This inspection took place on 29 and 30 October 2018 and was unannounced. At the last inspection completed in April 2018 the service had been rated as ‘requires improvement’. The provider was not meeting the legal requirements regarding safe care, staffing levels, dignity and good governance. The service was in special measures. It first entered special measures following an inspection that ended on 11 September 2017. The service remained in special measures following the last inspection. At this inspection we found the provider had endeavoured to make some improvements, although these had failed to improve the quality of care provided. We saw overall the standards of quality had deteriorated. The provider remained in breach of some legal requirements and we identified further breaches of regulations.

Angel Court 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 30 older people. At the time of the inspection there were 19 people living at the service, most of whom were living with dementia.

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.

The provider had not ensured that all incidents that may be considered as safeguarding concerns were identified, reported to the local safeguarding authority and investigated appropriately. People were not always protected from the risk of ongoing harm. Risks to people including those due to behaviours that can challenge, mobility and swallowing issues were not fully understood and managed safely.

People were supported by sufficient numbers of care staff although these staff were not always deployed effectively in order to ensure people’s needs were met. While some improvements had been made to medicines management systems, further improvements were still required. In particular around the management of creams and medicines that had been prescribed to treat those people with challenging behaviours.

People were not always supported by care staff who had been equipped with the skills and knowledge they required to support people safely and effectively. People’s consent to their care was not always obtained and steps were not taken in people’s best interests in line with the law where they lacked mental capacity. People’s basic nutritional needs were mostly met although improvements were still needed.

While care staff had good intentions, the care people received was not always caring. People’s dignity was not always upheld and people were not always treated with respect and empathy. People’s independence was not always fully promoted and they were not given maximum control over their choices and lives.

People did not always receive fully personalised care. They were not always involved in planning the care they received and care staff did not fully understand people’s needs. People did not have sufficient access to the leisure opportunities and they were not encouraged to pursue personal interests.

People were not encouraged to complain and share their views about the service in order to ensure improvements could be made.

People were not cared for by a staff team who were fully supported by the provider. People did not feel the culture within the service was open and that it was safe to speak out about concerns they had. People were not living in a service where a culture of continuous improvement was present. Further improvements were still needed to quality assurance and governance systems which remained ineffective.

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The inspection took place on 10 and 11 April 2018 and was unannounced. At the last inspection on 30 November and 04 December 2017, the provider was rated as Requires Improvement and found to be in breach of Regulations 9, 10, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found that although some of these regulations were now being met, others remained in breach and additionally, new breaches of regulation have been identified.

Following the last inspection, we met with the provider to ask the provider to complete an action plan to show what they would do and by when to improve each of the key questions of Safe, Effective, Caring, Responsive and Well Led to at least good. The provider submitted this action plan to us and we reviewed this during the inspection. We found that although some of the actions recorded were in progress, it was clear that the provider had not had much input into the action plan and as a result concerns were raised about their ability to make and sustain improvements at the service.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Angel Court 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.

Angel Court Residential Home accommodates up to 30 people in one adapted building. At the time of the inspection there were 19 people living at the home.

There was a registered manager in post. The registered manager was also the registered provider of 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 were not supported to manage risks to keep them safe. Where actions had been identified to mitig

The inspection took place on 30 November and 04 December 2017 and was unannounced. The last inspection took place in August 2017 and the provider was rated as ‘Inadequate’ in each of the five key questions. There were breaches in Regulation 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a further breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. At this inspection, we found that whilst some breaches had been met, others remained outstanding and the provider was not yet meeting all of the regulations.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Angel Court 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.

Angel Court Residential Care Home accommodates up to 30 people in one adapted building. At the time of the inspection, there were 21 people living at the home.

There was a registered manager in post who was also the provider. 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.

Potential safeguarding concerns were not always acted upon by the registered manager. Risks to people were not always accurately recorded or acted upon to keep people safe. Staff were recruited safely and action had been taken to ensure sufficient staffing levels to support people. Improvements had been made to the cleanliness of the home and people were supported with their medications in a safe way.

