Archived: North Court Care Home

North Court is a care home providing both personal and nursing care to up to 65 people. The service provides support to older people, some of whom live with dementia, younger adults and adults with physical disability. At the time of our inspection there were 42 people using the service.

North Court is close to the town centre of Bury St Edmunds. The home is an ex local authority care home building. There are two floors. Downstairs is for older people living with dementia. They have access to a courtyard garden and a small café that is open from time to time. The top floor is nursing care. Each floor is separately staffed and has a nurse designated to each floor.

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

People did not have appetising, well presented food to eat. The kitchens were not managed to a high standard and food hygiene put people at potential risk. Fluid charts showed that one person was receiving a low intake of fluid.

Risks to people were not effectively managed. Risk assessments were not specific to the person and meaningful. Risks relating to moving and handling were not adequately managed. We observed poor practice that placed people and staff at risk of injury. Risk assessment instructions on moving and handling were confusing. Repositioning charts had gaps in them.

The quality assurance system had not been effective in identifying the issues we found during the inspection.

The current manager has had a positive impact on North Court and is liked and respected by staff. But there have been many managers in recent times and the changes and inconsistencies have impacted upon the running of the service. There is no registered manager and the current manager was leaving for another post.

There is still high use of agency (we were told this had reduced) The figures for June compared to May show an increase in agency staff for carers and support staff, but a decrease in agency nursing staff. Agency staff are used to ensure numbers of staff are maintained, but feedback and our observations show negative impact.

Infection control processors were good. There was strong leadership in the housekeeping team and an infection control lead is in place.

Medicine management had clearly improved with learning from past errors. Audits have been effective and appear thorough. Medicines were safely managed.

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

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

Rating at last inspection The last rating for this service was good. (Published 2 November 2019)

Why we inspected

The inspection was prompted in part due to concerns received about medicines, staffing and moving and handling. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

You can see what action we have asked the provider to take at the end of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

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 monitor the service and will take further action if needed.

We have identified breaches in relation to quality monitoring and assessing risk at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

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

We found the following examples of good practice.

The service was accessing the government testing scheme which assisted them to promptly identify an outbreak. The service worked with the local authority infection, prevention and control (IPC) team and other health professionals in managing the outbreak.

The service was clean, hygienic and free of unpleasant odours.

All staff had received recent training in infection control and prevention.

Personal protective equipment (PPE) stations had been created throughout the service. Staff were observed wearing this appropriately.

Regular checks were in place to ensure effective infection prevention and control practices were followed.

Risks to staff identified any vulnerabilities they may have in relation to COVID-19 and any mitigating action that the provider needed to implement.

The service had appropriate infection control policies and procedures in place. These were developed in line with current government guidance.

Further information is in the detailed findings below.

North Court Care Home provides accommodation, nursing and personal care for up to 65 older people, some of whom are living with dementia. The home is arranged over two floors: Abbey on the ground floor provides residential care and Edmund on the first floor on the provides nursing care based on people’s needs and requirements. At the time of our inspection there were 52 people who used the service.

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

Whilst staff demonstrated an understanding of people’s individual needs and how to meet them, we found shortfalls with the care planning documentation and record keeping in the home. Improvements were needed to people’s care records to inform staff on the personalised care and support required. Action was being taken by the home to address the inconsistencies, but this was a work in progress and at the early stages of implementation, so we were unable to assess its effectiveness.

People were treated with kindness, respect and compassion and their privacy and dignity respected. People and their relatives described positive relationships with the staff and management team. People were encouraged and enabled to pursue their hobbies and participate in activities of their choice. There was a welcoming atmosphere in the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff were aware of risks to people’s safety and knew how to respond appropriately through safeguarding processes. People had access to healthcare services and appropriate referrals made when their needs changed.

Staff deployment and organisation across the home was effectively managed. Since our last inspection there was less reliance on agency use and this had led to continuity of care and a settled workforce.

Staff felt supported by the registered manager and enjoyed their job, the training was relevant to meet people’s needs and they were encouraged to professionally develop. The home was clean and hygienic throughout and safe management of medicines was in place.

A programme of works was underway to improve the environment for the people who lived there and to ensure their individual needs were met. Feedback from people, relatives and the staff were sought, and opportunities taken to improve the home.

The registered manager was held in high regard and there was visible leadership in the home. Quality assurance and risk management systems to independently identify issues or to improve the service were in place which supported effective governance and oversight arrangements.

