Sandrock Nursing Home

Sandrock Nursing Home provides accommodation for up to 28 people who require nursing or personal care. At the time of our inspection 7 people lived in the home. Since last inspected commissioners had helped support people to move out of the service.

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

During the previous four inspections we identified serious concerns with the safety and quality of the service being provided for people.

During this inspection, there continues to be breach of the regulations and evidence of non-compliance. With the provider’s poor regulatory history and repeated concerns from the past 4 inspections, we could not be assured that the quality of the service would improve in the areas identified at this inspection.

During this inspection the provider neglected the premises people lived in placing them at risk of harm. We found a series of concerns relating to the health and safety of both the inside and outside of the premises and regarding to poor management of infection control.

People told us they were comfortable and received good food and care from the staff. Some people told us there wasn't much to do but they liked to sit and watch the television.

The principles of the Mental Capacity Act (2005) were being consistently followed when providing care and treatment for people. 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.

People were protected from abuse because staff understood the correct procedure to follow if they had any concerns. Staff were knowledgeable about people's health.

Rating at last inspection and update

The last rating for this service was inadequate (report published 5 September 2023) and there were breaches of regulation.

At this inspection, we found that the provider had failed to make sufficient improvements. This meant the service continued to be in breach of regulation 17 for the fifth consecutive inspection and was found to be in continued breach of regulation 15 for the second time since the last inspection.

Why we inspected

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

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

Enforcement

We have identified breaches in relation to lack of effective governance of the service.

Follow up

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

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.

Special Measures

The overall rating for this service is 'Inadequate' and the service therefore continues to be in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the 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.

Sandrock Nursing Home provides accommodation for up to 28 people who require nursing or personal care. The home is in one adapted building. At the time of our inspection 15 people lived in the home.

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

During the previous three inspections we identified serious concerns with the safety and quality of the service being provided for people.

During this inspection, although the provider had made improvements to the concerns identified previously, there continues to be a breach of the regulations. With the provider’s poor regulatory history and repeated concerns from the past 3 inspections, we could not be assured that the quality of the service would improve in the areas identified at this inspection.

During this inspection the provider neglected the premises people lived in placing them at risk of abuse. We found a series of concerns relating to the safety of both the inside and outside of the premises.

Medicines management had improved, stock recording of medicines had improved, and people had their medicines as prescribed. Staff had been trained on administering medicines and their competence was regularly checked.

Monitoring to mitigate risks had improved. Care records were individualised and reflected each person's needs and preferences. Risks were assessed and identified, and staff had guidance to help reduce the risk of avoidable harm to people they were supporting.

The principles of the Mental Capacity Act (2005) were now being consistently followed when providing care and treatment for people. 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.

People were protected from abuse because staff understood the correct procedure to follow if they had any concerns. Staff were knowledgeable about people's health needs and the provider worked in partnership with other health professionals as a measure of providing the appropriate level of support .

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

Rating at last inspection and update

The last rating for this service was inadequate (report published 25 October 2022) and there were breaches of regulation. Following the inspection, we imposed 2 conditions on their registration. The first condition was for the provider to undertake an independent assessment of the competency of the registered manager and deputy manager in relation to medicines management. The second condition was, the registered provider must have a suitably qualified, skilled and competent professional undertake an independent assessment of the safe management of medicines within the service.

At this inspection, we found that the provider and registered managers had made some improvements to the service and were no longer in breach of regulations 12 and 11.

In other areas, the provider had failed to make sufficient improvements. This meant the service continued to be in breach of regulation 17 for the fourth consecutive inspection.

Why we inspected

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

During 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 inspections, by selecting the 'all reports' link for Sandrock Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to premises and effective governance of the service.

Follow up

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

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.

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the 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.

Sandrock Nursing Home provides accommodation for up to 28 people who require nursing or personal care. The home is in one adapted building. At the time of our inspection 19 people lived in the home.

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

During the previous two inspections we identified serious concerns with the safety and quality of the service being provided for people.

During this inspection, although we identified that some improvements had taken place; the provider continues to be in breach of the regulations in key areas which we had previously identified and highlighted to them. They have continued to miss repeated opportunities to ensure all the key systems at the home were effective and safe.

The management of people’s medicines remained unsafe. Stocks were not safely managed; staff did not always complete effective records when administering medication, and appropriate guidance was not always available for staff members.

