for people living with dementia.

The home did not have a registered manager, as the manager in post was awaiting the outcome of her application for her CQC registration. Following our inspection, the manager received her CQC registration. 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 majority of people at the home, their friends and relatives told us there were not enough staff on duty at important times. Seven of the ten care staff we spoke to told us they felt they were insufficient staff on duty at all times. They said this had an effect on the time they were able to spend with people and had a negative impact on the care and support that they were able to provide. The recording of people’s medicines was not managed safely. Plans to describe how people should be evacuated out of the building in the event of an emergency were not available for each person who lived at the home. Although members of staff told us they completed safeguarding adults training, two care assistants were unable to describe what constituted abuse.

Since our last inspection where breaches of regulation had been identified, we found staff had been receiving regular supervision. However, we found some of the supervision sessions had been undertaken by line managers who had not received training on how to carry out effective supervision sessions. We also noted that no members of staff had received an annual appraisal since our last visit.

There had been an increase in the number of staff who required, or were overdue refresher training, from the previous inspection in July 2014. Six members of staff, including registered nurses and the home manager were overdue their annual medicines training and medicines competency assessments. We also saw that medicines competency assessment certificates were not available for staff who had completed their annual medicines assessment update.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Safeguards (DoLS), and to report on what we find. These laws protect people who may lack capacity and their ability to make/be involved a particular decision at the time it needs to be made. It also ensures that unlawful restrictions are not placed on people in care homes and hospitals. Important decisions are made in the best interests of the people. We found a lack of knowledge and understanding around appropriate assessments and applications to supervising bodies for authorisations.

We were told by three health professionals who visited the home that people were not always supported to eat and drink to maintain their health, as advice and instructions given to staff were  not always followed. We observed there appeared to be a lack of knowledge and confidence amongst the staff about dementia care and the ability of staff to support people with mental illnesses.

People’s care records did not always accurately reflect their needs, or contain sufficient detail or information for staff to provide adequate support. Risk assessments for people who were nursed in bed and had swallowing difficulties and were at risk of choking were not consistently applied.

Current systems to regularly assess and monitor the quality of services or identify, assess and manage risks relating to people’s health, welfare and safety were ineffective. Previously identified breaches of regulations had not led to the necessary improvements required and additional breaches of regulations were also identified during the course of this inspection.

The majority of people and their relatives told us staff treated people with kindness. We saw caring interactions between people and staff and there was a friendly atmosphere around the home. People told us they enjoyed the meals at the home. Recruitment practices at the service were thorough, appropriate and safe. Three members of staff were singled out by a health professional for the care and support they provided and we saw that referrals had been made to the challenging behaviour team in relation to two people. This had resulted in a reduction in the level of distressed behaviour for one person. The majority of staff told us staff morale had improved following the arrival of the new manager at the home. All of the staff we spoke with felt the manager was supportive and approachable.

We have recommended that the service explores the relevant guidance in dementia care and supporting people living with dementia in meaningful activities.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of this report.

Inspection carried out on 17, 21 July 2014

During an inspection in response to concerns

We considered our inspection findings to answer 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?

Below is a summary of what we found.

Is the service safe?

We carried out this inspection in response to concerns we had received about the care and welfare of people using the service. One relative told us, �The staff are very good, but my father�s named nurse who knew him very well, has left. There are now two nurses on every day, but that�s just started and most are from and agency.� Other relative�s comments included, �Staff are very kind and seem to care for the people they look after. However, they seem very stressed and just seem to rush from person to person,� and, �I approached one of the carers about my concerns and was told they could only deliver basic care.� A visiting health professional commented, �There are no regular nurses who know people.�

People were cared for in an environment that was clean and hygienic. The building was clean, secure and other appropriate measures were in place to ensure the security of the premises. Equipment at the home had been well maintained and serviced regularly, therefore not putting people at unnecessary risk. A member of the management team was available on call in case of emergencies.

We found that care and treatment was not always planned and delivered in a way that was intended to ensure people�s safety and welfare. We also found that the service had not always taken steps to provide care in an environment that was adequately maintained. In addition, we found that there were not enough qualified, skilled and experienced staff to meet people�s needs. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the care and welfare of people who use the services, the safety and suitability of the premises and staffing at the home.

Is the service effective?

