This inspection took place on 18 December 2018 and was unannounced. This meant no-one at the service knew we were planning to visit.

We checked progress the registered provider had made following our inspection on 19 April 2018 when we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were Regulation 9, Person-centred care; Regulation17, Good Governance; and Regulation 18, Staffing.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, caring, responsive and well-led to at least good. During this inspection we found the registered provider was no longer in breach of Regulation 17 and 18. However, we found further breaches of Regulation 9 and a breach of Regulation 12, Safe care and treatment.

Jasmin 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. Jasmin Court is located in north Sheffield and is registered to provide accommodation for up to 50 older people who require nursing and/or personal care. Accommodation is provided over two floors, accessed by a lift. A dining room and two lounges are situated on the ground floor of the home. There were 26 people living at Jasmin Court at the time of this inspection.

There was not a registered manager at the service. The service was being managed by an interim manager and the regional manager. 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.

Medicines were not always managed and administered in a safe way.

Drinks were offered to people throughout the day, however these were left on tables beside people who required support from staff to drink. This support was not always given and we saw people with several full cups of untouched drinks left beside them.

There was a limited range of activities on offer to people living at Jasmin Court. Some people and their relatives told us they would like more activities and of a wider variety.

We saw the signage and decoration of the premises could be improved and updated to better meet the needs of people living there.

Not all the quality assurance and audits systems in place to monitor and improve service delivery were effective.

From our observations we saw there were enough staff employed to meet people’s care and support needs in a timely way. However, people and their relative’s views on staffing levels were mixed.

Safe recruitment procedures made sure staff were of suitable character and background.

There were systems in place to recognise and respond to any allegations of abuse. Staff had received training in this area. Staff understood what it meant to protect people from abuse. They told us they were confident any concerns they raised would be taken seriously by management.

Systems were in place to ensure people were supported by staff who had the knowledge and skills necessary to carry out their roles in meeting people’s needs. Staff were suitably trained.

People told us they enjoyed the food served at Jasmin Court, which we saw took into account their dietary needs and preferences. People were assisted to maintain their health by being provided with a balanced diet and supported to access a range of health and social care professionals.

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 and their relatives t

This inspection took place on 19 April 2018 and was unannounced, which meant the staff and registered provider did not know we would be visiting. The service was last inspected on 17 May 2017. The overall rating of the service was requires improvement. At this inspection, we found three continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9, Person-centred care, Regulation 18, Staffing and Regulation 17, Good governance. Our findings showed the registered provider had not monitored progress against plans to improve the quality and safety of the service, and had not taken appropriate action without delay where progress was not achieved as expected.

Jasmin 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. Jasmin Court is registered to provide accommodation for up to 50 older people who require nursing and/or personal care. Accommodation is provided on the first and second floors, accessed by a lift. Communal areas such as dining rooms and lounges are situated on the ground floor of the home. At the time of the inspection, 28 people were living at the home; one of those people was in hospital.

At the time of this inspection, the service was being managed by the regional manager and the deputy manager. The previous manager had recently left and had not registered 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 we spoke with told us they felt ‘safe’. Relatives we spoke with did not express any concerns about their family members’ safety. However, we received concerns from relatives about the staffing levels at the service, particularly at the weekends.

At our last inspection, we saw the deployment of staff, particularly during mealtimes, could be improved to ensure people were supported appropriately. At this inspection, we saw the arrangements in place to ensure people in their rooms received their meals in timely manner still required improvement.

We found the management of medicines required improvement to ensure medicines were handled safely. We saw evidence of poor stock control and ordering of medicines.

Staff had access to important information to help keep people safe and take appropriate action if concerns about a person’s safety had been identified. Staff knew these policies and procedures were available to them.

We found the system in place to ensure that fit and proper persons were employed at the service needed to be more robust.

We saw there were satisfactory arrangements in place to manage people’s monies.

People we spoke with were satisfied with the quality of care they had received. However, we saw that some people had not been supported appropriately with their personal care. This did not uphold their dignity. This showed that sufficient improvement had not been made at the service since our last inspection.

