Archived: Holly Grange Residential Home

Holly Grange Residential Home is a care home providing accommodation and personal care for up to 19 people aged 65 and over, some of whom may be living with dementia. At the time of inspection, the service was supporting 9 people in one extended and adapted building on the ground and first floor of three storeys.

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

Risks were not always safely managed. Known risk were not always assessed and mitigated and information on people’s risks to support staff in understanding what they needed to do had not always been recorded.

Medicines were not always safely managed, we found concerns with the recording, storage and stock checks of medicines. ‘As required’ medicines did not have protocols in place to ensure staff had the information required to administer medicines as prescribed.

People were put at risk of harm. We found concerns with unsafe mobility equipment, support with eating, hot food temperatures not being recorded and people having access to harmful substances. A staff member told us at times physical interventions were used for 1 person. Staff did not have the training or systems in place to protect people from the possible risks associated with inappropriate physical interventions.

Staffing levels were not sufficient to meet people’s individual needs. We observed communal areas with people who required support being left unattended throughout the inspection.

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. Consent had been given by people without the legal authorisation to do so

Systems and processes were either not in place or not effective in ensuring good management oversight of the service. When audits had been completed, they did not always identify the concerns found on inspection. Incidents, accidents, wounds and falls had not been analysed to identify any trends and patterns to reduce the risk of reoccurrence.

Care planning documentation was not always detailed with information regarding people’s individual needs. Not all care plans were person centred. However, some people had detailed ‘This is me’ documents which included their history, likes/dislikes and important relationships.

People were supported by staff who had been safely recruited, trained, inducted into the service and who felt supported by the manager. People told us staff were kind and caring. Staff understood safeguarding procedures and how to recognise signs of abuse.

People were protected from risks associated with their health conditions. Staff had the information required and supported people to access healthcare as required.

The provider had policies including complaints, safeguarding, recruitment, infection control and health and safety. The provider had requested feedback on the service offered from people, relatives and staff.

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 (published 23 December 2022) and there were breaches of regulation.

Why we inspected

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

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

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

Enforcement and Recommendation

We have identified breaches in relation to risk management, medicines, staffing, consent and management oversight at this inspection.

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

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.

Holly Grange Residential Home is a care home providing personal care for up to 19 people aged 65 and over, some of whom may be living with dementia. At the time of inspection, the service was supporting nine people in one extended and adapted building on the ground and first floor of three storeys.

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

The delivery of high-quality care was not assured by the registered person’s leadership, governance or culture. This had led to widespread shortfalls in the quality and safety of the service, resulting in continued breaches of regulation. Quality assurance processes were unreliable and had not identified emerging risks to people or managed them safely. Professionals had raised concerns regarding the registered person's competence and capability to manage the service effectively.

The registered person had a track record of failing to provide good standards of safety, which placed people at risk of harm. The registered person did not regularly review people’s dependency in relation to safe staffing levels to make sure that staff were able to respond to people’s changing needs. This meant enough suitable staff were not always deployed to keep people safe. Professionals raised concerns about staff competence to move and transfer people safely using supportive equipment, in line with their training and manufacturers guidance. The registered person did not always ensure risks to people were assessed and mitigated to keep people safe when they were receiving care. Staff managed medicines safely and effectively and followed the provider’s infection prevention and control procedures.

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 and in their best interests; the policies and systems in the service did not support this practice. Staff did not always follow correct procedures to obtain lawful consent and offer people choices before providing care to people. Staff understood the different strategies to encourage and support people to eat a healthy diet and the importance of remaining well hydrated. Visiting healthcare professionals told us that people they supported had experienced successful outcomes in relation to the management of their diabetes and mental well-being.

During the inspection we observed warm and meaningful interactions between people and staff. Staff provided reassurance patiently providing information and explanations to people, whilst delivering their care. For example, supporting people to move and become more comfortable. The kind and compassionate nature of staff visibly cheered people and had a positive impact their mood and well-being.