We were encouraged with the improvements made since the last inspection and the steps being taken by the senior management team to address the inconsistencies with records. Therefore, the overall rating of the home has improved to good.

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 06 September 2018).

Why we inspected

This was a planned inspection based on the previous rating.

North Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This comprehensive inspection took place on 18 July 2018 and was unannounced.

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.

At our last comprehensive inspection in August 2017 we rated the home ‘Requires Improvement’ overall with three breaches of the Health and Social Care Act. We were concerned at that inspection that people who were living at the home were not protected because control measures identified in risk assessments were not consistently in place for people. We were also concerned that health interventions in relation to catheter care, wound management, diabetes and bowel monitoring were not best practice and not always safe and effective. Additionally, we had concerns about fire safety, the effectiveness of the call bell system and the management oversight to ensure compliance.

We recognised at this inspection that whilst improvements had been made some of these were ongoing and not yet fully implemented, sustained and embedded into practice. The recently recruited registered manager had made progress in a number of areas and was committed to improving standards across the home. We have rated the home ‘Requires Improvement’ overall again, however there were no breaches of the regulations at this inspection and the key question of ‘is the service Responsive?’ has improved to a ‘Good’ rating.

Risks to individuals were assessed but measures to mitigate risk were not always in place. For example; there was not effective monitoring of people’s fluid intake to protect them from the risk of dehydration.

Whilst there were sufficient staff to meet people’s needs there were not enough permanent staff working in the home, which meant there was a reliance on agency staff who were not always familiar with people’s needs. We have recommended the provider continue to closely monitor staffing levels.

There was mixed feedback about the food available however there was a consultation under way to make changes. Staff said people had access to health care professionals and there was evidence of the management of people's care between the staff and external professionals.

Staff received ongoing training to ensure they were able to meet people's needs safely. They understood their roles and responsibilities to protect people from the risk of avoidable harm, and people said they felt safe living at the home. Staff followed the provider's policies and procedures to ensure people were protected from the risks of infection.

At this inspection we found they had met their legal requirements. With the basic principles of the Mental Capacity Act 2005 had been followed to ensure people's rights were upheld. Deprivation of Liberty Safeguards applications had been made and the registered manager kept these under review. People's interests and preferences were identified and recorded.

Staff interactions with people were kind and caring. Staff spoke kindly and sensitively with people when supporting them with their needs.

North Court is located in the centre of Bury St Edmunds and provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. At the time of our inspection there were 46 people living at the service. 23 people living with dementia in their ground floor unit.

The service had a registered manager who was present for the inspection visit. 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 spoke highly of this service and told us of staff who were caring and kind. We observed some genuine caring relationships that were mutually valued. The majority of people told us that they experienced a good service and were satisfied. People were supported by sufficient staff that were appropriately trained. People were provided with a range of activities and opportunities facilitated by activity staff. This included daily time spent with individuals who were residing in bed.

The manager was receptive to feedback given on the day and has sent an action plan with plans to address matters raised in this report. Concerns were fedback in relation to healthcare and nursing support within the service. Specifically; diabetes monitoring and response was not always clear in care plans, catheter care was not always safe and the monitoring of people’s bowel movements was not effective for clinical intervention and wound care was not always safe. In addition records made of nursing interventions were in some cases illegible and placed people at potential risk.

Risks to individuals were assessed but measures to mitigate risk were not always in place. For example; systematic failure to protect one person from developing further pressure sores. Fire safety was not systematically robust. Also we questioned the effectiveness of the call bell system in place and have requested this be reviewed.

Medicines were not consistently managed in relation to out of date equipment, such as a syringe driver, and the safe use of creams. There were systems in place to respond to concerns and complaints, but these needed to be further developed as an opportunity to learn and improve the service. The Deprivation of Liberty Safeguards (DoLS) was understood by the registered manager. However reviews required in the authorisation were not in place.

The registered manager had quality monitoring processes in place but had not identified the concerns and breaches that we have identified, therefore these processes were not effective and need to be reviewed.

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

We were made aware of some concerns in December 2016 which related to the safety of the service and which was linked to a possible impact on people’s health. The local authority placed an embargo on new admissions to the service and we carried out this focussed inspection on 24 and 25 January to assess the safety of the service. This report only covers our findings in relation to people’s safety and welfare. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for North Court Care Home on our website at www.cqc.org.uk

This inspection took place on 24 and 25 January. The inspection visit on 24 January was unannounced but the provider was aware we would be returning the following day to complete our inspection.