We saw some practices at the service that did not promote dignity and respect. This showed some of the training and support of staff had not been underpinned by the key values of kindness, respect and dignity of care. We also saw some staff did not fully understand the requirements about offering choice and/or obtaining consent. This showed the service had not always been well led.

At our last inspection, we received mixed views from relatives about their involvement in their family member’s care planning. At this inspection we found the system in place to ensure that an assessment of n

This inspection took place on 17 May 2017 and was unannounced, which meant the staff and registered provider did not know we would be visiting. The service was last inspected on 19 and 20 April 2016. The overall rating of the service was good. At this inspection we found the overall rating of the service was requires improvement.

The manager had started working at the service in November 2016; they had not yet registered with the Care Quality Care Commission. The manager told us they had obtained the documentation to apply to become the registered manager, but they had not submitted their application yet. 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.’

Jasmin Court is registered to provide accommodation for 50 older people who require nursing and/or personal care. Accommodation is provided on the first and second floors, accessed by a lift. Communal areas such as dining rooms and lounges are situated on the ground floor of the home. At the time of the inspection 36 people were living at the home.

We saw the deployment of staff particularly during mealtimes could be improved to ensure people were supported appropriately and in a timely manner. We saw examples when people’s calls for assistance were answered promptly, but we also saw examples when this was not the case.

The registered provider’s recruitment policy needed to be updated. We found the system in place to ensure that fit and proper persons were employed at the service needed to be more robust.

We found that some people’s risk assessments required improvement to ensure care was provided in a safe way.

We found that the registered provider had not ensured that people’s care plans were regularly reviewed or in response to change. This meant there was a risk that people would not receive appropriate care. We found there was contradictory information in some people’s care plans. We also found that some people’s care plans did not reflect the care that was being provided by the care staff. The manager told us they were in the process of reviewing people’s care plans.

We found the registered provider had not ensured that staff received appropriate training and support to enable them to carry out their duties. The manager told us that a programme of staff training was being delivered at the service to bring staff up to date. The manager had a staff supervision schedule in place.

People were satisfied with the quality of the food that was provided at the service. However, a few people we spoke with told us sometimes hot food had gone cold by the time it was served. We shared this feedback with the manager so appropriate action could be taken to ensure food temperatures were check.

There was a programme of activities for people to participate in, but we saw there was no one to one activities provided to people who were unable to leave their rooms. It is important that all the people living at a service are provided with meaningful activities.

We reviewed one person’s Deprivation of Liberty Safeguards authorisation which had been granted with conditions in March 2017. These conditions are legally binding and we saw that some of these conditions had not been met. This showed there was a risk that people would not receive appropriate care and treatment to meet their needs.

We found the registered provider had failed to ensure that people and their representative views were actively sought for the purpose of continually evaluating and improving the service.

Our findings during the inspection showed the registered provider systems to assess, monitor and improve the quality and safety of the service required improvement.

People we spoke with told us they f

This inspection took place on 19 and 20 April 2016 and was unannounced on the first day.

We last inspected the service in October 2015 when we found three breaches in legal requirements and the service was rated as ‘requires improvement.’ The breaches were in respect of care and treatment not always being provided in a safe way, including the management of infection control, the premises not always being suitable for the purpose intended, and a lack of a robust system to monitor how the home was operating.

The provider sent us an action plan detailing what improvements they intended to make and by when. You can read the report from our last inspections, by selecting the 'all reports' link for ‘Jasmin Court’ on our website at www.cqc.org.uk’

Jasmin Court is in north Sheffield and is registered to provide accommodation for 50 older people who require nursing and/or personal care. Accommodation is provided on the first and second floors, accessed by a lift. Communal areas such as dining rooms and lounges are situated on the ground floor of the home. At the time of the inspection 41 people were living at the home.

The service did not have a registered manager in post. However, there was a new manager who had been in post for around five months. They told us they had applied to become registered as manager 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.

