North Court Care Home provides accommodation, nursing and personal care for up to 65 older people some of whom may be living with dementia. At the time of our inspection there were 57 people using the service. The service is situated in the town of Bury St Edmunds in Suffolk. The home was arranged over two floors and offered nursing care based on people's particular needs and requirements.

North Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. This comprehensive inspection took place on 18 July 2018 and was unannounced.

There was a registered manager in post 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.

At our last comprehensive inspection in August 2017 we rated the home ‘Requires Improvement’ overall with three breaches of the Health and Social Care Act. We were concerned at that inspection that people who were living at the home were not protected because control measures identified in risk assessments were not consistently in place for people. We were also concerned that health interventions in relation to catheter care, wound management, diabetes and bowel monitoring were not best practice and not always safe and effective. Additionally, we had concerns about fire safety, the effectiveness of the call bell system and the management oversight to ensure compliance.

We recognised at this inspection that whilst improvements had been made some of these were ongoing and not yet fully implemented, sustained and embedded into practice. The recently recruited registered manager had made progress in a number of areas and was committed to improving standards across the home. We have rated the home ‘Requires Improvement’ overall again, however there were no breaches of the regulations at this inspection and the key question of ‘is the service Responsive?’ has improved to a ‘Good’ rating.

Risks to individuals were assessed but measures to mitigate risk were not always in place. For example; there was not effective monitoring of people’s fluid intake to protect them from the risk of dehydration.

Whilst there were sufficient staff to meet people’s needs there were not enough permanent staff working in the home, which meant there was a reliance on agency staff who were not always familiar with people’s needs. We have recommended the provider continue to closely monitor staffing levels.

There was mixed feedback about the food available however there was a consultation under way to make changes. Staff said people had access to health care professionals and there was evidence of the management of people's care between the staff and external professionals.

Staff received ongoing training to ensure they were able to meet people's needs safely. They understood their roles and responsibilities to protect people from the risk of avoidable harm, and people said they felt safe living at the home. Staff followed the provider's policies and procedures to ensure people were protected from the risks of infection.

At this inspection we found they had met their legal requirements. With the basic principles of the Mental Capacity Act 2005 had been followed to ensure people's rights were upheld. Deprivation of Liberty Safeguards applications had been made and the registered manager kept these under review. People's interests and preferences were identified and recorded.

Staff interactions with people were kind and caring. Staff spoke kindly and sensitively with people when suppo

This inspection took place on 7 August 2017 and was unannounced. The previous inspection on 24 and 25 January 2017 had highlighted breaches in the safe care of people and good governance. At this inspection we found a degree of progress to show that the service was moving in the right direction, but improvements were still to be made in these two areas.

North Court is located in the centre of Bury St Edmunds and provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. At the time of our inspection there were 46 people living at the service. 23 people living with dementia in their ground floor unit.

The service had a registered manager who was present for the inspection visit. 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 spoke highly of this service and told us of staff who were caring and kind. We observed some genuine caring relationships that were mutually valued. The majority of people told us that they experienced a good service and were satisfied. People were supported by sufficient staff that were appropriately trained. People were provided with a range of activities and opportunities facilitated by activity staff. This included daily time spent with individuals who were residing in bed.

The manager was receptive to feedback given on the day and has sent an action plan with plans to address matters raised in this report. Concerns were fedback in relation to healthcare and nursing support within the service. Specifically; diabetes monitoring and response was not always clear in care plans, catheter care was not always safe and the monitoring of people’s bowel movements was not effective for clinical intervention and wound care was not always safe. In addition records made of nursing interventions were in some cases illegible and placed people at potential risk.

Risks to individuals were assessed but measures to mitigate risk were not always in place. For example; systematic failure to protect one person from developing further pressure sores. Fire safety was not systematically robust. Also we questioned the effectiveness of the call bell system in place and have requested this be reviewed.

Medicines were not consistently managed in relation to out of date equipment, such as a syringe driver, and the safe use of creams. There were systems in place to respond to concerns and complaints, but these needed to be further developed as an opportunity to learn and improve the service. The Deprivation of Liberty Safeguards (DoLS) was understood by the registered manager. However reviews required in the authorisation were not in place.

The registered manager had quality monitoring processes in place but had not identified the concerns and breaches that we have identified, therefore these processes were not effective and need to be reviewed.

