Archived: Attlee Court

About the service

Attlee Court is a residential care home providing personal care for up to 68 people. Some people using the service were living with dementia. At the time of our inspection, there were 45 people using the service. Attlee court accommodates people on two separate units.

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

We carried out a tour of the home with the deputy manager and found several areas that required a deep clean. Following our inspection, the registered manager confirmed a deep clean of the home had taken place.

During our inspection, we identified some concerns regarding maintenance of equipment. The registered manager took action to address these issues.

Risks in relating to people's care were identified and managed safely. However, one person's moving and handling care plan did not document loop configuration to use. Following our inspection, the registered manager confirmed this had been updated and completed.

We found missed signatures on medication administration records (MAR’s), and topical medication was not always signed for when given. Some people were prescribed medications on an ‘as and when’ required basis, often known as PRN. Some people did not have PRN protocols in place, and MAR sheets didn't record why PRN medicine was required and whether it was effective. Medication audits identified similar themes and following this, supervision sessions took place to address the issues with staff. We made a recommendation for safe medication systems to be embedded into practice.

The service was not always person centred. Some care planning documentation was found in a lounge area. The home was not always dementia friendly. There was a lack of signage to help people navigate around the home.

The provider had a recruitment process in place which helped them employ suitable staff. We found there were enough staff available to meet people's needs.

People were safeguarded form the risk of abuse. Accidents and incidents were monitored and analysed to mitigate future incidents.

We observed staff interacting with people and found they knew people well and supported them in line with their needs and preferences.

The provider had a range of audits which were carried out by the management team. However, some audits had not identified concerns we raised during our inspection. For example, the infection control audit had not identified the home required a deep clean. We also identified some concerns with maintenance of equipment. These issues were promptly address by the registered manager after out site visit.

People were involved in the home and their feedback was used to develop 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

The last rating for this service was requires improvement (published 31 October 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, training, management and risks. A decision was made for us to inspect and examine those risks. 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 remained requires improvement, based on the findings of this inspection. We identified a breach of regulation in respect of good governance.

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 Attlee Court on our website at www.cqc.org.uk.

Follow up

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

Attlee Court is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Attlee Court has two floors with living accommodation on both. The first floor is for people living with dementia and is accessible by a lift. The home is registered to provide accommodation for up to 68 people and there were 33 people living in the home during our inspection

People’s experience of using this service:

Improvements had been made in relation to systems for managing risks to people’s health and wellbeing although staff did not always follow the detail in people’s risk assessments.

People told us they felt safe at the service.

Systems for managing medicines had improved and were safe.

Care records were inconsistent. This had been identified by the registered manager as being largely due to a mixture of electronic and paper based records. At the time of the inspection work was ongoing to revert to an entirely paper based system.

People said there were enough staff to meet their needs although some said they sometimes needed to wait for support. The registered manager gave assurances they would look at improving deployment of staff.

Staff felt supported by the registered manager and said they received effective training. Training was being arranged for staff supporting people living with dementia.

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. Some improvements were needed in relation to recording best interest decisions and mental capacity assessments.

People received support from health and social care professionals as needed.

People said they enjoyed the food, but improvements were needed in the systems to monitor food and fluid intakes.

People said staff were kind and caring and we saw positive interactions.

Care plans did not always evidence a person centred approach and there was a lack of consideration of people’s diverse needs within the care planning process.

People enjoyed the activities provided and said their relatives and friends were welcomed to the home.

People had confidence in the registered manager. Systems were in place to monitor quality and safety within the service. Some improvements were needed to make sure these systems were robust enough to identify all issues.

Rating at last inspection (and update)

This service has been in Special Measures since January 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Follow up

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

People’s experience of using this service:

Risks were not managed robustly to ensure people’s safely and this was a continuing concern from previous inspections.

People were at risk of not being given their medicines safely or consistently.

Care records were not always up to date and did not always reflect people’s current needs. Information was inconsistently recorded.

Staff deployment had improved since the last inspection, although there was little assurance of the skills and abilities of agency staff.

Staff employed by the service were supported through training and supervision.

Wound care management had improved since the last inspection.

Staff were kind and caring and there were sufficient numbers of staff to support people.

People enjoyed the activities and there was positive interaction when engaging with the activities staff.

The management team had changed since the last inspection; there was a new manager and deputy manager in post and staff were clearer about their lines of accountability.

