About the service: Shakespeare Court is a residential care home that was providing personal and nursing care to 39 people at the time of the inspection. Most of the people supported were over the age of 65.

People’s experience of using this service:

People told us they felt safe. Staff knew how to recognise and report concerns about people’s safety and welfare. Improvements had been made to the way staff were recruited, the required checks were done before new staff started work.

Risks to people’s health and welfare were identified and managed. Staff knew about people’s needs and care was delivered in line with people’s care plans. People’s medicines were managed safely.

There were enough staff to make sure people’s needs were met in a timely way. Staff received training and were supported in their roles. Staff were kind and compassionate and treated people with respect.

People were supported to eat and drink a varied diet which took account of their preferences and cultural and religious needs.

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.

Improvements had been made to the way people were supported to spend their time and take part in social interaction and activity.

The home was clean and checks were done to make sure it was safe. There were plans in place to improve to make further improvements to the environment and to the gardens.

The systems for monitoring the quality and safety of the service had improved since our last inspection. The management team and staff were committed to the continuous improvement of the service. The provider now needs to demonstrate these improvements can be sustained and developed over time.

Rating at last inspection: Requires improvement. (Report published 24 October 2018.) Although the overall rating was ‘requires improvement’ the service was placed in Special Measures in October 2018. We do this when services have been rated as 'inadequate' in any key question over two consecutive comprehensive inspections. The 'inadequate' rating does not need to be in the same question. In the case of Shakespeare Court, it was the well led domain which was rated inadequate in October 2018 and March 2018. 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. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Why we inspected: This was a scheduled inspection based on the previous rating.

Follow up: We will continue to monitor the service to ensure that people receive safe and effective care. Future inspections will be planned in line with our inspection programme. If we receive information of concern we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 7 and 16 August 2018 and was unannounced on both days. There were 47 people living at the home at the time of our inspection.

Shakespeare Court 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.

Shakespeare Court accommodates 80 people in one building. Within the building there are four units. Rowan and Aspen on the ground floor and Cedar and Willow on the first floor. Aspen and Rowan provide personal care with Rowan dedicated to care of people living with dementia. Willow and Cedar provide nursing care; Cedar is dedicated to the care of people living with dementia.

All parts of the home are accessible by means of passenger lifts and there is a small enclosed garden area.

The last inspection was carried out in November 2017; the report was published in March 2018. Following that inspection, the service was rated requires improvement overall and inadequate in well-led. The inadequate rating in the well-led domain was because this service has consistently failed to meet the fundamental standards, it has been rated requires improvement or inadequate since the first rating inspection in October 2014. The provider was in breach of four regulations relating to person centred care, consent to care and treatment, dignity and respect and good governance. Two of these, consent and good governance, were continued breaches from the previous inspection. Following the November 2017 inspection, we took enforcement action and issued a warning notice to the provider in relation to good governance.

During this inspection we found that although some improvements had been made the provider was in breach of five regulations. These related to safe care and treatment (Regulation 12), the employment of fit and proper persons (Regulation 19), person centred care (Regulation 9), dignity and respect (Regulation 10) and good governance (Regulation 17). Three of these breaches, person centred care, dignity and respect and good governance were continued breaches from the last inspection.

The overall rating for the service remains requires improvement. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in 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.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has dem

The inspection was carried out on 14 and 15 November 2017 and was unannounced on the first day. There were 59 people who used the service at the time of our inspection.

Shakespeare Court 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.

Accommodation is provided in four separate units, each unit accommodates up to 20 people. Nursing care was provided on two units, Willow and Cedar with Cedar specialising in the care of people living with dementia. Residential care specialised in nursing care, Cedar and Rowan, are dedicated to the care of people living with dementia.

The last inspection was carried out in January 2017; the report was published in March 2017. At the last inspection we found the provider was in breach of three regulations. These related to staff training, (Regulation 18), the management of covert (hidden) medicines, (Regulation 11), and governance, (Regulation 17). The overall rating for the service was ‘requires improvement’. Following the last inspection we met with the provider and they provided an action plan detailed the actions they would take to improve the service.

During this inspection we found that while some improvements had been made the provider remained in breach of regulations.

