Palm Court Nursing Home

Palm Court Nursing Home is a residential care home providing personal and nursing care up to 53 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 40 people using the service.

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

The service had recently implemented a new care planning and recording system which was not yet embedded into staff practice. Improvements were needed to reporting processes to ensure that accidents and incidents were correctly identified and investigated appropriately. People's care plans and risk assessments needed work to ensure they contained accurate information on how to support people safely.

People's daily records did not accurately reflect the care and support they were receiving or events that happened throughout the day. Recording was inconsistent, incomplete and there was a risk that information needed to keep people safe was being missed.

People were not always provided with person-centred care. Activities provided for people were not sufficient to keep people engaged. Staff did not always respond to people appropriately when people were upset. Guidance for how staff should support people if they became anxious or distressed was not clear. People and their representatives had not been given the opportunity to contribute to care planning and relatives wanted to be able to attend meetings at the home with other relatives.

There were enough staff to support people safely and staff knew people well. Improvements had been made to infection prevention and control processes as well as the environment. People were being admitted to the service safely. Some improvements had been made to governance and oversight.

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

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 2 February 2023) and there were breaches of regulation. CQC served a Warning Notice to the provider following this inspection relating to concerns around safe care and treatment, person centred care and governance.

At this inspection we found that although improvements had been made in some areas, the provider remained in breach of regulations.

Why we inspected

We undertook this comprehensive inspection to check whether the Warning Notice we previously served in relation to Regulations 9, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection.

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

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Palm Court Nursing Home on our website at www.cqc.org.uk

Enforcement

We have identified breaches in relation to safe care and treatment, person centred care and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Palm Court Nursing Home is a residential care home providing personal and nursing care to up to 53 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 34 people using the service. At the time of our inspection, only the ground floor was being used.

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

We identified widespread failures around the governance of the service. Audit systems and processes failed to identify risks to people's safety and other aspects of the service that required improvement. Improvements in relation to the environment, oral hygiene and accurate record keeping had not been made since their last inspection. Additional concerns were identified during this inspection in relation to reporting of incidents and person-centred care. Records did not accurately reflect the care people received.

People were not always safe from environmental risks. The home was not always clean and hygienic, and some furniture and fixtures were broken. People were at risk of injury from bed rails being used inappropriately. Although risks around people's health conditions were being safely managed, people's risk assessments did not always reflect current risks. Unexplained injuries had not always been investigated appropriately to identify the cause and reduce the risk of injuries reoccurring. People's fluid intake was not being recorded consistently or effectively.

People were not always receiving person-centred care. Systems to keep people's care plans up to date were not effective and people's care plans were not always relevant. People were not being admitted to the service safely. Activities were not always person-centred and there were limited opportunities for interaction and engagement for people who spent time in their rooms. People were not being appropriately supported with oral hygiene.

Although the management of people's topical creams required improvement, other aspects of medicines were managed safely. Staff received training before supporting people with their medicines and medicine records were completed. There were enough staff to support people and staff were recruited safely.

Staff spoke to people with kindness and in accordance with people's communication needs. The registered manager responded appropriately to complaints and suggestions made to improve the service.

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

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 13 December 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections. This service has failed to achieve a good rating over the last ten consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 25 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

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 and well-led which contain those requirements. We also looked at the responsive key question.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to safe care and treatment, person-centred care, good governance and reporting at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. There was a lack of oversight at present as the improvements identified through audits were not prioritised and completed. For example, care plans, risk assessments and fire safety risk assessments.

Daily notes and care records were not completed consistently, Gaps were found in food and fluid charts meaning staff would not have an accurate overview of their food and fluid intake. Peoples’ oral health was not consistently monitored to ensure good practice was consistently followed.

There were some people who did not have sufficient clear information documented regarding their care needs to keep them safe and promote their well-being. Areas of risk management of peoples specific health needs were not reflected in care plans and risk assessments leaving people at risk from uninformed staff. For example, diabetes, and wound care.

