The inspection took place on 16 and 17 April 2018 and was unannounced.

Abbey 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Abbey Court Care Home accommodates 88 people in one purpose built building. The home is split into four units with a nursing unit (Jasmine)and a residential unit (Sunflower) down stairs and two secure dementia units (Bluebell and Forget Me Not) upstairs.

At the last inspection we found two breaches of our regulations. We found that the provider was not keeping people safe from the risk of abuse and that they had failed to submit notifications of events they were required to tell us about by law. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well led to at least good. At this inspection we found that the provider had made the improvements necessary to meet all the requirements of the regulations. The number of incidents where people were put at risk of harm from other people living at the home had reduced and the provider had ensured that notifications were submitted whenever required.

At the last inspection the home was rated as requires improvement, at this inspection we found that the provider had made the improvements necessary and was rated as good.

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

There were enough staff available to meet people’s needs and staff had the training required to ensure that they delivered safe care to people. In particular, the provider had ensured that staff had received training in supporting distressed people living with dementia to reduce the number of incidents in the home. The registered manager used a tool which looked at the needs of people to calculate the staffing levels needed on each unit to keep people safe. There was concern about the continued use of agency staff and the registered manager was working to recruit more staff so there was less reliance on agency staff to cover shifts. The provider’s recruitment processes ensured that staff were safe to work with people living at the home.

People’s ability to eat safely was assessed and where necessary people were referred to healthcare professionals for advice and support. The provider had reviewed their assessment of people’s ability to swallow following two incidents where people appeared to choke and had ensured that the assessment followed the latest best guidance practice. The incidents had been referred to the coroner. In the case which had been concluded the coroner found that there was no fault with the care provided. Other risks to people were also identified and care was planned to keep them safe. Incidents were reviewed to see if any changes were needed in the way that care was delivered.

Medicines were safely managed and administered to people in a timely manner. Staff had received training in infection control and how to minimise the risk to people by using protective equipment. The environment had been updated and now supported people living with dementia.

People received an assessment before moving into the home and were also involved in developing their care plan to meet their needs. There were systems in place to ensure that any changes in legislation or best practice were identified and shared with staff to ensure they were able to reflect this in the care they provided.

There was a good relationship between people living at the home and staff. Staff promoted people’s ability to make choices about the daily care they received and ensured that people’s privacy and dignity were respected. There was a variety

The inspection took place on 10 and 11 May 2017 and was unannounced.

Abbey Court Care home is registered to provide accommodation and nursing care for up to 88 people some of whom may be living with a dementia. The ground floor provides residential and nursing care to people in the Sunflower and Jasmine units. The first floor is split into two secure dementia care units Bluebell and Forget-Me-Not. There were 81 people living at the home when we inspected.

There was a registered manager for the home. However, they were no longer working at the home and had applied to cancel their registration. There was a new manager in place who had been working at the home five weeks when we inspected. They told us they would be submitting an application to become a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

Our last inspection took place on 9 March 2016. We found that the provider was in breach of the regulations relating to safe care and treatment. Following the inspection the provider wrote to us and told us about the improvements they planned to make. At this inspection we found the provider had made the improvements needed to comply with this regulation. However, the provider was not meeting the legal requirements in two areas of care provided. They had not ensured that people were safeguarded from abuse and they had failed to notify us about certain incidents. You can see the actions we have asked the provider to take at the back of this report.

Systems in place to monitor the quality of care provided were not always effective. They had not identified the concerns we found at this inspection and did not support the provider to drive improvements in the care people received. However, the manager was proactive at taking action when we identified concerns.

Care plans accurately reflected people’s needs and identified the care they needed. Care plans recorded the risks to people while receiving care and provided information to support staff to provide safe care. In three units the care was provided in line with the care plans and met people’s needs. However, on Forget-Me-Not unit people living with dementia were often confused and displayed distressed reactions. Relatives told us that staff needed more training in caring for people living with a dementia.

Most people were happy with the activities they were able to access. However, people living on the Forget-Me-Not unit had not been provided with sufficient activities to keep them entertained and engaged.