There was a registered manager 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.

We found people’s medicines were managed safely and improvements had been made to the way covert medicines were managed. However, we found the provider was still not working in line with the Mental Capacity Act. This was because they had not always ensured people’s representatives had the correct legal authority to make decisions about their care and treatment.

Most people told us they felt safe. Two people told us they sometimes felt unsafe because of actions by other people who lived there. Staff knew how to recognise and report concerns about people’s safety and welfare..

In most cases risks to people’s safety and wellbeing were identified and managed. Incidents were reviewed and ways to improve the service were identified. However, we found this learning was not always put into practice.

There were enough staff deployed. However, the home was finding it difficult to recruit nurses and needed to use a lot of agency staff. This sometimes meant there was reduced leadership on the nursing units. This also had a negative impact on the effectiveness of the management team. Improvements had been made to staff training. Staff told us they felt supported to carry out their duties.

The home was clean and safe. Some areas were in need of refurbishment and this was being addressed. There had been some adaptations to the building to support people living with dementia.

People had enough to eat and drink and there was a varied menu. Feedback about the food was mixed. We found people were not always supported to make informed choices about what they wanted to eat. We found more needed to be done to improve people’s meal time experiences.

Staff knew about people’s physical care needs but did not always know much about people’s life stories and this information was not always recorded. This is important to delivering person centred care.

Most people were satisfied their needs were met. However, we found inconsistencies in people’s care records which created a risk people would not always receive appropriate care.

People were supported to meet their healthcare needs and had access to the full range of NHS services.

Most people told us

Handsale Limited - Shakespeare Court Care Home Nursing Home provides accommodation and nursing care to a maximum of 80 people some of whom are living with dementia. The home is split into four separate units each accommodating up to 20 people. All the accommodation is in single rooms and there are communal lounges and dining rooms on each unit. At the last inspection on 15 July 2015, the home was given a rating of ‘Requires Improvement’ although no breaches of regulation were identified.

We inspected the service on 24 January 2017and it was unannounced. On the day of the inspection 58 people were living at the home.

The person previously registered as manager was due to leave the service two days after our inspection. They had cancelled their registration with the Care Quality Commission. This person is referred to in the report as the outgoing manager. A person registered as manager at another of the providers’ services had started work at Shakespeare Court and was due to take over management responsibility. This meant there was not a registered manager for the service at the time of 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.’

People and relatives we spoke with told us the service delivered good quality care and they did not raise any significant concerns with us. People said they felt safe and trusted the staff. They said staff were kind and care and support provided was appropriate and met their individual needs. People told us they did not have to wait for staff attention. People said they were treated with dignity and respect and their privacy was respected. This was confirmed by our observations.

Staff understood how to identify and act on any safeguarding concerns. Systems were followed to report safeguarding concerns appropriately. Risks to people’s health and safety were assessed. Care plans included any necessary risk assessments based both on actual and perceived risk.

Overall, we concluded medicines were safely managed although some improvements were needed. People received their medicines as prescribed and medicines were stored securely.

Overall, we found there were sufficient staff to meet people’s needs although we have recommended the provider ensures this is kept under continuous review. Safe recruitment procedures were in place. Staff training was not up to date and the induction programme was of a poor standard.

The premises was safely managed. There were pleasant communal areas for people to spend time and the required maintenance and checks took place to make sure the building was safe. The service was clean and tidy.

People told us the food was good and that they had sufficient choice. We found mealtimes to be a pleasant experience and people were provided with diets that met their religious and cultural needs. Nutritional needs were assessed but monitoring of nutritional intake and people’s weight was not always sufficient.

The service had failed to take action in relation to a recommendation we made during our previous inspection and therefore was not always acting within the legal framework of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

People’s needs were assessed and clear and person centred plans of care put in place. People and their relatives told us they were involved in care planning. Staff we spoke with had a good understanding of the people they were caring for.

A programme of activities was in place, provided by an activities co-ordinator. However this was insufficient to meet the needs of all of the people living at the home.

A system was in place to record, investigate and respond to any complaints. People had responded positivel

We completed an unannounced inspection on 15 July 2015. This meant the provider and registered manager did not have notice we would be inspecting the service on this date.