The service was in the process of changing the type of care being provided and had ceased to offer nursing care. Staff were adjusting to the changes and there had been some changes to the staff team and their responsibilities.

Quality audits were more detailed and consistent than at previous inspections. However, they still lacked rigour and did not robustly address some aspects of continued concern from the previous inspection, particularly where people were at risk of receiving unsafe care.

Rating at last inspection: Requires Improvement (last report published 13 March 2019). The service had not improved sufficiently at this inspection and the rating remains Requires Improvement.

Why we inspected: This inspection was based on the previous rating and our ongoing concerns about the quality of the care provided.

Enforcement: The service met the characteristics of Inadequate in the key question of safe,

and Requires Improvement in Effective, Responsive and Well Led. We are taking enforcement action and will report on this when it is completed.

Follow up: We will continue to monitor the service closely and discuss ongoing concerns with the local authority.

The service remains in '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.

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.

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.

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 will have contact with the provider following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

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

Attlee Court is a ‘care home’ for up to 68 people. The home was divided into two units; dementia care upstairs, with nursing care and residential care combined downstairs. At the time of the inspection there were 35 people in the home and there was a measured approach being taken by the provider for ensuring gradual admissions. People in care homes receive accommodation and nursing or personal care as a single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager in post who had been at the home since April 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.

Staffing levels were acceptable, although staff were not always effectively deployed. Where agency staff were used, their identity checks and induction were not always completed and this had been a concern at the last inspection, which had not been sufficiently addressed.

Staff were patient, kind and caring. People’s dignity was respected and people did not have to wait for staff to assist them when required. We saw activities taking place and staff spent time with people in between supporting their physical needs.

We found care documentation was still in the process of being transferred to electronic records, and there was still a lack of consistently completed information to enable staff to have a thorough understanding of people’s care needs.

We found continuing concerns regarding risks to individuals, which were not always recognised, documented or managed safely. Accidents and incidents were recorded but there remained poor management oversight, analysis or investigation of these to identify potential or recurring themes.

Staff understood safeguarding and whistleblowing procedures and they were confident to raise any concerns. However, not all safeguarding concerns had been appropriately referred to the safeguarding authority.

There were weaknesses in the systems and processes for managing medicines.

People’s mental capacity was appropriately assessed and where people had Deprivation of Liberty Safeguards in place, these were followed up with the local authority to ensure they remained valid. Decisions recorded as being in people's best interests needed reviewing.

People enjoyed the meals. There were individual diet sheets kept in the kitchen but these were not in place for everyone and were not always accurate or up to date. People had suitable access to drinks. However, people’s fluid intake was still not consistently recorded or managed. There was limited evidence of monitoring by senior staff or what action was taken when people’s food and fluid intake was poor.

At the last inspection we had seen some limited evidence of emerging quality assurance systems. However, we did not yet see sufficient evidence these were robustly embedded. There were continued weaknesses in the leadership and management of the home, although the supporting management structure was being strengthened to effect clearer oversight moving forward.

The overall rating for this service continues to be ‘requires improvement’ and the service therefore 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.

Attlee Court is a ‘care home’ for up to 68 people. The home was divided into two units; dementia care upstairs, with nursing care and residential care combined downstairs. At the time of the inspection there were 31 people in the home and there was a voluntary embargo on placing any further admissions. People in care homes receive accommodation and nursing or personal care as a single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a newly registered manager in post who had been at the home since April 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.

We found staffing levels had improved and staff were more effectively deployed. Changes had been implemented to shift patterns so more staff were available to respond to people at busy times of the day. However, staff on the downstairs unit lacked clear direction in their work and at times were not visible within communal areas. Where agency staff were used, their identity was not always checked.

Staff were kind and caring in their approach to people’s care on the whole. People’s dignity was supported better as staff were available to assist them in a timely manner. There was more meaningful activity taking place and staff spent more time engaging in conversation with people.

Safeguarding procedures were known by staff and there was an increased confidence in raising safeguarding concerns. However, although people’s mental capacity was appropriately assessed, where people had a Deprivation of Liberty Safeguard in place, these had expired and had not been followed up in a timely way.

Risks to individuals were not always recognised or managed safely. Accidents and incidents were recorded but there was poor management oversight and analysis or investigation of these. Systems and processes for managing medicines had improved. Care documentation was in the process of being transferred to electronic records, but written care records within each person’s room were not consistently completed or information of concern followed up.