During this inspection we looked to see if improvements had been made since our last inspection in October 2015. We found that substantial improvements had been made.

The home had a welcoming, friendly atmosphere, which people said they liked. Throughout our inspection we saw staff supporting people in an inclusive, caring and responsive manner. They encouraged people to be as independent as possible, while taking into consideration their abilities and preferences. The people we spoke with told us they felt the home was a safe place to live and they were happy with the care and support they received. They made positive comments about how staff delivered care and said the available facilities met their needs.

We saw there were systems and processes in place to protect people from the risk of harm. The management team were knowledgeable about safeguarding people from abuse and all staff had received training in this subject. Assessments identified any potential risks to people and care files contained information about how to reduce these risks.

Medicines were stored safely and procedures were in place to ensure they were administered correctly. We saw people received their medications from staff who had been trained to carry out this role.

There was enough skilled and experienced staff on duty to meet the needs of the people living at the home and suitable pre-employment checks were undertaken before employing new staff.

Staff had received a structured induction on how the home operated and their job role at the beginning of their employment. They had access to a varied training programme and support to help them meet the needs of the people who used the service.

The requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were in place to protect people who may not have the capacity to make decisions for themselves. The MCA sets out what must be done to make sure that the human rights of people who may lack mental capacity to make decisions are protected.

Records demonstrated the correct processes were being followed to protect people’s rights, including when Deprivation of Liberty Safeguards were considered.

People were provided with a choice of healthy food and drink ensuring their nutritional needs were me

We last carried out inspections under the Care Quality Commission’s old methodology on 23 September 2014 and 4 December 2014, during which we found a number of breaches of regulation. This, focussed, inspection took place to look at whether any improvements had been made since those inspections.

This report only covers our findings in relation to this topic. You can read the report from our last inspection by selecting the 'all reports' link for Jasmin Court on our website at www.cqc.org.uk

We undertook this focused inspection to determine people experienced a service which was well led and effective. We have not yet carried out a comprehensive inspection to provide a rating for this service under the Care Act 2014

Jasmin Court is located in the city of Sheffield, approximately two miles north of the citry centre in the suburb of Pitsmoor. The home is a purpose built building set in its own grounds with parking facilities. The ground floor has lounges and dining areas, and the bedrooms are a mix of those with ensuite bathrooms and some without.

The home had a registered manager, however, they had left their post several months before the inspection. They had not yet applied to the Commission to cancel their registration. There was also a new manager in post, but they had not yet applied to be registered with the Commission. 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.

At this inspection we found, while most people said they were happy with the home, we identified a number of concerns. Our observations and the records we looked at did not always match the positive descriptions some people gave us. We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in that people did not receive care which met their needs, and the systems in place to monitor and assess the quality of the service were not always effective.

Parts of the premises were in a poor condition, and some areas had been damaged. Repairs had not taken place to address this, despite the provider’s action plans stating that this work had been completed.

We identified incidents which the provider was legally required to notify the Commission about, but they had failed to do so, and the provider’s complaints policy contained incorrect information. This had been identified in previous inspections, but the provider had not addressed this.

The arrangements in place for acting in accordance with people’s consent, and assessing people’s mental capacity, were inadequate. Where people lacked the mental capacity to make decisions about their care and welfare, the correct legal procedures were not followed. One person had a notice in their file stating that resuscitation should not be attempted, which was in direct contradiction of their expressed wishes. A CQC inspector referred this matter to the local authority’s safeguarding team after the inspection.

Staff had not all received sufficient training to undertake their roles effectively. A number of staff had not received training in relation to safeguarding, mental capacity or moving and handling. The home’s manager contacted us after the inspection to tell us that the training records were incorrect.

The home’s management team had devised a wide range of audits in order to monitor and improve the quality of service people received, however, these audits did not always reflect an accurate picture of the home, and were not always carried out at the frequency they were intended to be carried out at.

We are taking action against the provider, and will report on this at a later date.