During our inspections on 13 and 21 August 2014, 11 November 2014 and 3 February 2015 we identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The breaches related to; care and welfare, infection control, respect and involvement, nutrition, safeguarding, staffing, records and quality assurance. This inspection was to check improvements had been made in these eight areas and to re-rate the service.

Shakespeare Court is a care home with nursing and provides services to a maximum of 80 people. The service provides care to older people and people living with dementia. It is a modern building and internally is divided into four separate units. At the time of this inspection 38 people used the service.

The service did not have a registered manager. However, the manager had submitted an application to become the registered manager. Their application was being processed by the Commission at the time of this 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.

During this inspection we found improvements had been made in all eight areas and no new breaches were identified. The manager had plans in place to ensure improvements continued and were sustained and both they and the staff team told us they were committed to ensuring this happened. The manager and operations manager were clear that an increase in occupancy would be gradual and carefully managed to ensure there were no adverse effects on the quality of care provided. Following our inspection we met with the provider to ensure they were aware of the need to sustain and build upon these improvements.

Staff had a good understanding of how to keep people safe and were supported by robust protocols in relation to safeguarding, emergency procedures and staff recruitment. There were sufficient numbers of suitably skilled staff to ensure people were cared for safely. However, the manager and operations manager were clear that the arrangements in place for assessing staffing levels would need to be continually reviewed as the occupancy of the home increased. Care staff were provided with effective training and support to ensure they could safely care for people.

Improvements had been made to the quality and accuracy of information within care records. Staff translated this information into person centred care and support. People’s healthcare needs were being met and improvements had been made to how nutritional risk was managed and the overall mealtime experience.

People were listened to when they complained and were involved in making changes to improve the quality of care and service provided. Feedback from people who used the service about the quality of care provided and care staff was good.

We found medicines were being safely managed. However the arrangements in place in relation to one person who received their medicines covertly were not sufficiently robust. We recommend the provider considers current guidance on giving people covert medicines and takes action to update their practice accordingly.

Staff were respectful, patient and caring when providing people with support. People’s consent was sought and appropriately used to deliver care. Staff at all levels had a good understanding of how the Deprivation of Liberty Safeguards (DoLS) might affect their role.

Significant improvements had been made to the governance and audit systems. The systems in place still needed some minor refinements, however overall we found they helped to improve the quality of care provided. The manager took learning from incidents and accidents to help improve practices and the quality of care provided. Staff spoke positively about the new management team and the changes they had made. They also told us that staff morale had greatly improved since our previous inspections.

During the inspection we had the opportunity to speak with people who used the service, a Bradford College work placement student and staff members.

The people who used the service told us they were looked after very well and felt safe with the care and treatment provided. Their comments included: "It is very nice here", “I like it here”, “They are all lovely” and “I love living here”.

We spent time observing the four lounges and dining areas during the day of our inspection. We looked at how people spent their time and how staff interacted with people.

The interactions we saw between staff and people who used the service and visitors were respectful. We saw some people engaged in activities with members of staff such as watching TV, enjoying beverages and snacks and reading a memory book.

We used a number of different methods to help us understand the experiences of people who used the service. This included observing how people were cared for.

In one of the areas where we carried out an observation we saw staff spent a lot of time standing in the corridors. They talked with people who were walking up and down the corridor but they did not have much interaction with the people who were in the lounge area. We saw that for the most part staff only interacted with people in the lounge area when there was a specific care task to be carried out.

We saw that staff did not always explain to people what they were doing, for example, when helping someone to transfer with the aid of a hoist. We saw that staff did not always talk to people when supporting them to eat and did not always explain to people what they were being offered to eat and/or drink.

We looked at some people’s care records and found that the records did not always include accurate information about their care needs.

There were policies and procedures in place to make sure vulnerable people were protected from the risk of abuse.

We found there were systems in place to make sure staffing levels were reviewed and took account of the needs of the people who used the service. The staff we spoke with did not raise any concerns about the numbers of staff on duty.

There was a complaints procedure and the records showed people’s complaints were taken seriously and addressed.

