Glanmor 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 service is registered to provide personal care and accommodation for up to seven people with mental health and associated health needs. At this inspection six people were being supported by this service.

This inspection took place on 8 and 9 October and was unannounced.

A registered manager was in post at the time of this inspection. The registered manager was on a period of absence from the service and was not available during our 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Our inspection was supported by the director of the service and a deputy manager.

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is part of an ongoing Local Authority safeguarding investigation and may in the future be considered by CQC under our specific incident process. The information shared with CQC about the incident indicated potential concerns about the management of risk of incident within the service. This inspection examined those risks.

At the last comprehensive inspection in June 2016, the service was rated Good overall and Requires Improvement in the 'Safe' domain. We undertook a focused inspection in May 2017 to check that they had followed their plan and to confirm that they now met the legal requirements. Following this focused inspection, the service was rated Good overall and in the ‘Safe domain’.

At this inspection we found concerns across all the five domains and the ‘Safe’ and Well-led domains are now rated as Inadequate. We identified four breaches of the Regulations, Regulation 10 Dignity and respect, Regulation 12 Safe care and treatment, Regulation 17 Good governance and Regulation 18 Staffing.

The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The recording of incidents and accidents, subsequent investigations, actions taken and measures to minimise risks had not been safely managed. Staff confided there were times when it had been hard to reach the registered manager and they felt isolated in dealing with situations without appropriate guidance being given.

There were people who at times expressed their frustrations and anxiety using behaviours which staff found difficult to manage. Approaches from staff were not always consistent and documentation in place lacked guidance and mitigation of the risks.

Risks in the home had not always been safely managed or action taken to prevent harm in a timely manner. We found serious fire safety concerns at Glanmor that potentially risked the safe evacuation of people and unsuitable measures in place to manage a fire. Following our inspection, we made an immediate referral to the Fire safety team who ha

Glanmor is a care home which provides accommodation and personal care for up to seven people with mental health needs. At the time of our inspection seven people were living at the home.

This inspection took place on 12 April 2017 and was unannounced.

There was a registered manager in post at the service. 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 and associated Regulations about how the service is run. The registered manager was not available on the day of the inspection due to other commitments.

We previously carried out a comprehensive inspection of this service in June 2016. A breach of legal requirements was found. The service was rated Good overall and Requires Improvement in the ‘Safe’ domain. After the comprehensive inspection, the provider wrote to us to say what actions they would take to meet legal requirements in relation to the breach of Regulation 12 of the Health and Social Care Act Regulated Activities Regulations 2014.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the 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 Glanmor on our website at www.cqc.org.uk. We found on this inspection the provider had taken all the steps to make the necessary improvements.

Medicines held by the home were securely stored and people were supported to take the medicines they had been prescribed. Medicine administration records had been fully completed, which gave details of the medicines people had been supported to take.

People told us they felt safe and staff were kind to them. Comments includes, “I like living at Glanmor. I feel safe here” and “The staff treat me well and are kind”.

There were systems in place to protect people from abuse and harm and staff knew how to use them. Staff understood the needs of the people they were supporting.

The inspection of this service was carried out on 12 March and 13 June 2016 and was unannounced. At the time of the visit seven people with mental health care needs were living at the service. The last inspection of this service was in May 2013 and all standards inspected were being met.

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.’

Medicine systems were not always safe. Protocols were developed for medicines to be administered “when required”. The Medicine Administration Records (MAR) charts were not always appropriately completed. MAR charts were not always signed by staff when the medicines were administered and on other occasions the staff had signed the MAR charts but had not administered the medicines. This meant people were not having their medicines as prescribed and there was potential for confusion between staff.

Support plans were developed in line with people’s preferences. The support plans included aspects of care people were able to manage for themselves, and the action plans gave staff guidance on the person’s preference for their delivery of their care and treatment. However, support plans were not developed for people with mental health care needs. This meant staff may not be aware of the potential signs and actions needed for detecting any deterioration in a person’s mental health.

People said they mostly felt safe living at the home. The staff knew the procedures for safeguarding vulnerable adults from abuse. This meant they were able to describe the types of abuse and the actions they need to take if they suspected abuse. A copy of the No Secrets guidance was available for staff working at the service for reference.

Risks were assessed and assessments developed on minimising potential risks. Staff were aware of the risks to people and the actions they must take to ensure people’s safety and for them to take risk’s safely.

People said the staff responded to their request and spent time with them. The staff rota in place showed there was lone working for part of the day and at night. An on call system was in place for staff to gain advice and support. . This meant that staff were able to gain advise and additional support should aggressive incidents towards staff occur when they were lone working.

Staff were supported to maintain and develop their skills. New staff had an induction to prepare them for their role and responsibilities. Training courses were available each month and staff said there was a variety of courses and the quality of the training was good.

People had capacity to make their own decisions. The staff used the most appropriate approach for people who at times, used verbal aggression towards them.

People were supported by the staff to manage their ongoing health conditions. Staff consulted with people about arrangements for making appointments. This included the times of appointments and whether the staff were to accompany them on these visits.

Quality assurance arrangements in place ensured people's safety and well-being. The views of people were gathered and their feedback about the service was positive. Monthly visits from the area manager took place to monitor the quality of the service people received.

We spoke with three people who lived in the home who all said they were consulted about the care and treatment they received. One person said “Staff always ask you what you want or prefer”. During our visit we observed that staff consulted with people about the choices which were available to them.

We looked at four care plans for people who used the service. The care plans were based upon people’s preferences and gave detailed information on all aspects of the person's daily life, such as, communication, diet, finances, mental health and emotional well-being, cultural, spiritual and social values. People had an end of life care plan in place which documented their wishes.

On a previous inspection in November 2012 we found that not all areas of the home were clean and we asked the provider to make improvements. When we visited in May 2013 we found the home to be clean throughout. The provider had also made improvements to the maintenance of the home. A new wet room had been installed and a second bathroom and a shower room had been renovated and repairs carried out which ensured people who used the facilities were safe. A new shower unit had been installed in the second bathroom and copper heating pipes exposed in the entrance hall had been boxed in. The home's policies and procedures were in place and current.

One person showed us their room and said, "it's the best room in the house, I like living here". When we asked people about their experiences of living in the home everyone had positive comments to make.

Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We looked at three care plans for people who used the service. The care plans gave detailed information on all aspects of the person's daily life, such as, communication, diet, personal hygiene, mental health and emotional well-being, cultural, spiritual and social values. The care plans were personalised and provided detailed guidance about how people's needs should be met.

We talked with people about being safe. They said they felt safe in the home and would not hesitate to report any concerns they may have. We saw that staff and people who lived in the home had formed positive relationships. Staff said they felt they knew people well, their likes and dislikes and were familiar with their care plans. Staff said how much they enjoyed their work.

We found that people were not protected against the risks of unsafe or unsuitable premises because the property had not been adequately maintained throughout and we asked the provider to take action. The home regularly audited the quality of its service however we asked the provider to ensure that the cleanliness of the home was maintained and audited.

People told us that their care and support needs were well met and that staff treated them with dignity and respect. We were told that staff were approachable and had a good understanding of peoples needs.

People were fully involved in planning and reviewing their care and encouraged to maintain or develop theri independence skills.

People said that Glanmor was a safe place to live and that they felt able to report concerns or issues if they had any.

Staff received regular training, supervision and held frequent team meetings. Staff told us they were well supported and worked effectively as a team.