Since our last inspection the provision of meaningful stimulating activities had deteriorated due to the unforeseen absence of the activities’ coordinator. A new activities coordinator was appointed in October 2022 and people now experienced a wide range of activities, which had improved their mobility and coordination. People and relatives told us that staff supported people to maintain relationships that were important to them. People and relatives knew what to do and who they would talk to if they had any concerns. They were confident action would be taken if they did raise concerns.

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

Rating at last inspection and update

The last rating for this service was requires improvement (report published 2 November 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance, safe care and treatment, safeguarding, staffing and notification of other incidents. This service has been rated requires improvement or inadequate for six of the last seven inspections and requires improvement for three consecutive inspections.

Why we inspected

We undertook an unannounced comprehensive inspection of this service on 31 May 2022. Multiple breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance, safe care and treatment, safeguarding, staffing and notification of other incidents.

We undertook this focused inspection to check the registered person had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions Safe, Effective, Caring, Responsive and Well-led which contain those requirements.

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

Enforcement

We have identified continued breaches in relation to good governance, safe care and treatment, staffing and notification of other incidents. We have identified a new breach in relation to consent to care.

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 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.

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 of 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.

Holly Grange Residential Home is a care home providing personal care for up to 19 people aged 65 and over, some of whom may be living with dementia. At the time of inspection, the service was supporting 10 people in one extended and adapted building on the ground and first floor of three storeys.

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

The service was not consistently well led. Governance and performance management was not always reliable and had not identified where quality and safety were being compromised. Quality assurance processes had not always effectively identified the continued breaches of regulation we found during inspection. The registered person did not always demonstrate a clear understanding of the legal requirements of their role or their responsibility to manage quality performance and risk effectively.

The provider had not always ensured staff provided safe care. Risk assessments had not always been updated when necessary in order to meet people’s changing needs. The registered person did not deploy enough staff with the skills, competence and experience to support people to stay safe or take part in stimulating activities relevant to their interests.

Where incidents had occurred the registered person and staff did not always recognise when potential abuse or neglect may be occurring and did not always follow required procedures if they did. When things went wrong, investigations were not sufficiently thorough and necessary improvements were not always identified and made.

Staff had completed the safe management of medicines training and their competency to administer medicines had been assessed every six months registered manager and an accredited assessor. We were assured the provider was implementing effective infection prevention and control measures, in line with government guidance to keep people, staff and visitors safe.

Staff were effectively supported to develop and maintain the required skills and knowledge to support people according to their needs. Staff emphasised the importance of eating and drinking well and reflected best practice in how they supported people to maintain a healthy balanced diet.

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 experienced caring relationships where staff treated them with kindness and compassion in their day-to-day care. People were supported to make decisions about their care which were consistently respected by staff. Staff treated people in a respectful manner and intervened discretely to maintain their personal dignity. Staff knew how to comfort and reassure different people when they were worried or confused.

People received information in a way they could understand and process, allowing for any impairment, such as poor eyesight or hearing. People were supported to keep in touch with family and friends, which had a positive impact on their well-being. People knew how to make complaints and were confident the management team would listen and address their concerns. The service worked closely with healthcare professionals and provided good end of life care, which respected people’s wishes and ensured they experienced a comfortable, dignified and pain-free death.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 19 April 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

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.

The inspection was prompted in part due to concerns received about unsafe staffing levels, staff working too many hours, poor moving and positioning practice, including people being handled roughly, staff not seeking medical advice when required and falls not being recorded or reported appropriately to local safeguarding authorities or the CQC. 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, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

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 four breaches of regulations in relation to safe care and treatment, staffing and good governance.

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.

Holly Grange Residential Home is a care home providing personal care to 11 people aged 65 and over at the time of the inspection. The service can support up to 19 people. People live in one extended and adapted building, on the ground and first floors of three storeys.