Our inspection looked at our five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, speaking with the staff supporting them, speaking with the home’s manager and looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Where people were exposed to risk, this was not always adequately assessed.

The environment in which people were cared for was not hygienically clean, and some areas were damaged to the extent that they could not be cleaned to a sufficient standard. Staff did not always follow correct procedures in relation to cleanliness and infection control. We have told the provider that they must take action in relation to hygiene and infection control.

Is the service effective?

People did not always receive the care they were assessed as requiring, and did not always receive care or support in a timely manner. We have told the provider that they must take action in relation to people's care and welfare.

Is the service caring?

People’s privacy was not always respected, and staff did not always take appropriate steps to uphold people’s dignity. People were not always given sufficient opportunity to make choices about their care. A compliance action has been set for this and the provider must tell us how they plan to improve.

Is the service responsive?

Staff did not always act when people required help or support. Where people’s needs changed, their care plans did not always reflect this.There was a complaints system in place and this was accessible to people using the service. However, some of the information contained in the complaints procedures was incorrect. We have told the provider that they must take action in relation to people's care and welfare.

Is the service well-led?

There was a quality assurance system in place, where audits of all aspects of the service were carried out, however, it was not effective in identifying areas of concern. The system for monitoring accidents and incidents was inadequate as it did not identify where the provider had failed to meet certain legal requirements. We have told the provider that they must take action in relation to the assessing and monitoring of quality.

During our inspection in April 2013 we identified a number of concerns about the records kept by Jasmin Court. The issues identified did not protect people against the risks of unsafe or inappropriate care and treatment. A warning notice was issued following this inspection as the concerns were a continual breach of the associated regulation of the Health and Social Care Act 2008

To check compliance, we reviewed the care records of six people. We found that the standard of records throughout Jasmin Court had improved. The home had implemented new care planning documentation and we found that, for the most part, this better enabled the home to maintain accurate and up to date records of people’s health and social care needs.

During this inspection we identified that concerns noted about the flooring within corridor areas of the home during our inspection in April 2013 had not been adequately addressed. The uneven flooring and the provider’s failure to adequately address this, continued to present a risk of people, staff and visitors tripping or falling.

This inspection also included checking that improvements had been made to people's involvement in discussions about their care and treatment and people’s records.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

People were positive about the support they received. One person stated, “I’m happy here, I wouldn’t want to live anywhere else.”

We saw that people’s rooms were homely and personalised with their own belongings and found that appropriate checks had been undertaken to ensure the suitability and safety of the premises.

An effective recruitment process was in place to ensure that employees were of good character and held the necessary checks and qualifications to work at the home.

The training staff had received about the Mental Capacity Act 2005 (MCA) had not equipped them about the principles of the Act and how they would apply the MCA in their day to day practice.

We found that there was an appropriate system in place to gather, record and evaluate information about the quality and safety of care provided at Jasmin Court.

People were not protected against the risks of unsafe or inappropriate care and treatment due to some records containing a lack of proper information.

We looked at four care plans and found little information to indicate that people had consented and been involved in decisions about their care and treatment. We also found that assessments of people’s capacity to make decisions were not being undertaken in accordance with the Mental Capacity Act 2005.

People were positive about the care and treatment they received at Jasmin Court. We saw that the direct care provided at Jasmin Court was safe, appropriate and took people’s individual needs into account.

We found that Jasmin Court was clean and that staff were knowledgeable about how to control and prevent the spread of infection.

Our observations and conversations with people and staff demonstrated that people benefited from equipment that was used safely and met their needs.

We found that staff received a range of training courses as well as supervision and appraisal.

We found that whilst a policy and system was in place to investigate complaints, people were not always aware of this and that this was not always followed.

We identified a number of issues relating to the records in place at Jasmin Court. There was a lack of information within people’s records that could result in people not receiving appropriate care and treatment. We also found that the majority of the records reviewed during our inspection did not detail or reflect the care observed during our inspection.

