Burgess Manor

We found the following examples of good practice.

The home facilitated face to face visits, in line with government guidance. Visiting policies had been updated to reflect the recent changes to government guidance.

The home had a designated visiting area which had its own entrance, this helped keep people safe by minimising traffic within the home. Alternatives to in-person visitation, such as virtual visits, were also supported.

A ‘booking in’ procedure was in place for visitors to the home including a health questionnaire and evidence of a negative lateral flow test. This helped prevent visitors spreading infection on entering the premises.

The home facilitated people to access the community in a safe way. Staff supported people with the use of risk assessments, PPE and good hand hygiene practices.

Individual COVID-19 risk assessments for people and staff at risk had been completed. This helped mitigate the risks of contracting the virus.

People and staff were tested regularly for COVID-19. Staff employed at the home had been vaccinated, to help keep people safe from the risk of infection. Some staff had received their COVID-19 booster vaccinations.

The home had a team of long standing staff, this helped keep people safe by minimising the need to use staff from external sources, such as agency staff.

Infection control policies and procedures helped ensure that the home adopted best practice which complied with current guidance. The home was clean and hygienic. We noted some chipped and damaged paintwork in the communal corridors which could prevent effective cleaning, however, this had already been identified by the registered manager. Plans were in place to continue refurbishing parts of the home.

The home employed full time domestic staff. Cleaning schedules and audits were in place to help maintain cleanliness and minimise the spread of infection.

The home comprised of four units, meaning that during times of a COVID-19 outbreak, any people who were COVID-19 positive could be cared for separately from those with a negative status.

Staff were trained and competent in infection prevention and control best practices and how to put on and take off PPE. The home had adequate supplies of appropriate PPE. Staff had a designated area of the home where they could change into their uniforms and put on PPE before each shift. A COVID-19 policy file was in place which provided staff with up to date guidance.

The registered manager maintained links with external health professionals to enable people to receive the care and intervention they needed. Virtual consultations took place as and when necessary.

People’s experience of using this service

People we spoke with told us they felt safe in the home.

Arrangements were in place for checking the environment to ensure it was safe in relation to infection control and the threat of Covid-19. We found the policies and procedures in place followed current national guidance.

We spent time on the mental health unit as there had been several recent safeguarding concerns involving management of risk and challenging behaviour. People were settled on the unit and any risks in relation to their mental health needs had been carefully assessed.

The home was staffed appropriately. There was a core of long serving staff in the home who had good knowledge and rapport with the people they supported.

Staff had been trained in safe holding and de-escalation, but this had not been updated for some time. The registered manager and the trainer for the company had recently attended external update training and would be rolling this out to staff. We had some discussion around staff support following incidents of restraint and the registered manager assured us this would be included in any updated policy for the home. Episodes of restraint were minimal and were carefully recorded and monitored through the home’s quality assurance processes.

There had been settled management of the home since the last inspection. People felt the care staff had the skills and approach needed to help ensure they were receiving the right care. Staff we spoke with felt supported by the registered manager and enjoyed working at Burgess Manor.

Rating at last inspection:

The last rating for this service was Good (published 23 January 2020).

Why we inspected:

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. A decision was made for us to inspect and examine those risks. We had concerns about the way the provider was managing policy and practice related to infection control; specifically, around COVID19. We also received some safeguarding concerns about the way staff responded to managing clinical risk for people.

The Care Quality Commission have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about.

Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

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

Fleetwood Hall is a residential care home providing personal and nursing care to 41 people at the time of the inspection. The service is registered to support up to 53 people.

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

There was a manager in post. They already worked for the organisation and had submitted their registration forms to CQC. There was a temporary manager who had been managing the home for the last few months with support from senior managers and a registered manager from another home. Most people knew who the new manager was and told us they had introduced themselves. Other people said there had been different managers and they were not sure who was who. Staff we spoke with said they felt well supported by the management. The temporary manager and the supporting managers worked well together to ensure the service was running as well as possible and information was up to date and actions and audits were being completed.

People told us they felt safe. There were some mixed comments around staffing, which we raised with the manager at the time of our inspection. They assured us they would look into this. Medication was stored and administered correctly. People told us they received their medication on time. Risk assessments were detailed and informative and gave clear and accurate instruction on how to minimise risk of harm occurring. Checks and maintenance were routinely carried out, and infection control procedures were robust.