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

We carried out an unannounced comprehensive inspection of this service on 10 July 2016 and rated it as Requires Improvement. The service had previously been rated as Requires Improvement following an inspection on 13 April 2016. Prior to that inspection the service had been in Special Measures and rated Inadequate.

We were made aware of some concerns in December 2016 which related to the safety of the service and which was linked to a possible impact on people’s health. The local authority placed an embargo on new admissions to the service and we carried out this focussed inspection on 24 and 25 January to assess the safety of the service. This report only covers our findings in relation to people’s safety and welfare. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for North Court Care Home on our website at www.cqc.org.uk

This inspection took place on 24 and 25 January. The inspection visit on 24 January was unannounced but the provider was aware we would be returning the following day to complete our inspection.

The service provides accommodation and nursing care for up to 65 people, some of whom are living with dementia. At the time of our inspection 42 people were resident.

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.

This report specifically focuses on the key area of Safe with regard to keeping people safe from abuse, the management of risks to people’s health and safety, staffing levels, the skills and expertise of staff and the management of medicines.

Staff had received training related to keeping people safe. General risks to people’s health and safety such as fire and legionella bacteria had been assessed and action taken to minimise them. Fire systems and most equipment, such as moving and handling equipment, were checked to ensure they was safe to use but some medical equipment was found not to be fit for use at the time of our inspection.

The service was not managing risk well and staff’s poor recording and lack of skills placed people at risk of harm. There were particular concerns related to the management of pressure care, moving and handling, eating and drinking, catheter care and falls. Staff understanding and knowledge was not always clear and records throughout the service, although plentiful, did not provide sufficient guidance for staff and did not accurately record care given. This made it difficult to assess if people had received the care they needed to keep them safe. Given that we found incidences of people who had lost weight and people with pressure sores developing we concluded that care was not always being delivered as required. New nursing staff had also identified some of the issues we were concerned about and had already begun to address these which gave us some reassurance.

Medicines were mostly well managed and people received their medicines within an appropriate timeframe. However, medicines delivered via a patch were not applied in line with manufacturer’s recommendations. This placed people at potential risk of harm. Some records related to medicines administration were not in place or were not accurately completed. The provider had not followed their own policy for determining whether covert administration of medicines was appropriate.

There were systems in place which were designed to protect people from the risk of abuse. Staff had received training in keeping people safe from abuse and suspected safeguarding concerns had been referred to the local authority adult protection team to investigate. Concerns raised during this inspection were not promptly referred.

Staffing levels enabled people to ha

The inspection took place on the 10 June 2016 and was announced. The purpose of this inspection was to follow up on the compliance actions identified at the last inspection on the 13 April 2016. The service was initially inspected and placed in special measures on the 11 and 16 November 2015. This meant we had significant concerns about the service and judged it to be providing inadequate care for people using the service. As well as identifying a number of breaches of regulation, we also placed a condition on the services registration. This meant they were not able to admit anyone else to the service until we were satisfied they were able to provide a safe service which could effectively meet people’s needs. We have communicated with the Local Authority who have followed up on individual safeguarding concerns and have been instrumental in supporting the service to improve.

We have since the inspection of November 2015, met with the provider several times and received updated action plans. We inspected in April 2016, as the provider said they were confident that they had made considerable improvements. Our findings following this inspection indicated that there were still concerns. This inspection was undertaken on the 10 June 2016 and had advised the provider of this date a day in advance, as we felt it essential that the manager and Regional manager should be present so we could establish what changes had been made. We found that the service had improved and there were no longer breaches of regulation

The service is registered for up to 65 people who might have a nursing need and, or living with dementia. On the day of our most recent inspection there were 34 people using the service.

Following our inspection in November 2015, the registered manager resigned and a temporary manager has been in post since then. They have recently applied to be registered as manager with the CQC and were successful.

‘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 our inspection on the 10 June 2016 we found: People’s needs were assessed and staffed accordingly. There were enough staff to deliver effective care and continuity was being maintained. However high staff vacancies could potentially threaten the stability of the service.

Medicines were usually administered as prescribed but we identified a number of gaps on the medication recording sheet and a number of occasions where people did not get their medicines as prescribed. We have made a recommendation around more effective medicine auditing.