People were supported by staff who had received training and supervision in order for them to support people effectively. Assessments completed did not consistently consider peoples protected characteristics under the Equality Act. People were supported by staff who understood how to seek consent but staff knowledge of people who required Deprivation of Liberty Safeguards varied. Records held in relation to the Mental Capacity Act were not always accurate or complete. People had their dietary needs met but improvements were required to people’s dining experience. People had access to healthcare services where required. We have made recommendations about ensuring a Dementia friendly environment.

People felt that although staff were kind, they did not always make time to spend with people. There were instances where people’s dignity was not respected and people were not always involved in their care or given choices. People had been supported to access advocacy services where required.

People were involved in the planning of their care but had not been involved in reviews. Staff knowledge of people’s preferences with regards to their care varied and care records did not always hold personalised information about people’s wishes; particularly in relation to end of life care. People had been informed on how to complain but some continued to be concerned about repercussions of raising complaints. Complaints procedures were not available in an accessible format for people.

People did not feel the home was well led. Audits were being completed but these were not robust and did not show where actions had been taken to make improvements. Feedback had not been sought from people in relation to their experience of care.

This inspection took place on 22 and 23 August 2017 and was unannounced. A final day of inspection was completed on 11 September 2017 to see if the provider had taken the action they had outlined to us in order to protect the people living at the service. At the last inspection completed in March 2016 we found the provider was meeting all of the legal requirements. We identified some improvements were required under the key question of ‘is the service effective?’. At this inspection we found these improvements had not been made and more significant improvements were now needed across the service.

Angel Court Residential Home provides accommodation and personal care for up to 30 people. At the time of the inspection there were 28 people living at the service, most of whom were older people living with dementia. There was a registered manager in post. The registered manager was the same individual as the registered provider. 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 provider had failed to ensure people were sufficiently protected from the risk of harm to both their physical and emotional well-being. Safeguarding concerns were not always identified and investigated appropriately. People were exposed to the risk of harm such as injury due to inadequate risk management processes. People were not protected due to inadequately maintained premises and equipment.

People were not supported by sufficient numbers of care staff. People were not being supported by care staff who had the training, skills and knowledge to support them effectively. Pre-employment checks were completed for new care staff although some improvements could be made.

People received medicines such as tablets as prescribed by their doctor. We were not able to confirm people received their creams as needed due to the administration of these medicines not being recorded.

People’s rights were not protected by the effective use of the Mental Capacity Act 2005. The risks associated with people’s nutritional needs were not always monitored and effectively managed. People did have contact with healthcare professionals to maintain their health, however, this was not consistent and people sometimes did not receive interventions as required.

People were not supporting in a kind and caring way. Their dignity and independence was not protected and promoted. People were not supported to be actively involved in choices around their care.

People were not involved in developing their care plans and care provided did not always meet their needs and preferences. People were not enabled to access meaningful leisure opportunities and to choose how they wanted to spend their time.

People did not feel they were able to raise complaints. People did not feel their complaints were heard and addressed appropriately.

People were not protected by effective quality assurance systems that identified areas of improvement and ensured the required actions were taken. People were not sufficiently involved in the development of the service and discussing issues that affected them. People did not feel their views were heard.

People were being cared for by a staff team who felt unsupported in their roles. The culture within the service was not open and transparent.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within th

This inspection was unannounced and took place on 2 March 2016. At the last inspection in March 2014, we found the provider was meeting all of the requirements of the regulations we reviewed.

Angel Court Care Home is registered to provide accommodation for up to 22 people who require personal care and support. On the day of the inspection there were 21 people living at the home.

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

The registered manager was registered to manage two homes and split her time between the two homes. To support the registered manager in the management of the home two deputy managers were in place to oversee the home on a day to day. Each deputy manager had specific areas of responsibility.

People liked the food provided and received the food and drink they required to remain healthy. Mealtimes were not always well managed and referrals for follow up on weight loss were not always actioned.

People were kept safe because staff knew the signs to look for and were able to escalate any concerns they had.