People’s capacity had been assessed and recorded. Their ability to contribute to important decisions regarding their care and support had been considered, and best interest meetings were held if required. Rationale for any decisions made on someone’s behalf was recorded in their plan of care and more formally in the DoLs authorisations. Care plans did not always evidence involvement, however people told us their care was discussed with them. The food had improved in the last few weeks, and they were able to choose what they ate. Where people needed support with specialist diets, this was clearly documented and guidance from Speech and Language Therapy (SALT) teams was written into their care plans.

We observed staff treated people kindly, and the comments we received from people confirmed this. People's personal items were treated with care and the staff kept inventories of people’s possessions. Equality and diversity needs were considered, and people had freedom to choose how they spent their day. Some activities were tailored around people’s hobbies and interests. People told us staff respected their privacy and knocked on doors.

On day one of our inspection we raised some concerns with the managers which people had discussed with us. We saw on day two of our inspection these concerns had been dealt with appropriately. People’s care plans were personalised and contained a good level of information around their likes, dislikes and backgrounds. There was a complaints procedure in place, and people told us they knew how to complain. We tracked some complaints through and saw they had been responded to in line with the policy. Staff were trained in end of life care and support. People told us there were activities on offer and we saw people being support with activities during our inspection.

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

Rating at last inspection

The last rating for this service was requires improvement (Published 21/02/2019)

Why we inspected

The inspection was prompted in part due to some anonymous concerns we received about the environment, infection control, staffing concerns, and management not addressing issues. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from these concerns.

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.

People’s experience of using this service:

Quality assurance procedures had improved since we last inspected the home in January 2017. This is because more thorough action plans were being produced when audits identified areas of improvements.

People told us they felt safe living and Fleetwood Hall and we received positive feedback from everyone except one person, which we shared at the time with permission.

People said there was enough staff, although there was still some dependency on agency staff for some of the shifts. Staff were recruited safely and checks took place on their character and suitability to work. incidents and accidents had been appropriately documented and a detailed analysis of the incident was completed by the manager.

Risk assessments were in place and contained detailed information with regards to the action the staff were expected to take to minimise the risk of harm.

The environment and equipment was safe and well maintained. There were compliance checks for gas, electricity and legionella and emergency evacuation plans were in place to ensure people were safe in the event of a fire. Medications were managed and administered safely. We raised that some creams, although they were being applied correctly, would benefit from being stored more securely in locked boxes.

The home had recently been audited by infection control and there were some actions points which required addressing. We viewed the action plan and saw that the registered provider had taken action to address most areas. Further improvements were being made to sluice areas.

There was an improvement plan in place to address some of the décor in the home, however, we saw that the unit for people living with dementia needing improving and we have made a recommendation about this.

People were being supported in line with the principles of the Mental Capacity Act. Best interest meetings were in place for people who required them.

Staff were trained and supervised in line with the registered providers policies and procedures. Some of the training percentages required improvement, however the registered provider had identified this on a recent audit and this was being addressed.

Most people told us they enjoyed the food and were offered a choice of food. People were screened for the risk of developing malnutrition and staff were keeping records in relation to this. We did raise that some records were incomplete, this was rectified on day one of our inspection.

People said the staff were caring, one person raised a concern which we followed up with permission at inspection. Care plans demonstrated people had been involved in them. People could choose how they spent their time at the home.

Care was personalised to suite people routines and choice. People were assessed before they moved into Fleetwood Hall.

Complaints were recorded, investigated and responded to in line with the registered providers complaints procedure.

There was no registered manager in post at the time of our inspection. The role had been temporally filled by the deputy manager, whom staff were complimentary about and said they felt happy to raise any concerns with them.

The registered provider showed openness and transparency regarding some of the ongoing improvements required at the service and there was a plan in place to address these. The service had improved since the last inspection and was not in breach of any legal requirements.

Rating at last inspection: Requires Improvement. Report Published 22 January 2018.

Why we inspected: This inspection was planned in accordance with our inspection programme.

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.

Fleetwood Hall is a ‘care home’. People in care homes receive accommodation and nursing or 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.

Fleetwood Hall accommodates 53 people across five separate units, each of which had separate adapted facilities. One of the units specialises in providing care to people living with dementia, and is split into a male and female side. The other unit specialises in supporting people with mental health needs, and is also split into male and female sides.

