Duchess Gardens is a 'care home.' People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The manager told us there is no longer a separate nursing unit so the number of places has been reduced to 49. The accommodation is provided in an adapted building and is arranged over four floors.

The service provides personal care and nursing care to people living with dementia, older people, younger adults, people with physical disabilities, people with sensory impairments and people living with mental health issues. At the time of our inspection there were 44 people using the service.

At the last inspection in July 2018, the service demonstrated to us that improvements had been made and was no longer rated as inadequate overall or in any of the five key questions. Therefore, this service is now out of 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. However, while we concluded improvements had been made these needed to be sustained and further developed to make sure people consistently receive safe and effective care and treatment. This is reflected in the overall rating for the service which was ‘requires improvement.' Since then we have had some concerns raised with us about safe staffing levels.

At the last comprehensive inspection in July 2018 we found the service was in continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014(Regulation 19 (3) (a) and (b)). This was in relation to staff recruitment procedures which were not being operated effectively and required documentation was not available. The provider sent us an action plan of the action they had taken.

We undertook an unannounced focused inspection of Duchess Gardens on 13th December 2018. This inspection was conducted following information which we received that was of concern which included concerns about the staffing level at the service. The primary aim of the inspection was to check the safety of the service and any risk of harm to people. The team inspected the service against two of the five questions we ask about services; 'Is the service Safe?' and 'Is the service Well Led?'

There was a manager in post who had applied for registration with the CQC. A registered manager is a person who has registered with 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.

We found there were not enough staff on duty to provide people with timely or person-centred care. We found the manager did not always deploy staff effectively.

We found at breakfast time there were not enough staff to provide people with the support they needed to eat and drink. People fell asleep at the table and were not moved to sit more comfortably in a lounge area.

Staff told us the staffing levels were low. They said people were becoming frailer and they thought more staff was needed. Relatives and people also told us staff levels were low and required improvement.

Whilst systems were in place to monitor training needs, these were not effective.

Redecoration and refurbishment at the home was on-going and we saw areas had improved since our last visit. The home was clean, tidy and comfortable.

Following the inspection, the manager sent us information showing/stating the service has increased its staffing level.

We found two breachs of the He

This inspection took place on 31 July 2018 and was unannounced.

Duchess Gardens 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 is registered to provide 131 places. However, the manager told us there are no longer any double bedrooms so the number has been reduced to 85 places. The accommodation is provided in an adapted building and is arranged over four floors.

The service provides personal care and nursing care to people living with dementia, older people, younger adults, people with physical disabilities, people with sensory impairments and people living with mental health issues. At the time of our inspection there were 48 people using the service and one person in hospital. The number of people using the service was reduced as no admissions had been taken since the last inspection.

There was a manager in post who had applied for registration with the Care Quality Commission (CQC). A registered manager is a person who has registered with 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.

Our last inspection took place on 31 October, 2 and 20 November 2017 and at that time we found the service was not meeting nine of the regulations we looked at. These related to person-centred care, dignity and respect, need for consent, safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, fit and proper persons employed, staffing and good governance. The service was rated ‘Inadequate’ and was placed in special measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. This inspection was therefore carried out to see if any improvements had been made since the last inspection and if the service should be taken out of ‘Special Measures.’

During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the five key questions. Therefore, this service is now out of Special Measures. However, while we concluded improvements had been made these need to be sustained and further developed to make sure people consistently receive safe and effective care and treatment. This is reflected in the overall rating for the service which is now ‘Requires Improvement.'

We found vast improvements had been made to the care and support people who used the service were receiving. They were being cared for by staff who knew them well and understood how they wanted their care and support to be delivered. People were treated with kindness, compassion, dignity and respect. There was a relaxed and friendly atmosphere in the home, with good positive interactions between people who used the service and staff. There were enough staff to care for people and to keep them safe.

Care plans were comprehensive, person centred and up to date. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified. People felt safe at the home and appropriate referrals were being made to the safeguarding team when this had been necessary.

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 supported this practice.

People’s healthcare needs were being met and medicines were being stored and managed safely.

Staff knew about people’s dietary needs and preferences. People told us there was a good choice of meals and said t

Duchess Gardens Care Centre is a converted four floor building and is registered to provide personal care and nursing to a maximum of 131 people. The home provides care for older people, people living with dementia and people with long term mental health needs. At the time of our visit 64 people were using the service and one person was in hospital.

This was the first inspection of the service since it was taken over by Qualia Care Limited in February 2017. Prior to this the service had been in administration and the last inspection had been completed in September 2015. At that time we identified three breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and assessed the service as being requires improvement in all domains and requires improvement overall. This meant the provider knew improvements needed to be made.

There was no registered manager in post. A manager had been recruited but had not made an application to CQC to be registered. 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. Since the registered manager left the service in March 2017and one of the nursing staff had been acting manager until a permanent manager was appointed in September 2017.

Staff were not always being recruited safely and there were not enough of them to keep people safe and deliver person centred care. Whilst some staff were seen to deliver caring, kind and compassionate care, others were not treating people with dignity and respect. A lot of staff training was out of date and some staff supervisions were overdue.

Although staff could tell us about safeguarding procedures, we found incidents were not always being reported to the safeguarding team. Important information was missing from the emergency fire files about people’s evacuation needs should an emergency arise.

People’s care plans were not person centred and did not always provide accurate and up to date information about their current needs. Information was difficult to find or contradictory. Risk assessments were being completed; however, these were not always being followed or had been completed incorrectly. This meant we were not confident action was being taken to mitigate risks to people using the service.

Medicines were being managed safely. However, advice about people’s healthcare needs was not always being sought in a timely way.

People who used the service made some positive comments about the meals; however, we found people’s nutritional and hydration needs were not always being met. We also found people’s mealtime experience was variable depending which unit they lived on.

There were some activities on offer and trips out were being arranged

We found the service was not working within the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards. People were not supported to have maximum choice and control of their lives and staff did not support people in the least restrictive way possible; the policies and systems in the service did not support this practice.

Generally the home was clean and tidy; however, there were areas where unpleasant odours were present. A redecoration and refurbishment plan was in place.

There was a complaints procedure in place and formal complaints had been investigated.

There was a lack of leadership and direction for staff, with no oversight of clinical risks or key issues for people's care. Systems and processes for monitoring the quality of the care provision were weak and there was no robust management of the service. At the time of the inspection there was a new management team in place. They had produced an action plan for improving all aspects of the service. However