Risks were protected from harm because risks had been identified and plans put in place to manage them.

People received their medicines as prescribed.

People were supported by sufficient numbers of staff that had the skills, knowledge and experience needed to provide effective care.

People’s consent was sought before care was provided and systems in place ensured that their human rights were protected.

Arrangements for meeting people’s healthcare needs were in place.

People were supported by staff who were caring and treated them with respect and that supported people to be involved in making decisions about their care and support. People were treated with dignity and offered choices in a way they could understand.

People were able to express their views about the service they received.

People, relatives, professional visitors and staff felt the home was well managed. The provider had systems in place which monitored the quality of service the home provided.

During our inspection we looked at information to help us gather evidence about the quality of care and support people that lived at the home received. The provider told us that 19 people lived at the home at the time of our inspection.

We spoke with nine people that lived there and observed how people were supported by staff at lunchtime and in communal areas of the home. We spoke with two relatives, the provider and three members of staff.

Is the service safe?

All of the people and their relatives spoken with told us that they felt that the care provided was safe. A person living at the home told us, “It’s good here.”

We saw that people’s care was planned and any risks associated with providing their care was assessed and managed appropriately.

Systems were in place to make sure that managers and the staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped the service to continually improve.

We saw that the environment within the home was maintained to ensure that people lived in a suitable safe home. We saw that equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Recruitment records that we looked at were mostly in line with the requirements of the regulations. Some improvements were needed in respect of obtaining references from previous employers and not relying on general letters of recommendation.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and hospitals. We saw that people’s rights were protected and they were safe because people were presumed to have capacity to make decisions. Only where people were not able to make decisions were relatives and other relevant people involved in making decisions in their best interests. No-ones liberty had been restricted.

Is the service effective?

Care plans were detailed and kept under regular review, so that staff had up to date information on how to care for people.

Health information was detailed so that staff had the information they needed to support people safely.

We saw that where people required equipment to support their care this was available and maintained to ensure that they were suitable.

All but one of the people and their relatives spoken with told us that they were receiving the care that they wanted. We saw that some people’s needs were not always met in the way they wanted .

Is the service caring?

All of the people and their relatives spoken with told us that they felt that the service was caring. One relative spoken with told us, “They (staff) are always kind and staff do their best.”

We walked around the home and watched to see how staff treated people. We saw good interactions between people and staff. We saw that staff were friendly and offered support and reassurance when people who lived there had disagreements. We saw that people were given the opportunity to see health care professionals. One person told us, “The doctor keeps coming to see me but I don’t need them.”

We saw that people were dressed in clothing appropriate to their age, gender and the weather. We saw that everyone living at the home looked cared for.

Is the service responsive?

All the people and their relatives that we spoke with told us that they had no concerns or complaints about the care provided. Both relatives told us they felt that they could raise any concerns they may have and that they would be addressed

We saw that staffing levels needed to be reviewed as people’s needs had increased and we saw that people’s needs were not always met at the time they wanted.

We saw that call bells were accessible to people so that they could summon support if needed.

We saw from care records looked at that the home involved other professionals in supporting people’s care as required. For example, dieticians were involved for people who were not eating enough to maintain or increase their weight where needed.

People were able to practice their faith and religious beliefs and care plans were designed to ensure that people’s diverse needs were recorded and catered for.

We saw relatives freely visited the home whilst we were there, so people could maintain relationships with family and friends.

Is the service well led?

All the people and their relatives that we spoke with had no concerns about the service.

Systems were in place to monitor the quality of the service. Where people had raised concerns we saw that these were investigated and resolved.

We saw that there was a good atmosphere in the home. People were consulted about the quality of service they received. We saw that comments and concerns were analysed and improvements were put in place where they had been identified. All staff spoken with said they thought that the home was well managed. They said that staff meetings were held and they were able to put forward ideas for improvement in the home.

We carried out this inspection as a response to concerns raised by Birmingham City Council (BCC) commissioners. We looked at records relating to people’s care, staff personal files and spoke to staff.

