About the service: Lower Farm Care Home with Nursing is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection the service was providing nursing and/or personal care to 39 people.

People’s experience of using this service:

Although the provider had made some improvements in Safe and Well-Led, these were not enough to ensure people always received safe and consistent care. Both key questions remain rated as Inadequate.

People were still not always fully protected from risk, particularly the risks posed by the environment. Where the provider had assessed risks, systems designed to monitor and manage these risks were not always robust.

Electronic and paper recording systems did not work in tandem and oversight of how people’s risks were being managed was not good.

Medicines were not always managed safely and this had the potential to place people at increased risk of harm.

The lack of effective auditing, alongside confusing records and poor assessment of risk, meant that concerns remained with regard to the safety and leadership of the service.

New systems to improve communication within the service required further development so that important information about people’s care was clear to all staff.

You can see what action we told the provider to take at the back of the full version of the report.

Rating at last inspection: At the last comprehensive inspection the service was rated Inadequate (report published 21 November 2018.)

Why we inspected: Following the last inspection we received an action plan outlining how the service would make the required changes to improve the service and to address the six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified during that inspection.

We carried out this inspection to check that the improvements with regard to the breaches of Regulations 12 (Safe Care and Treatment) and 17 (Good Governance) had been made and sustained. We had also received information of concern which led us to continue to question the safety of the service and the quality of the leadership.

Follow up: We have issued further requirement notices for breaches of regulation as a result of this inspection. We will require the provider to send us another action plan and will meet with the provider to discuss their failure to make the required improvements and to discuss how they plan to ensure significant improvements are made and maintained. Failure to achieve this will result in CQC considering a more robust regulatory response which may include a notice of proposal to cancel the service’s registration.

This inspection took place on 7 and 8 August and 5 September 2018. We carried out an unannounced inspection visit on 7 August out of hours, during the evening. This was done to help give us a more comprehensive picture of the service. At that visit we told the provider of our intention to carry out a daytime visit the following day on 8 August. The inspection visit on 5 September was unannounced and was carried out to gather further information following feedback from the local authority safeguarding team, the local clinical commissioning group and relatives.

Lower Farm Care Home with Nursing provides accommodation, support and care for up to 46 people, some of whom are living with dementia. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 40 people were using the service. Lower Farm is an adapted older building on three floors. The building is spread out and people have access to the ground floor areas via a lift. It is near King’s Lynn town centre but transport would be needed to access local facilities.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection, which was carried out on 8, 13 and 19 September 2017, we rated the service as Requires Improvement. During that inspection we identified breaches of Regulations 9, 11, 12, 14 and 18. These breaches related to person centred care, consent, safe care and treatment, nutrition and hydration and staffing. Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the all the key questions to at least good. At this inspection we found that, although the provider had made some improvements and introduced new systems, there were still some significant concerns about the management of risk and the leadership of the service. We have identified continued breaches of Regulations 9, 12 and 18 as well as additional breaches of Regulations 15, 17 and 20a. These new breaches relate to the suitability of the premises, leadership and a failure to display the CQC rating.

We could not be assured that medicines were always managed safely as stocktaking measures were not effective, medicines were not always in stock and medicines were not being stored safely. We also noted a medication error during our inspection.

Risks were not always well managed. Risks assessments were present in care records but the risks posed by an unfenced lake and doors which gave access onto a main road, had not been fully assessed and mitigated. Some risks had been noted at our previous inspection and the provider had not taken effective action to address them. Staffing levels meant sometimes people were left without staff support which increased any potential risks. Systems did not fully protect people from the risk of dehydration or of developing a pressure sore.

Staff understood their responsibilities with regard to keeping people safe from the risk of abuse and appropriate safeguarding referrals had been made. We noted a safeguarding matter during our inspection and this was referred to the local authority by the service.

Infection control procedures were in place but some staff practice placed people at potential risk and had not been addressed by the provider.

Staff received a comprehensive induction and the training they needed to carry out their roles. Staff felt well supported but information systems were not robust and did not ensure that staff always had all the information the

The inspection took place on 8, 13 and 19 September 2017. Each inspection visit was unannounced.

The service provides residential and nursing care for up to 46 people, some of whom are living with dementia. At the time of our inspection 34 people were using the service and two people were in hospital.

A registered manager was in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Archers Healthcare Limited had taken over this service in May 2017. The service had been rated Inadequate under the previous provider and placed into special measures following an inspection on 4 and 5 July 2016. This inspection was carried out to ensure that improvement had been made in the intervening period. CQC would usually give any new provider a longer period to address the issues we found but a number of complaints and safeguarding issues were raised with us and so we brought our inspection forward.

During this inspection we established that many of these issues, which were raised by relatives and by staff acting as whistleblowers, were not fully substantiated. However we did find evidence of a poor staff culture. This impacted negatively on the staff and in turn on the people who used the service. We found the provider and the registered manager to be dedicated to driving the improvements that the service required but questioned the intimidating management style of the provider.

We found the service had improved under the new provider but further improvements were required. It was encouraging that both the provider and the manager were already aware of many of the issues we raised and had tried to start tackling them. The provider had only been registered for a matter of weeks and had many areas of poor practice to address. This meant that our inspection was likely to see only the beginnings of a change and this was the case.

The manager and provider had worked hard to introduce new systems and procedures and to overhaul paperwork and staffing levels. Some areas had been more successful than others and we continued to have some significant concerns regarding the safety of the service. However we found the manager to be open and honest with us and had confidence that any issues raised in this report would be addressed as a priority.

Risks were assessed, documented in care plans and measures put in place to reduce them. However routine health and safety checks were not always undertaken and audit systems did not identify this. Where risks to people’s health and safety were identified action did not always follow to address this. The risks related to pressure care were not well managed. Staff practice with regard to the prevention and management of pressure ulcers was not always effective and records were not detailed and did not guide and inform staff.

Staffing levels, and the deployment of staff, were a concern for some people and had an impact on the timeliness of care provided. Measures had been put in place to review staffing levels and these were viewed positively by some people. Our observations were that, in particular on the third day of our inspection, staffing was not adequate and people did not receive the care they needed.

Staff were patient, caring and treated people with kindness. People’s dignity was occasionally compromised as staffing levels meant that staff did not always have the time they needed to provide care which met people’s needs promptly.

Medicines were managed safely and people received their medicines as prescribed. Staff were confident in the management of medicines and were knowledgeable about people’s healthcare conditions and the medicines they required to support them.

Infection control measures were in place and staff had an app