We talked to one person who was given their tablets by the nurses, but kept their inhalers in their room. They said that they always got their tablets on time.

We spoke with seven people who lived at Jasmin Court in order to gain their experience of living at the home. One person told us, “it suits me living here, I love it, I couldn’t be happier.” Another person told us, “I get help when I need it, staff do what they can to the best of their ability”, and that “they all treat me nicely.” People also told us that they felt safe living at Jasmin Court. One stated, “staff watch without you realising. The care is extremely good. I’ve been here 2 ½ to 3 years and I’ve never seen a member of staff ill treat anyone, maybe a little short but that’s all.”

People were positive about food within the home. One person described the food as, “great” and said, “I always get two choices and if I don’t like them I can get a sandwich.” This person also appreciated the fact that the home always had their favourite flavour of ice-cream in stock.

People we spoke with were positive about the activities coordinator, the range of activities provided and their enjoyment of these. One person told us that they had enjoyed a trip to the pantomime. Another person told us that they enjoyed singing, music, playing dominoes, skittles and snakes and ladders.

We spoke with two relatives during our inspection. One relative said, “the staff are always pleasant to us as visitors, they are always caring.” Relatives were confident in the staff. They told us that staff were always available and that they always listened to, and acted upon, any concerns they may have had.

When we spoke with people using the service they told us staff were very respectful. One said, “I’d soon open my mouth if they weren’t. They’re excellent and always knock on the door before they come in.” Another said, “Yes, they knock on the door. Their attitude is really good and welcoming to visitors.” One person said, “Staff always knock on the door. Staff are good in how they speak to you, help you and do what they can.”

People told us they can get up and go to bed when they like and one told us they had been asked about whether they would like breakfast in their rooms. It was unclear about what their real preference was, but they did say they would like to go downstairs sooner, because they liked company.

Activities took place at the home, but some people didn’t know about this. One person using the service told us they enjoyed the activities and particularly liked the person who carried these out called John. They said he was very popular. They provided examples of the activities they took part in. This included a Chinese meal when it was the Chinese New Year. They said he’d arranged for a greenhouse for people to use. They said activities had lapsed more recently, because people had, had to spend time in their rooms, because of the lift being out of order and the floor being replaced.

Another person told us they had communion every Sunday. They told us the activities co-ordinator had changed and were doing extremely well.

Someone else also told us they went to church on Sunday, with their friend. They didn’t think they’d be able to go otherwise because they wouldn’t have the staff to do it. They said, “Activities aren’t every week, there’s sometimes bingo. I’m a Christian. Christ Church Choir come to the big lounge every month and sing for us.”

One said, “The lift was broken yesterday and it made it a long day. I was sat all day like this.” We saw there was nothing to occupy them in their room. There was no TV, radio or any books or magazines. They said, “We were all together the first couple of days I was here. They took us downstairs for activities and I sat and sat. I’d look at the floor and count to ten and then I’d look at the wall and count for ten, there was nowt else to do. I don’t know if the lifts broken today? I don’t know what’s happening today. I want to keep my brain occupied and going. I don’t know what there is to do. Not had a chat to know what’s on offer.”

We spoke with people using the service about the care provided and the routines in place. They said:

“Sometimes you have to wait too long for assistance, when they’re short staffed. It seems to be increasingly happening the last few weeks. I wet myself because of this, but it doesn’t happen often. I’d like to go down to the lounge after I’m dressed, but I have to be helped and the staff are busy.”

“It’s definitely not a rigid routine, flexible, call bells are regularly checked. Bedtime might be more rushed. It’s excellent. Can’t fault meals.” They told us their care plan had been done when they came in, but hadn’t been reviewed since. They weren’t aware if their relative had been involved.

“They (staff) put me to bed when I’m ready. I got up this morning when I wanted, between 7 and 8. I like to be up early.” They said they hadn’t seen their care plan, but they expected they would have one.

“You’re offered choices for breakfast – toast, cereals. I had porridge and they made it the way I like it.”

