The inspection took place on 27 June 2018, 6 July 2018, 2 and 6 August 2018 and was unannounced on day one.

The last inspection on 16, 17 and 18 October 2017, found that the registered provider was not meeting the requirements of the Health and Social Care Act 2008 in relation to person-centred care; need for consent; safe care and treatment; safeguarding service users from abuse and improper treatment; receiving and acting on complaints; staffing and governance. The overall rating of the provider was "inadequate" and they were placed into special measures by the Care Quality Commission.

We conducted this inspection to review whether sufficient improvements had been made since the last inspection. We found that improvements had been made although the registered provider remained in breach of regulations relating to safe care and treatment, need for consent, person-centred care and governance. However, the inspection found that there was sufficient improvement to take the service out of special measures. 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.

Cypress Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Cypress Court accommodates up to 60 people in one purpose built two storey building. It has a lift to the first floor and an open plan reception area. There are large lounge areas and a dining room to each floor. At the time of our inspection the service was accommodating 40 people.

We identified that the provider had not always delivered care and treatment in a safe way and was therefore in breach of relevant regulation. This was because professional guidance had not been followed with regard to a person’s risk of choking; we became aware of an incident of unsafe administration of medicines and risk assessments relating to people’s specific needs were not always in place.

The service did not have a registered manager 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. Since the last inspection day to day running of the home has been overseen by one of the provider’s Resident Experience Managers (RESM). A new home manager had recently been appointed and safe recruitment checks were underway.

With the exception of one incident, we found that medicines management and administration procedures were established and safe. People received their medicines as prescribed.

Policies and procedures were in place to safeguard people using services from abuse and for staff to whistle-blow if needed. Staff told us that they felt able to raise concerns if necessary and that they would be listened to.

Staff told us and we observed that there were sufficient staff to meet the needs of the people living at Cypress Court although some people expressed that there were busy periods and this sometimes impacted on the care they received. For example, people told us that they could not have a shower as often as they wanted one. We discussed this with the management team on the first day of inspection and when we returned on the third day we saw people had improved access to shower facilities.

The service followed safe recruitment practices. Staff were complimentary about the management team and told us they were supportive and fair. Staff received regular supervision, appraisal and the training they needed to provide effective support.

The home was clean and tidy. We saw that health and safety checks were carried out to

The inspection was unannounced and took place on 16, 17 and 18 October 2017.

Cypress Court Nursing Home was previously inspected in January 2016 when it was found to be meeting all the regulatory requirements which were inspected at that time.

Cypress Court is a purpose-built residential and nursing home in Crewe, Cheshire. The home can accommodate up to 60 older people, it has a lift to the first floor and an open plan reception area. There are large lounge areas and a dining room to each floor. At the time of our inspection the service was accommodating 49 people. Some refurbishment has recently taken place.

There was a registered manager in place at the time of the inspection. 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 a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 related to: person-centred care, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment; receiving and acting on complaints, staffing and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Procedures for protecting people from abuse and neglect were not sufficiently established or operated effectively. Staff reported a culture of fear of reporting or that concerns were not followed up when they did so.

We saw that accidents/incidents were not always recorded, investigated or followed up robustly.

Several people had experienced a high level of weight loss during 2017 and we saw that malnutrition risk assessments were not completed accurately. Although actions had recently been taken to review this matter, it was not identified in a timely manner and therefore people were left at risk of continued weight loss.

We found that medicines were not always managed satisfactorily; for example, we identified some discrepancies in stocks; that medicines were not stored as required and that manufacturer’s instructions were not always followed.

People using services, visitors/relatives and staff told us that they felt there had been insufficient staff to meet people’s needs although this had improved recently as staffing levels had been increased.

Risk assessment and a record of people’s consent was not always in place, for example, for the use of bedrails. We found that call bells were not always within reach leaving people unable to summon help in an emergency.

The registered manager had not carried out supervision or appraisal with staff as required.

Monitoring charts that were put in place were not completed effectively, for example for fluid intake to monitor the risk of dehydration and for positional changes, to reduce the risk of pressure damage to skin.

