This inspection took placed on 04 and 05 December 2018 and was unannounced. At the last inspection completed 02 October 2017 we rated the service as ‘requires improvement’. At this inspection, we found improvements had been made in some areas. However, poor governance systems had exposed people to the risk of harm.

Drake 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 care home accommodates up to 29 people in one adapted building. At the time of our inspection there were 28 older people living with dementia, many of whom had 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.

People who required a texture modified diet were not always protected from potential harm as the risks to them were not being consistently managed. Care staff did understand how to manage other risks to people effectively although these required actions were not always documented in care plans.

The provider was not ensuring people were sufficiently protected as their governance and quality assurance systems were not always identifying issues of concern within the service. Records relating to people’s care were not always fully accurate and complete and this had not been identified.

People were supported by sufficient numbers of staff to keep them safe from harm. However, staff were extremely busy due to the increasing demands of people with challenging and distressed behaviours.

People were supported by a staff team who understood how to protect them from potential abuse. People’s medicines were managed safely and were administered as prescribed. We found infection control practices were strong and people were sufficiently protected.

People’s rights were protected by the effective application of the Mental Capacity Act 2005 (MCA). People’s day to day healthcare needs were met and people were happy with the food and drink they received.

People were supported by a staff team who were kind and caring in their approach. Care staff were committed to their roles, worked well as a team and were passionate about providing a good standard of care to people. People’s privacy and dignity was respected and their independence was promoted.

People or their representative when appropriate were involved in the development of their care plans. People’s needs were reviewed on a regular basis and the care they received was updated in line with their changing needs. People were getting access to an increasing range of leisure opportunities.

People understood how to make a complaint if this was required. People were involved in the development of the service and were consulted about any changes being made. People felt the registered manager was approachable and supportive. People were also supported by a care staff team who themselves felt valued and supported in their work.

The provider was not meeting the requirements of the law in relation to safe care and effective governance. 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 02 October 2017 and was unannounced. At our last comprehensive inspection completed on 11 and 12 October 2016 we rated the service as ‘requires improvement’. The provider was not meeting the regulations around the need for consent and the effective governance and management of the service. We returned on 16 May 2017 to check the provider was now meeting these legal requirements. We found the requirements of the law were now being met although some improvement was still required. At this inspection we found further improvements had been made.

Drake Court Residential Home provides accommodation and personal care for up to 29 people. At the time of our inspection there were 28 older people living at the service, most of whom were living with dementia.

There was 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.

The provider had made improvements to quality assurance systems although further work was required to improve record keeping and some audits. Some improvements were required to risk management systems. Medicines administration records indicated creams were not always applied as prescribed. People also told us they felt more staff were required in the service.

People were supported by a staff team who had been reviewed for their suitability to work by the registered manager. We did find some improvements could be made to checks around staff member’s prior employment history.

People were supported by a staff team who understood how to protect them from potential abuse or mistreatment. People were supported by a care staff team who had the required skills to care for them effectively. The registered manager was making appropriate decisions in people’s best interests when they lacked capacity.

People’s nutritional needs were met and they enjoyed the food and drink they received. People’s day to day health needs were met.

People were supported by a care staff team who were kind and caring towards them. People enjoyed living at the service and felt valued and important. People were given choices around their care. People’s dignity was upheld and independence promoted.

People felt the care they received met their needs and preferences. People were able to access activities and leisure opportunities.

People felt able to complain if required. Where people raised concerns, their views were heard and action taken to make improvements. People felt the service was well-led. People were cared for by a staff team who felt supported in their roles by the management team.

This focused inspection took place on 16 May 2017 and was unannounced. We carried out an unannounced comprehensive inspection of this service on 11 and 12 October 2016 and provided a rating for the service of ‘requires improvement’. Breaches of legal requirements were found regarding the need for consent and the effective management of the service. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to these breaches.

We undertook this focused inspection 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 those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Drake Court Residential Home on our website at www.cqc.org.uk.

Drake Court Residential Home is a care home that provides accommodation and personal care for up to 29 people. At the time of our inspection there were 29 older people living at the service, most of whom were living with dementia.

There was 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.

People were cared for by a staff team who were receiving the training and support required to support them effectively. People were enabled to consent to the care they received wherever possible. The staff and manager’s knowledge around the Mental Capacity Act 2005 (MCA) had improved although not all relevant decisions were being considered under the Act.

People were happy with the food and drink they received. Special dietary requirements were understood by care staff and met appropriately. People were supported to maintain their day to day health.