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

The service was not consistently well-managed and led, which meant regulations may or may not be met. Governance and performance management was not always reliable and had not identified where quality and safety were being compromised. Quality assurance processes had not always effectively identified breaches of regulation we found during inspection. The registered person did not always demonstrate a clear understanding of the legal requirements of their role or their responsibility to manage quality performance and risk effectively.

People did not always receive care that was responsive to their needs. Risks to people and changes in their needs were not always identified and managed safely. People’s care needs were not always regularly reviewed, and people and their relatives were not always involved in decisions about their care. When things went wrong, reviews and investigations were not always sufficiently thorough and necessary improvements were not always made.

The service did not always provide enough staff that had the right mix of skills, competence or experience to support people to stay safe. The provider did not operate a comprehensive competency framework to ensure staff remained competent to deliver all aspects of people’s care in accordance with their training.

The provider had not always fully assessed and mitigated the risks to people, related to the safety of the premises and equipment. Improvements were required to the internal and external premises to ensure the environment was suitable for people living with dementia.

People’s choice of activities was limited due to the availability of the activities co-ordinator and resilience to support them, due to the workload of other staff.

The provider had safely recruited and retained staff, who were able to develop meaningful relationships and nurture trust in people. Staff managed medicines safely and involved people and where appropriate their representatives, in regular medicines reviews and risk assessments. The provider was preventing visitors from catching and spreading infections and staff were using personal protective equipment safely. The provider was accessing testing for people using the service, staff and visitors. The home was very clean and hygienic, with no unpleasant odours.

The registered manager operated a system of training, supervision and appraisals. This enabled staff to develop the required skills and knowledge to support people according to their needs. Staff understood the different strategies to encourage and support people to eat a healthy diet and the importance of remaining well hydrated. One health and social care professional thought the service needed to improve gaining more specialist support for people when required. Whilst others praised successful outcomes for people, due to the diligence of staff.

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.

Staff consistently used a person-centred approach whilst interacting with people, ensuring they were involved in decisions about their day-to-day-care. People were supported to maintain relationships that were important to them, particularly during the pandemic. Communication support plans provided staff with guidance about how to meet people’s specific communication needs and share information with them effectively. People and relatives knew what to do and who they would talk to if they had any concerns. Staff were aware of the provider's complaints procedure and knew what to do if anyone raised a concern. People and their representatives had completed an advance care plan, which detailed their end of life care wishes.

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 (report published 6 June 2018)

Why we inspected

This was a planned inspection based on the previous rating. The inspection was prompted in part due to concerns received about staffing levels, staff training, safeguarding people from harm, risk management, safety of the premises, poor leadership and the service culture. A decision was made for us to inspect and examine those risks.

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 have found evidence that the registered person needs to make improvement. Please see the safe, effective, responsive and well-led sections of this full report.

You can see what action we have asked the registered person to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Holly Grange our 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.

We have identified breaches in relation to the safe care and treatment of people, staffing, premises and equipment and good governance.

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

Follow up

We will meet with the registered person 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.

At this comprehensive inspection we found that the registered manager had acted to address the previous issues and where previous improvements had been made, these had been sustained.

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

The service accommodates up to 19 people in one adapted and extended building. At the time of inspection there were 13 people receiving care in the service. A registered manager was in place.

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 kept as safe as possible in the service. Health and safety and service checks were carried out and action had been taken to address any shortfalls found. Potential risks to people were assessed and action taken to minimise them. People themselves felt safe there. Specialist equipment was available to assist people with limited mobility.

People’s needs were assessed and they were involved in planning their care as much as they were able and wished to be, together with their representatives, where appropriate. People’s wishes with regard to end of life were explored with them and recorded.

People’s rights and freedom were maintained and staff supported their dignity and privacy. People’s individual and diverse needs were identified and provided for. Information was provided in accessible formats where necessary. People’s views about the service were sought via annual surveys and periodic resident’s meetings. People were supported to have maximum choice and control of their lives and care staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice .

