The inspection took place on 2 and 3 August 2018 and was unannounced. The first day of the inspection was carried out by two inspectors, a pharmacy medicines inspector, an assistant inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert had personal experience of services for people living with dementia. Two inspectors and an assistant inspector returned for the second day.

The last inspection of this service was on 7 and 8 December 2017 where we found breaches in six regulations of the Health and Social Care Act 2008, including concerns that placed people at serious risk of harm. These were in relation to service user safety, falls prevention, mitigating known risks, training of staff, medication, staffing levels and shift management, the monitoring of fluids and the governance and leadership at all levels. Following the inspection, we asked the service to take some immediate action and told the home to produce an action plan to address the issues we had found. We returned to Four Oaks on 19 January 2018 to check that these actions had been taken and the action plan was being implemented.

At the last inspection, we rated the service overall inadequate and the service has been 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 time frame. During this inspection the service demonstrated to us that improvements have made and is no longer rated as inadequate overall or in any key questions. Therefore, this service is now out of Special Measures.

At this inspection, we found significant improvements had been made for the safety and welfare of people living at the home. Further details can be found throughout the body of the report.

Four Oaks 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. Four Oaks is a modern purpose-built property which can accommodate up to 62 people in four separate units on two levels. Two units specialise in providing care for people living with dementia. At the time of our inspection there were 59 people living at Four Oaks.

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.

A new computerised care planning system, person centred system (PCS) had been implanted throughout the home which had largely improved the care planning of each person living at the home. The system was easy to use and staff could record onto the system in real time which had improved daily recording for people. Staff also had access to people’s care and support needs quickly and the system gave prompts to staff to ensure they had completed each task required.

Everyone living at the home said they felt safe. People told us if they had concerns about their safety, then they would have no hesitation is telling someone. Staff we spoke with were aware of their responsibilities in reporting any concerns they had and had completed safeguarding training to enhance their knowledge.

Staffing levels across the home had improved and staff were visible throughout our inspection. All staff we spoke with said there was enough staff on duty. We received mixed responses from people living at the home and relatives with comments being that the home was short staffed at weekends. Agency staff were still used and rotas showed that staffing levels re

This inspection took place on 7 and 8 December 2017 and was unannounced. Four Oaks was last inspected in July 2017 and was rated as requires improvement when no breaches of the Health and Social Care Act 2008 were identified.

At this inspection we found breaches in six regulations of the Health and Social Care Act 2008, including concerns that placed people at serious risk of harm. These were in relation to service user safety, falls prevention, mitigating known risks, training of staff, medication, staffing levels and shift management, the monitoring of fluids and the governance and leadership at all levels.

Following the inspection we asked the service to take some immediate action and told the home to produce an action plan to address the issues we had found. We returned to Four Oaks on 19 January 2018 to check that these actions had been taken and the action plan was being implemented. Our findings for the 19 January visit are reported at the end of each section of this report.

Full information about the CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what other action we have told the provider to take at the back of the full version of the report.

Four Oaks 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.

Four Oaks is a modern purpose built property which can accommodate up to 62 people in four separate units on two levels. Two units specialise in providing care for people living with dementia. At the time of our inspection there were 56 people living at Four Oaks.

At the time of our inspection there was a new manager in place at the home who told us they had started to complete the application from to be registered as the manager with the CQC. 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 were insufficient staff on duty to meet people’s assessed health and well-being needs. Staff were task orientated and were not visible in communal areas of the home as they were supporting people. Relatives told us they had had to support their loved ones themselves as there had not been any staff available.

Risks had not been clearly assessed and guidance was not available for staff to follow to mitigate any risks identified. For example people had had multiple falls and did not have a falls risk assessment in place. Hot kettles were left in the kitchenettes of each unit which people had access to with no staff being present. This posed a risk of scalding for some people living at the service. Behaviour management plans were not in place for those people who displayed behaviour that challenged the service.

Initial care plans for a person moving to the service were being written on the morning of their arrival. The staff team were not aware of this person’s needs. Most care plans were brief, generic and did not provide sufficient details to guide the staff to deliver person centred care. Some care plans were more detailed, for example the dementia care plans.

People and relatives said they had not been involved in developing the care plans.

Staff said they did not have time to access the care plans on the computer system used at the service. Handover of relevant information between shifts was not robust, with staff stating they did not always receive the information about any changes in people’s health or well-being.

Medicines were not safely managed. On the first day of our inspection the morn

The inspection took place on 19 July 2017 and was unannounced. Four Oaks Care Home is a purpose built home for up to 62 people who require nursing or residential care. It is situated over two floors, with passenger lifts and has pleasant grounds and a car park. At the time of the inspection there were 48 people using the service.

There was a manager in place who was in the process of registering with the Care Quality Commission. 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 told us they felt safe at the home. Toiletries were not stored safely and could have potentially caused harm to some people who used the service. Actions were taken immediately this was identified, to ensure people’s safety.

Recruitment was robust to help ensure staff were suitable to work with vulnerable people. Staff rotas evidenced good numbers of staff.

Safeguarding policy and procedures were in place and staff we spoke with demonstrated an understanding of safeguarding issues and were confident to report any concerns. Accidents and incidents were logged appropriately and analysed for patterns and trends.

Health and safety information was in place and up to date. Medicines were managed safely at the service and staff were trained appropriately.

Staff induction was thorough, training was on-going and staff supervision sessions took place regularly.

Nutritional and hydration records were in place, but were not all complete and up to date. The mealtime experience was good and a number of choices were offered with regard to food and drink.

The service was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and the Deprivation of Liberty Safeguards (DoLS).

We observed care throughout the day and saw that interactions between staff members and people who used the service were friendly and respectful. People’s dignity was respected and care was offered and given discreetly and sensitively.

Residents and relatives meetings took place on a regular basis. Information was given to prospective users of the service and their families.

Advanced care plans, where the person’s wishes for when they were nearing the end of their lives had been expressed, were included within the care files.

Care files we looked at evidenced that care was person-centred. There was a range of health and personal information and people’s preferences, likes and dislikes were recorded.

There was an appropriate complaints policy and people felt able to raise concerns if they needed to. Compliments had been received from relatives in the form of thank you cards and letters.

The manager had been in place for a short time and had made some improvements to the service.

The manager was described as approachable by staff and relatives and staff members told us they were well supported.

We saw minutes of staff meetings, which were undertaken regularly.

Audits were undertaken regularly by the service. Audits for issues such as accidents and incidents were analysed to look at how continual improvements could be implemented. Reviews of care plans were undertaken but were not robust enough and had not always picked up inconsistencies in the records.