Risks were not always safely assessed, monitored and managed. The provider had failed to ensure that information about people’s needs was available and accurate for staff to use. This placed people at risk of receiving inappropriate care that didn’t meet their needs safely.

Information was not gathered effectively to support staff and registered managers in assessing risk.

The principles of the Mental Capacity Act (2005) were not consistently followed when providing care and treatment for people. People’s care plans did not always provide appropriate guidance for staff on their ability to consent to their care and treatment. This meant that people did not consistently have the protection of the legal framework in place in regard to significant decisions that may impact their wellbeing.

A series of checks, audits and action plans had been undertaken at the home. However, in several key areas they had not been effective.

This service has a poor regulatory history over multiple inspections spanning eight years. In eight out of the past nine inspections, the service has been rated requires improvement or inadequate. There have been repeated breaches of regulations that follow patterns across multiple inspections. The provider, at times has reacted when issues have been highlighted to them; but improvements are not sustained.

There had been some areas of improvement in relation to record keeping. For example, we were now assured that the provider was supporting people to minimise the spread of infection and pre-employment checks had taken place on the background of new staff and their suitability for the role.

The provider had implemented an effective training programme. They had identified the training they considered to be mandatory for staff providing care and the timescale in which this training was to be refreshed. A high percentage of staff had now completed this training.

People told us they felt safe with the care and support provided by staff at the home. People's family members gave us positive feedback about the care provided at the home; and It was clear that people had positive relationships with staff members.

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 wad inadequate (published 18 February 2022).

Why we inspected

At our two previous inspections, the provider was found to be in breach of regulations 11 (Need for consent), 12 (Safe care and treatment), 17 (Good governance), 18 (staffing) and regulation 19 (Fit and proper persons employed).

We undertook this inspection to follow up on the action we had previously told the provider to take and to check whether the provider was now compliant with the health and social care regulations in the domains of Safe, Effective and Well-led.

During 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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

At this inspection, we found that the provider and registered managers had made some improvements to the service and they were no longer in breach of regulations 18 and 19.

In other areas the provider failed to make sufficient improvements. This meant the service continued to be in breach of regulations 11, 12 and 17 for the third consecutive inspection. The overall rating for the service has therefore not changed and remains inadequate. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to the application of the principles of the Mental Capacity Act (2005), assessing and responding to risks, medicines management and effective governance of the service.

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

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Sandrock Nursing Home provides accommodation for up to 28 people who need help with nursing or personal care. At the time of the inspection 22 people lived in the home. Some of the people living in the home, lived with dementia.

People's experience of using this service

At the last inspection, we identified serious concerns with the management of risk, care planning, the delivery of care, medicines, infection control, staff recruitment and training, the implementation of the Mental Capacity Act, record keeping, leadership and governance. At this inspection we found the same.

Information relating to people’s needs and risks remained insufficient and unclear. This meant staff lacked adequate guidance on how to provide safe and appropriate care. Records relating to the care people received were not always accurate and did not show that people received the support they needed to mitigate risks or keep them safe and well.

Medication management was unsafe and placed people at risk of significant harm. Basic good practice guidance was not being followed. People did not always receive the medicines they needed. Medicines could not always be accounted for, and were not always given safely. Safeguards in respect of controlled drugs were not adhered to.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems and practices employed in the service did not support this practice.

The recruitment and selection of staff was not robust and there still remained staff who had not completed the provider’s mandatory training modules or whose training had not been refreshed appropriately.

On the day of inspection, there appeared to be enough staff on duty. However, staffing levels were not consistent and the provider failed to have a system in place to determine what staffing levels should be, based on people’s needs.

There were some improvements with infection control and COVID-19 management, but these improvements were insufficient to ensure risks were adequately mitigated in the day to day delivery of the service.

Accident and incidents and safeguarding events were recorded. However, some of these incidents had not been properly investigated by the manager or reported to CQC as required.

The systems in place to monitor quality and safety were ineffective. The management of the service remained ad hoc, with no adequate oversight of care delivery. This is the fourth time, the service has been rated inadequate. The provider and manager lack an understanding of their regulatory requirements and how to provide people with safe and appropriate care.

Staff were observed to be kind and caring, and people told us they felt safe. People and the relatives, we spoke with were positive about the service and had no complaints.

Rating at last inspection

The last rating for this service was inadequate (published 18 June 2020).

