Azalea Court 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. Azalea Court is a nursing home for 83 people. The main building accommodates up to 75 people and is divided into three units. Astor unit accommodates people who need nursing care due to medical needs. Lavender and Poppy units accommodate people living with dementia. There is a separate unit in the grounds for eight people who have more complex nursing needs requiring specialist care.

We carried out an unannounced comprehensive inspection of this service in April 2017. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We had also received a number of safeguarding alerts and complaints about the service which prompted us to undertake this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Azalea court nursing home on our website at www.cqc.org.uk.

This was a focussed inspection looking at whether the service was safe and well led. There were safeguarding allegations being investigated at the time of the inspection by the London borough of Enfield and we did not know the outcomes. We looked at safety and safeguarding issues and we did not find any concerns.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At the last inspection there was a breach of legal requirement as risk assessments did not meet the required standard. At this inspection, we found that the registered manager and provider had made improvements to risk assessments. This meant that people had risk assessments that addressed the risks for them as an individual, helped to keep them safe and respect their freedom.

Nurses working at the service demonstrated good clinical knowledge and a good understanding of infection prevention and control, risk assessments and safety. Staff were trained in safety topics including medicines management, fire safety, first aid, basic life support and safeguarding people from abuse.

There were enough staff on duty but at mealtimes staff were very busy so a few people had to wait for support. At other times people said staff were responsive and there were enough staff on duty to meet people's needs.

There were no breaches of regulation found at this inspection. We have made a recommendation for improvement in the giving and recording of medicines.

The home was well led with a commitment to continuous improvement. The provider and management team carried out regular audits and had good daily oversight of the care provided in the home. There was a clear management structure. The management team worked well with partner agencies to ensure safe care. People and their relatives had good and regular opportunity to contribute to their care planning.

Azalea Court is operated by Twinglobe Care Limited. The service provides residential and nursing care for up to 83 older men and women at purpose built accommodation in a residential area of north east London. The home is divided over four floors, with a separate eight-bed younger adults unit in another purpose built facility in the grounds. Residential and nursing care is provided across each floor except the fourth floor of the main building which is where the kitchen and laundry were located.

This inspection took place on 24, 25 and 26 April 2017. At our previous comprehensive inspection on 24 October 2014 the service was not providing medicines safely to all people or auditing medicines administration to identify if any issues were present. Subsequent to that inspection we carried out a focused unannounced inspection on 25 April 2015 and found that these previous issues had been rectified and the service overall was rated as good.

There was a registered manager 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.

There was a lack of clarity regarding potential risks for some people living at the home. Some people living at the home were at risk of unsafe care due to some risks to people not being clearly identified or reviewed when necessary.

Staff had access to the organisational policy and procedure for protection of people from abuse. They also had the contact details for the safeguarding team at the local authority in which the service is located. Staff had been trained in abuse awareness.

Medicines were well managed and people received their medicines in a safe way and at the time they needed them.

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 support this practice.

People were supported to maintain good health. Nurses were on duty at the service 24 hours and a local GP visited the home each week. Healthcare needs were met effectively and staff supported people to make and attend medical appointments. The GP told us of their confidence in the way the service managed healthcare needs.

People who used the service, relatives and friends, praised staff for their caring attitudes. Staff were approachable and friendly towards people and based their interactions on each person as an individual, as well as demonstrating how well they knew the people they were caring for.

Audits of the service were carried out. The audits carried out since December 2016 identified issues around risk assessments and care planning requiring updates and improvement. Issues had not been fully addressed on each unit. The provider showed us an action plan which stated the remaining improvements they had identified were to be completed within the next month.

The service was transparent with communication and involving people, and took people’s views seriously and responded to those views.

As a result of this inspection we found one breach 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.

This inspection took place on 25 April 2015 and was unannounced. When we last visited the home on 24 October 2014 we found the service was not meeting all the regulations we looked at.