“I’m hoisted. The staff are nice when they hoist me. I had a bad night last night with a tummy upset. The night staff were marvellous. As soon as I rang that bell they came and sluiced me down. They kept me clean and didn’t leave me long. There’s lots of lifting and stretching for them but they were good and kept me marvellously clean.”

“I get myself up at 8am. I go downstairs for dinner if I can. I couldn’t yesterday because the lift didn’t work. I have varicose eczema. They dress my legs twice a week after my shower. They don’t ask if I want a shower, they tell me when I’m having one, it’s OK with me. There’s lovely meals. There are two choices for the mains and a pudding. I couldn’t go downstairs last week. They took the carpets up and were doing stuff to the floorboards. They found things. It lasted just over a week. I laid in bed and watched TV in my room. A lot of us can’t go downstairs if the lifts out of order.”

Another person told their relative they hadn’t had their hair brushed when they had been helped to get dressed that morning. Their relative did it for them.

We spoke with people about their medication. One told us they always get their medication on time, staff know the right tablets and doctors visit regularly.

One person said, “They bring it to me and I take it myself, I get it on time, I had it 10 minutes since.” This was 10.35.

We asked people using the service their opinions about the level of staffing. They said:

“You don’t have to wait long before they’re there.” Another, “They’re professional.”

“They don’t seem to have enough on in the day. They do what they can but they are always busy.”

“Staff treat me very well, they’d do anything for me. If I need anything I use the buzzer, but there’s often several going at the same time so they may be a few minutes.”

“They’re all very good, but it can vary when the buzzer gets answered.”

We asked people about the management of the service. They said:

“It’s well organised and well run.”

“Not really been here long enough to know. Just looks like they need more staff.’

“Chris the area manager is nice, he often comes and has a chat when he’s here. Felicitas is OK. She sent a letter about having my room decorated. I have a choice about floor and wall covering. I’ll move to another room when it’s being done.”

In regard to maintaining people’s privacy and dignity, people told us staff keep the doors and curtains closed while they are providing care.

People told us they can’t do as they want to at times. They said, “it’s not like your own home, there’s rules and regulations”. As examples, people told us you have to go get up and go to bed when staff say, because they’re busy. They said they wait to be taken downstairs after breakfast. Everyone goes downstairs then.

In respect of activities, some people told us they preferred to spend time on their own, in their own room, doing what they wanted to do and were able to do this.

For others, activities took place at the home. People enjoyed these and particularly liked the person who engaged with them called John. They said he was very popular. People told us it was John who provides the entertainment, but he was on holiday this week. They provided examples of the activities they took part in. These included keep fit and shows. One person said, “but some are never satisfied”.

Six out of eight people we spoke with had no complaints about the care provided and thought they were kept clean and were well cared for. People’s comments included:

“I find it very good. I’ve got a lot of friends. I’ve never been so happy. I’ve had a rotten life and it’s the best I’ve ever had. It’s luxury”.

“They know when to see to you. They don’t boss you about. They’re always coming to see if you’re alright”.

“I’m clean and well cared for. I’ve no complaints about the care”.

“It’s a very good service”.

One person told us they always make sure the buzzers are there. They said they didn’t have to wait long for assistance and staff are as quick as they can be. However, others said, “You send for them to go to the commode and they’re ages before they come”. Other comments about staff included, “It’s better when they’re not short staffed. Sometimes it’s ok, sometimes not. They have quite a few sisters (nurses) on”, “They’re always in a rush. They don’t listen to what you’ve got to say, before they’re gone” and "Staff don’t spend time talking. They seem to be rushed”.

The majority of people using the service told us they felt staff were very caring, considerate and they were all good to them. They said they were friendly and helpful. They told us they felt that staff knew what they were doing. One person said, “They’re sociable. We have a laugh”. Another said, “One’s lovely, but she’s not on this week. She really looks after me. You can’t complain really. Some are good, but some can’t get out of the room quick enough. Others talk to you like sergeant majors. Some snap your head off”.