The service provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. At the time of our inspection 42 people were resident.

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

This report specifically focuses on the key area of Safe with regard to keeping people safe from abuse, the management of risks to people’s health and safety, staffing levels, the skills and expertise of staff and the management of medicines.

Staff had received training related to keeping people safe. General risks to people’s health and safety such as fire and legionella bacteria had been assessed and action taken to minimise them. Fire systems and most equipment, such as moving and handling equipment, were checked to ensure they was safe to use but some medical equipment was found not to be fit for use at the time of our inspection.

The service was not managing risk well and staff’s poor recording and lack of skills placed people at risk of harm. There were particular concerns related to the management of pressure care, moving and handling, eating and drinking, catheter care and falls. Staff understanding and knowledge was not always clear and records throughout the service, although plentiful, did not provide sufficient guidance for staff and did not accurately record care given. This made it difficult to assess if people had received the care they needed to keep them safe. Given that we found incidences of people who had lost weight and people with pressure sores developing we concluded that care was not always being delivered as required. New nursing staff had also identified some of the issues we were concerned about and had already begun to address these which gave us some reassurance.

Medicines were mostly well managed and people received their medicines within an appropriate timeframe. However, medicines delivered via a patch were not applied in line with manufacturer’s recommendations. This placed people at potential risk of harm. Some records related to medicines administration were not in place or were not accurately completed. The provider had not followed their own policy for determining whether covert administration of medicines was appropriate.

There were systems in place which were designed to protect people from the risk of abuse. Staff had received training in keeping people safe from abuse and suspected safeguarding concerns had been referred to the local authority adult protection team to investigate. Concerns raised during this inspection were not promptly referred.

Staffing levels enabled people to have their needs met most of the time but sometimes the service was stretched and basic recording tasks were not always completed. This placed people at risk as information did not provide an accurate picture of people’s needs. Staffing levels were assessed according to a recognised dependency tool but it was not clear how people’s particular needs with regard to deteriorating health conditions and increasing needs influenced staffing levels.

We found several breaches of regulation during this inspection.

We have since the inspection of November 2015, met with the provider several times and received updated action plans. We inspected in April 2016, as the provider said they were confident that they had made considerable improvements. Our findings following this inspection indicated that there were still concerns. This inspection was undertaken on the 10 June 2016 and had advised the provider of this date a day in advance, as we felt it essential that the manager and Regional manager should be present so we could establish what changes had been made. We found that the service had improved and there were no longer breaches of regulation

The service is registered for up to 65 people who might have a nursing need and, or living with dementia. On the day of our most recent inspection there were 34 people using the service.

Following our inspection in November 2015, the registered manager resigned and a temporary manager has been in post since then. They have recently applied to be registered as manager with the CQC and were successful.

‘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 our inspection on the 10 June 2016 we found: People’s needs were assessed and staffed accordingly. There were enough staff to deliver effective care and continuity was being maintained. However high staff vacancies could potentially threaten the stability of the service.

Medicines were usually administered as prescribed but we identified a number of gaps on the medication recording sheet and a number of occasions where people did not get their medicines as prescribed. We have made a recommendation around more effective medicine auditing.

Risks were mostly managed well but we identified a number of issues around records and these not always reflecting current practice. Risks associated with long term conditions and poor health status were not always clearly documented or records showing how these were being monitored.

Staff had a good understanding of how to report concerns and safeguard people in their care as far as reasonably possible.

Staff recruitment was robust at the last inspection so was not inspected again.

Staff were being supported through a robust programme of training, support and direct observation. New staff were being supported through a detailed induction and where possible staff were encouraged to undertake additional qualifications in care. There was a notable shift in culture and practice but some of these changes would take a while to become embedded.

People were supported to eat and drink according to their preferences. There were systems in place to monitor what people were eating and drinking but this could be strengthened by clearer records and a clear concise evaluation. We have made a recommendation about this.

People’s health care needs were documented but we did identify some gaps which again we attribute to the homes record system and clinical oversight. Some improvement is still required.

Staff were complying with the Mental Capacity Act 2015 but were confident in staffs practices and records underpinning capacity and choice.