Azalea court is a nursing home that is registered to provide nursing and personal care for up to eighty people on three floors. On the day of the inspection there were 72 people using the service.

The home had 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 received all their medicines when they needed them.

Audits of medicines showed that medicines were administered correctly and action had been taken to improve the medicines administration.

This inspection took place on 24 October 2014 and was unannounced. When we last visited the home on 04 July 2014 we found the service was not meeting all the regulations we looked at.

Azalea court is a nursing home that is registered to provide nursing and personal care for up to eighty people on three floors. On the day of the inspection there were 74 people using the service.

The home had 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.

Medicines were not being managed safely and this was putting people at risk. There were gaps in the recording of medicines when they were given to people.

People were treated with dignity and respect. Staff knew what to do if people could not make decisions about their care needs.

People were involved in decisions about their care and how their needs would be met. Risk to people were identified and how these could be prevented. Staff were available to meet people's needs.

People were provided with a choice of food, and were supported to eat when this was needed. People were supported effectively to ensure their health needs were met.

People were treated with dignity and respect. Staff understood people’s preferences, likes and dislikes regarding their care and support needs. Care was planned and delivered in ways that enhanced people’s safety and welfare according to their needs and preferences.

People using the service, relatives and staff said the manager was approachable and supportive. Systems were in place to monitor the quality of the service and people and their relatives felt confident to express any concerns, so these could be addressed.

At this inspection there was a continued breach of Regulation 13 (management of medicines). We are taking another form of action against the provider. We will report on this when the action is completed.

The inspection team which carried out this inspection consisted of an inspector, a medicines inspector and two experts by experience. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well- led?

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

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

Is the service safe?

People's needs were not always being met as staff were not deployed effectively to care for them in a way that maintained their safety and well-being. Most people and relatives spoken to were concerned that staff were not always available to meet their needs. One person said, "staff are very busy and don't have a lot of time for us."

Two relative’s commented, "they often seem to be short of staff," and "they needed more carers on this floor (the third floor) as most people need a lot of assistance." Staff spoken to told us that they did not feel that they had enough staff to meet people's needs. Staff gave examples when they were short in the morning, which meant that people did not receive their personal care when they needed it.

We saw that appropriate arrangements were not in place in relation to the recording of all medicines. We saw evidence of people’s current medicines on the Medication Administration Records (MAR). One person had no warfarin recorded as administered for two days and our stock count indicated that no stock had been used. For this same person a hormone medication was not recorded as given and the stock remained in the packaging.

We saw on one MAR that one person did not receive their medicine for Parkinson’s disease and then heard that they had been given the wrong persons medication. We heard how the error happened and the action the home took which included seeking emergency health advice. This incident meant that two people did not receive their medicines as prescribed and were put at risk.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People who use services were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under DoLS. We found that the service had proper policies and procedures in place that ensured staff had guidance if they needed to apply for a deprivation of liberty for a person who used the service. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People who used the service were positive about the care they received. One person said, “staff are very good.” People felt that staff knew how to meet their needs. However, staff said that they had not been supervised and supported in their work with people. The manager told us that supervision should take place six times a year. We looked at three staff records of supervision and these showed that staff had not received regularly supervision. Staff told us that they had received an appraisal in the last year. Staff had not received appropriate professional development.

People’s health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. People told us that when they asked staff to contact their general practitioner this was done quickly. One person told us, "I can ask to see the doctor."

Is the service caring?

We observed staff supporting people at lunchtime on Lavender unit. Staff were caring and responsive to people's needs and assisted them to eat and drink. However, people who use the service and relatives told us that care was not always provided that met people's needs and maintained their well-being. Two relatives spoken to said that they had found on the day of the inspection that there were relatives had not received personal care and were wearing soiled clothing. Relatives had raised similar concerns with the Care Quality Commission and professionals prior to the inspection.

Is the service responsive?