At the time of our inspection there were 43 people living in the home.

A registered manager was 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 home had a focused inspection in June 2017 to follow up on breaches from the previous comprehensive inspection. We found that the home had met the breaches however was still rated requires improvement. Following this inspection the home was rated as Requires Improvement overall.

This is the second consecutive time the service has been rated Requires Improvement.

Systems relating to governance arrangements were not always robust. We saw numerous incident forms and audits across the service provision which required further action to be taken which were not fully completed. This meant we could not always be sure who was responsible for overseeing that action plans were adhered to. We did see a new auditing system which had just been introduced which was more robust, however, that had not been implemented yet. Therefore, we could not check its effectiveness at this inspection. We spoke at length to the registered manager and director about this during our inspection.

There was a process in place to document, analyse and review incidents and accidents. We saw that the records were not always clear in relation to incidents and accidents and some of the information was missing. This made it difficult to see if patterns and trends had been identified. We have made a recommendation regarding this.

We saw that all checks on the environment were being completed. We did however receive a concern during our inspection that the key coded gate was not locked as it should be. On the second day of our inspection we saw that the gate was unlocked, so we raised this with the registered manager who took immediate action to rectify the problem.

Staff were able to describe the process they would follow to ensure that people were protected from harm and abuse. All staff had completed safeguarding training, some were due refreshers which were being booked. There was information around the home which described what people should do if they felt they needed to report a concern.

We discussed some recent safeguarding concerns with the registered manager to ensure that improvements had been made as a result of concerns raised. We saw some evidence that lessons had been learnt as a result of these.

Risk assessments were in place and were reviewed every month or when there was a change in people's needs. We saw risk assessments in place to manage people's mobility needs, falls, pressure areas, personal care and mental health and behaviour. Risk assessments were linked to an accompanying plan of care which was informative and fully described how staff were required to support the person.

We saw that rotas were fully staffed; however there was a heavy reliance on agency staff. The registered manager had a process in place to recruit new staff and we saw that some new staff were due to start working at the home. Most of the agency staff were used regularly. This meant that they were familiar with the service.

Medication was managed, administered and stored securely by registered nurses on each unit. Each person had a medication file in place which contained information about them and their preferences for taking medication.

There were domestic staff around the home ensuing that rooms and bathrooms were kept clean. There was hand gel available around the home and personal protective equipment (PPE) for staff to use to prevent the spread of infection.

People's needs and choices were assessed prior to them being admitted to the home.

The training matrix showed that staff were trained in all subjects which were mandatory to their role, and as stated in the provider's training policy. We saw however, that the provider had introduced so much new training at once and not separated it from the mandatory training. This meant that it affected the overall percentage of staff trained as some staff had not been able to complete these additional training courses yet.

Staff received regular supervision and appraisal.

People were supported to eat and drink in accordance with their needs. People, who were assessed as at risk of weight loss, had appropriate documentation in place to monitor their food and fluid intake. Where specialist diets were needed for some people, the chef had good knowledge of this.

The service worked in conjunction with physiotherapists, registered mental health nurses (RMN')s psychiatrists and tissue viability nurses to ensure people had effective care and treatment.

Everyone had records in their files relating to external appointments with healthcare professionals such as GP's, opticians or chiropodists. The outcome of these appointments was recorded in people's records.

Most areas of the home and some people's bedrooms had been refurbished to a high standard. The dementia unit had directional signage and there was additional refurbishment plans in place.

The service was operating in accordance with the principles of the Mental Capacity Act (MCA). Applications to deprive people of their liberty had been appropriately made following best interest decisions.

We observed kind and familiar interactions between staff and people who lived at the home.

People were consulted with and involved in key decisions regarding their care and support.

Care plans were written in way which encompassed people's diverse needs, maintained their dignity and respected their right to choose.

There was information with regards to people's backgrounds, routines and preferences and this was all recorded in their plan of care. Care plans viewed demonstrated that people were getting the care which was right for them in accordance with their assessed needs.

Complaints were documented and responded to in line with the provider’s complaints policy. People we spoke with told us they knew how to complain. The complaints procedure was displayed in the communal areas of the home.

People who required end of life care were supported at the home and staff had received training to enable them to care for people sensitively and with compassion.