The staff demonstrated care and compassion and had a good understanding of people’s needs. Care was centred around the individual and we saw good outcomes for people.

Complaints and feedback about the service were used to improve the service as required.

The home was responsive to people’s needs and gave people the opportunity to participate in a range of activities which were appropriate to their needs and enhanced their sense of well- being.

Documentation had improved since our last inspection and records gave a good account of people’s needs and actions staff should take to ensure people’s health and well- being were maintained.

The home was being well managed and inclusive of the local community and family members. Staff felt well supported and the organisation of the service had improved.

Audits and quality assurance systems were in place to monitor the service delivery and take into account how the service was being provided. As a result of audits actions plans had been implemented. Further audits based primarily on observation by experienced quality assurance staff were being rolled out to try and capture the experiences of people who might not be able to tell staff about their feelings or complete a questionnaire.

Although the service had come along way further improvements are required to achieve a good rating

The inspection in November 2015 was planned as a responsive inspection because of concerns received about the safety and well- being of people using the service.. During our November inspection we found wide spread failings and breaches of a number of the regulations.

We rated the service as inadequate and put the service in special measures which meant the service was given a specific period of time to improve We also took enforcement action to ensure to restrict further admissions to the service until such a time we had judged them to be providing safe care.

Following the inspection in November 2015 we met with the Regional manager and Registered manager to discuss our concerns. We have also communicated our concerns with the Local Authority so they could continue to support the service to improve. Following this inspection in November, the service sent their action plans stating what they had already done and what they were going to do to improve the service. They told us when they expected to have addressed all of the concerns identified.

We carried out this inspection on 13 April 2016. At the time of our inspection the Registered Manager was no longer working at the service. The provider had acted swiftly to appoint a new manager who came into post in February 2016. The provider also appointed a deputy manager and had a member of staff working as clinical lead in an administrative role. This new team are starting to establish good practices within the service but it is too early to judge the effectiveness of this. The manager has put in an application to be registered with the Care Quality Commission which will be processed in line with expectations.

At this inspection in April 2016 we found that staff knew how to raise concerns and protect people as far as possible from avoidable harm or poor care and treatment. A number of staff had raised concerns previously but felt their concerns had not been listened too but were more confident in the current management and response from the organisation.

Risks to people’s health and safety were not always clearly documented and we found variable practice within the home. We identified hazards to people’s safety and in particular poor monitoring and poor infection control. We also identified improvements were required in the way people received their medicines. Records relating to this required improvement.

Staffing levels had improved and the considerable staff vacancies reduced. We were not fully confident about the skills mix and competencies of all the staff due to poor past supervision and monitoring of staffs practice and lack of clarity around roles and responsibilities. Staff shortages also occurred occasionally. The impact of this was that people did not always receive the care according to their expressed wishes.

Staff felt well supported through induction, training and monitoring of their performance which will take a while to embed.

Support people received at lunch time varied and people did not always receive adequate monitoring of what they were eating and drinking and if it was appropriate to their needs. Some of this was due to poor record keeping and not all staff being fully aware of people’s needs.

Peoples health care needs were not always adequately monitored so staff could respond appropriately for reasons cited above.

The service supported people appropriately and worked in accordance with the legal requirements in terms of their capacity. Staff did not always provide information in a way which enabled people to make an appropriate choice.

The staff were caring and care practices had improved with people receiving care which was more responsive to their individual needs.

Consultation with people using the service was improving and people’s preferences of care were taken into consideration along- side their feedback about the quality of care and overall satisfaction.

Although staff were more responsive to needs care plans did not always give us enough information about people’s needs or how staff should meet them. The level of activity for some people were not adequate. This meant that for some people there was little evidence of them participating in any activity which they might have done if sufficiently supported to by staff.

The service had an established complaints procedure and people had growing confidence in raising concerns.

Improvements have been made in the overall quality and experiences for people using the service. There was better engagement with the voluntary sector, improvements in staffing levels, activities of daily living and the environment. However we still have concerns about the quality of the nursing care provided and found records not up to date or reflecting people’s current needs or risks. We were not confident with the staffing mix and whether all staff were sufficiently competent to fully meet the needs of the people they cared for.

We have also been concerned that a number of incidents/concerns either have not been reported to us or documents have not been forwarded to us in a timely way when requested. This has resulted in a loss of confidence in the service and their processes in terms of openness and transparency.