Areas of the management of fire safety needed to be improved. Bedroom doors were found wedged open which was not included in risk assessments and we found stairs were blocked by moving equipment, which would impede an evacuation in the case of fire.

People received care and support from sufficient numbers of staff who had been appropriately recruited and trained to recognise signs of abuse or risk. One visitor said, “There always seems to be enough staff, from what I’ve seen I think they are amazing with them. I’ve seen the care the staff provide – I think it’s first class.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.

The home was clean and hygienic. There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and that staff supported them with the lateral flow test and personal protection equipment (PPE). There were some areas that required review such as the storage of PPE, staff disposal of PPE and a dedicated area for visitors to change. We have signposted the provider to resources to develop their approach.

Referrals were made appropriately to outside agencies when required. For example, GPs, community specialist nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

Feedback from families was very positive, and included, “I can sleep at night, I don’t have to worry about them. Their clothes and room are always well cared for.”

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

Rating at last inspection and update:

The last rating for this service was Requires Improvement (published 08 September 2020)

Why we inspected

This inspection was prompted due to information received of risk and concern to fire safety, cleanliness and management of risk which had impacted on care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The concerns raised were looked at during this inspection and have been reflected in the report.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led questions of this full report.

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

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.

Palm Court Nursing Home provides personal and nursing care for up to 53 people. There were 35 people living at the service when we inspected, most of whom were living with dementia.

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

Following the last inspection in August 2020, the provider sent us their action plan. This included information about the steps they had taken to make improvements to the home.

The home was clean and hygienic and there was a designated housekeeping team. However, improvements needed to be made to the cleaning of frequently touched surfaces. Some communal bathrooms had items in them that needed to be removed.

Staff were wearing personal protective equipment (PPE) and were seen to wear masks at all times, however we observed that one staff member was not always following safe PPE practices. We informed the registered manager who assured us this would be addressed. Staff received competency checks around putting on and taking off PPE safely.

People living at the home were supported to social distance from each other. Chairs in communal areas were spaced out to encourage this. Small groups of people were supported to spend time in the lounge each day.

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

Rating at last inspection and update

The last rating for this service was requires improvement (9 September 2020) and a breach of regulation was found in relation to infection control. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found that improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

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

The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC 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.

Palm Court Nursing Home provides nursing and personal care for up to 53 people, most of whom were living with dementia. There were 33 people living at the service when we inspected.

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

Following the previous inspection in February 2019, the provider sent us their action plan. This included information about the steps they had taken to make improvements at the home.

The home was clean and tidy and there were designated housekeeping staff. However, the provider had not ensured that Personal Protective Equipment (PPE) was being worn in accordance with current government guidance to help prevent the risk of Covid-19, this meant people and staff were at risk in relation to the spread of infection. This had not been identified through the audit system.

We have made a recommendation about staff understanding of how to report a safeguarding externally. We have made a recommendation to ensure the provider and registered manager continually update their knowledge of government guidance and best practice.

Quality assurance systems had been introduced and were continuing to be developed and improved. This included audits of medicines, accident and incidents, care documentation and charts completed for peoples care and support needs and the environment.

The provider, registered manager and staff team had worked hard to address the areas for improvement following the last inspection in February 2019. Medicine systems had been overseen by the registered manager and improvements implemented to ensure medicine procedures were safe. As required (PRN) medicines were recorded including the reason for administration. Documentation was recorded in relation to people’s individual risk. For example, skin integrity, pressure area and wound care. Information regarding behaviours that may challenge were included in people’s care plans including appropriate charts completed to document when incidents occurred. Risk assessments provided guidance for staff about individual and environmental risks.