We found that people received their medication as prescribed by their doctor. Medication was stored securely in locked cabinets. However most drugs are kept on the drugs trolley in the dining room where the temperature is above the manufacturers recommended levels. This can affect the effectiveness of the medication. This meant appropriate arrangements were not in place to ensure medicines were stored safely.

We found that the provider had not carried out appropriate checks to ensure that staff were fit to work with vulnerable people.

We found that staff received supervision however records showed that supervision focussed on concerns raised by service commissioners and the care quality commission. This meant that staff did not receive the guidance and support they need to carry out their tasks.

We found that people’s files contained all the information staff needed to meet their needs. We observed care staff delivering support to people as described in their individual care plans. We saw that all personal records were stored securely, but were accessible by staff that needed them.

The people who lived at the home had dementia and nursing care needs. People told us about their experiences, we looked at records and observed staff caring for them. One person told us, ''The staff are great, they look after us.''

We saw that people’s consent was always sought before any care and treatment was carried out. Staff said, “I always check that people are ok with what I am doing with them.’’

We saw that people's needs had been assessed and care plans had been devised to describe how people liked to be supported. Risks to people's health and well-being had been identified and measures had been put in place to protect people. Staff we spoke to was able to tell us about people's care needs so that they received support and care in a way that they preferred. Relatives told us they were kept informed about their relative's health so that they felt involved with their relatives care. One relative said, 'Staff always talk to me about their care.''

We saw that systems were in place to keep people safe from harm. A relative told us about their relative and said, ''She is very safe.'' Staff received a range of training so that they were able to support the people who lived in the home. One person told us, ''Staff are very good to me.''

There were systems in place to monitor how the home was run, to ensure people received a safe and quality service.

At this visit we found there had been improvements in assessment and care planning for people. This meant that staff had clear instructions about the care people needed. The care people received was reviewed regularly and where necessary the care plan was changed. People had their hygiene needs met and were more appropriately dressed. People were smiling and some were singing at times during our visit and showed signs of well being. We saw that people were at ease with the care staff.

People did not have to wait as long for their breakfasts as previously; the cook was starting work earlier. Menus were available and displayed in the dining room. People were given choices of food and drink throughout the day and this helped to ensure people were not hungry and were well hydrated.

Medicines were administered appropriately and there were appropriate checks and records to ensure that medicines were safe.

There were enough care staff and ancillary staff to ensure that people had appropriate care.

There was a lack of contingency planning. This meant that when emergencies arose there were not clear plans or instructions to minimise the effect on people. On this visit one of the two heating boilers was not working and areas of the home were cold. On a previous visit the call alarms not working and clear checks were not being evidenced. Foreseeable emergencies such as whether the laundry could manage an infection outbreak effectively were not being considered.

We visited Angel Court Residential Home on 02 August 2012 without telling them we would be visiting. We visited to look at improvements made since our last visits on 29 March, 4 April 2012 and 23 May 2012. We had issued warning notices following the two earlier visits. The provider told us on 12 June 2012 they had met all the shortfalls and were now compliant with the regulations.

We spoke with six of the seventeen people living in the home. People told us that they were happy living there. We observed interactions and care given by care workers throughout the day.

People told us they were happy with the care workers. One person told us: "They are all nice ladies here." "They care for us." However we noted that half of all the staff employed were trainees or apprentices.

We observed that they were good interactions between care workers and people living in the home. We saw that there was more interaction with people than we observed the meal time than previously. People were asked about their enjoyment of the meal, complimented on their hair and responded to when they raised concerns.

On our visit we found that whilst some improvements had been made that there was a continued lack of effective systems in place to identify shortfalls and ensure improvements were maintained.

New care plans that the provider told us about on 12 June 2012 were not available for all people living in the home. Assessments were not completed correctly to ensure that people who may be at risk of malnutrition could be identified and receive appropriate help.