Two relatives said that people who use the service often spent long periods in their bedrooms without receiving any attention from staff. We found, and professionals had told us that checks to see if people were safe and comfortable were not always being carried out. These checks had not been recorded. A relative summed this up when they said, "if you are alone in your room you miss out."

Is the service well- led?

People who use the service were at risk of receiving unsafe and inappropriate care as care and treatment had not been monitored effectively. While the service had carried out an annual survey of the views of people, relatives and professionals this had not been used to inform how care could be improved. People who use the service and relatives did not feel consulted or that their views will be acted upon about the care and treatment being provided by the service. One relative told us, "you have to initiate all discussions about care. Staff listen, but then there is no feedback about what if anything will change."

We found that the last medication audit had been completed in March 2014. We looked at the medication administration records and found that there were gaps in recording and examples when administration of medicines had not been recorded to show that people had been given their medicines. We saw 17 omissions in recording administration of medicines in 33 of the records we inspected. These issues had not been highlighted or addressed as the service did not have a system for carrying out random checks of medications to ensure that they were being administered safely. No action plans were in place that addressed how the service would prevent these omissions in recording of people's medication from re-occurring.

We carried out an unannounced inspection to check whether the provider had dealt with the compliance actions arising from our last inspection of 19 April 2013. At that time appropriate steps were not being taken to ensure that at all times there were sufficient numbers of suitably qualified, skilled and experienced persons employed. Additionally an effective complaints system was not in place for responding appropriately to complaints and comments made by people or persons acting on their behalf.

At this inspection we found that matters had been dealt with. The provider was taking appropriate steps to ensure that there were sufficient numbers of suitably qualified, skilled and experienced persons employed to safeguard the health, safety and welfare of people. There was a system in place for identifying, receiving, handling and responding to complaints and comments made by people using the service and those acting on their behalf. Complaints were being investigated and monitored and improvements were made.

We observed that staff worked with people with care and were respectful. The manager told us that relatives were key people they work with to involve people's care.

We saw and were told by people, relatives and staff that people gave their consent verbally and in writing. One relative told us “I am here nearly every day and sign all the forms.”

Records showed that appropriate checks were undertaken before staff began work and effective recruitment, selection and employment processes were in place.

We were told of some dissatisfaction from people living at the service who told us that staff were slow to assist and were rushed. One member of staff told us that they needed more one-to-one time with people. Records showed that there was no overlap of staff time between shifts. This meant that the provider was not taking appropriate steps to ensure there were enough staff to provide a handover and continuity of care.

The provider had a system in place for identifying, receiving, handling and responding to complaints and comments made by people using the service and those acting on their behalf. However this was not effective as some people told us that they were not aware that there was a complaints system. One person we spoke with told us “the manager should come to see us and ask us how we are doing.” Whilst individual complaints had been responded to there was no action plan to deal with issues affecting the service.

People had up to date care and support plans and risk assessments based on their current assessed needs.

Staff were supported to develop their skills and received training relevant to their role. Staff received supervision and new staff completed an induction.

Systems were in place to monitor and make improvements to the quality of care and support provided to people by the home including the management and administration of medication.

People we spoke with told us that staff were helpful and that they had no problems with the arrangements for their medicines. They told us that they were able to see the doctor when they needed to, They told us they were asked regularly if they needed pain relief so they were not left in pain.

Staff spoke to people politely and asked how they wanted things to be done. A relative said, “People are treated well by staff."

We saw staff trying to engage people in board games and completing manicures.

Relatives said that people received the care and support they needed. A typical comment was, "The staff do try to meet people’s individual needs."

People were not always given assistance promptly so that they could enjoy their meal. We saw people offered food too quickly. Therefore people were not assisted appropriately and were put at risk of choking.

A relative said people were “safe”.They had information about what to do if they had concerns about the way they were being treated.

We observed a number of occasions when people did not receive safe care. For example, when three people were being assisted to transfer from their wheelchair staff used an under harm lift to assist with the transfer.

Our observations showed that staff did not always understand how to communicate with people who have dementia.