During our inspection on 8 August 2014 we found that the service had made the improvements we had asked them to.

During this inspection we were met by the manager who was not yet registered with the Care Quality Commission as they were relatively new in post. The manager told us that they had started the process to become registered with us. We also met the Area Manager.

During our inspection we spoke with 5 people who used the service, two people's relatives and observed the care on both the ground and first floor. We looked at six people's care plans and other associated care records. We also looked at staffing records, quality audits and health and safety records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

The entrance of the building was secure and staff checked our identity. People were free to move about but a key code system gave people additional security. We saw that a number of people had door sensors which would alert staff as to when people were mobile and at an increased risk of falls.

People received adequate supervision from staff and records showed us that people were regularly checked to ensure they were safe.

Staff had received training in safeguarding vulnerable adults from abuse, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were provided with the information that they needed to recognise and report concerns so that people were protected from abuse as far as possible.

The environment was well maintained and free from offensive odours. We noted a carpet that needed replacing during our previous inspection of 1 May 2014, it had been replaced.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that the records had been reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met.

We saw that staffing levels were being maintained in accordance with people's assessed needs which meant staff were able to meet people's needs. The service had taken action to address our concerns that the service was failing to meet people's social needs at our previous inspection. An activities person had been appointed, had set up a schedule of activities, begun to talk to people independently about their preferences, and had produced a newsletter.

Is the service caring?

The staff interactions we observed were kind and we found staff responded appropriately to people's requests and needs. We spoke with some relatives, one told us, 'The staff are so good and helpful.' Another said, 'They (the service) care about me as well as (their relative).'

Is the service responsive?

We saw call bells were answered promptly and people's needs were responded to quickly. We observed lunch and saw that most people received the support they needed in a timely way and staff did not outpace people when supporting them with their meals. The staff team appeared relaxed and frequently interacted with people, even when just passing through communal lounges they would stop and acknowledge people in an appropriate manner.

Is the service well led?

The manager who was new at our previous inspection on 1 May 2014, has now become 'bedded in' and had made themselves known to all the people who used the service and their relatives by arranging relative and resident meetings and spending time with people. One person's relative told us, 'The manager is like a breath of fresh air, so open and friendly.'

The manager no longer covered shifts unless it could not be avoided or by choice so that they could 'keep their hand in', which they did occasionally.

We saw the service's records which related to infection control and the maintenance of equipment, such as lifting equipment. We found that all the records we looked at relevant to the management of the service were accurate and up to date.

We saw that complaints were dealt with effectively and recorded in line with the provider's complaints policy. However, there was one complaint that was still being dealt with and had also been referred to us, the Care Quality Commission. We will continue to monitor this complaint to its conclusion.

The manager ensured that staff were appropriately supported throughout their shift and that they received regular supervision of their practice and annual appraisals.

There were regular audits of the quality of the service and the care provided to people. This meant there were systems in place to identify where the service was meeting regulation and where it needed to improve. We saw that audits took place across the day and night shift which enabled the manager to see the service provided over a 24 hour period.

During our inspection we spoke with 14 people who used the service, three relatives, six staff members and observed the care on both the ground and first floor. We looked at six care plans and other associated care records. We also looked at staffing records quality audits and health and safety records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

The entrance of the building was secure and staff checked our identity. People were free to move about but a key code system gave people additional security. We saw that a number of people had door sensors which would alert staff as to when people were mobile and at an increased risk of falls. We saw that call bells were in people's reach and answered promptly by staff. People received adequate supervision from staff and records showed us people were regularly checked to ensure they were safe. We saw that staff worked closely with the falls prevention coordinator and records showed very few recorded falls in the last few months which meant the staff were taking necessary action to keep people safe.

Staff had received training in safeguarding vulnerable adults from abuse and the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were provided with the information that they needed to recognise and report concerns so that people were protected from abuse as far as possible.

The environment was well maintained and we saw a schedule of maintenance which ensured equipment was in good working order and fit for purpose. Staff were employed in sufficient numbers to ensure the building was hygienic and the risk of infection was kept at a minimum. We observed staff wearing personal protective clothing as appropriate and we saw daily, weekly and monthly cleaning schedules were in place. We noted one carpet which needed replacing urgently because of a strong smell of urine. We told the manager about this.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that the records had been reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met.