Risks were mostly managed well but we identified a number of issues around records and these not always reflecting current practice. Risks associated with long term conditions and poor health status were not always clearly documented or records showing how these were being monitored.

Staff had a good understanding of how to report concerns and safeguard people in their care as far as reasonably possible.

Staff recruitment was robust at the last inspection so was not inspected again.

Staff were being supported through a robust programme of training, support and direct observation. New staff were being supported through a detailed induction and where possible staff were encouraged to undertake additional qualifications in care. There was a notable shift in culture and practice but some of these changes would take a while to become embedded.

People were supported to eat and drink according to their preferences. There were systems in place to monitor what people were eating and drinking but this could be strengthened by clearer records and a clear concise evaluation. We have made a recommendation about this.

People’s health care needs were do

We last inspected this service on the 11 and 16 November 2015 and found the service was failing to meet the required standards. At the time of this inspection in November 2015 there was a registered manager in post.

The inspection in November 2015 was planned as a responsive inspection because of concerns received about the safety and well- being of people using the service.. During our November inspection we found wide spread failings and breaches of a number of the regulations.

We rated the service as inadequate and put the service in special measures which meant the service was given a specific period of time to improve We also took enforcement action to ensure to restrict further admissions to the service until such a time we had judged them to be providing safe care.

Following the inspection in November 2015 we met with the Regional manager and Registered manager to discuss our concerns. We have also communicated our concerns with the Local Authority so they could continue to support the service to improve. Following this inspection in November, the service sent their action plans stating what they had already done and what they were going to do to improve the service. They told us when they expected to have addressed all of the concerns identified.

We carried out this inspection on 13 April 2016. At the time of our inspection the Registered Manager was no longer working at the service. The provider had acted swiftly to appoint a new manager who came into post in February 2016. The provider also appointed a deputy manager and had a member of staff working as clinical lead in an administrative role. This new team are starting to establish good practices within the service but it is too early to judge the effectiveness of this. The manager has put in an application to be registered with the Care Quality Commission which will be processed in line with expectations.

At this inspection in April 2016 we found that staff knew how to raise concerns and protect people as far as possible from avoidable harm or poor care and treatment. A number of staff had raised concerns previously but felt their concerns had not been listened too but were more confident in the current management and response from the organisation.

Risks to people’s health and safety were not always clearly documented and we found variable practice within the home. We identified hazards to people’s safety and in particular poor monitoring and poor infection control. We also identified improvements were required in the way people received their medicines. Records relating to this required improvement.

Staffing levels had improved and the considerable staff vacancies reduced. We were not fully confident about the skills mix and competencies of all the staff due to poor past supervision and monitoring of staffs practice and lack of clarity around roles and responsibilities. Staff shortages also occurred occasionally. The impact of this was that people did not always receive the care according to their expressed wishes.

Staff felt well supported through induction, training and monitoring of their performance which will take a while to embed.

Support people received at lunch time varied and people did not always receive adequate monitoring of what they were eating and drinking and if it was appropriate to their needs. Some of this was due to poor record keeping and not all staff being fully aware of people’s needs.

Peoples health care needs were not always adequately monitored so staff could respond appropriately for reasons cited above.

The service supported people appropriately and worked in accordance with the legal requirements in terms of their capacity. Staff did not always provide information in a way which enabled people to make an appropriate choice.

The staff were caring and care practices had improved with people receiving care which was more responsive to their individual needs.

Consultation with people using the service was improving an

We carried out an inspection on the 3 February 2015. At the previous inspection on the 8 August 2014 we found the service compliant with the outcomes inspected and found the new registered manager had made some significant improvements following concerns with this service in the previous year.

The home is a nursing and residential home which can accommodate up to 65 people. It is divided into three separate units to accommodate people with differing needs. The home accommodates some people that have a dementia.

The home had a registered manager 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were kept as safe as possible because individual risk assessments were in place for any identified risk to people’s health and safety, such as risk of falls or developing pressure sores. These assessments were kept under review and showed what actions staff were taking to minimise risks to people.

Medicines were administered by staff who were trained to do this competently. Audits were completed to check that medicines were appropriately stored, kept at the right temperature and there were adequate stock so people could receive their medicines as required.

There were enough staff to meet people’s needs and this was kept under review to ensure any change to people’s needs was recognised and staffing levels could be reviewed accordingly. This ensured people’s needs were met in a timely way and people’s health and welfare was promoted.