We carried out this inspection in response to concerns we had received about the care and welfare of people using the service. We looked at how staff were supported to deliver care and treatment safely and to an appropriate standard. One person told us, �The staff are very good and very obliging. They look after me well and they seem confident and competent in what they do.� One relative told us, �Given the current staffing difficulties, I think my mum is very well cared for.� Another relative commented, �The staff all seem really pleasant and very helpful. She always looks clean and well presented, but staff do not have time to spend with people.�

However, we found that staff did not always receive appropriate training and suitable appraisal and supervision arrangements were not fully in place. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staff training, appraisal and supervision arrangements.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. Our observations confirmed this. One person told us, �The care is really good here, the staff are all lovely.� One relative told us, �The staff are always very nice, pleasant and always speak. They are very good with the residents and their care and support is very good.� Another relative commented, �Staff are very kind and seem to care for the people they look after.�

Relatives of people cared for on the nursing unit told us they were concerned about the standards and continuity of care provided. They were aware of recent staff changes, but felt they had not been kept well informed about what was happening in the home.

Is the service responsive?

People's needs were not always assessed before they moved into the home. We found in one instance, this had resulted in a person having no care plans for meeting their needs. Other people had care plans which set out how staff would support them with their physical and mental health and social needs. These included advice given by other health care professionals. However, care plans were not always routinely reviewed or updated in response to people's changing needs.

We saw the provider had a written complaints policy and procedure, which detailed the process that should be followed in the event of a complaint. The registered manager told us, and records confirmed that three complaints had been received by the service within the 12 months. We also noted that five compliments had been received by the service within the last 12 months.

Is the service well-led?

The registered manager for the service had left and the service was being managed by an acting manager.

Staff had a good understanding of the ethos of the home and some quality assurance processes were in place. Relatives were able to complete a customer satisfaction survey. Staff told us they were clear about their roles and responsibilities. The provider undertook some audits and risk assessments to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

The provider had in place systems to monitor the quality of the service people received. However, we found that they were not always effective, or currently undertaken on a regular basis. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to establishing effective quality monitoring systems.

Some relatives and staff told us they felt the quality of services provided at the home had deteriorated. They were concerned about changes in the staff team and leadership. One relative told us, �X (the former manager) was lovely and really good; my mother got on with her very well and we are sorry to see her go. In an ideal world, they should have had a replacement manager in place to take over as she left.�

Inspection carried out on 12 February 2014

During an inspection looking at part of the service

We found action had been taken to improve the personal records of people who used the service. People�s needs were thoroughly assessed and they were involved in decisions about their care planning. Care plans and corresponding records were kept up to date to make sure they reflected the care and treatment that people received.

Inspection carried out on 18, 19 July 2013

During a routine inspection

Some people who used the service had complex needs which meant they could not share their experiences. We used a number of methods to help us understand their experiences, including carrying out an observation and speaking with people who used the service who could share their experiences. During our observation we saw people were treated with consideration and respect.

People told us they were happy with the care which was provided. One person said, �This is a good home; I've been in a few, but I'm happy here." Another person said, "The staff are very good. They look after us well." We spoke with two members of staff. Staff were knowledgeable about people's care needs and what they should do to support them.

There were enough staff to meet people�s needs and appropriate arrangements were in place to manage medicines.

There was an effective complaints system available and people were given information about how to make a complaint.

However we found that records had not been accurately maintained.

Inspection carried out on 26 July 2012

During a routine inspection

We spoke with four people who lived in the home, they told us their choices and preferences were respected. One person said, �I like to and sit in the garden on a nice day�. Another person said, �I choose every day what I�d like to eat, the staff come and ask me each day what I�d like from the menu. It�s important to enjoy your food, and it�s really good here�.

People said that the service supported them to maintain their independence, one person said, �I like to be independent, I can still do things for myself, so why wouldn�t I? When I have a bath staff help me to the bathroom, and they come and get me when I ask, but I do the rest myself�.

All of the people we spoke with told us they were happy with the care which was provided to them. One person told us, �It suits me down to the ground here�. Another person said, �I�ve lived in another home before, but this one is the best�.

People we talked with spoke highly of the staff team within the home. One person said, �The staff are wonderful�. Another person, when talking about the staff said, �The lasses are smashing, I couldn�t fault them�.