There were enough staff working to provide the support people needed. Recruitment procedures ensured only suitable staff worked at the service.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 14 June 2019). There were two breaches of regulation. Regulation 12, Safe Care and Treatment and Regulation 17 Good Governance. We told the provider to make a number of improvements. At this inspection, although significant improvements had been made in a number of areas including care documentation, medicines and governance, the provider remained in breach of regulation 12, Safe Care and Treatment. This was because the provider and registered manager had not followed national guidelines in response to the Covid-19 pandemic.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 13 and 14 February 2019. Breaches of legal requirements were found for Safe Care and Treatment and Good Governance. We placed a condition on the provider’s registration which meant that the provider was required to send a monthly report to CQC of all new people admitted to Palm Court Nursing Home. Information requested included the admission date, a brief summary of each person's care needs and the name of the person who carried out the assessment. The provider was also required to ensure there was a suitably qualified, and competent person, to undertake oversight of medicines management at Palm Court and to provide monthly audits to the CQC. After the last inspection the provider completed an action plan to show what they would do and by when to improve.

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 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 remained Requires Improvement. This is based on the findings at this inspection.

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

Enforcement

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. Please see then action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Palm Court Nursing Home provides accommodation for up to 53 people in one extended and adapted building. Nursing care is provided to people who have nursing needs; most people were living with dementia. There were 25 people living at the service when we inspected. Since our last inspection the provider had agreed with the local authority that there would be no new admissions to the service until the health and safety arrangements were addressed.

At inspections carried out in September 2016 and June 2017 the home was rated Inadequate and placed and remained in special measures as there were continued breaches of Regulations. CQC took enforcement action in accordance with its procedures. We met with the provider and asked the provider to complete an action plan to show what they would do to meet the requirements of the Regulations. We received the provider's action plan and we followed up on breaches at an inspection in November 2017. At that time improvements had been made and although there was still a breach of Regulation 17, the home was rated Requires Improvement overall.

Our last inspection was carried out on 19 and 24 July 2018 and we rated the service Inadequate. The home was placed into special measures again. This was because we found breaches of Regulation 12 in relation to safety and Regulation 17 in relation to good governance.

We carried out this inspection on 13 and 14 February 2019 and found that although improvements had been made in many areas, there were still areas in relation to the management of medicines and to governance that had not sufficiently improved and were continuing breaches of Regulations 12 and 17. We also found that there was a lack of stimulation and meaningful activities for people and we made a recommendation to improve this area.

The registered manager had left their position in June 2018. 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. A new manager had been appointed and started in post on 2 July 2018. At the time of our inspection their application for registration was being processed and the manager has since become registered.

Concerns with the management of medicines mainly centred on the management of medicines prescribed on an as required (PRN) basis for the management of agitation as it was not always possible to see why medicines had been given. Linked with this was a lack of documentation in relation to records that demonstrated actions taken by staff to support people with behaviours that challenged before resorting to medicines. We found that whilst auditing had improved in many areas these had not identified areas we found on inspection, for example in relation to the management of medicines and shortfalls in recruitment records. Further time is needed to build on the progress made and to fully embed new systems into every day processes. Improvements were also needed to ensure people were offered regular opportunities for person centred activities.

Significant progress had been made in relation to the management of health and safety. All equipment was now serviced and inspected regularly and the records demonstrated that when faults were noted they were addressed in a timely manner.

Care plans provided detailed advice and guidance about how people’s needs should be met and we saw that staff were kind and caring and supported people in a way that suited their needs. One person told us, “Yes the staff are very kind and caring, always treat me with respect and dignity yes, knock on my door.” A relative told us, “Definitely the staff are kind, caring and patient with her, they know her needs well, she is always treated with dignity and respect, never seen it otherwise.”

People were supported to attend health appointments as needed and referrals were made for further advice and guidance when appropriate. For example, if someone experienced swallowing difficulties or if there was a concern about someone’s skin. A professional told us, “Staff are very nice and helpful. They know people’s needs well.”

At the time of our last inspection there was a high use of agency staff. Vacant posts had been filled and agency staff were now rarely used. There were enough staff to meet the needs of people safely.