People enjoyed the meals and people’s individual dietary needs were known. People's access to drinks had improved through more effective deployment of staff at times such as early morning when people may require a drink on waking. However, recording of people’s fluid intake was not consistently managed.

The new manager was enthusiastic and confident and we saw some limited evidence of emerging quality assurance systems. However, leadership and management of the home was not robust and quality assurance processes did not adequately monitor practice or identify risks and areas to improve. Systems for communication within the staff team were improving and staff felt more supported in their work.

The overall rating for this service is ‘Requires Improvement’ and the service therefore 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.

Attlee Court is a ‘care home’ for up to 68 people. The home was divided into three units; dementia care, nursing care and residential care. Before the second day of the inspection, the provider combined the units for residential and nursing care. At the time of the inspection there were 43 people in the home. People in care homes receive accommodation and nursing or personal care as a single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

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

We identified five breaches in the regulations relating to person centred care, dignity and respect, safe care and treatment, staffing and good governance. We asked the provider not to admit any further people to Attlee Court and to increase the staffing levels with immediate effect. The provider agreed to do this and we saw this had been initiated by day two of the inspection.

We found staffing levels were insufficient to meet people’s needs and this impacted throughout people's care and support. We saw many instances where people had to wait considerable lengths of time to have their basic needs met.

Staff had a kind and caring attitude towards people they cared for, although they lacked time to spend with people other than when completing personal care. People’s dignity was at times compromised when staff were unable to support them in a timely manner. There was a lack of person centred care because staffing levels prevented staff from responding properly to meet people’s needs. There was little meaningful activity taking place and people remained in their beds or in their chairs for long periods of time.

Staff knew the signs of potential abuse although they did not all feel confident to raise safeguarding concerns, particularly where this was in relation to whistleblowing.

Risks to individuals were not always assessed, recognised or managed safely. Accidents and incidents were recorded but there was poor management oversight and analysis of these. Systems and processes for managing medicines were not robust.

There was poor leadership and management in the home and quality assurance processes were not rigorous enough to monitor practice or identify risks and areas to improve. Systems for communication within the staff team were not always effective or reliable. Staff did not always feel supported to carry out their role and we found information was not always shared in a timely or supportive way.

People enjoyed the quality of the meals and the cook was knowledgeable about people’s individual needs. However, some people's access to drinks was limited and people were not always served drinks when they needed them, such as when they woke in the morning.

People’s mental capacity was appropriately assessed although people were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. People were not consistently involved in planning their care. Care plans where completed were up to date, although we found two people’s care records which were blank, which meant staff had no information about how to support these people. Records of people's daily checks and care provided were not completed in a timely way to show when such care was carried out.

The overall rating for this service is ‘Inadequate’ and the service has therefore been placed 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.

Attlee Court provides accommodation and nursing care for up to 68 people. The service has

two floors and provides care and support for people with nursing and residential needs including people who are living with dementia. On the day of our visit there were 23 people living at the home as only a small number of people at a time were being admitted due to previous concerns. This inspection was to consider whether improvements we had seen at our previous inspection had been sustained.

The service did not have a registered manager in post at the time of our inspection although there was a home manager who had been in post since August 2015 and had applied for registration. The home manager was on annual leave on the day we visited; however the area and deputy managers were present. We spoke with the home manager on their return from leave.

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

People were safe and this view was supported by relatives. People felt confident in staff’s abilities and staff were able to explain what action they would take if they found anything of concern. We saw the manager had taken appropriate action in regards to recent concerns.

We found risk assessments were person-specific and contained risk reduction measures to limit the likelihood of harm. Staff received guidance from these assessments as to how best care for people with differing needs, whether this was due to physical or mental health needs. We did highlight to the area and deputy managers that moving and handling risk assessments needed further detail in regards to the method of transferring someone so that staff had specific instructions. They agreed to remedy this promptly.

Staffing levels were sufficient on the day we inspected and we saw staff had time to spend talking to people and the atmosphere was relaxed. It was evident staff were focused on the needs of people in the home at all times.

We observed medicine administration and found concerns around this practice. One person was receiving covert medicine without the necessary authorisation and in addition this medication was crushed without direct medical guidance. We discussed this with the area manager who immediately took action by speaking to the member of staff. The area manager acknowledged our concerns and arranged for the staff member to receive further training and support for this role. The area manager also changed the processes for covert medicine on our guidance.

People were supported with nutrition and hydration, and were able to access health and social care services as required. Care records showed regular visits from chiropodists, social workers and GPs.