Where people had been unable to make the decision to live at the home the provider had submitted appropriate applications for assessment under the Deprivation of Liberty Safeguards. Where people were not able to make decisions for themselves decisions had been taken in their best interest and family members had been included in the decision making process.

People were supported to maintain a healthy weight. They were offered choices at meal times and encouraged to eat and drink enough to meet their needs. However, people’s independence with food was not supported as there was a lack of food which was accessible for people living with dementia. Medicines were safely stored and staff administered the medicines in a safe methodical manner to reduce the risk of errors.

Staff were kind and caring. However, the use of agency staff impacted on the care people received as agency staff were not always aware of how to personalise their care. Staff and systems in the home did not always support people’s dignity. People’s privacy was respected.

People knew how to raise concerns and had a growing confidence that the new manager would take action to improve the care people received.

Abbey Court Care Home provides residential and nursing care for up to 88 older people, including people living with dementia. The home is purpose built and is divided into four wings. On the ground floor up to 17 people live in the Residential wing and up to 19 people live in the Nursing wing. The first floor is reserved for up to people living with dementia. Upstairs, up to 31 people live on the East wing and up to 21 people on the West wing. There were 86 people living in the home on the day of our inspection.

Our last full inspection of the home was conducted in February 2015. At that inspection we identified a breach of legal requirements relating to care staffing levels. We also identified a number of other areas where improvement was required, including medicines management and protecting people’s privacy. In October 2015 we conducted a focused follow up inspection to review care staffing levels specifically and found that the provider was no longer in breach of legal requirements in this area.

We conducted this further full inspection of the home on 9 March 2016 to check what progress had been made since February 2015. The inspection was unannounced.

The service had a registered manager (‘the manager’) in post. A registered manager is a person who has registered with CQC to manage the service. Like registered providers (‘the provider’), 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.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves. At the time of the inspection the provider had submitted DoLS applications for 51 people living in the home and was waiting for these to be assessed by the local authority.

During our inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s medicines were not managed consistently in line with good practice and national guidance and some people were not protected properly from the risk of falling. You can see what action we told the registered person to take at the end of the full version of this report.

We also found that some staff did not have the necessary skills and knowledge to meet the needs of people living with dementia. We have made a recommendation about staff training in this area.

Although staffing levels were sufficient to meet people’s personal care and support needs, further action was needed to ensure people had sufficient stimulation and occupation.

People or their relatives were not offered the opportunity to be involved in the review of people’s individual care plan and the provider’s audit and quality monitoring systems were not consistently effective.

We did find some areas in which the provider was meeting people’s needs effectively.

Food and drink were provided to a good standard and people had prompt access to any specialist healthcare support they needed.

The provider had sound recruitment procedures in place and formal complaints were well-managed. The manager had an open and supportive leadership style and met regularly with people and their relatives to discuss any concerns or suggestions.

We carried out an unannounced comprehensive inspection of this service on 4 February 2015, at which a breach of legal requirements was found. This was because there was insufficient staffing to meet the needs of people living in the ground floor nursing wing of the home.

After the comprehensive inspection, the registered provider (‘the provider’) wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 20 October 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our comprehensive inspection by entering ‘Abbey Court Care Home’ into the search engine on our website at www.cqc.org.uk.

Abbey Court Care Home provides residential and nursing care for up to 88 older people, including people living with dementia. The home is purpose built and is divided into four wings. On the ground floor up to 17 people live in the residential wing and up to 19 people live in the nursing wing. The first floor is reserved for up to people living with dementia. Up to 31 people live on the East wing and up to 21 people live on the West wing. There were 87 people living in the home on the day of our inspection.

At our focused inspection on 20 October 2015 we found that the provider had followed their plan and legal requirements had been met.

Staffing had been increased on the ground floor nursing wing and this increase had been sustained.

There was a calm, relaxed atmosphere in the nursing wing and we saw that staff had time to engage with people individually and provide them with the personal assistance they required. People told us that they received the support they needed at the time they wanted it. However, although there were enough staff to meet people’s care needs, they were not always deployed in a way which enabled them to spend sufficient time with people on a one-to-one basis and helping them engage in personal interests and activities.