Staff were supported to develop their knowledge and practice. All staff had completed numerous eLearning training since our last inspection in a wide variety of subject areas. The manager also carried out observations on staff to make sure staff were able to apply the learning they received. For example, they assessed people supported with moving and receiving personal care to make sure people were afforded privacy and dignity. Staff now attended regular supervision meetings and told us they felt supported.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The management and staff had attended training in the Mental Capacity Act 2005 and DoLS and were aware of current guidance to ensure people were protected. DoLS applications had been requested when needed to ensure people were safe.

Feedback was sought from people, relatives and staff about the services provided through regular meetings and satisfaction questionnaires. Visitors told us they were made to feel very welcome.

We found two continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is 'Requires Improvement.’ Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

We are now in a position to publish the action taken. Following our inspection, we took enforcement action and have applied positive conditions on the provider’s registration requiring them to:-

Provide a monthly report to CQC of all new people admitted to Palm Court, setting out the admission date, a brief summary of each person’s care needs and the name of the person who carried out the assessment.

The provider is also required to ensure there is a suitably qualified, and competent person, to undertake oversight of medicines management at Palm Court and to provide monthly audits to the Care Quality Commission. Audits must address analysis of any errors or shortfalls in medicines management and details of who will be responsible for taking actions and timescales for completion.

Palm Court Nursing Home provides accommodation for up to 53 people in one extended and adapted building. Nursing care is provided to people who have nursing needs, some people were living with dementia. There were 27 people living at the service when we inspected, admissions had slowly increased following the last inspection as sanctions imposed by the local authority and a voluntary agreement by the provider until the service improved had been lifted.

At inspections carried out in September 2016 and June 2017 the home was rated Inadequate and placed and remained in special measures as there were continued breaches of Regulations. CQC took enforcement action in accordance with its procedures. We met with the provider and asked the provider to complete an action plan to show what they would do to meet the requirements of the regulations. We received the provider's action plan and we followed up on breaches at an inspection in November 2017. At that time improvements had been made and although there was still a breach of Regulation 17 the home was rated requires improvement overall. We asked the provider to complete an action plan to show improvements they would make, what they would do, and by when, to improve the key questions in well led to at least good.

This inspection took place on 19 and 24 July 2018 and was unannounced. The registered manager had left their position in June 2018. 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. A new manager had been appointed and started in post on 2 July 2018. They had yet to apply for registration with CQC.

At this inspection we found the provider had not ensured effective leadership and direction at the service. Improvements made at the last inspection had not been sustained. There were continuing breaches of regulations. The new manager had spent their first two weeks in post assessing the provision of care and had a detailed action plan of the matters that needed to be addressed. Following the inspection, the local authority confirmed that although the suspension on placements had been lifted following the last inspection, a temporary placement break had since been agreed with the provider that meant there would be no further admissions to the service until safety concerns identified at this inspection had been met, and there was mutual agreement to start admissions again.

Significant health and safety matters were identified that had the potential to place people and staff lives at risk. These were in relation to fire and gas safety. East Sussex Fire and Rescue service were asked to visit the service to assess the situation. Further work has since been carried out to ensure the safety of the premises.

Although during our inspection we saw people were treated with respect and dignity, some people told us this was not always the case. We found two incidents of unexplained bruising that had not been reported to the safeguarding team for possible investigation. Although there were good systems to assess the needs of people who had behaviours that challenged, the actual advice on how to support people in heightened anxiety was less clear. There were no protocols for the giving of medicines prescribed on an ‘as required’ basis for agitation.

We identified areas of record keeping that needed to improve to document more clearly the running of the home. The provider’s auditing systems had not identified areas of practice that needed to improve and their quality assurance and monitoring system continued to be ineffective. Investigations into concerns raised by relatives were not always carried out effectively.

Care plans contained detailed information about people’s needs and wishes. However, due to the location of the care plans, staff did not refer to them regularly. There were plans to change the location of the care plans to increase accessibility. There were no effective systems to monitor the actual provision of some aspects of personal care such as oral hygiene and baths/showers.

Records to demonstrate staff had the skills and experience to meet people’s needs were not accurate and up to date. The manager told us although training had been scheduled this had not happened as there was no provision to ensure staff were paid on the days they attended training. This was also the reason given as to why staff meetings had not been held.