People’s likes, dislikes and preferences were not sufficiently reflected.

We found that the home had some systems in place to assess and monitor the quality of service that people received. However, these systems had not been sufficiently robust or managed effectively to identify the issues raised within this inspection.

People had access to a choice of menu. Records also showed that people had access to a range of health care professionals subject to individual need.

We observed staff interacting with people using the service in a caring manner although we observed that a person was spoken with abruptly on one occasion. Management took appropriate actions immediately and the member of staff offered their apologies.

Advocacy services were available for people who may need this support.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in spec

Our inspection took place on 21 and 22 January 2016 and was unannounced.

Cypress Court is a purpose-built residential and nursing home in Crewe, Cheshire. The home can accommodate up to 60 older people, at the time of out inspection there were 52 people living at the home. The home is a two storey building and has a lift to the first floor, there is an open plan reception area. There are large lounge areas and a dining room to each floor.

At the time of the inspection 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.

The manager was available throughout the inspection and engaged positively with the inspection process. The manager was friendly and approachable, she operated an open door policy for people using the service, staff and visitors.

The service was safe. We found that there were sufficient numbers of suitably qualified staff to meet the needs of people living at the home. There had been a focus on the skill mix and staffing levels had been increased. New staff roles had been introduced which had improved the general organisation of staff.

Staff knew the importance of keeping people safe and appropriate procedures and systems were in place to prevent people from harm and abuse. Staff had received training about protecting people from abuse and harm. The management team had access to and understood the safeguarding policies of the local authority and followed the safeguarding processes.

The registered manager and care staff used their experience and knowledge of people’s needs to assess how they planned people’s care to maintain their safety, health and wellbeing. Risks were assessed and management plans implemented by staff to protect people from harm.

People's consent was gained before any care was provided and the requirements of the Mental Capacity Act (MCA) were followed.

We found that people were well cared for and treated with compassion. Staff supported people in a caring manner. They knew the people they were supporting well and understood their requirements for care. People were treated with dignity and respect. People and visitors were very complimentary about the care that they received.

Care records were personalised and they reflected the support that people needed so that staff could understand how to care for the person appropriately. However not all care plans were up to date to reflect changes to a person's needs. The staff were in the process of re-writing people's care plans and were providing appropriate care. Daily charts were not always completed fully or at the time that the care was provided. We saw that staff responded to people’s changing needs and sought involvement from outside health professionals as required

People were able to take part in a range of activities should they choose to. Two activities organisers arranged an entertainment programme and also provided one to one support to individuals.

The home was well led. There were very good quality assurance systems in place, to enable areas for improvement to be identified. There was an excellent system in place for ensuring that people's view were sought about the care that they received.

The registered manager made notifications to CQC as required, however there had been an over sight in making recent notifications relating to DoLS authorisation

We carried out this inspection to follow up concerns from our inspection in July 2013. The provider had given us an action plan of how they were planning to address these concerns. We are not satisfied that most of these issues had been dealt with or resolved.

When we arrived at the home the deputy manager told us that the manager was unavailable. We spoke with a senior manager who told us they had recently started supporting the home as the provider had recognised that concerns were not being dealt with. We also spoke with a regional manager who came to the home to assist with the inspection. During the afternoon we were informed that the manager of the home had resigned from their post.

We looked at how the home involved people in their care and we looked at the standard of care that people received and we saw that this was not of an acceptable standard.

We had not planned to look at medication but we did because we observed practices that were unacceptable. We saw that the home had taken steps to improve the arrangements to protect people from abuse and that staff had been trained and understood their responsibilities in relation to safeguarding vulnerable adults.

We looked at the quality monitoring procedures and the records and were not satisfied that these had been improved to an acceptable standard.

We spoke with 11 people who used the service and three relatives. 10 of the 11 people we spoke with were happy with the care and support they received whilst living at Cypress Court. People and their families informed us that when they had raised any concerns these were dealt with by the manager.

We met with the registered manager and spoke with five staff members during the course of the inspection.