Staff knew what steps to take if they though a person was at risk from abuse or intentional harm. Staff were provided with training to help them recognise abuse and policies and procedures told staff what actions they should take. This helped promote people’s safety.

Staff had the necessary skills, experience and support to meet people’s needs effectively and help people make decisions about their care and welfare. Where a person was assessed as lacking capacity to make decisions about their care and welfare, staff acted lawfully to ensure decisions were made in their best interest and were properly recorded.

People were not fully supported to eat or drink enough for their needs. People’s records did not always show us how staff ensured people were adequately nourished. This meant we could not be assured people were always adequately nourished or protected from unintentional weight loss. This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of this report.

People needs were assessed before admission to the home and a care plan was put in place and told staff what people’s needs were and how they should be met. People’s needs were kept under review to ensure any actions identified remained appropriate and to ensure people’s health and welfare was promoted. Care plans included information about how people’s health care needs were monitored and met by multiple agencies as required. They also told us how people were provided with occupation to keep them active through planned one to one and group activities which provided people with mental stimulation and helped reduce social isolation.

Staff were kind, caring and met people’s emotional needs. They were aware of people’s individual needs and provided care to people based on their expressed wishes and preferences. They were respectful and provided care which was dignified and enhanced people’s privacy, and independence.

The home had an effective complaints procedure and took into account the views of people who used the service to help them improve the service.

The home was well led with systems in place to assess and evaluate the effectiveness of the service delivery and to assess risks to people’s care and welfare so these could be reduced. However we identified concerns around the monitoring of people food and fluid intake and this specific area requires improvement. There was a positive ethos in the home and it was run in the interest of people using the service.

We inspected this service on the 8 August 2014 to follow up areas of concern identified at a previous inspection on the 1 May 2014. The service had sent us their action plan, telling us what action they where taking to become compliant in the areas were we had concerns.

During our inspection on 8 August 2014 we found that the service had made the improvements we had asked them to.

During this inspection we were met by the manager who was not yet registered with the Care Quality Commission as they were relatively new in post. The manager told us that they had started the process to become registered with us. We also met the Area Manager.

During our inspection we spoke with 5 people who used the service, two people’s relatives and observed the care on both the ground and first floor. We looked at six people’s care plans and other associated care records. We also looked at staffing records, quality audits and health and safety records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

The entrance of the building was secure and staff checked our identity. People were free to move about but a key code system gave people additional security. We saw that a number of people had door sensors which would alert staff as to when people were mobile and at an increased risk of falls.

People received adequate supervision from staff and records showed us that people were regularly checked to ensure they were safe.

Staff had received training in safeguarding vulnerable adults from abuse, the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were provided with the information that they needed to recognise and report concerns so that people were protected from abuse as far as possible.

The environment was well maintained and free from offensive odours. We noted a carpet that needed replacing during our previous inspection of 1 May 2014, it had been replaced.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that the records had been reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met.

We saw that staffing levels were being maintained in accordance with people’s assessed needs which meant staff were able to meet people’s needs. The service had taken action to address our concerns that the service was failing to meet people’s social needs at our previous inspection. An activities person had been appointed, had set up a schedule of activities, begun to talk to people independently about their preferences, and had produced a newsletter.

Is the service caring?

The staff interactions we observed were kind and we found staff responded appropriately to people’s requests and needs. We spoke with some relatives, one told us, “The staff are so good and helpful.” Another said, “They (the service) care about me as well as (their relative).”

Is the service responsive?

We saw call bells were answered promptly and people’s needs were responded to quickly. We observed lunch and saw that most people received the support they needed in a timely way and staff did not outpace people when supporting them with their meals. The staff team appeared relaxed and frequently interacted with people, even when just passing through communal lounges they would stop and acknowledge people in an appropriate manner.

Is the service well led?

The manager who was new at our previous inspection on 1 May 2014, has now become ‘bedded in’ and had made themselves known to all the people who used the service and their relatives by arranging relative and resident meetings and spending time with people. One person’s relative told us, “The manager is like a breath of fresh air, so open and friendly.”

The manager no longer covered shifts unless it could not be avoided or by choice so that they could ‘keep their hand in’, which they did occasionally.