Why we inspected

At the last inspection, the provider was found to be in breach of regulations 11 (Need for Consent), 12 (Safe Care and Treatment), 17 (Good Governance), 18 (staffing) and regulation 19 (Fit and proper persons) were found.

We undertook this inspection to follow up on the action we had previously told the provider to take and to check whether the provider was now compliant with the health and social care regulations in the domains of Safe, Effective and Well-led.

During 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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

At this inspection, we found that the provider and manager had failed to make sufficient improvements. This meant the service remained in continued breach of regulations 11, 12, 17, 18 and 19. The overall rating for the service has therefore not changed and remains inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection, we found continued breaches of regulations 11 (Need for Consent), 12 (Safe care and treatment), 17 (Good governance) 18 (Staffing) and 19 (Fit and Proper Persons). Enforcement action was commenced by CQC following the previous inspection in April 2021 and is still in progress.

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

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.

Follow up

We will work with the local authority to monitor progress. If we receive any concerning information, we may return to re-inspect whilst CQC enforcement action is in progress.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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

At this inspection, the provider had not made enough improvement to meet regulatory requirements. At the time of this inspection, enforcement action is still in progress.

Sandrock Nursing Home provides accommodation for up to 28 people who need help with nursing or personal care. At the time of the inspection 27 people lived in the home. Some of the people living in the home, lived with dementia.

People's experience of using this service

At this inspection, we identified serious concerns with the management of risk, care planning, the delivery of care, medicines, infection control, staff recruitment and training, the implementation of the Mental Capacity Act, record keeping and leadership and governance.

Staff did not always have sufficient or accurate information about people’s needs and lacked guidance on how to provide safe and appropriate care. Medication management was unsafe and placed people at risk of avoidable harm.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There was little evidence to show that infection control protocols were in line with government guidance or that they were followed to protect people and staff from the risk of infections such as COVID-19.

We found that staff members were not always recruited safely. Some staff training was out of date and some staff had not completed the provider’s mandatory training modules. This meant there was a risk that some staff did not have the up to date knowledge and skills to provide safe and appropriate care.

Record keeping in relation to people’s care and the management of the service were poor. It was difficult to see what support people needed and what support they received. We found that some people did not receive the right diet or fluids to mitigate risks to their health and wellbeing. Some people’s clinical needs were not properly monitored to keep them safe and where professional advice had been given, this had not always been followed.

Accident and incidents and safeguarding events were recorded. However, some of these incidents required notification to CQC in accordance with the regulations but had not been reported appropriately.

The systems in place to monitor quality and safety were ineffective. The management of the service was ad hoc, with no adequate oversight of care delivery. The manager did not demonstrate they understood the requirements of the health and social care regulations in respect of providing safe and appropriate care.

This is the third time, since 2017 that the service has been rated inadequate since 2017 and despite improvements being made at the last inspection, these have not been sustained. It was clear that both the provider and manager lacked an understanding of regulatory requirements and how to ensure people received safe and appropriate care. This placed people at significant risk of avoidable harm.

There were enough staff on duty to support people. Staff were observed to be kind and caring and people told us they felt safe. People and relatives we spoke with were positive about the service.

Rating at last inspection

The last rating for this service was good (published 25 April 2019).

Why we inspected

This focused inspection followed a CQC infection control visit that raised serious concerns about infection control and the management and governance of the service overall. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked again at infection prevention and control measures under the Safe key question. We saw that the manager had put an action plan in place following CQC infection control visit to drive up improvements in this area.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

People’s experience of using this service:

The registered manager was working to an action plan to make sure people’s risk assessments and care plans were person centred and accurately reflected people's needs.

People told us staff were kind and respectful and we saw caring relationships had been developed between people and staff.

The dining experience had improved. people received the support they needed to eat and drink and were given choice of where and what to eat.

People had choice and control over how they spent their time. People were supported to pursue their interests such as listening to their favourite radio station or visit the local pub.

People received their medicines when they needed them and were supported to receive support from healthcare professionals.

People felt safe in the service and with the staff that supported them. There were enough safely recruited staff on duty and staff responded to people's request for assistance.

The service was clean and fully accessible and bathrooms had been adapted. People had been able to personalise their rooms with their own furniture and personal affects.

People’s capacity to make decisions was assessed and people were supported with decision making.