The service worked closely with the local authorities and hospitals to support hospital discharges.

People were positive about the registered manager and the directors. Most incidents had been reported to CQC as required. However we saw that two incidents had not been reported appropriately. We spoke to the registered manager about this at the time of our inspection.

Feedback from staff and people who lived at the home was positive regarding the registered manager and the directors of the service. We saw there had been lots of improvements regarding the environment of the home, most of which were still on-going.

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

Fleetwood Hall is a large care home set in its own grounds on the outskirts of Southport. The home is registered to provide accommodation for up to 53 people across three units. The units include:

a mental health unit that can accommodate men and women (separately) with enduring mental health needs, a dementia care unit that can accommodate six men and women and a general nursing unit for up to 14 people, both men and women.

The service was last inspected in November 2016, and at that time was found to be in breach of regulations 12 and 11 relating to safe care and treatment and consent. We had also made a recommendation under the ‘well-led’ domain with regards to the effectiveness of quality assurance systems. Following the inspection the provider sent us an action plan detailing what action they were going to take to address the concerns we found. We checked this as part of this inspection.

This inspection was ‘focussed’ in that we only looked at the two breaches of regulations to see if the home had improved and the breaches were now met. We also checked if quality assurance procedures had improved. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover only three of the domains we normally inspect whether the service is 'Safe' ‘Effective’ and ' Well led'. The domains ‘Caring’ and ‘Responsive’ were not assessed at this inspection.

During this inspection we found that improvements had been made and the provider had taken action to address the concerns raised at the last inspection. Care plans were easy to read and follow, and information was accurate, complete and up to date. Additionally, documentation around people’s capacity was updated and recorded. The registered manager had also attended an advanced course in the principles of the MCA (Mental Capacity Act). The provider was no longer in breach of these regulations. We checked the quality assurance procedure during this inspection to ensure its effectiveness had improved since our last 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.

At our last inspection in November 2016, the service was in breach of regulations in relation to safe care and treatment. This was because some records relating to people’s care and treatment were disorganised, missing, or lacked a sufficient amount of clinical detail about that person. After the inspection the provider sent us an action plan detailing what action they were going to take and we checked this as part of this inspection.

The records we saw during this inspection had been re-organised into coloured coded sections. This made it easier to find information. Care plans and risk assessments had also been recently reviewed. The provider was no longer in breach of this regulation.

At our last inspection in November 2016, the service was in breach of regulations relating to consent. This was because the registered manager did not have a full awareness of DoLs and any conditions on people’s DoLs were not being appropriately managed. Best interest processes were not being considered for some people who did not have capacity to make decisions around their care. Following our inspection the provider sent us a list of actions detailing what steps they were going to take to address this, and we checked this during our inspection. We found that sufficient improvements had been made, and the provider was no longer in breach of this regulation.

During our last inspection, we found that procedures relating to the governance of the service had improved enough for the provider not to be in breach of regulation; however we did make a recommendation regarding this due to the inconsistencies we found with risk assessments and the MCA. We checked the providers approach to quality assurance at this inspection to see if any improvements had been made. We saw that the registered manager had adapted their quality assurance process to ensure that clinical information was checked and updated, also the nurse in charge was issued actions if there was anything which required following up. There was a new file in place which contained all the people who were subject to DoLS at the home, the application stage, and any conditions. This file was audited as part of the quality assurance process.

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

The home was last inspected in March 2016 and judged as ‘inadequate’ overall and placed into ‘Special Measures.’ We identified eight breaches of the regulations. These were in relation to safe care and treatment, dignity and respect, staffing, person centred care, governance, complaints, safeguarding and consent. We imposed a condition on the provider’s registration to stop admissions into the home until the provider was compliant with the Health and Social Care Act 2008. This unannounced inspection took place to check if the provider had made enough improvements to enable us to remove the restriction on admissions to the home.

Fleetwood Hall is a large care home set in its own grounds on the outskirts of Southport. The home is registered to provide accommodation for up to 53 people across three units. The units include: a mental health unit that can accommodate men and women (separately) with enduring mental health needs, a dementia care unit that can accommodate six men and women and a general nursing unit for up to 14 people, both men and women

At the time of the inspection 26 people were living at the home.

A manager was present at the time of inspection but had not yet completed their registration with us. 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.