People felt the staff were kind, caring and listened to them. People knew how to complain and any complaints made were addressed. A range of activities and entertainment was provided which people could choose whether or not to join in with.

The service liaised effectively with external healthcare services to ensure any more complex needs were met. People’s nutritional and hydration needs were monitored and met. People had been consulted about the meals provided.

Staff received thorough induction training and attended ongoing training updates to maintain their skills. They were supported through regular supervision, annual performance appraisals and periodic team meetings.

The registered manager had systems in place to monitor the operation of the service and plans for ongoing improvements which were being actioned.

We carried out a focused inspection on 11 August 2016 to ensure the requirements of the three warning notices had been met. We found the registered manager had taken, or was in the process of taking, action to address all of the areas identified within the warning notices.

This inspection, carried out 8 and 9 December 2016, was a comprehensive inspection to follow up all of the previously identified breaches of regulations and make a judgement about the overall compliance of the service. We found the service had made sufficient improvements that it was now compliant with regulations and could come out of ‘Special measures’. However, there remained a need for further developments in some areas and it was too soon to be sure that the recent improvements would be sustained. We will monitor this at subsequent inspections.

Holly Grange Residential Home is a care home without nursing that provides care for up to 19 people with needs relating to old age. Twenty four hour support is provided by a small regular team of staff. At the time of this inspection, eleven people were receiving support.

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

People felt safe and well cared for by the staff and that they were consulted and involved in decisions about their care. They confirmed their views about the service had been sought and felt the registered manager was accessible.

Health and safety checks and servicing had been carried out as required with the exception of testing of mains electrical circuits, which was overdue. The registered manager was in the process of arranging for the required testing to be carried out. Other health and safety and fire safety matters had been addressed.

Staff were aware of their responsibilities and how to keep people safe from abuse. No new safeguarding issues had arisen since the last inspection.

People's risk assessments had been improved to address identified risks to individuals and an emergency contingency plan for foreseeable emergencies was in place. People’s medicines were well managed on their behalf when they were unable to do this for themselves.

The service had a robust recruitment procedure in place. However, ongoing recruitment of permanent staff was still proving difficult and significant numbers of agency staff were needed to provide support.

Staff supported people’s day to day health, nutritional and care needs effectively. People were treated with respect and the rights and dignity were supported. People’s preference regarding the gender of staff providing intimate personal care were sought and respected.

Staff induction and training had been improved. The registered manager had attended training to enable him to complete competency assessments for staff working towards the ‘Care Certificate’. Support and development of staff had been improved through the commencement of a new supervision and appraisal programme.

The level of activities and entertainment had been improved but there remained room for further development in this area to maximise the social and emotional support provided.

We have made a recommendation that the service consult with a reputable source for advice on developing their activities provision.

The quality and content of care plans and related documents had been improved, with more records of people’s individual wishes and preferences. They were subject to monthly monitoring and review.

Communication with staff, people and their families had improved with people being more involved and informed about the changes in the service. The views of people and their relatives had been sought through a survey. The registered manager had devised a development plan for the service going forward.

The registered manager had responded positively to the support and advice of the ‘Care home support team’ and local authority quality monitoring team and had taken action to address the wide range of issues which arose from the inspection in March 2016. He had sought external supervision and support to meet his own needs in continuing to develop the service.

A registered manager was in place as required. 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 inspection took place on 11 August 2016 and was carried out by one inspector. We gave short notice of this inspection because we needed to ensure the manager would be present to assist us.

At the previous inspection in March 2016 we found significant breaches and concerns across eight regulations. As a result we issued warning notices regarding three regulations. When we carried out this focused inspection we found that the registered manager had taken or was in the process of taking action to address all of the areas identified within the warning notices. Sufficient action had been taken that the warning notices had been complied with. We found no new or continuing breaches of the regulations.