Staff were knowledgeable about safeguarding procedures and how to raise any concerns they had. Referrals to the local authority safeguarding team had been made appropriately. Staff received regular training to ensure they had the skills to meet people’s needs.

Staff felt well supported by the registered manager and told us they could raise any concerns with them.

There were systems in place to assess and monitor the quality of the service.

Rating at last inspection: Requires Improvement (report published 8 September 2018)

Why we inspected: This was a planned inspection based on our inspection schedule for new services.

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.

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

The home had a manager who was registered with CQC. 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 of the service in April 2018, we identified breaches of Regulations 9, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated ‘inadequate’ and placed into ‘special measures’ by CQC.

During that inspection we found that people’s care plans were not reviewed to ensure they remained appropriate to their needs and preferences. Information relating to people’s level of risk was contradictory and some people’s risk management plans were not followed. Wound care documentation was poor and unclear. People who required special diets were not always provided with the diet they needed and some people’s food and drink charts did not show that they always got enough to eat and drink. The administration of medication was unsafe. The provider had audits in place to check the quality of the service but these had not been effective.

During this inspection we found that the home had a computerised care planning system, but this did not always provide the format staff needed for keeping specific records, for example wound care records. The manager told us that they had decided to use paper records for recording wound care and we saw that these were well completed, with photographs that showed the progress of healing.

Risk assessments were completed on the computer system. Following completion of the risk assessment tool, the computer generated suggested actions. These actions were not individualised and were not used in planning the care the person needed. The manager showed us that the plans for keeping people safe were recorded as care plans and not as part of the risk assessment process. We discussed with the manager that this needed to be made clearer to avoid any confusion.

Daily charts recording personal care, repositioning and food and fluid intake were well completed by the care staff and showed that people had received the support they required in these areas. However, we observed that people did not always receive the support they needed to enjoy their meals.

We looked at the arrangements for the management of people’s medication. Two people we spoke with confirmed that they received their medicines on time. Medication was stored appropriately and at the right temperatures. We saw no evidence of stocks running low or medicines being out of stock, which had been found at the last inspection.

We saw no specific guidance for staff regarding the administration of medication prescribed to be given ‘as required’, however the nurse we spoke with knew people well and could describe under what circumstances the medication would be used. We recommend that written protocols are put in place to ensure that PRN medication is administered consistently by all of the home’s nurses.

We looked at the medication administration record (MAR) sheets and there were no missed signatures. Spot checks we carried out tallied with the records. Boxed medication was counted every night by the night staff and checked by the manager. Other daily checks had been put in place but were not always completed.

During this inspection we found that improvements had been made to the way people’s care and support was reviewed each month and nurses had written more detailed and meaningful evaluations.

The provider’s quality monitoring systems were being improved so that they would be more effective in showing where further improvement was required.

Improvements to the premises were on-going and up to date safety certificates were in place for utilities and equipment. Fire doors had been fitted with smoke seals.

There were enough staff to meet people’s care and support needs and improvements had been made to staff recruitment and training.

The service was compliant with the Mental Capacity Act 2005.

The atmosphere at the home was relaxed and homely, and a range of social and recreational activities was provided. People considered that the staff were kind and caring.

The home provides accommodation for people who require nursing or personal care. The home can accommodate up to 28 people. At the time of our inspection 23 people lived at the home.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ The registered manager has worked at the home for many years.

At our last inspection in December 2017, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to regulation 11 (Need for consent), regulation 12 (Safe care and treatment) and regulation 17 (Good governance). The service was rated required improvement. During this visit we followed up the breaches we identified at our previous visit. We found that some of the improvements made by the provider and manager of the service with regards to Regulations 12 and 17 had not been sustained. This meant at this inspection the rating for the domains of safe and well-led were downgraded to ‘Inadequate’. The issues associated with Regulation 11 had been addressed but a new breach of Regulation 9 (Person centred care) of the Health and Social Care Act was identified with regards to the ongoing review of people’s care to ensure it remained appropriate to their needs and preferences. These issues have affected the overall rating of the service at this inspection and the service has now been rated inadequate once again for the second time in 12 months.

We looked at six care plans and found some improvements to the information relating to people’s needs and wishes had been made but other information was poor. Some of the information relating to people’s level of risk was contradictory, some of the risk management advice stated was inadequate and some people’s risk management plans were not followed. This meant that there was a risk that people’s health and welfare were not being managed properly. Clinical wound care assessment and management remained poor and unclear. This meant it was difficult to tell which people had pressure sores in place and what care they were receiving. Pressure area care to prevent the development of a pressure sore was not always provided consistently and some staff lacked adequate knowledge of what this care was.