We saw the service's records which related to infection control and the maintenance of equipment, such as lifting equipment. We found that all the records we looked at relevant to the management of the service were accurate and up to date.

We saw that complaints were dealt with effectively and recorded in line with the provider’s complaints policy. However, there was one complaint that was still being dealt with and had also been referred to us, the Care Quality Commission. We will continue to monitor this complaint to its conclusion.

The manager ensured that staff were appropriately supported throughout their shift and that they received regular supervision of their practice and annual appraisals.

There were regular audits of the quality of the service and the care provided to people. This meant there were systems in place to identify where the service was meeting regulation and where it needed to improve. We saw that audits took place across the day and night shift which enabled the manager to see the service provided over a 24 hour period.

We inspected the service on the 1 May 2014 to follow up areas of concern identified at a previous inspection on the 9 October 2013. During this inspection we were met by the manager who was not yet registered with the Care Quality Commission as they were new in post. We also met the Area Manager who was also new to the role.

During our inspection we spoke with 14 people who used the service, three relatives, six staff members and observed the care on both the ground and first floor. We looked at six care plans and other associated care records. We also looked at staffing records quality audits and health and safety records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is the summary of what we found:

Is the service safe?

The entrance of the building was secure and staff checked our identity. People were free to move about but a key code system gave people additional security. We saw that a number of people had door sensors which would alert staff as to when people were mobile and at an increased risk of falls. We saw that call bells were in people’s reach and answered promptly by staff. People received adequate supervision from staff and records showed us people were regularly checked to ensure they were safe. We saw that staff worked closely with the falls prevention coordinator and records showed very few recorded falls in the last few months which meant the staff were taking necessary action to keep people safe.

Staff had received training in safeguarding vulnerable adults from abuse and the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were provided with the information that they needed to recognise and report concerns so that people were protected from abuse as far as possible.

The environment was well maintained and we saw a schedule of maintenance which ensured equipment was in good working order and fit for purpose. Staff were employed in sufficient numbers to ensure the building was hygienic and the risk of infection was kept at a minimum. We observed staff wearing personal protective clothing as appropriate and we saw daily, weekly and monthly cleaning schedules were in place. We noted one carpet which needed replacing urgently because of a strong smell of urine. We told the manager about this.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that the records had been reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met.

We saw that staffing levels were being maintained in accordance with people’s assessed needs which meant staff were able to meet people’s needs. However the service was failing to meet people’s social needs. The activities person had left in February 2014 and had yet to be replaced. This left people with little or no opportunities to have support to engage in social activities and hobbies?

Is the service caring?

The interactions we observed by staff were kind and we found staff responded appropriately to people’s requests and needs. We spoke with some relatives, one told us, and “The staff are smashing.” Another said, “My family member’s needs are met by staff.”

Is the service responsive?

We saw call bells were answered quickly and people’s needs were responded to quickly. We observed lunch and saw that most people received the support they needed in a timely way and staff did not outpace people when supporting them with their meals. The staff team appeared relaxed and frequently interacted with people, even when just passing through communal lounges they would stop and acknowledge people in an appropriate manner.

People were supported to see other professionals such as general practitioner, community dentist, chiropodist, optician, and district nurse. This showed that people’s general health care needs were considered and that the service was responsive to people’s changing needs.

Is the service well led?

The service was fully staffed and staff told us that staff sickness and shift vacancies were managed well? The manager would use bank staff to cover shifts but we were concerned that the manager was also covering shifts which meant that they had not had the time to implement some of the changes they wanted to introduce to improve the service.

The manager was ensuring that staff were appropriately supported throughout their shift and was in the process of ensuring they received regular supervision of their practice and annual appraisals. We saw evidence that not all staff had received a recent supervision which meant we could not be assured that all staff were properly supported.

There were regular audits of the quality of the service and audits on the care provided to people. This meant there were systems in place to identify where the service was meeting regulation and where it needed to improve. We saw that audits took place across the day and night shift which enabled the manager to see the service provided over a 24 hour period. We saw poor consultation with people using the service. The annual questionnaire sent out to people and, or their families had a very low response rate of 4% and we could not see what others ways the service were actively engaging people or seeking their views about the service. The provider told us they planned to hold resident/relatives meetings every other month but no meetings had been held in recent months and there were no planned forthcoming dates. The manager told us six monthly reviews would be held to review people’s needs but we did not see a schedule of planned reviews or evidence of six monthly reviews in people’s care plans.