Abbey Court Care Home provides accommodation for up to 88 people who require nursing or personal care. The service provides residential and nursing care for people and also supports people living with dementia.

The service is purpose built and divided into four wings. On the ground floor, 17 people live in the residential wing and 19 people in the nursing wing. The first floor was reserved for people living with dementia and this was split into two wings, East and West. There were 31 people living on the East wing and the West wing supported 21 people. Although people generally choose to stay on the floor where their bedroom is located, they could and do move between floors. There were 85 people living in the service at the time of our inspection.

This was an unannounced inspection carried out on 4 February 2015. At the time of our inspection the service did not have 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 and associated Regulations about how the service is run. The service had an interim manager in post and had recruited a permanent manager who was due to start in March 2015. The interim manager was not available on the day of the inspection.

We last inspected Abbey Court Care Home in August 2014. At that inspection we found the service was not meeting all the essential standards that we assessed. We found breaches in relation to the regulations regarding cleanliness and infection control, privacy and dignity and how the provider ensured the quality of the service.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect themselves. At the time of our inspection the registered provider had made referrals to the local authority.

People were not consistently helped to stay safe as some of the arrangements for people’s medicines were not always safely managed. Although people told us that they felt safe in the service, there were times when there were not enough staff to meet people’s needs on the nursing wing. This impacted on the support that people received.

Staff knew how to recognise and report any concerns so that people were kept safe from harm and background checks had been completed before new staff were appointed. Staff helped people to avoid having accidents.

Staff had been supported to assist people in the right way, including people who lived with dementia and who could become distressed. People had been helped to eat and drink enough to stay well. People had access to a range of healthcare professionals when they required specialist help. The design of the floor reserved for people who lived with dementia had many positive features. However, it lacked signage to promote people’s orientation.

Staff understood people’s needs, wishes and preferences and they had been trained to provide effective and safe care which met people’s individual needs. People were treated with kindness, compassion and respect. However, we saw examples on the nursing unit when staff did not always respect people’s privacy.

People were able to see their friends and families when they wanted. There were no restrictions on when people could visit the service. Visitors were made welcome by the staff in the service. People and their relatives had been consulted about the care they wanted to be provided. Staff knew the people they supported and the choices they made about their care. People were offered the opportunity to pursue their interests and hobbies.

People were not always offered choice around what food they would like. There were no pictorial aids available for people and menus did not reflect the food on offer, so people were unable to choose.

There were systems in place for handling and resolving complaints. However, not everyone was aware of the formal complaints procedure. The service was run in an open and inclusive way that encouraged staff to speak out if they had any concerns.

Below is a summary of what we found when we inspected Abbey Court Care Home on 06 August 2014.

Our inspection team was made up of three inspectors and an expert by experience. During our inspection we focused on our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

The following summary is based on our observations during our visit, our discussions with people who used the service visiting relatives and staff who supported them. We also looked at seven people’s care records, management records and other documentation.

If you want to see the evidence supporting our summary please read the full report.

Is the service caring?

During our inspection on 28 November 2013 we found that people’s care and treatment was not always planned and delivered in a way that was intended to ensure people’s safety and welfare. The provider was asked to send us an action plan which set out the actions they would take to meet compliance.

During our inspection on 06 August 2014 we found that some improvements had been made.

People’s care plans were monitored through audits which ensured they accurately recorded the care people needed.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when they supported people. One person we spoke with told us: “I have nothing bad to say about the home and the staff, they are there when I need them.” A relative we spoke with told us: “xxx has been here about a year. The staff have become like family to me and I couldn’t fault the care that xxx has had.”

However, during our inspection on 06 August 2014 we found that people’s privacy and dignity was not always maintained and respected. There was a distinct difference between the two floors in the home in relation to the décor, environment and atmosphere which did not encourage a dementia friendly environment.

We observed that at times people were left unattended for long periods in communal areas in the home. There appeared no way for people to alert staff should they require assistance.