People who required special diets were not always provided with the diet they needed and some people’s food and drink charts showed that they did not always get sufficient amounts to eat and drink. This meant people’s care was not provided in way that sufficiently mitigated risks to their health and welfare in order to maintain their well-being.

The administration of medication was unsafe. People’s medication was not always ordered in a timely manner to prevent them from running out. The balance of medication stock in the home did not match what had been administered and it was clear that some people had not received the medication they needed. There were no system in place to record the administration of prescribed creams, topical ointments and thickening medications for people who needed to have their drinks thickened so that they could swallow safely. This meant there was no evidence that these medications had been administered appropriately or in safe way. Some of the medication in the home was not accounted for on people’s medication charts yet they had been administered. People’s health and welfare are placed at serious risk when medication is not administered safely or as prescribed.

Improvements had been made to the way people’s ability to make decisions about their care had been assessed and the way people’s legal consent was obtained was now compliant with the Mental Capacity Act 2005. This was an improvement since our last inspection.

People had access to a range of social or recreational activities in support of their emotional well-being and the atmosphere at the home was relaxed and homely. Staff interacted with people well and were kind and considerate in all of their support interactions. People and the relatives told us that there were enough staff on duty to meet their needs and we saw that during our inspection, staff were attentive to people’s needs and responded to them in a timely manner. People told us that staff were kind, well trained and treated them well.

One staff member had been employed since our last inspection and they had been recruited safely. Improvements had been made to staff training and staff appraisals were up to date. Changes had been made to the way staff were supervised. The new framework was designed to improve staff effectiveness and morale by looking at workloads, training and achievement but the supervision and competence of staff in their provision of their duties was an area that was not currently covered.

Some improvements were needed to the cleanliness and state of repair of the premises but the home’s gas, electric and moving and handling equipment had all been certified as safe to use. The home’s fire doors needed attention in order to ensure they offered sufficient protection in the event of a fire.

The provider had audits in place to check the quality of the service but these were ineffective. Improvements to the care planning and the delivery of care identified at the last inspection had not been sustained through good management and some aspects of service delivery had declined in terms of quality and safety. For example medication administration and nutritional care. The audit and governance systems in place failed to pick up and address these issues. Managerial and provider oversight was insufficient and by consequence the ability to mitigate risks to the health, safety and welfare of people who lived at the home was seriously compromised.

This service was not well-led. 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.

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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.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ The registered manager was a long standing member of staff and had been in post for over 13 years.

At our last visit to the service in June 2017, we identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated inadequate and placed in special measures. During this visit we followed up the breaches we identified at our previous visit and found that improvements had been made. We found that some further progress was still required with regard to Regulation 11 in respect of the need to obtain consent in accordance with the Mental Capacity Act 2005 and Regulation 12 with regard to safe care and treatment and the service remained in breach of these regulations. This demonstrated that there were still aspects of the service that were not well-led which meant the service remained in breach of Regulation 17 in respect of good governance. It was clear however that the manager and staff team had worked hard in the six month timescale between inspections to address the majority of the concerns previously identified. As a result of the improvements made, the domains of safe, effective and well-led which were rated inadequate at our last inspection, received a new rating of ‘requires improvement. The ratings for the domains of caring and responsive remained the same.

We looked at the care files belonging to six people. We saw that the assessment of people’s risks had improved. The majority of people’s risk management plans contained sufficient information for staff to follow to mitigate risks in the delivery of care and people’s care plans were person centred. This meant that people’s individual needs, preferences and wishes in relation to their care were documented for staff to be aware of in the delivery of care. We identified continued concerns with the documentation of people’s wound care. This information still remained unclear which meant it was difficult to tell if people’s wounds were healing and if people were in receipt of the care they needed. Risk assessments demonstrating that some people’s bed rails were suitable for their use were not always available or regularly reviewed to ensure they continued to be the safest option to meet people’s needs. We spoke with the manager about both of these issues.

It was obvious that the manager had considered the use of the Mental Capacity Act 2005 in the planning and delivery of people’s care since the last inspection but further improvements were required. This was because some people’s capacity to consent to decisions about their care had been assessed where their capacity to consent was in question, but other people’s capacity had not. This meant there was no evidence that some people’s consent to their care had been legally obtained.