This was a focused inspection specifically to check whether the issues identified in the warning notices, following the previous inspection, in March 2016 had been addressed. As a result, the overall rating for this service remains ‘Inadequate’ and the service remains in ‘special measures’.

A further comprehensive inspection will be carried out in due course to review the service’s compliance across all areas and review the rating in order to decide whether the service will come out of ‘special measures’.

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

People were potentially at risk because staffing levels within the service during the day and at night, were not sufficient to meet people’s needs and some staff were working excessive and potentially unsafe hours. Staff rotas were either inaccurate or were not available to establish who was scheduled to be on duty.

Staff were not properly inducted, supported or trained to ensure they had the necessary skills to meet people’s needs.

The service did not always provide safe care and treatment. A number of health and safety and fire safety risks had either not been identified, or had been identified but not addressed. There was no evidence that necessary safety checks, such as of bath/shower water temperature, had taken place. Some moving and handling equipment was unsafe and some safety equipment was missing, located inappropriately or not regularly tested. These issues placed people at risk of potential injury.

Care plans and other records sometimes lacked sufficient detail, contained conflicting information or had not been updated effectively to make the current information readily available to staff to meet people’s needs. Where risks to people had been identified, this was not always reflected in the care plan with details of the actions staff needed to take to minimise the risk of harm. Inaccurate skin integrity risk assessments placed people at risk of not receiving appropriate care.

There was no evidence of follow up with regard to injuries noted on body charts, in order to identify the cause and any necessary actions to reduce the risk of recurrence.

People were not always kept safe. On one occasion we found the front door open and unsecured, meaning that people could have left the service unobserved or unauthorised people could have gained access to the building.

Some additional fire safety equipment and written guidance regarding evacuation in the event of fire was required and the service had no contingency plan in the event of foreseeable emergencies.

People were placed at potential risk of infection. The service did not have appropriate equipment to sterilise commode pots.

No Legionella testing of the water supply had been carried out to ensure the water supply was free from this hazard.

Support provided to people with their medicines was not fully compliant with national guidance. This meant people may not receive their medicines in accordance with their wishes or in a consistent way in the absence of clear guidelines.

The registered manager did not have a clear understanding of the legislation around people’s rights, freedom and consent. It was not clear whether, or to what degree, people had the capacity to make decisions for themselves, or who had the right to do so lawfully on their behalf. It was not clear whether some people should be safeguarded under the Deprivation of Liberty Safeguards associated with the Mental Capacity Act 2005.

Some equipment had been, or was being used, which could potentially restrict people’s liberty. It was not clear whether appropriate consultation had taken place to ensure that consent was obtained or the decision had been made in the person’s best interests.

People were not always treated with respect and dignity, their views had not always been sought and their wishes were not always respected. At times staff failed to knock on people’s bedroom doors before entering. The language used within records of people’s care was not always respectful.

The service was not well led. There was no effective system for the ongoing monitoring and review of the operation of the service. The registered manager had failed to identify or address a range of fire safety, infection control and health and safety-related issues which were identified at this inspection and by the commissioning local authority. He had failed to carry out effective review and monitoring of the quality and content of care records. The staff rotas misrepresented the actual staffing levels.

The registered manager was not fully aware of the relevant legislation in respect of the service. This meant that people’s wellbeing, rights or proper communication with others could be compromised.

Overall, we found the management of the service to be largely reactive rather than proactive. This meant that people were not fully protected and the service was not adhering to the most up-to-date and effective care practices.

The registered manager failed to notify the Care Quality Commission as required, of a person having left the service unnoticed and having been returned by the police.

People’s health and dietary wellbeing were supported. Some improvement had been made in the range of activities offered to people since the previous inspection. People’s spiritual needs were provided for through clergy or church representatives visiting the home. People could choose to what extent they were involved in group or individual activities.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We issued Warning Notices to the registered manager and provider regarding three of the breaches. The registered manager is working with us with the support of the local authority care home support team, to address the issues raised.