Person centred activities were described in the activity folders but records that showed these were met were not effective. The manager had advertised for an additional activity coordinator and had lots of plans to expand the opportunities and experiences available to people. We made a recommendation to increase person centred activities.

People were supported to make choices where possible. The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst DoLS applications had been made and the home was awaiting authorisations for some, the manager confirmed there were areas that need reviewing to ensure all restrictions requested were needed, for example in relation to bed rails.

The manager had introduced some new changes so birthdays were now celebrated with a special cake. Fruit pots were served in the mornings and tea was served after lunch each day. People told us they were happy with the new arrangements. Relatives told us they were very happy with the care provision. One relative told us, “It’s so bright and airy. I have been very impressed with the care provided.”

There were enough staff working in the home to meet people’s needs safely and advertisements had been made to increase the staff compliment further by recruiting an additional chef and activity coordinator. People were treated with respect and we saw lots of examples where people were supported discretely by staff to meet their individual needs at mealtimes.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.”

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We are now in a position to publish the action taken. Following our inspection, we took enforcement action and have applied positive conditions on the provider’s registration requiring them to:-

Provide a monthly report to CQC of all new people admitted to Palm Court, setting out the admission date, a brief summary of each person’s care needs and the name of the person who carried out the assessment.

The provider is also required to ensure there is a suitably qualified, and competent person, to undertake oversight of medicines management at Palm Court and to provide monthly audits to the Care Quality Commission. Audits must address analysis of any errors or shortfalls in medicines management and details of who will be responsible for taking actions and timescales for completion.

Palm Court Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Palm Court Nursing Home accommodates up to 53 people in one extended and adapted building. Nursing care is provided to people who have nursing needs, some people were living with dementia. There were 22 people living at the service when we inspected, there had been no new admissions due to a sanction imposed by the local authority and by a voluntary agreement by the provider until the service improved.

At the last inspection on 6 and 15 June 2017 the service was rated ‘Inadequate’ overall and there were some continued breaches of Regulations. Following that inspection, we met with the provider and asked the provider to complete an action plan to show what they would do to meet the requirements of the regulations. We received the provider’s action plan and followed up the breaches of Regulations at this inspection.

Following our last inspection the provider had prioritised some areas that needed immediate attention including: medicines; staffing levels; staff training, especially in moving people safely and updating care plans. At this inspection we found their medicines systems had been reviewed and changed; care plans had been updated; more staff had been recruited and staff had received additional training. The provider said they wanted to concentrate on the immediate priorities and now planned to move on to other priorities including supporting people’s interests and hobbies and providing meaningful activities for everyone.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was a registered nurse and they had implemented some changes that had led to improvements including increased and more in depth checks and audits.

The service had been inspected five times since 2015. At the inspections in December 2015 and January 2016, June 2016 and September 2016 we found multiple breaches of regulations. At the inspection in September 2016 the home was rated as inadequate and placed into special measures. Following this inspection the CQC took enforcement action in response to the continued breaches of regulations. A further inspection took place in June 2017 and there were still breaches of regulations. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We returned in November 2017 to see if improvements had been made. We found that the service had improved; however, there were still breaches of the regulations.

At the last inspection the provider had failed to ensure that risk was managed safely and did not make sure people experienced person centred care that met their needs and reflected their personal preferences. At this inspection improvements had been made. Risks to people had been identified and assessed, however some assessments were contradictory and inaccurate and did not reflect the care and support that people were receiving. Some of the care plans were difficult to read and some had not been reviewed and updated to reflect peoples changing needs. However, staff knew how to provide the care and support that people needed. Other care plans contained detailed guidance regarding how to support people. Accurate and complete records were not maintained for all people. People's confidentiality was respected and their records were stored securely.