Concerns identified at the last inspection with regards to the premises, the call bell system and the recruitment of staff had all been addressed. A new call bell system was in place and operational in all parts of the home. People had access to call bells and there was an automated system in place to alert staff to check on the welfare of those people unable to use their call bell. This helped mitigate risks to people’s health and welfare. New flooring had been installed in the lounge, the garden had been tidied and made secure and a faulty fire door had been fixed. Improvements to the standard of fire safety arrangements had also been made. Attention was needed to some of the home’s window restrictor which did not meet current safety standards and the appearance of the home in some parts still required refreshing.

During our visit, we saw that staff were kind, considerate and compassionate and we observed that staff ensured people had a choice with regards to how they lived their lives at the home and consented to the care that was given. People we spoke with told us that the staff team were kind and treated them well. Relatives confirmed this. Relatives told us they felt people were happy with life at the home, were always smartly presented when they visited and felt people got enough to eat and drink. People we spoke with told us that although they did not always have a list of menu options to choose from at mealtimes, an alternative was always provided if they did not like what was on offer. People confirmed that they got enough to eat and drink and were happy with the quality and quantity of food and drink they received.

People who lived at the home and relatives had mixed opinions on the quality of the activities provided at the home. Some activities were provided such as quizzes and bingo but it was clear that people felt there should be more variety. The activities co-ordinator was on annual leave at the time of our inspection so we discussed the activities on offer with the manager. They showed us evidence that they were looking into ways to improve the range of activities available.

We checked medication management and found that medicines were managed safely and administered correctly. Stock levels were correct and medication was stored securely and at the right temperature. We found that the actual time people’s medication was administered was not recorded. Recording the actual time that medication is administered is important. It ensures people have the right time interval between medication rounds and is important for time critical medication that needs to be given at certain times of the day. This aspect of recording required improvement.

Staff were spoke with were knowledgeable about people’s needs and the people they cared for. They spoke about people warmly and it was clear they had genuine affection for the people they looked after. All of the people we spoke with felt staff had the skills and experience to care for them effectively. We saw that the gaps identified in the training of some staff members at the last inspection had been addressed. The majority of staff had now completed the provider’s mandatory training programme and we saw that staff received appropriate support to do their job role.

New systems for the monitoring of the quality and safety of the service had been introduced since our last inspection and were a work in progress. These systems were designed to help the manager and the provider to mitigate risks to people’s health, safety and welfare. Audits were in place for checking and addressing issues with regards to the home’s environment, the equipment in use, care plans, medication and accident and incidents. We saw that action plans were developed were concerns were identified.

All of the people and relatives we spoke with were complimentary about the service, the manager and staff and all felt the service was well led. During our inspection, we found the manager to be pleasant, open and receptive to our feedback. Staff were welcoming and friendly and atmosphere was relaxed and homely. It was clear that the staff team had worked hard to improve the service since our last inspection. The overall rating of this service at the last inspection was inadequate, at this inspection the rating had improved to ‘requires improvement”. As a result of the improvements made, the service is no longer in special measures.

The home had a manager who was registered with the Care Quality Commission. 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.

Our last inspection of the service was on 2 August 2016 and we found breaches of Regulations 15 and 17 of the Health and Social Care Act 2008 because the provider had not ensured that the environment was properly renewed and the provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service.

During this inspection we found that some improvements had been made to the décor of the home and to the home’s quality assurance processes, however we found breaches of Regulations 9, 11, 12, 13, 17, 18 and 19 of the Health and Social Care Act because: people were not kept safe; people’s capacity to consent to their care had not been assessed; safeguarding incidents had not been reported; there was inadequate information to show that staff employed were of good character; not all staff had received training; people’s care records were incomplete; and the provider’s quality assurance processes had failed to identify and address these issues.

We found that most people did not have access to a nurse call bell either in their bedroom, in toilets or in the lounge. Some people told us they would ‘shout’ if they wanted to ask for support.

When we opened a fire exit leading into the back garden this did not activate any alarm. The back garden was overgrown and contained rubbish and the gate leading to the road was unsecured. This meant that people who may not be safe to do so could leave the building without staff being aware.