Care plans had been re-written and contained relevant information for most people, however we still found some inaccuracies in care plans where information was either incomplete or inaccurate. We spoke to the manager about this and they have assured us they were taking action to address this for everyone at the home. The provider was still in breach of regulation.

At the last inspection we raised concerns regarding the staffing levels in the home. The provider was in breach of regulations relating to this. Some people now told us that the use of agency staff had decreased in the last few months, and there was a more consistent staff team. Staff told us they felt there were sufficient numbers of staff available to be able to complete their roles effectively; we did not observe anyone being left waiting for assistance in any of the units throughout the day. The provider was no longer in breach of this regulation.

Previously we raised concerns about staff’s understanding of the Mental Capacity Act (MCA) 2005. At this inspection staff had a good understanding of the Act and associated principles. We found the provider had improved in this area however there were still some inconsistencies with how the MCA was applied. The provider was still in breach of this regulation.

During our last inspection we raised concerns around people’s dignity and safety. People living at the home and their relatives told us they now felt safe. The provider had made various improvements in these areas, which included separating the male and female units in the home to help protect people’s dignity. These units provided mixed accommodation at the time of our last visit.t. The women living on these units told us this segregation was better as they felt comfortable in their home and their dignity was protected. The provider was no longer in breach of this regulation.

At our last inspection we found that people were not always protected from abuse and the provider was in breach of regulations relating to this. We found that the procedure for reporting and acting on safeguarding’s had improved since our last inspection in March 2016. Records and certificates showed that all staff had completed training in this topic and were able to describe to us the action they would take if they felt someone was being harmed or abused in anyway. The provider was no longer in breach of this regulation.

During our last inspection we found that procedures were not robust and found errors with regards to the recording of medication which put people at risk of harm. During this inspection we looked at the procedure for storing, administering and recording medications. We found this had improved and people were now receiving their medications safely. We found medicine procedures were robust and changes had been made, including additional medicine training for registered nurses (RN’s) and regular medicine audits by the manager. The provider was no longer in breach of this regulation.

During our last inspection, we identified that not all staff had received fire safety training and observed that some doors were being wedged open which was a potential fire hazard. At this inspection we saw that regular checks were being completed on the building, including fire safety checks. We saw that fire doors were now kept closed, and not ‘wedged’ open; the provider was no longer in breach of this regulation. All staff had received fire safety training; this was updated in the records we saw.

During our last inspection we found that staff did not always have the right training to support people and were not engaging in regular supervision. We identified a breach of regulation. During this inspection we saw that staff had been trained in subjects such as safe holds, (which is a form of restraint) safeguarding, fire safety and medication. We asked staff about their training and all staff confirmed they had attended training in the last few months and they felt this had improved their skills. We saw that staff were also attending regular supervision sessions and saw a supervision schedule on the notice board in the office. The provider was no longer in breach of this regulation.

We found during our last inspection that family members and people who lived at the home were not involved in decisions about their care and support, and the provider was in breach of this regulation. We saw that some improvements had been made, however two family members told us they were not always involved and would like to be more included. Other people told us they were now involved with their plan of care which had been discussed with them. We discussed this with the manager who was taking action to ensure family members were more involved, this includes setting up a family stirring group, chaired by one of the family member’s. We saw this was work in progress and the manager was in the process of developing a feedback involvement form to send out to families. We found that enough improvement had been made so that the provider was not in breach.

During our last inspection, we found that recreational activities were not taking place which were meaningful or person centred, which meant that people were not receiving a person centred service. We saw during this inspection that this had improved. There was now a ‘Sky Café’ where people and their families could choose to have Sunday lunch together, a hairdressing salon and a bar. We saw that regular functions had taken place and we observed people from other parts of the home having a ‘dinning’ experience in the sky café. We saw on one of the units people were making Christmas decorations. There was a clear ongoing plan for activities and people had been consulted with to ask them what they would like to do. The provider was no longer in breach of this regulation.

During our last inspection we identified that some complaints had not been responded too and family members did not feel listened too. We saw at this inspection complaints were being well recorded and managed. We received feedback from family members that this had improved. The provider was no longer in breach of this regulation.