People felt the service was well managed, they felt able to raise concerns and felt they would be listened to and heard. People were supported by a staff team who felt well supported and motivated in their roles. People were protected by a developing quality assurance system that had begun to identify areas of risk and improvement required within the service. Further development was still required to ensure that all issues were identified and records were maintained accurately.

The inspection took place on 11 and 12 October 2016 and was unannounced. At the last inspection completed on 17 and 18 November 2015 we found the provider was not meeting the regulations around providing person-centred care, the need for consent, safeguarding people and the good management of the service. At this inspection we found significant improvements had been made although further improvement was still required. The provider was still not meeting all of the legal requirements.

Drake Court is a residential home that provides accommodation and personal care for up to 29 people. At the time of our inspection there were 29 older people living at the service, many of whom were living with dementia. There was 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.

People were supported by a staff team who could recognise signs of abuse and knew how to report any concerns. Staff understood potential risks to people and how to keep them safe, although actions taken by staff were not always recorded in risk assessments. People were supported by sufficient numbers of staff who had been recruited safely for their roles. People’s medicines were administered and stored safely. However, medicines administration records did not always show that people received all of their medicines as prescribed.

People’s rights were not always upheld as decisions about the care of people who lacked capacity were not made in line with the Mental Capacity Act 2005. Where people were deprived of their liberty, the required legal applications had not been submitted to the local authority. People did not always receive the support they needed to prevent the risk of malnutrition. People did receive access to healthcare professionals such as doctors, dentists, chiropodists and opticians. People were supported by a staff team who were undertaking regular ongoing training to ensure their skills and knowledge were developed.

People were supported by a staff team who were kind and caring towards them. People were supported to make day to day choices about the care and support they received. People’s privacy and dignity was protected and promoted. People were supported to maintain their independence.

People were happy with the care they received. The care people received was under ongoing review and improvements were being made. People were supported to access leisure opportunities that they enjoyed. People developed relationships with others and enjoyed living in the service. People felt able to complain and raise concerns. They felt they were listened to and issues were resolved.

People knew who the registered manager was and felt they were approachable. People were involved in the development of the service. People were cared for by a staff team who were motivated in their role and felt supported by the registered manager. The registered manager had developed a positive staff team and an open, transparent culture within the service. A quality assurance system had been developed that had resulted in improvements being made throughout the service. This system was not yet effective in identifying and resolving all areas of concern that we found.

The provider was not meeting the regulation around the need for consent and good governance of the service. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced inspection on 14 October 2014. During our last inspection on 11 September 2013, we did not identify any concerns.

Drake Court provides accommodation and support for up to 29 people who may also have a dementia related condition. At the time of our inspection, 26 people used the service.

There was a registered manager at Drake Court. 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.

Some parts of the home had not been suitably maintained to ensure the environment was safe. We needed to inform the registered person to provide immediate work to the office area during our inspection to ensure the building was safe. The provider had not taken action previously, although they were aware of the concern.

The home had not been adapted to meet the needs of people with dementia or people who had a visual impairment. This meant some people needed support from the staff to move around the home to keep safe.

Recruitment checks were carried out to ensure staff were suitable to work with people who used the service. We saw there were sufficient staff to meet people’s assessed needs and systems were in place to ensure additional staff were available to cover annual leave or sickness.

People who used the service were able to make decisions about their care. The staff had received training and demonstrated a good knowledge of the Mental Capacity Act 2005 and Deprivation of

Liberty safeguards (DoLS). This would ensure that where people were no longer able to make decisions, these would be made in their best interests. Nobody who used the service was subject to any restraint or were being deprived of their liberty.

Staff received training although we saw this was not always effective. We saw people were not always supported to move safely.

Staff cared for people respectfully. People told us the staff were kind and supported them in a dignified manner. People were satisfied with the care they received and how this was delivered.

People were provided with opportunities to engage in activities in the home and the community according to their interests. People were supported to attend religious services at their usual place of worship.

People were able to raise concerns and were confident that suitable action would be taken.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection was a follow up to check what actions had been undertaken since our last inspection in April 2013. This was to ensure that the service was now compliant with the regulations. The inspection was unannounced and the provider, manager or staff did not know we would be visiting.

We looked at how people with diabetes were cared for. We spoke with two people about their care and their life within the home.

People we spoke with told us they were happy living in the home. One person said: "I love it here. I have been happy since day one. They are wonderful people, everyone is so nice and the food is good". Another person said: "It's lovely here, everyone is lovely".