We saw that staffing levels were being maintained in accordance with people's assessed needs which meant staff were able to meet people's needs. However the service was failing to meet people's social needs. The activities person had left in February 2014 and had yet to be replaced. This left people with little or no opportunities to have support to engage in social activities and hobbies?

Is the service caring?

The interactions we observed by staff were kind and we found staff responded appropriately to people's requests and needs. We spoke with some relatives, one told us, and 'The staff are smashing.' Another said, 'My family member's needs are met by staff.'

Is the service responsive?

We saw call bells were answered quickly and people's needs were responded to quickly. We observed lunch and saw that most people received the support they needed in a timely way and staff did not outpace people when supporting them with their meals. The staff team appeared relaxed and frequently interacted with people, even when just passing through communal lounges they would stop and acknowledge people in an appropriate manner.

People were supported to see other professionals such as general practitioner, community dentist, chiropodist, optician, and district nurse. This showed that people's general health care needs were considered and that the service was responsive to people's changing needs.

Is the service well led?

The service was fully staffed and staff told us that staff sickness and shift vacancies were managed well? The manager would use bank staff to cover shifts but we were concerned that the manager was also covering shifts which meant that they had not had the time to implement some of the changes they wanted to introduce to improve the service.

The manager was ensuring that staff were appropriately supported throughout their shift and was in the process of ensuring they received regular supervision of their practice and annual appraisals. We saw evidence that not all staff had received a recent supervision which meant we could not be assured that all staff were properly supported.

There were regular audits of the quality of the service and audits on the care provided to people. This meant there were systems in place to identify where the service was meeting regulation and where it needed to improve. We saw that audits took place across the day and night shift which enabled the manager to see the service provided over a 24 hour period. We saw poor consultation with people using the service. The annual questionnaire sent out to people and, or their families had a very low response rate of 4% and we could not see what others ways the service were actively engaging people or seeking their views about the service. The provider told us they planned to hold resident/relatives meetings every other month but no meetings had been held in recent months and there were no planned forthcoming dates. The manager told us six monthly reviews would be held to review people's needs but we did not see a schedule of planned reviews or evidence of six monthly reviews in people's care plans.

The service had a temporary manager in place that was working to ensure systems in place were safe and effective. However, we found that improvements were needed in the management of diabetes and wound care. We found that trained nurses needed to be more aware of current practices.

Records in place did not support the service effectively. We found records cumbersome, repetitive and key issues such as diagnosis and reason for using the service hidden in the mass of recording.

We found that the service had appropriate arrangements in place for obtaining consent to care. We saw that people had been consulted in the consent to their care. Where appropriate the service had assessments in place for people in accordance with the Mental Capacity Act 2005.

There was enough equipment to promote the independence and comfort of people who use the service. We found that medication was generally well managed and people received medicine that was prescribed for them. There had been improvements in the provision of equipment, especially relating to pressure relieving equipment.

We found that the service had improved since our visit in April 2013. We observed some good interactions between staff and people who used the service. We observed some instances of staff kindness and caring ability to support people. We also observed that staff did not interact positively with some people using the service upstairs and that some staff talked about people in front of them and shouted over their heads. Some staff demonstrated a lack of understanding around ensuring the dignity of people living with dementia.

We noted that there had been a change in leadership within the service and the team working at the service including an area manager, peripatetic manager and new home manager were working to ensure the required improvements are made. This showed that the provider was taking concerns raised by the Commission seriously and was acting to improve the quality of the service provided.

We saw the provider did regular audits to check the administration of medicines was being recorded correctly. We saw the provider did daily checks on the stock levels of medicines. Records showed any concerns were highlighted and action taken.

We observed that staff did not interact positively with some people using the service and that staff talked about people in front of them and shouted over their heads. Some staff demonstrated a lack of understanding around ensuring the dignity of people with dementia. We saw that procedures to ensure that people were restrained appropriately had not been followed and we have reported this to the local authority safeguard team.

We saw that some people with diabetes did not always have their care needs assessed or appropriately treated. People's skin integrity had been risk assessed but preventative equipment was not always in place to mitigate the identified risks. Nursing staff had not received up to date training around tissue viability and diabetes.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

At our return inspection, the manager told us that they have now recruited additional staff. We saw the rotas for the past two months and these showed that staffing levels had been adequate. We spoke with four members of staff who confirmed that additional staff had been brought in and that staffing levels were sufficient. The manager told us that they were carrying out a workforce planning assessment to decide future staffing levels.