At the last inspection the provider and registered manager had failed to make sure they had a system in place to effectively monitor the quality of the service they provided. At this inspection improvements had been made. Regular audits were carried out to identify any shortfalls and this had led to improvements in areas such as medicines management and staff competencies. Incidents, accidents and complaints had been looked at and analysed for any patterns but not all incidents and complaints had been included in the audits. Therefore it was difficult to pick up on any trends or patterns. Lessons had been learnt when things had gone wrong. The provider had sought feedback from people, their relatives and other stakeholders about the service. The provider had not informed every one of the results and of the action they planned to take in response to people’s suggestions and comments. Staff told us that the service was well led and that the registered manager was supportive and approachable. The provider was building relationships with the local community.

At the last inspection people did not have enough meaningful activities to take part in. At this inspection there were some activities provided for people and these were improving. However, people said they wanted to do more and were sometimes bored. The environment was improving to support people living with dementia, however further improvements could be made.

There were sufficient numbers of staff on duty at all times. Staff had support from the registered manager and senior to make sure they could care safely and effectively for people. The registered manager and senior nurse were involved with supporting people and the staff on a day to day basis. Staff had received one to one meetings; however one to one meetings were not as frequent as they should be. The registered manager said they had fallen behind with one to one meetings. This was an area for improvement.

Staff received induction training when they first started work at the service however it was not clear how the training was carried out and when. There was no evidence that staff competency had been checked after they completed their induction. Staff said they shadowed established staff until they were confident to work on their own. At the last inspection the provider had continued to fail to ensure that staff had the skills and expertise to make sure people experienced safe care and treatment. Improvements had been made. There was a training programme in place and staff had received the training to do their jobs effectively and safely. Staff were checked to make sure what they had learnt was put into practise. We saw that people with mobility needs were consistently moved safely.

People received their medicines safely and when they needed them. There were robust systems in place to ensure that medicines were stored correctly and safely.

People were encouraged to eat a healthy diet. The cook knew people's preferences and choices. People enjoyed their breakfast and lunch. If people needed further support with their dietary needs, food was monitored and if required further advice and support from health care professionals such as a dietician was sought. The nursing staff monitored people's health needs and sought professional advice when it was required. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Deprivation of Liberty Safeguards, and the relevant DoLS applications had been made.

There had been no new people admitted to the service since the last inspection. There were policies and procedures in place to assess people to ensure their needs could be met before they came to live at the service.

Staff understood people's specific needs and had good relationships with them. Most of the time people were settled, happy and contented. Throughout the inspection people were treated with dignity and kindness. People's privacy was respected and they were able to make choices about their day to day lives. Staff were respectful and caring when they were supporting people. When people became anxious staff took time to sit and talk with them until they became settled.

Staff were familiar with people's life stories and were very knowledgeable about people's likes, dislikes, preferences and care needs. They approached people using a calm, friendly manner which people responded to positively. Care plans about the care and support people wanted at the end of their lives could be improved.

There was information available for people regarding how to complain and any complaints had been documented and investigated in line with the provider's policy. Staff had been recruited safely. Staff knew how to recognise and respond to abuse and any potential safeguarding issues had been reported to the local authority. The provider had notified us of important events that had happened in the service and had displayed their rating at the service, as required by law.

The staff carried out regular health and safety checks of the environment and equipment. This helped to ensure that people lived in a safe environment and that equipment was safe to use. The building was fitted with fire detection and alarm systems. Regular checks were carried out on the fire alarms and other fire equipment to make sure it was working. People had a personal emergency evacuation plan (PEEP) in the event of an emergency.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. You can see what action we have asked the provider to take at the end of the report.

The home had a registered manager. 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 has been inspected four times since 2015. At the inspections in December 2015 and January 2016, June 2016 and September 2016 we found multiple breaches of regulation. At the inspection in September 2016 the home was rated as inadequate and placed into special measures. Following this inspection the CQC took enforcement action in accordance with its procedures.

At this inspection we found the rating for the service remains ‘Inadequate’ and the service will continue to be in ‘special measures’. Although there had been some minor improvements, we found the provider and registered manager had not made the significant improvements expected and remain in breach of a range of regulations of the HSCA 2008 (Regulated Activities) Regulations 2014. The local authority was not currently admitting people to the home, due to the ongoing and significant concerns identified by CQC.

