The inspection took place on 15 August 2018. It was unannounced.

Charters Court provided nursing, residential and residential dementia care. It is registered to accommodate up to 60 people. Charters 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.

On the day of our inspection there were 47 people living at the home.

The home is a modern purpose-built building, which was on two floors. There were four self-contained houses each catering for up to 15 people in each. One of these was dedicated to people living with dementia and another for people with nursing needs. The other two houses were for people needing residential care, a number of whom live with some cognitive impairment. Each house has shared facilities such as a lounge and dining area, adapted facilities and individual en-suite bedrooms.

On the day of our inspection the registered manager was not present due to being away on holiday. 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 Deputy Manager was present and supported us with the inspection. Following the inspection, we spoke with the senior manager responsible for the service.

This was the first inspection since the service was registered with a new provider in Sept 2017. The last inspection with the previous provider was in November 2015 when it was rated as “Good.” At this inspection we had concerns about staffing and about the management of the service. This had an impact on the safe care and treatment of people living at the home. Improvements were required, and action was needed from the new provider to address the issues we found.

People’s care and well-being was affected by a loss of permanent staffing over the past six months and an over reliance on agency staff who did not always know about people and their needs. There was a risk of insufficient staff deployed across the service, including that of qualified nursing care. Medicines were not always administered on time and in line with the home’s own policy and best practice.

There were risks to people’s safe care because of the lack of instructions for staff on managing people’s risk and lack of knowledge by agency staff coming to work at the home. Where people had behavioural needs, the best approach for management and support was not well recorded for staff.

People’s mental capacity to consent and make decisions about their care or medicines was not being assessed and recorded in line with the legal requirements of the Mental Capacity Act 2005 (MCA). Where decisions were made on the person’s behalf, in their best interests, this was not always well documented.

Not all staff were compliant with their mandatory training which may put people at risk. There had been delays for staff in getting access to online training in place and receiving one to one supervision from a manager.

Care plans, daily records and reviews did not always show how people were involved and include their preferences, views or personal information to ensure personalised care could be provided.

The assessment of people’s hydration levels, where they were approaching the end of their life, needed to be improved.

The new provider and management of the service was not well thought of. Some staff, relatives and people were concerned about a deterioration in the service and they did not always feel they were being listened to.

Whilst staff were committed, they told us they were not happy. They did not feel involved, valued or supported. At the inspection, the deputy manager d