During the inspection some staff raised concerns about the care practices of other staff members. These we reported to the manager and to the local authority safeguarding team for safeguarding procedures to be followed. We had received information from a whistle blower in that call bells were not always accessible to people at night. We visited the home unannounced at 5.30am and found that call bells were in place and accessible.

We saw that there were enough staff on duty and saw that the manager responded to staff sickness and absence promptly. We saw that people need more activity and stimulus. We also noted that the manager had advertised for an additional activities co-ordinator.

We found that the providers own quality assurance procedures at Cypress Court had not identified the issues found during the inspection.

We looked at records management and found we could readily access archived historical records. However we saw that accurate information was not always available within the care plan documentation in the files we reviewed.

In May 2012 we completed an unannounced inspection at Cypress Court and we found that the service was not meeting three of the standards, respecting and involving people, care and welfare and assessing and monitoring of the quality of the service provision and that improvements were needed. We completed an unannounced inspection in November 2012 and found that improvements had been made in all these areas.

During the course of the inspection, we spoke with 26 of the 48 people who used the service and nine family members/visitors to the home. The majority of people who used the service and their family members told us that they were happy with the care and support provided by the staff.

Relatives and visitors we spoke to said they felt they would if they had any be able to raise any issues or concerns about their family members care or support with the manager. We found that systems for assessing and monitoring the quality of service provision had improved.

One person who used the service said: "I love it here, they are good girls, very helpful." Another person said: “The staff are kind and gentle I have no complaints." We spoke with one person who told us they had raised a complaint about the service via their family member. They did not wish to discus the details. The manager told us that they would address and investigate any comments or complaints raised in accordance with their policy and procedures.

As part of this review we asked relatives to comment on the management of the home and the standard of care provided. We also asked Cheshire East Local Authority and a visiting health care professional for their views of the service.

People using the service told us:

"I like to spend my time in my room. Staff respect that, but they always let me know what activities are going on so I can attend if I want."

One person said: "It's not like home but it’s very good."

We were told that the staff do seem busy at times and one person said: "Don't get me wrong the staff do chat with you when they are helping you in your room but sometimes they do talk to each other rather than us."

One person living in the home said: "I don't recall everything I was asked about when I came to live here, as I was unwell. I do know that they (the staff) often ask me if I am alright and when we chat I know we speak a bit about my life before I came to live here and about things I enjoy."

One person told us that they had made a suggestion pre the relatives/resident meeting and felt that their suggestion had been listened to and taken up by the staff.

We were told: "I enjoy living here, well as much as you can when away from your own home.”

Another person told us: "Staff understand what I need and how to take care of me. I have no communication issues with the staff. They all seem skilled enough and I've seen the carers ask the nurses if they are not sure."

One person told us: "The laundry is very good I don't get other peoples' clothes, I like the food, it's very good really, all in all I have no complaints."

Relatives of the people using the service we met said they were happy with the care provided. They said the staff were approachable and responsive to any issues raised. Comments made by relatives included:

"We are happy and satisfied with the care provided here and have no concerns."

"My relative tells us that they are happy here and feels safe. My relative talks about particular carers and thinks well of them and tells us about what has happened during the day. We visit the home at different times of the day and visit most days, the staff are approachable and my relative always looks well presented, the room is clean and tidy and the home doesn't smell like some we have visited."

"Staff are cheery and welcoming and I feel that the care is good here."

We carried out this inspection to check that improvements had been made in areas of concern that we had found on our previous visit in November 2013.

We spoke to 12 people who lived in the home and four relatives. We received very mixed responses regarding the care that people described and the staff who supported them.

We spoke to the new manager, the peripatetic manager, the regional manager and seven other members of staff. they all told us that they were very pleased with the improvements that had been made in the home.

We looked at how the home respected people's choices and supported them to make their own decisions. We saw that people's choices were now recorded clearly in people's care plans.

We looked at systems in place to manage people's medicines and saw that staff had all completed refresher training and had competency tests carried out to ensure that they were working safely in accordance with the home's policies.

We looked at the quality assurance arrangements in place and we saw that that these had significantly been improved. We also looked at the home's records and saw that some of these had improved.