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

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

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

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

As part of this inspection we spoke with four people who use the service, the relatives or friends of three other people, the manager and two staff. We also reviewed records relating to the management of the home which included care plans, risk assessments and other records. We also spoke with a visiting GP and a Community Psychiatric Nurse (CPN).

Below is a summary of what we found. The summary described what people using the service, their relatives and the staff told us and the records we looked at.

Is the service safe?

People received care and support in accordance with agreed care plans which were regularly reviewed and evaluated. People or their representatives were involved in reviews of their care. People's care plans were completed and up to date aside from the one for the most recent admission which required completion.

Where people had healthcare needs, the home had sought the advice of external healthcare specialists appropriately to maintain their wellbeing and safety. We saw that GP's, district nurses, CPNs and other external healthcare specialists had been consulted appropriately. The visiting GP and CPN we spoke with were happy with the care they had seen.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home had liaised effectively with the local authority DoLS team and had made an application under the Deprivation of Liberty Safeguards for one person. The manager was aware of a recent Supreme Court judgement relating to 'deprivation of liberty' and agreed to liaise with the local authority regarding its possible implications for other people in the home.

The people, relatives and friends we spoke with were very happy with the service and praised the friendliness of the staff and management.

Is the service effective?

We saw that people's physical and healthcare needs were met by the staff team. People's social needs had not been as effectively met because limited activities had been provided to support them to enjoy a fulfilling life. We saw that people enjoyed positive relationships with the staff. The healthcare professionals we spoke with told us the home met people's needs effectively. The home was said to have worked well with one person in particular to settle them in and improve their wellbeing.

The relatives and friends we spoke with told us that the home was effective in meeting people's needs. People in the home felt their needs were met.

Is the service caring?

We saw staff working in a caring and respectful way while supporting people. They enabled people to make decisions and choices and gave them time to make decisions. Staff were heard to offer praise and encouragement to the people they were supporting. People could choose where they spent their time and ate their meals and could opt to spend time away from the group.

The people, relatives and friends we spoke with thought the service was very caring. This was reflected in the survey responses received by the home, to date.

Is the service responsive?

We saw that people's care plans and other documents recorded people's needs and where these had changed. Care files showed that the home responded promptly to any changes and sought appropriate healthcare advice where necessary.

Care was provided based on people's known and indicated wishes and preferences. However, people had access to a limited range of meaningful activities to enable them to enjoy a fulfilling life.

People and their relatives felt that they were involved and consulted and that the service responded to people's needs. The CPN told us the home had worked well with one person to help them settle in, despite them being initially resistant to coming into a care home.

Is the service well-led?

We found that the home provided good care to people and was effectively managed. A limited range of audit and monitoring systems were used by the manager to maintain an overview of the home's operation. The manager was present daily during the week and oversaw things on a day-to-day basis, without recording this. However, he planned to introduce a new monthly audit tool to provide evidence of this for the future. Action had been taken to address issues where these were identified. The views of people's relatives were sought and acted upon.

However, the provider did not have suitable arrangements for obtaining the consent of people in relation to the care and treatment they received. People were unaware of their care plans and had not seen their risk assessments. They not been involved in monthly reviews of their treatment and had not signed any records to show their consent or involvement.

People and their relatives praised the quality of care provided. One person told us, 'I'm so lucky to be here. I can't tell you how perfect this place is. I didn't want to come here but now I feel like it is my home.' The relative of another said, 'The staff are so kind and gentle. If he hadn't come here he wouldn't be with us today.'

We were told by people that they trusted staff who made them feel safe. Relatives told us that the staff provided excellent care, which gave them confidence in the quality of their training.

People who used the service were protected against the risk of inappropriate care or unsafe care by effective assessment and monitoring of the quality of the service provided.