The provider and registered manager continued to fail to act on feedback provided by the local authority, an external consultant and CQC. They had not provided effective leadership and direction at the service. The required improvements had not been made with regard to activities and personalised care and these were continuing breaches of these regulations. People were not always treated a kind and caring way, and did not have their safety protected at all times. The provider and registered manager’s auditing systems had not identified areas of practice that needed to improve and their quality assurance and monitoring system continued to be ineffective

Staff did not consistently treat people with dignity and respect, although we did observe some good practice in this area. People did not always have their preferences and choices met, and people’s needs were not always accurately assessed or recorded in their care plans. People’s care needs had not always been properly identified and the most up to date and relevant information about each person was not available to staff, to help them meet people’s care needs. Care plans were complicated and did not consistently contain accurate or up to date information about the person. There was a risk staff would provide the wrong care for people because of this.

Although the provider had increased the amount of training available for staff, they did not make sure this training was effective. We observed staff using unsafe moving and handling techniques, as well as providing support to people that was not centred on their individual needs. Staff learning and competency were not assessed after training, so the provider and registered manager could not be assured that staff training had been effective.

Risk assessment and risk management practices continued to put some people’s health at risk. Senior staff and the registered manager were not clear about why they were assessing risk, or the purpose of a robust risk management plan to keep people safe.

Food was of good quality and people gave us positive feedback. However, people’s individual dietary needs were not taken into account when food was prepared, and people were not supported to have a positive mealtime experience.

Although there were more staff on duty since the last inspection, they were not always deployed appropriately. There were enough staff to meet people’s basic care needs, but not enough staff to support people to spend their time as they wished, such as go out for a walk. Recruitment practices had improved and all of the relevant checks were completed before staff began work.

A complaints procedure was in place. Staff addressed issues they could deal with at the time and referred other concerns to the registered manager or provider. However, some relatives felt the management did not listen to their concerns or respond to them properly. Staff felt supported by the registered manager, and gave positive feedback about them.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff understood the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards, and the relevant DoLs applications had been made. Staff had attended safeguarding training and they knew how to protect them from the risk abuse. People said they were comfortable and relatives told us they thought people were safe.

The overall rating for this service continues to be inadequate and the service remains in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found four continuing and one new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

CQC is currently considering what action we will take against the provider.

This inspection took place on 26 and 27 September 2016 and was unannounced.

The service has not had a registered managed since January 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A manager had been appointed nine weeks before this inspection and they informed us they would be applying to register with the CQC as the registered manager.

Palm Court Nursing Home consists of two older properties at the front that have been converted to provide bedrooms on the ground and first floor, some with en suite facilities, communal bathrooms, three lounges and a dining room. An extension to the rear has bedrooms with en suite facilities on the ground floor and the building has been further extended to link up with a newly converted property on the side of the original home. This provides bedrooms, with en suite facilities on two floors, communal bathrooms, a dining room and a large lounge. The provider wants to extend the number of people that can live in the service but this has not yet been registered with the commission.

The quality assurance and monitoring system was not effective. Improvements had not been made with regard to staffing, training, activities and personalised care; some of these were continuing breaches of regulations and, the provider’s auditing system had not identified areas that required improvements.

The manager and staff were open regarding their concerns about staffing at the home. They had realised this meant the care and support provided was task orientated at times and did not consistently take into account the needs of people living with dementia. Some activities were provided and people enjoyed spending time with staff. However, these were not personalised to each person, and there was no evidence they followed current guidance for best practice.

Risk assessments had been completed as part of the care planning process. However, they did not include all the information needed to plan care or relevant guidance for staff to follow to meet people’s individual needs. There were systems in place for the management of medicines, but nurses did not always follow appropriate guidelines.

The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff had knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards, and the manager understood the process for applications for DoLS. Some staff had attended safeguarding training and they knew how to keep people safe and protect them from abuse. People said they were comfortable and relatives told us they thought people were safe.