We spoke with the manager and three staff about supporting people. We found that all the staff we spoke with were knowledgeable about signs and symptoms of both low and high blood sugar and actions required to ensure people's health and wellbeing needs were being met.

We found that there were improved systems in place to manage and respond to complaints and when needed, address people's concerns. People told us they were confident that if they had any concerns they would be addressed.

We found that the service had made the required improvements and was compliant with the regulations.

We spoke with six people who lived at the home. People we spoke with were positive about the care and support that they received. One person told us: "Everything is grand here". Another person said: "I am definitely happy here".

We found that care records required improvement to ensure that people's needs were identified.

The service had required systems in place to protect people from abuse and take appropriate action if any concerns about abuse were identified. We found that required improvements had been made since our previous inspection to safeguard people from abuse.

The home had systems in place to manage people's medicines and safeguard them from the risk of unsafe or inappropriate practice.

People told us that staff were caring and that staff assisted them when they needed it. One person said: "I have to ring the bell for staff to come to me in the night but they come quickly ". Another person said: "The staff are all grand". The service had additional staff since our previous inspection which meant that people had more social opportunities. There was a need to assess staffing requirements more proactively to ensure that the service continues to provide sufficient staff to meet people's needs.

The service had appropriate systems in place to enable people to raise concerns. Improvements were needed to how the service responded to any concerns to provide assurance that people's complaints would be appropriately addressed.

We carried out this inspection as part of our planned programme of inspections. The visit was unannounced and neither the staff nor the provider knew that we would be visiting.

The inspection included the observation of care experienced by people living at the

home, talking to people who were living in the home, talking with the manager and staff on duty, looking in detail at all aspects of care for three people some of whom had complex needs, viewing people's rooms and discussing their care with staff. This process is known as pathway tracking.

We spoke to four people who live at the home and three relatives. People we spoke with were all positive about the care and support that they or their relative received. One person told us, "It’s a good place to live".

We found that the home was comfortable and spacious and that people were able to personalise their bedrooms as they chose to reflect their taste and interests.

People were consulted about their care. People told us how they spent their day. They said that they got up and went to bed when they chose to. They told us that their friends and relatives were able to visit them.

People told us that staff were kind and caring. They told us that staff assisted them when they needed it. One relative said, "Staff always do their best", they are very caring”.

Improvements were needed to refer all incidents of abuse or potential abuse to protect people from harm.

This inspection took place on 17 and 18 November 2015 and was unannounced. At the last inspection completed on 14 October 2014 we found the provider was not meeting the regulations regarding the safety and suitability of the premises and also safe care. At the most recent inspection we found that further improvements were required.

Drake Court Residential Home is a care home that provides accommodation for up to 29 older people who require personal care. At the time of the inspection there were 28 people living at the service, some of these people were living with dementia. The service is required to 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. At the time of the inspection there was not a registered manager in post. A new manager had joined the service during the week prior to the inspection and we were told they would be completing their registration with CQC.

People were not protected from potential abuse or inappropriate treatment. The provider did not have adequate procedures in place to ensure that concerns were identified, reported and managed effectively.

People were not always protected by effective risk management or safe practise around supporting people to move without risk of harm or injury. People told us that they were happy with the way they received their medicines. We found that medicines weren’t always stored appropriately.

Staff recruitment practices had been improved by the provider ensuring that people were supported by staff who had the required pre-employment checks completed. People felt there were sufficient numbers of staff available to support them.

People’s human rights were not always supported by their consent to care being obtained in line with current legislation. Principles of the Mental Capacity Act had not been followed. People were not supported by staff who felt sufficiently trained to fulfil their roles effectively.

People told us that they enjoyed the food and drink that they received. People told us that their day to day health needs were met and people had access to external healthcare professionals.

People’s privacy, dignity and independence was not protected by staff in the way that care was provided and people were communicated with. Some people told us that they were able to make choices around the care they received. However, this practice was sometimes inconsistent across the service.

People told us that they weren’t involved in planning their own care. People’s care plans did not always reflect their needs and preferences and staff weren’t always aware of people’s needs. People told us that they did not always have access to leisure opportunities that met their preferences.

People told us that they knew how to complain if required. The provider had failed to establish systems that monitored and improved the quality and safety of the service provided to people. The provider had also failed to establish systems that monitored and managed risks to people.

Feedback about recent management changes were positive. Staff felt that the new manager would make the required improvements within the service and they recognised areas requiring further improvements.

We found that the provider was in breach of some regulations under 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.