We observed on the dementia floor that several people appeared unkempt. We spoke with staff and checked people's personal care records to check if people had received personal care. Staff were unable to tell us and personal care records had not been completed.

Is the service responsive?

We saw when care staff had raised concerns about people's health and social care needs, that the provider had contacted appropriate health and social care professionals.

The provider had a complaints policy in place. Information on how to raise a complaint was displayed around the home, should people who lived there or their relative wish to raise a concern.

People completed a range of activities in and outside the service and were supported by an activities team.This would ensure that all people had access to activities in the home.

Is the service safe?

During our inspection on 28 November 2013 we found that there were not always enough qualified, skilled and experienced staff to meet people's needs.The provider was asked to send us an action plan which set out the actions they would take to meet compliance.

During our inspection on 06 August 2014 we found that improvements had been made. New care staff had been recruited and the home no longer used agency members of staff to supplement their numbers. We found that the skill mix of staff on the dementia floor had been reviewed. An additional registered nurse was now on duty during the day and night, and an additional member of care staff now worked at night.

During our inspection on 28 November 2013 we found that people were not always protected from the risk of infection. Systems in place to reduce the risk and spread of infection were not always effective and the environment was not always clean.The provider was asked to send us an action plan which set out the actions they would take to meet compliance.

During our inspection on 06 August 2014 we met with the registered manager and reviewed the action plan and found that some improvements had been made.

Staff had undertaken training in infection control and prevention. We noted that additional housekeepers had been recruited and there were now policies and procedures in place in relation to cleaning within the home.

However, during our inspection on 06 August 2014 when we walked around the dementia floor we found significant concerns around cleanliness, the décor and the environment.

During our inspection on 28 November 2013 we found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. The provider was asked to send us an action plan which set out the actions they would take to meet compliance.

During our inspection on 06 August 2014 we looked at people’s care records and found that they were now managed in a consistent way. This meant that staff could access information quickly when required.

The provider had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA states that every adult has the right to make their own decisions about their care and treatment and must be assumed to have capacity to make them unless it is proved otherwise.The Deprivation of Liberty Safeguards are part of the MCA. DoLS supports people in care homes and hospitals to be looked after in a way that does not unlawfully restrict their right to freedom.

Is the service effective?

People’s health and care needs were assessed. People and where appropriate, their representative, were involved in reviewing their care plans.

We looked at people’s records which showed that care plans set out people’s individual care needs. They were up to date and the records showed they had been reviewed on a regular basis and adjustments made when a person’s care needs changed.

During our inspection we observed that members of staff knew people's individual health and wellbeing needs.

Is the service well led?

During our inspection on 28 November 2013 we found the provider did not always assess and manage risk appropriately.The provider was asked to send us an action plan which set out the actions they would take to meet compliance.

During our inspection on 06 August 2014 we reviewed the action plan with the registered manager and found that some improvements had taken place.

We received positive feedback about the performance of the registered manager. Staff told us that they felt supported and listened too. People who lived in the home and their representatives told us that the manager was responsive and had had a positive impact on the way the home was managed.

The service had a quality assurance system and records seen by us showed that shortfalls were addressed promptly.

However, during our inspection on 06 August 2014 we found that the quality assurance monitoring systems had failed to highlight the issues around cleanliness, the décor and the environment on the dementia floor.

We found that care staff’s work was not organised to ensure that people were safely cared for in communal areas. The housekeeping rota had not been planned effectively as there was only one on duty for the whole home.

The home is a purpose built care home and has a bed capacity of 88. On the day of our visit there were 68 people living at the home. The home has two floors, the downstairs unit was for people who needed nursing and residential and the first floor unit which was for people with dementia.

People’s needs were not always planned or delivered in a way that ensured their safety.

We saw people were supported to maintain a healthy weight through their diet. Special dietary needs were recorded and met.

There was no member of staff taking an active lead in infection control. There were not enough housekeeping staff to ensure the environment was kept clean and hygienic.

People using the service and staff told us there were not enough staff to provide care for people in a timely fashion. Staffing levels were not formally calculated using people’s dependency needs.