Staff supported people to make their own decisions about the food they wanted. People thought the food was good and choices were available. Relatives and friends could visit at any time, they were made to feel very welcome and said the staff were very good.

People used bedrooms in all parts of the home; some preferred to remain in their rooms or were supported to do so because of their health care needs, while others were assisted to move into the large lounge in the new extension.

A complaints procedure was in place. Staff addressed issues they could deal with at the time and referred other concerns to the registered manager or provider.

Staff felt supported by the manager, they were included in discussions about how the service could be improved and felt like active members of the team.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

This inspection was carried out by two inspectors.

The service currently has an embargo on admissions implemented by the local authority.

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?

Is the service safe?

Systems were in place to ensure that the management and staff had learnt from issues identified at previous inspections. This reduced the risks to people and helped the service, improve although not yet fully embedded..

If the service effective?

We found at this inspection that the service was effective. People told us, 'The staff are always around if we need them'.

Is the service caring?

We saw at this inspection that staff were aware of people's needs and offered kind and considerate support. One person said, "The staff are very good, they know what we need'.

Is the service responsive?

A range of social activities were available for people to join in if they wished. Support was flexible and we saw that people made choices.

Is the service well-led?

We found that staff we spoken with were clear about their roles and responsibilities, and they had a good understanding of people individual needs.

We spoke with ten of the people who lived at the home. However, some people were not able to tell us about their experiences of living at Palm Court, because of their complex needs. People told us they were very comfortable and that the food was good. One person said, 'I am happy I moved in'.

We spoke with two relatives, five care staff, the cook, three housekeeping staff, the deputy manager and the provider. We reviewed four care plans and associated documentation; we looked at the systems in place for the control or infection, staff rotas and the processes used to assess and monitor the services provided.

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?

Is the service safe?

We found that during our inspection the service was safe. Relatives we spoke with told us they felt people who lived at the home were safe. Staff felt they provided care and support in a way that ensured people's safety, although they also recognised that this limited some people's choices..

Systems were in place to ensure the management and staff learned from events, such as incidents and concerns, and some of the issues identified at the last inspection had been addressed.

Is the home effective?

We found that during our inspection the service was not effective. People's health and social care needs had been assessed, and they had been involved in this process, with the support of relatives or representatives. However, the support and care provided was not always based on people's choices and preferences, and may not meet people's individual needs.

Is the service caring?

We found that during our inspection that the service was caring. We saw that people were supported by kind, patient staff, who encouraged some people to make decisions about how they spent their time.

Is the service responsive?

We found that during our inspection that the service was responsive. We saw evidence that when people's needs had changed, the manager had made appropriate referrals to outside agencies.

Is the service well-led?

We found during our inspection that the service was not well led. An effective quality assurance system was not in place, consequently shortcomings in the services provided were not identified and acted upon.

Staff we spoke with were clear about their roles and responsibilities. They had some understanding of the needs of people who lived at the home and they said they were able to talk to the management if they had any concerns. They also said that these concerns were not always addressed.

We saw that staff asked people for their consent before they provided care and support, and people were asked where they wanted to sit in the lounge.

We examined five care plans. We found that there were inconsistencies in the information recorded, and the way records were kept.

We looked at the policies and procedures for medicine management and how the service ensured people were safe.

Staff told us they had attended infection control training and there was evidence to support this. However, we found that appropriate systems to protect people from the spread of infection were not in place.

We reviewed the home's recruitment procedures and found them to be effective.

We looked at care plans and daily records. We found that they needed to be reviewed and updated.

We saw that staff offered support and care to people who used the service in a way that respected their privacy and dignity. We spoke with relatives and they were positive about the care and support offered in Palm Court.

We looked at the staff rota's, staff training records and activity records. We found that there were sufficient staff working in the home and they had attended training relevant to the support and care they offered. We observed that activities were provided for people who wanted to take part, although the care plans did not reflect this.