We saw that people had Deprivation of Liberty Safeguards in place where their freedom was restricted due to a lack of mental capacity to assess risk, and that decision-specific mental capacity assessments had been competed for all aspects of people’s care needs.

Staff displayed confidence in their role and had access to regular training which was supported by regular supervision. We saw staff had a good rapport with people; they spent time listening to them and displayed a sound knowledge of people’s preferences and routines. Consent was sought each time they supported someone and privacy and dignity were respected.

People were occupied throughout the day with a variety of things to do such as sitting in the garden, playing games and chatting to each other and staff. We observed high levels of interaction during the afternoon bingo game where it was evident there were positive relationships between people.

Care records reflected individual needs and were based on people’s wishes. They were regularly reviewed and any changes implemented as a result. Complaints were handled sensitively and investigated thoroughly.

The home and area managers had scrutinised the previous inspection report in depth and developed a robust action plan. This had resulted in a detailed action plan which had been followed and was evident in all aspects of the home. The home had shown evidence of sustainability and persistence, and through its new processes would be able to identify any concerns much earlier and take action quicker.

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

Attlee Court is a nursing home currently providing care for up to a maximum of 68 people. The service has two floors and provides care and support for people with nursing and residential needs including people who are living with dementia. On the day of our visit there were 20 people living at the home and the provider had a voluntary stop on placements.

The service did not have had a registered manager in post at the time of our inspection, although there was a home manager who had been in post since August 2015 and had applied for registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The home manager was on leave on the day of the inspection and we arranged to give feedback upon their return.

Since the last inspection there had been significant improvements in the home. Renovations had been completed and there was more robust management of work being carried out within the home.

The environment was much more welcoming and homely than had previously been found at the last inspection, particularly for those people living with dementia.

The management of risk had improved in relation to the premises and for some aspects of individual people’s care needs. There were some areas of concern in relation to accurately identifying risks from some equipment.

Standards of cleanliness in the home had improved and we found most areas to be visibly clean and free from odours.

Staffing levels ensured people’s physical and social needs were met. There had been some staff changes since the last inspection and changes in senior management had helped to drive improvement.

Medicines were managed appropriately.

Staff were kind and caring, and the quality of interaction with people who were living with dementia had improved since the last inspection.

There were activities and improved resources for people to be meaningfully engaged.

There was improved management oversight in relation to the premises and to individual people’s care needs. Better systems were in place to check the quality of the provision but these were not all robust enough with regard to some aspects, such as safety checks.

Attlee Court is a nursing home currently providing care for up to a maximum of 68 people. The service has two floors and provides care and support for people with nursing and residential needs including people who are living with dementia. On the day of our visit there were 26 people living at the home.

The service did not have had a registered manager in post at the time of our inspection, although there was a manager who had been in post since August 2015 and had applied for registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The new manager had begun to make some improvements to the service and feedback from people, staff and relatives was positive. However, we found renovations were being carried out at the time of the inspection and there were no care strategies or risk assessments in place to ensure people’s safety and well-being in relation to the work being done. The management of the refurbishment work was poor and lacked organisation or consideration for associated hazards, such as fire safety.

The premises were in the process of redecoration in response to the previous inspection findings; however, improvements were not complete at the time of this inspection and the environment was not welcoming or homely, particularly for those people living with dementia.

The management of risk was very poor, in relation to the premises and to individual people’s care needs. We discussed this at length with the manager during the first two days of the inspection. However, little action had been taken by the time we arrived on day three and we found continued concerns.

Staff practised appropriate infection control measures, such as cleaning and the use of personal protective equipment. However, there were some aspects of infection control and prevention that were not adequately monitored and standards of cleanliness were not always maintained.

Staffing levels were adequate and people did not have to wait for staff assistance. Staff were confident in how to recognise and report suspected abuse, although policies and procedures did not clearly illustrate how staff should report concerns.

Staff recruitment and vetting was appropriately carried out, but where agency staff were used, suitability checks were not robust. Staff induction was not fully evidenced for new staff.

Medicines were managed appropriately.

The menus had been revised since the new manager came into post and people reported improvements in the quality of the meals.

Information in care plans was easy to locate, however, there was conflicting information in some of the records we looked at. Individual risks assessments for people were not always clearly stated, such as for moving and handling.

Staff were kind and caring, although the quality of staff interaction with people varied. There was little respect for this being people’s home whilst the building works were ongoing.