Personal emergency evacuation plans, to show how people should be supported to leave the building in case of emergency, were not fit for purpose, for example they did not specify either the floor of the building or the bedroom number. A significant number of staff had no date recorded for fire safety training.

Care plans did not provide sufficient risk management advice. This led to unsafe moving and handling practices and lack of clarity regarding the use of thickeners in people’s drinks. Only six members of staff had attended practical moving and handling training in 2016 and none in 2017.

Accidents and safeguarding incidents had been reported and investigated internally but had not been reported to external bodies.

Personnel files for two new staff did not contain verified references and 17 members of staff had a criminal records disclosure that was more than ten years old. This meant that we could not be sure that all of the staff team were safe to work with vulnerable people.

In general, medication was managed safely, however two people’s eye drops had not been dated on opening and another bottle of eye drops was dated February 2017, which meant they were past their expiry time.

We found a lack of information about people’s ability to make decisions and people’s mental capacity had not been assessed as required by the Mental Capacity Act. The manager was unclear about her responsibility with regard to mental capacity assessments. Consent to care had been obtained from people’s relatives who did not have Power of Attorney to give them legal power to do this.

Some staff had completed the home’s electronic training programme, but others had very little training recorded. This meant that staff may not know how to provide support to people in a safe manner. We found a similar situation during our last two inspections of the home.

People did not have the mobility equipment they needed nearby and were discouraged from mobilising independently. Several people who could potentially use walking aids needed to rely on carers to support them in moving around. This did not uphold their human rights.

Care plans were not person centred and information given to staff was often generic. Personal care records in people’s rooms showed gaps in the care provided.

People we spoke with said they or their relatives/friends felt safe there and all said they thought the home was kept clean. The home looked clean, although some places would be difficult to completely clean owing to wear and tear.

During the inspection we saw that there were enough staff to support people and meet their needs. Everyone we spoke with said there were usually enough staff around but several people said that they felt that staff were very busy.

People we spoke with were very happy with the staff and with the care provided to them. Everyone reported that the staff spoke to them in a courteous way. Everyone was very positive about the attitude and kindness of the staff and considered that staff preserved people’s privacy and dignity.

Visitors were welcome at any time. Social activities to provide entertainment or stimulation were planned throughout the week, and trips out took place regularly.

Everybody we spoke to said they or their relatives/friends had plenty to eat and drink and comments about the quality of the food were mostly positive, however most people did not have the opportunity to have their meals at a dining table.

It was evident that people were comfortable speaking to the manager. There was a low staff turnover and staff told us they felt supported in their work. The manager and all of the staff we spoke with were pleasant and helpful.

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.

The home had a manager who was registered with the Care Quality Commission. 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.

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

We found that the home was clean and routine maintenance tasks were carried out, however it is an old building and many areas required redecoration and refurbishment to provide a pleasant environment for people to live in.

The manager carried out some audits of the service, however these had not all been kept up to date and did not provide useful information to show how the service could improve.

During the inspection we saw that there were enough staff to support people and meet their needs. People we spoke with were very happy with the staff and with the care provided to them. The care plans we looked at gave details of people’s health and support needs and had been kept up to date. Medicines were generally stored and managed safely, however some improvements were needed.

The manager was aware of her responsibility with respect to the Mental Capacity Act and Deprivation of Liberty Safeguards.

People told us they enjoyed their meals but we considered that some people would benefit from the opportunity to have their meals at a dining table.

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

On the day of our inspection we found the environment to be clean and fresh.

We saw enough staff on duty to meet the needs of the people who lived at the home and were told that the manager or senior nurses were always available either working in the home or on call in case of emergencies.

People who lived in the home and their relatives told us that the service was safe and they felt safe living there.

We saw training records which identified that staff received training relevant to the needs of the people who lived in the home. The training programme did however identify that staff required up dates to ensure they were up to date with good practice.

The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of this inspection one application had been made by the home and was being implemented by the home with the support of the local authority.

We looked at the use of equipment in the home and found that in relation to the use of the bedrails and protective bumpers there were monthly reviews and daily checks of their use to keep people safe.

There were issues in relation to the safe storage of frozen food in the home.

Is the service effective?

People told us that they were happy with the care and their needs were met. It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and knew them well. One person told us. "The staff are wonderful here. I could not be happier the way they care for my relative".

Staff had received training to meet the needs of the people living at the home, however the provider may wish to note that they need to ensure the training programme is met more effectively as there are gaps for some staff.