We carried out an unannounced comprehensive inspection of this service on 13 and 21 August 2014. Eight breaches of legal requirements were found and we issued three warning notices. As a result we undertook a focused inspection on 11 November 2014 to follow up on whether action had been taken to address the breaches of regulations in relation to the warning notices. We found the provider continued to breach legal requirements.

After our inspection on 11 November 2014 we met with the provider and attended a multi-agency meeting. During these meetings we received information that the provider had taken immediate action to ensure improvements were made. As a result we undertook another focused inspection on 3 February 2015 to assess these improvements.

You can read a summary of our findings from all three inspections below.

Comprehensive Inspection 13 and 21 August 2014

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

We inspected Shakespeare Court on 13 August 2014 and 21 August 2014 and the visits were unannounced.  Our last inspection took place in February 2014 and at that time we found the home was meeting the regulations we looked at.

Handsale Limited – Shakespeare Court is registered to provide accommodation and nursing care for up to 80 people accommodated over four units. This includes two residential units and two nursing units.  Two units of the home cater for people living with dementia. 

A registered manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

Cleanliness and hygiene standards in the home were not being met and we saw some poor infection control practices. This put people at risk of transferring and acquiring infections. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Staffing levels were not adequate to keep people safe. People told us there were not enough staff. People were not adequately supervised and had to wait for support and assistance. Staff did not have the time to provide meaningful interaction with people. This was a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

People were not protected from abuse. There was a lack of evidence of action taken following incidents to keep people safe. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

People’s care needs were not always assessed and people did not receive care in line with the requirements set out in their care plans.  This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The manager had sought and acted on advice where they thought people’s freedom was being restricted. This helped to ensure people’s rights were protected.

Most people said staff treated them with dignity and respect. However, we saw staff did not always treat people with dignity and respect or respect their privacy. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Most people spoke positively about the quality of food at the home. However, we found the mealtime experience required improvement with unnecessary delays in serving food.  People were not always appropriately supported at mealtimes and appropriate action not always taken following the identification of the risk of malnutrition. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

Quality assurance processes were inadequate; the issues we found had not been identified by the provider’s own monitoring and audit processes.  Risks to people’s health, safety and welfare were not appropriately assessed and managed.  This was a breach of Regulation 10, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Accurate records were not always maintained in respect of each person who used the service. For example a lack of information on people’s life histories and preferences.  This was a breach of Regulation 20, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider is required by law to notify the Commission of any allegation or instance of abuse. We found seven notifiable incidents which should have been reported and were not. This was a breach of Regulation 18, of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010

Systems were in place to ensure medicines were managed safely.  We found that medicines were ordered in a timely way and recorded, stored, administered and disposed of safely.

Focused inspection 11 November 2014

After our inspection of 13 and 21 August the provider wrote to tell us what they would do to meet legal requirements in relation to the breaches identified. We undertook this unannounced focused inspection to check the provider had followed their plan and to confirm that they now met legal requirements in relation to; care and welfare of people who use services, cleanliness and infection control and assessing and monitoring the quality of service provision. We focused on these three areas because these were the three areas where we had served warning notices.

The provider had not taken appropriate action to ensure they met the requirements of the warning notices in relation to monitoring the quality of the service and cleanliness and infection control. They had met some requirements of the warning notice in relation care and welfare. However, further improvements were required to ensure the legal requirements in this area were fully met. You can see what action we told the provider to take at the back of the full version of the report.

Focused inspection 3 February 2015

Following our inspection on 11 November 2014 we met with the provider and attended a multi-agency meeting chaired by the local authority. During these meetings information was shared which indicated that the provider had taken immediate action to ensure improvements were made in relation to infection control and how they assessed and monitored the quality of the service. We also received regular updates from the new manager about what action had been taken to ensure improvements were made. We decided to return to the service to undertake another unannounced focused inspection to review these improvements. We focused on these two areas because these were the areas where we had found that the provider had previously not met the warning notices.

During this inspection we found improvements had been made in relation to cleanliness and infection control and assessing and monitoring the quality of the service. However, we were unable to test the long term effectiveness of the arrangements the provider had in place to ensure these improvements were sustained. We also found that further improvements were still required to ensure the regulatory requirements in these areas were fully met.