There was a comprehensive system in place to monitor the quality of the service provided. However the provider had not reacted to concerns raised by staff and people using the service around staffing levels. We saw the provider did not respond to incidents to ensure systems were reviewed to reduce the risk of them re-occurring.

The provider did not complete accurate records for each person.

During this follow up visit we found the home had made improvements in relation to the environment in which people live and the way the provider assured itself of the quality of care it provided.

We noted there were no unpleasant odours in the home and carpets had been cleaned appropriately. On member of the housekeeping staff told us, “We will shampoo a carpet immediately if there is any kind of stain or smell.”

We saw people’s dignity was respected. People were appropriately dressed and were well presented.

We reviewed the audits the acting manager had carried out in July 2013. We saw audits were part of the provider’s overall compliance regime. Systems for assessing the quality of the service wee adequate.

During this follow up visit we found some improvements with the quality of care provided. We did not identify any major risks to people’s safety and well being. However, we found other areas of concern. We saw people living at the service were not always respected or involved in discussions about their care. Systems for assessing the quality of service provided to people were not adequate and the premises did not always meet the needs of people living there.

We spoke with a number of people who lived in the home. Some of them told us they were satisfied with the service they received. One person told us, “It’s excellent here, I am being very well looked after. The girls are great.” Another person said, “I have no complaints at all. The staff treat me with dignity and respect.”

Some of the people who lived in the home were not able to tell us their experiences. The SOFI tool allowed us to spend time watching what was going on in the service and helped us to record how people spent their time and whether they had positive experiences. This included looking at the support given to them by staff.

We spent 60 minutes watching people who were sitting in the first floor lounge. We saw staff provide some positive interactions with people. The outcome of the observation had improved since our last inspection, however we identified some issues where staff did not offer choices and did not ensure people’s dignity was respected.

When we visited Abbey Court we spoke with some of the people who lived there. Most of the people we spoke with told us they were being well looked after, although some people told us there were not enough staff around. We identified several areas of concern around the planning and delivery of people’s care.

One person who lived in the home told us, “The care staff are nice, I’m being well looked after.” Another person said, “I’m being well looked after thanks.”

The SOFI tool allowed us to spend time watching what was going on in the service and helped us to record how people spent their time and whether they had positive experiences. This included looking at the support that was given to them by the staff.

We spent 50 minutes watching people who were sitting in the first floor lounge. We saw people were left for periods of up to twenty minutes with no supervision or contact with staff. The people in this lounge had dementia and were not able to ask for help. One person was trying to get up out of the chair but could not and was moving towards the edge of the chair. We saw by looking at their care records they had been assessed as being at a high risk of falling and had recently fallen from their chair and been found kneeling on the floor.

We identified two people who were not provided with any personal care for more than 6 hours. The staff told us they had not got round to helping them as they were too busy.

We spoke with four relatives. All of them told us the staff were providing good care but they thought people were not being closely monitored. One relative said, “The staff are brilliant, very kind and caring. There is not enough staff, we have brought this up at every single relatives meeting.”

Another relative told us, “You couldn’t wish for better carers but they are rushed off their feet, there’s simply not enough staff. There should be someone in the lounge at all times. When I’m visiting I have to help people. There is no way people can call for help as the bell is not in reach in the communal areas.”

Following our visit to the service we reported our concerns to the Lincolnshire County Council Adult Safeguarding Team. The safeguarding team visited the home and have told us they did not identify any major risks to people however they found some areas where quality could be improved.

People told us they felt respected and cared for. They said they were treated well by the staff. One person said, “It is 10 out of 10 this place.” Another person told us they were very happy living in the home. They said, “It is wonderful, it is like being at home.”

Another person said, “I use equipment, which I need to help support me and help me get out of bed.”

People told us they felt safe in the home and they trusted the staff that cared for them. They said that the staff was fine and they had no complaints. One person said, “I feel safe here, they treat me very well.”

We spoke to a relative who told us they felt the staff were very good, and very polite. They added, “You could not wish for better. I feel they know their job.”