Is the service caring?

We spent time in all areas of the home where we observed staff caring for people with dignity and respect. People living at the home appeared settled and well cared for and did not raise any issues of concern with us. One person visiting the home told us ''The staff keep me very involved as I visit daily'' another commented ''The home cares for my relative extremely well''. People told us that they were happy with their care. We spoke with staff and found that they knew the people living in the home very well.

Is the service responsive?

People's needs were assessed before they moved into the home and records confirmed people's preferences, interests and health needs were recorded. We saw that when people's needs changed they had been referred appropriately to the relevant health professionals such as the G.P. chiropodist and dietician. A family member told us that their relatives care and support had been reviewed and altered according to their changing needs.

Is the service well led?

Staff had a good understanding of what was required of them in their role and the good standards of care that they were expected to deliver. We were told that the provider of the service and the registered manager spends a lot of time in the home. People who lived in the home told us that they are always available for a chat. We saw that the provider now had a continuous program of refurbishment and improvement to ensure that people lived in safe comfortable surroundings. Staff told us that the manager supported them to attend training.

Prior to re-inspection of the service we received concerning information about maintenance of equipment and lack of working call bells. We found these issues had been, or were being acted on and addressed. There was a plan in place for improvements to the premises and a considerable amount of work had been carried out since our previous inspection. Infection control issues and maintenance checks had been carried out and the provider was working towards a robust audit plan to ensure they were continually monitoring and improving themselves.

We observed people were well cared for and staff and residents interacted well. Eight people spoken with said they were happy with the service provided. Comments included "I am very well looked after", "I feel safe and the girls are respectful", "I am kept clean and well, I am comfortable and I like the staff". A relative told us "I come here every day and I would know if there was anything bad going on - I am all eyes and ears".

People we spoke with and their relatives told us they were very happy with the care provided. Comments included:

"Mum is always clean. Staff have been here a long time and they know her care needs.";

"I am happy living here and I am comfortable."; and

"The girls are good, and they look after me.";

We spoke with the registered manager and reviewed the records that we had concerns about. Records had been re-written and we found that care plans were person centred and informative and clearly identified each person's care need. There was instruction to staff about how care needs should be met and where risks had been identified there were management plans in place. The manager said all the care records were being re-written in this way.

There were environmental health concerns such as kitchen windows without fly screens and food stored inappropriately alongside cleaning substances. We saw loose floor tiles, cracked bath tiles and inadequate storage facilities creating potential hazards and making the premises unsafe and unsuitable. Steps were being taken to address some concerns.

We observed care throughout the inspection and saw that people living at the home were spoken to respectfully and caringly by staff looking after them. We saw people were consulted about their care, received assistance when required and were given choice. We saw the activities co-ordinator carrying out a session with those who wished to join in. People were smiling, animated and busy with activities at the time of our inspection.

We found that there was a selection of foods available and were told that alternatives were available. One person said "I eat what's put in front of me - there's no choice" but four other people told us that the food was fine and they could choose alternatives if they did not like something. One person said "If I don't like what is on the menu I will ask for something else".

There were enough staff at the home and staff we spoke with told us they were happy at work and understood the needs of the people they cared for.

We reviewed compliance actions set at the last inspection and found that information about people's care needs continued to be insufficiently recorded. We also found that the provider still had ineffective processes in place to assess and manage risks and monitor the quality of the service provided. We have asked the provider to take action to resolve this.

We spoke with four people who used the service and a relative. They told us they were treated very well and with dignity and respect. People told us they were spoken to with respect; staff listened to them and acted upon their choices. They told us staff responded well and with timeliness if they called for assistance. They told us they were very happy living at this home. They said:

'I love it here, I never want to leave', 'I am very happy living here, they look after me very well'.

We observed that staff treated people well and in a caring manner. They understood people's different behaviours and responded accordingly, adjusting their manner and how they cared for them to the person's needs.

We found that care records contained relevant information in relation to personal details, assessment of care needs, risk assessments and care plans. We found that records identified people's needs and how their needs were to be met. Risk assessments were in place and were individualised. However care records were not accurate nor were they stored safely.

We found that improvements had been made in respect of staff training, supervision and appraisal and in monitoring the quality of service provided. However action plans were still in progress by the manager in order to achieve compliance within timescales agreed.