There were too few activities for people to be meaningfully engaged and as a result, some people were frequently bored or passive.

There was little management oversight in relation to the premises and to individual people’s care needs. Some systems were in place to check the quality of the provision but these were not thoroughly implemented and did not identify concerns we found at this inspection.

The overall rating for this service is ‘Inadequate’ due to the multiple and continued breaches we found. We noted the provider had made some improvements to the service and was still working towards their action plan at the time of the inspection, but progress was slow.

We spoke with four staff and five people who lived in the home on the first day of the inspection. We spoke with the manager on the second day of the inspection. We spoke with two relatives.

We found the provider had addressed the concerns raised at the previous inspection and had taken significant measures to improve the quality of care for people. Some of our actions had been fully addressed and there were ongoing plans for continued improvement.

We saw people's care and the quality of staff interaction had improved. People were settled and content overall and their needs were appropriately met.

People had sufficient food and drinks and staff understood each person's dietary needs. Closer attention was paid to weight monitoring and supporting people's individual food and drink intake.

Systems for assessing and monitoring the quality of the provision had improved and we discussed with the manager how this would be further developed to ensure clear audits of people's care.

We observed care in all areas of the home. We spoke with ten people, three relatives, the manager, regional manager, three care staff and the chef.

We focused our inspection closely on people's experiences in the dementia care units and our specialist adviser, who was a dietician, looked at how people's diet and nutritional needs were met.

We found the provider had taken steps to improve the environment for people with dementia and had separated the unit into two smaller units. We saw this provided much calmer surroundings for people. However, we remained concerned some people did not receive care appropriate for their needs.

We reviewed documentation which showed people's care, particularly in relation to nutrition, was inconsistent with gaps in recording within care plans. Although the provider told us they had taken steps to improve and audit care records, we saw these still did not illustrate people's needs were met effectively.

We found staff were appropriately supported to do their role.

We found that the home had systems which monitored and assessed the quality of service. However we were concerned the areas of non-compliance we identified in the report had not been picked up through these processes. This meant the effectiveness of the quality monitoring systems was not assured.

At the previous inspection on 25 April 2013 we noticed one person had not received prompt medical attention following an injury. We also saw that care records contained conflicting information with regard to the risk of falls. We asked the provider to send us a report by 22 June 2013 detailing how they planned to meet the essential standards. The provider submitted an action plan and told us they would be compliant by 31 July 2013. Therefore we did not follow this area up but we will do so at a later date. However, at this responsive inspection we found additional areas of concern.

We found people's needs were not always assessed and care and treatment was not planned and delivered in line with their individual care plan.

We found the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. Although the provider had carried out audits, we found in some areas, such as care records, these audits had not identified the issues we found.

We saw that staff were kind and caring with people and they understood their individual needs. We observed people frequently enaged in conversation with staff. People said they were happy and that they enjoyed good food and a comfortable bed. We noticed one person had not received prompt medical attention following an injury. We also saw that care records contained conflicting information with regard to the risk of falls.

We saw that medicines were stored and administered appropriately overall, with all details recorded. People told us that they got their medicines on time. Staff told us they were confident to give medicines and they understood the medication policies and procedures.

We saw that the first floor had undergone some refurbishment. People and their relatives told us that they thought the home looked smart. We saw that the premises were safe and accessible for people who lived there and for staff. We talked to maintenance staff about ongoing improvements. Staff told us that they knew the procedures to follow in an emergency.

We saw records to show how premises had been maintained and how regular checks were carried out by the manager to ensure quality of care for people.

On arrival at the home the atmosphere was calm and well organised on both units. We spoke with two people who used the service who were seated in the lounge area of the nursing and residential unit. They said they felt there were sufficient numbers of staff to meet their needs and had no concerns.

Due to communication difficulties we were unable to speak with people on the dementia unit. Instead we observed how people were cared for and how people interacted with each other and staff. People who were up were appropriately dressed and well cared for and we saw how they were treated with dignity and respect by staff.

We spoke with seven members of care staff. They told us they had concerns, particularly during busy times when people needed assistance preparing for bed at night and getting up in the mornings. The manager agreed to look into the concerns raised by staff and to consider how these should be addressed to ensure the welfare of the people who live in the home and the staff who care for them.

On the day of our visit we saw that people using the service were receiving appropriate care, the home was actively recruiting new and experienced staff and the manager was making changes to shift patterns to meet the demands of the service.