We observed how people were cared for over two meal times. We found that there had been improvements in the management of meals. However the range and variety of the food stocks available indicated that the menus that had been agreed with people using the service were not being used. There were stocks available of value foods such as beef burgers, fish fingers, pies and pasties.

The systems for checking medicines did not ensure that medicines were disposed of if people no longer needed them or that all medicines were only given in the circumstances for which they were prescribed.

People were happy with the care that they received and thought that the care workers were good. However at times half the care workers on duty were apprentices some of whom who were not as experienced in meeting the care needs of the people at the home. Staff levels were lower when care workers took over ancillary roles such as cooking and cleaning at times at the weekend which meant that staff received less direct supervision in delivering safe quality care to people living in the home.

We looked at how the service monitored and checked the quality of their service. We found that although improvements had been made there were still areas in respect of care and welfare of people, food, medicine management and staffing that needed to be improved. The provider did not have effective systems in place to identify shortfalls or to monitor the quality of the service provided.

We visited Angel Court Residential Home on 23 May 2012 without telling them we would be visiting. We visited to look at improvements made since our last visits on 29 March and 4 April 2012. We had issued warning notices following the two earlier visits.

The safe handling of medicines was assessed by a pharmacist inspector. Again the reason for this was to follow up on a warning notice about medicines management following a previous visit on 29 March 2012. We looked at the storage of medicines, people's medicine records and some care plans.

We spoke to nine out of the 20 people living in the home. We observed how the breakfast and lunch time meals were served. We observed interactions between care workers and people living in the home at points throughout the day.

People were happy with the personal care they received and how care workers treated them.

We saw that three people had injuries to their skin. We looked at how these injuries had happened and what steps had been taken to lessen risks of further harm to them. We did not find that all measures had been taken to lessen the risks to people.

People were generally happy with the meals provided. However planned improvements of new menus had not been implemented. People continued to get food combinations they did not like.

We looked at how the service monitored and checked the quality of their service. The registered manager had sent surveys for people's views. There had been some action on some of their comments. Audits of risks to people had not been taken in all areas these risks had not resulted in changes to how people were cared for.

We visited Angel Court Residential Home on 29 December 2011. We had concerns about people's health, care and welfare. We found that systems were not in place to ensure that people had a consistently good service.

We met with the registered provider on 8 February 2012. We told them about the seriousness of our concerns and that improvements were needed.

We visited again on 29 March 2012 to check medication administration. We found that not all medicines were stored, administered, ordered and recorded correctly. Some risks to people were not identified and appropriate checks were not put in place.

People were at risk of an error with their medicines occurring. This could affect their health well being. There was a separate report written about this issue.

On 4 April 2012 we visited again to look at the overall service provided. The service was not able to show that sufficient improvements had been made to ensure people had a consistently good service.

We have issued warning notices to the registered provider about this. We will be visiting again to ensure that the necessary improvements have been made.

We visited Angel Court Residential Home on 29 December 2011. We had concerns about how people's medicines were being administered. We found that medicines were not always stored and administered safely. We met with the registered provider on 8 February 2012. We told them them about the seriousness of our concerns and that improvements were needed. We visited again on 29 March 2012 to check that improvements had been made .

On 29 March 2012 we found that not all medicines were stored, administered, ordered and recorded correctly. Some risks to people were not identified and appropriate checks were not put in place.

People were at risk of an error with their medicines occuring. This could affect their health well being.

We have issued a warning notice to the registered provider about this. We will be visiting again to ensure that improvements have been made.

People told us that care workers assisting them were kind and helpful. They were concerned that care workers did not always understand them. This was because most of the care workers did not have English as their first language.

People were not happy with the food. They told us: "It is not the food I would usually eat. There is no choice of food, we do not get asked. Tea time you get a choice of sandwiches." We found that there was no choice of lunch on the day of our visit.

People were not in control of the care they were receiving. People did not think they had a choice in the time they were assisted to get out of bed in the morning or going to bed at night. Care plans were not detailed enough about the care people needed and how they wanted to receive it.

People were happy with how their room was decorated and the facilities they had. One person wanted to move to a ground floor room.