During our last inspection, we identified a breach of regulation in relation to inconsistencies in the information recorded via the quality assurance system. At this inspection we checked the home’s procedures for effective quality assurance. The quality assurance process had become more robust and the manager was more involved in audits and incident reporting so they had a good knowledge of what was going on in the home. The manager showed us a new quality assurance tool they were implementing, which encompassed more robust checks on care plans. The home’s current quality assurance systems and processes however still need some further development as they had not picked up some of the issues we found relating to care planning and the MCA. The improvements made to date also need time to embed to ensure a consistent approach for the development of the service.

Everyone told us they felt safe at the home, and they liked the staff that supported them.

People told us they enjoyed the food and were given a choice about what they ate.

The overall rating for this service is ‘requires improvement’. To achieve a rating of good would require a longer time frame to ensure all improvements have been implemented. We will review this on our next inspection.

Following this inspection we have removed the notice to restrict admissions and the service had begun a phased admissions process which was being monitored by ourselves and partner agencies

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

The home was inspected in January 2015 and judged as ‘inadequate’ overall. We identified eight breaches of the regulations. The provider (owner) agreed not to admit any people to the home while the breaches in regulation were being addressed. We inspected the home again in July 2015 and judged it as ‘Requires improvement’ overall. While significant improvements had been made since the inspection in January 2015, we did not revise the ratings for each domain above ‘Requires improvement’. To improve a rating to ‘Good’ would have required a longer term track record of consistent good practice. However, we did identify one breach of the regulations.

Fleetwood Hall is a large care home set in its own grounds on the outskirts of Southport. The home is registered to provide accommodation for up to 53 people across three units. The units include:

• A mental health unit that can accommodate men and women with enduring mental health needs

• A dementia care unit that can accommodate six men and women

• A general nursing unit for up to 14 people, both men and women

At the time of the inspection 33 people were living at the home.

A registered manager was 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.

Effective recruitment processes were in place to ensure new staff were suitable to work at the home. Staff told us they had not received supervision or an appraisal for some time. Staff training was not up-to-date.

Women told us they did not feel safe living at the home. They said they felt unsafe around some of the men. The previous separate male and female mental health units had been brought together and men and women were sharing the same lounge areas and bathrooms/toilets. Women told us they did not like sharing these facilities with men. Although signs were put on doors on the second day of our inspection to separate out male and female toilets, staff said some men may not adhere to this due to needs associated with memory. Staff told us some people stayed in their bedrooms because of other people living there who presented with unpredictable behaviour that was challenging.

The system to manage and monitor incidents was not robust, including the process for analysing incidents as it did not lend itself to the clear identification of any emerging themes. The incident monitoring system was not identifying the level of risk that we identified during the inspection.

There was limited understanding amongst managers, registered nurses and care staff about what constituted adult safeguarding. Training records showed the majority of the staff team were not up-to-date with safeguarding training. We found numerous incident reports that should have been reported as safeguarding concerns but had not. The adult safeguarding policy did not reflect local area procedures.

Registered nurses and care staff working on the units could not definitively tell us how many people were being lawfully deprived of their liberty. Staff had not received awareness training regarding consent and mental capacity. Mental capacity assessments were completed in a generic way and were not specific to the decision the person needed to make.

People living at the home told us there were not enough staff on duty at all times. Equally, visiting families and staff said there were insufficient numbers of staff on duty at all times to ensure people’s safety and to facilitate recreational activities. From our observations, we concluded there were not enough staff on the mental health unit at all times to sufficiently minimise risk.

The management of medicines was not robust and we found numerous errors in relation to the administration, storage and monitoring of medicines. The home’s medicines audits had not identified the discrepancies we found. Covert (disguised in food or drink) medicines were not being given in accordance with the home’s medication policy and the principles of the Mental Capacity Act (2005).

People and families were satisfied with the quality of the food and the choice of meals available.

People told us they had access to a range of health care practitioners when they needed it. Families confirmed this. We found care records, including assessments and care plans did not always reflect people’s current needs and these discrepancies had not been identified through the home’s internal auditing processes.

People living at the home told us there was nothing much to do. They said they liked the group trips out in the mini-bus that happened sometimes but said they did not have activities planned specifically around their hobbies, interests and preferences.

People and families told us they were not involved in developing or reviewing care plans. In addition, they said their views about the service and how it could be improved upon had not been sought.

A complaints procedure was in place but it was not effective as there were mixed views about how many complaints had been received. A complaint made by a family in February 2016 had not been acknowledged.