Where people were not satisfied with the care provided, one was able to describe those reasons as:

“I was promised a bath four days ago and I’ve had one this morning, but I’ve had to fight for it. Every day they’ve (the care staff, not nurses) have kept saying something’s cropped up”. Three days ago they said they didn’t get a wash, because the same staff members that kept putting them off having a bath said they were coming back and didn’t.

They were a diabetic and should receive their breakfast earlier. Today it was 12 noon. The person told us this was because they had to get washed and dressed first. They said they didn’t want to complain.

They said you send for them to go to the commode and they’re ages before they come.

We inspected Jasmin Court on 12 and 13 October 2015. The inspection was unannounced. When we visited the home in September 2014 we identified concerns in relation to person-centred care, dignity and respect, safety and governance. A follow up inspection in December 2014 identified ongoing breaches. From 1 April 2015 the regulations changed. The breaches we had found in September and December 2014 correlated with regulation 9, care and treatment, regulation 10, dignity and respect, regulation 12, safety, and regulation 17, governance, of the Health and Social Care Act 2008 (regulated activities) regulations 2014.

We carried out a further inspection on 12 June 2015, where we identified concerns in relation to regulation 9, care and treatment, regulation 11, consent, regulation 17, governance and regulation 18, staffing, of the Health and Social Care Act 2008 (regulated activities) regulations 2014. We are undertaking enforcement action in relation to these breaches, and will report on this at a later date.

At this inspection we found that the provider had made some improvement and changes had been implemented which had reduced but not eliminated the level of risk on those people who used the service.

Jasmin Court provides personal and nursing care and is registered for 50 people. On the day of the inspection 25 people were receiving care services from the provider. The home had a manager who had been in post since January 2015. The manager had not registered with the Care Quality Commission (CQC). During our inspection we discussed the requirement of the manager to be registered. The manager had not understood the process of applying to register, but assured us that they would begin the registration process immediately. 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 this inspection we found that people who used this service were not always safe. Environmental risks such as uneven floors, which had been previously identified, had not been addressed. People with mobility difficulties, who required moving with a hoist, were supported to do so without the appropriate sling.

The care staff knew the people they were supporting and the choices they had made about their care and their lives. People who used the service and those who were important to them, were included in planning and agreeing to the care provided.

The decisions people made were respected. People were supported to maintain their independence and control over their lives. People received care from a team of staff who they knew and who knew them.

People were treated with kindness and respect. One person who used the service told us, “I like it here. Please don't send me anywhere else. This place is a proper community.”

The manager used safe recruitment systems to ensure that new staff were only employed if they were suitable to work in people’s homes. The staff employed by the service were aware of their responsibility to protect people from harm or abuse. They told us they would be confident reporting any concerns to a senior person in the service or to the local authority or CQC.

We observed the lunchtime on both days of our inspection. We found most people were supported with their dietary requirements. We found a varied, nutritious diet was provided. People we spoke with told us they enjoyed the food. However the experience could be improved, the service was very slow and on the second day one person had to ask for their meal as they were forgotten by staff.

The manager had introduced new systems to manage infection, prevention and control. There was an infection control lead in post and we found the standard of cleanliness throughout the service to be to a good standard. However, some improvements were still required to the environment.

The manager carried out regular audits of the service provided, and identified where areas for improvement were. However, the provider’s own audits of the service lacked robustness. We found that, where issues were identified, the manager did not increase the frequency of audits to ensure the service improved or was delivered safely.

We found staff approached people in a kind and caring way which encouraged people to express how and when they needed support. People we spoke with told us that they were able to make decisions about their care and how staff supported them to meet their needs.

Staff told us they felt supported and they could raise any concerns with the manager or the deputy and felt that they were listened to. Staff had received formal supervision. Qualified nursing staff told us they received clinical supervision. Annual appraisals had been scheduled by the manager. These ensured development and training to support staff to fulfil their roles and responsibilities was identified. We found at the time of our visit there were enough skilled and experienced staff to meet people’s needs.