Arrangements to monitor the safety of the environment were not rigorous. Parts of the flooring on the corridor in the mental health unit moved about, which was a risk to people who used mobility aids. Staff said it had been reported to maintenance but there was no record of this. We found fire doors wedged open on the mental health unit.

There had been a number of management changes in recent years and staff told this was unsettling and impacted on morale. The registered manager acknowledged that there were shortcomings with the service, particularly in relation to staff culture and out-dated practice. The registered manager and provider had already started to address these issues. However, it was too early to see the impact these changes were having in ‘turning the service around’.

Systems to monitor the quality and safety of the service were ineffective. Audits and checks of the service had not picked up on serious issues we identified. Operational policies we looked at did not always reflect local practice and/or local/national guidance.

The provider was not informing the Care Quality Commission (CQC) of all the events CQC are required to be notified about.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We are taking action to protect people due to the significant concerns found at this inspection and will report on our action when it is completed.

' 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. The summary is based on our observations during the inspection, discussions with people who lived at the home, their relatives, health care professionals, staff providing support and looking at records.

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

Is the service safe?

Safeguarding measures were in place to help keep people safe and staff understood how to safeguard the people they supported.

Incident and accidents were recorded. To date there had been no formal audits [checks] to identify themes or patterns and to help protect people. Following the inspection we were informed that the incident form had been amended to record actions and outcomes, as part of monitoring incidents.

The home protected the rights and welfare of the people in accordance with the Mental Capacity Act [2005]. At the time of the inspection there were a number of Deprivation of Liberty Safeguard [DoLS] plans in place to keep people safe. DoLS is part of the Mental Capacity Act and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom.

On occasions there were not sufficient numbers of suitably qualified staff to ensure people's care needs were being met. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring sufficient numbers of skilled and experienced staff are available to care for people at the home.

Is the service effective?

People's health and care needs were assessed with them where possible and/or with family/representatives. They were involved with writing up their plan of care. We looked at a number of care files and found some care plans were not detailed or there was no plan of care for specific care needs. Care plans were therefore not able to support staff consistently 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 ensuring sufficient information is recorded to support people with their care needs.

Visits were conducted by external health professionals and records were maintained of these visits, as part of monitoring people's care provision.

Visitors confirmed they were able to see their family member in private and that they were able to visit the home at any time.

Is the service caring?

People who lived at the home told us the staff were kind and attentive. Their comments included, 'Very good staff', 'The staff are nice to be around' and 'I feel settled here.' We saw staff encouraging people with daily activities and providing support as needed. People told us they could choose how to spend their day and we could see people's preferred choices and wishes were respected. Examples of these were meal choices and time of getting up and retiring at night.

Relatives we spoke with told us the staff kept them informed about their family member's health and care provision. A relative said, 'The slightest change and they let me know.'

Is the service responsive?

We could see from the care records that people's treatment and care was regularly reviewed by a multi-disciplinary health team. The service worked well with other agencies and services to make sure people received their care in a joined up way.

People told us they could see their GP if feeling unwell and the staff were prompt in arranging appointments for them.

People told us they felt confident to approach the manager if they had any concerns or complaints about the service. We found there had been no complaints made to the home since our previous inspection visit.

Is the service well led?

It was clear that the home carried out some safety checks and audits and the manager was in the process of developing a more comprehensive quality assurance system. Current systems in certain areas however, were not as robust as they needed to be to monitor the quality and safety of the service. On this visit we highlighted aspects of the quality of some care records, the environment, staffing and staff support. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people benefit from an effectively run service.

At the time of our inspection there was a new manager in place. The new manager was in the process of applying to the Care Quality Commission [CQC] for the position of Registered Manager. The Registered Manager stated on the report no longer works at the home and will be required to submit an application to CQC to deregister.

We observed that staff were attentive and responsive, interacting with people in a positive and meaningful way. There was a calm and relaxed atmosphere in the home throughout the inspection. One of the people living there told us, 'It is a relaxed and chilled home.'

People's care records informed us that individualised needs assessments, risk assessments and care plans had been developed. These were regularly reviewed to reflect people's changing needs.

There were sufficient numbers of staff available to support people with their individual needs.

Processes were in place for managing and responding to people's concerns and complaints.