This inspection was conducted to follow up enforcement action taken in April 2013. The service submitted an action plan which cited actions that would be implemented to improve how people were treated to ensure that they were treated with dignity and respect.

We found that the service had improved since our visit in April 2013. We observed some good interactions between staff and people who used the service. We observed some instances of staff kindness and caring ability to support people. We also observed that staff did not interact positively with some people using the service upstairs and that some staff talked about people in front of them and shouted over their heads. Some staff demonstrated a lack of understanding around ensuring the dignity of people living with dementia.

We noted that there had been a change in leadership within the service and the team working at the service including an area manager, peripatetic manager and new home manager were working to ensure the required improvements are made. This showed that the provider was taking concerns raised by the Commission seriously and was acting to improve the quality of the service provided.

As part of this inspection we looked at the medicine administration records for 15 people. We saw appropriate arrangements were in place for recording the administration of medicines. These records were clear and fully completed .The records showed people were getting their medicines when they needed them, as they were prescribed.

We saw the provider did regular audits to check the administration of medicines was being recorded correctly. We saw the provider did daily checks on the stock levels of medicines. Records showed any concerns were highlighted and action taken.

We spoke with nine relatives of people using the service. One relative told us, "Nursing staff are gentle with my relative and they understand their needs. Sometimes there is a language barrier as many staff do not speak English as a first language." Another relative told us, "Some carers are better than others. They seem to be in a constant state of hurry." A third relative said, "Staff do not really have time to interact with my relative on a one to one basis. [My relative] cannot understand what some of the staff say. Some of the staff are abrupt with my relative."

We observed that staff did not interact positively with some people using the service and that staff talked about people in front of them and shouted over their heads. Some staff demonstrated a lack of understanding around ensuring the dignity of people with dementia. We saw that procedures to ensure that people were restrained appropriately had not been followed and we have reported this to the local authority safeguard team.

We saw that some people with diabetes did not always have their care needs assessed or appropriately treated. People's skin integrity had been risk assessed but preventative equipment was not always in place to mitigate the identified risks. Nursing staff had not received up to date training around tissue viability and diabetes.

Where areas of non-compliance have been identified during inspection they are being followed up and we will report on any action when it is complete.

At our last inspection we found that some staff had concerns about the adequacy of staffing levels during the day time and particularly at night. The risks were increased due to the complex needs of some people using the service. Some staff told us that here had been instances where staff sickness had not been covered.

At our return inspection, the manager told us that they have now recruited additional staff. We saw the rotas for the past two months and these showed that staffing levels had been adequate. We spoke with four members of staff who confirmed that additional staff had been brought in and that staffing levels were sufficient. The manager told us that they were carrying out a workforce planning assessment to decide future staffing levels.

We spoke with people using the service throughout our inspection on 3 July 2012. We also spoke with five relatives by telephone.

Comments received were generally positive about the quality of service provided. Three people using the service told us that they felt safe and that the food was good. Another person responded positively to our questions about care provided by the staff.

We spoke to five relatives by telephone. Three stated that they were happy with the care their relative received, for example “Staff communicate any problems to me promptly and they seem to know my relative well. When I visit, my relative tends to be in the lounge watching television and they are usually calm. It would be good if they could have more interaction and activities.”

Two people expressed some concerns, “My relative rarely leaves their room. I feel that they would benefit from being able to access a communal area.”

Another relative told us, “Cleaning has become an issue of late and there is often an overpowering smell of urine when I visit. I think that personal care could be better. Many staff, especially at night, do not speak English as a first language which, I feel, can be confusing for people living with dementia. Staff seem very rushed and do not have time to spend interacting with people who use the service.”

During this review, we have visited this service on three occasions to assess their compliance against the essential standards. Originally, we went to the home in response to someone raising concerns with us anonymously. However, we did not find any evidence to substantiate these concerns.

The people living in North Court and their family members told us that they liked living there, that the care staff showed them respect and worked hard to look after them. They also told us that they were comfortable in the home.

We carried out this comprehensive inspection on the 11 and 16 November 2015 and this was unannounced. The purpose of this inspection was to follow up on a number of safeguarding concerns received about people’s experiences of poor care and people not being supported adequately with their nutrition and hydration which placed people at risk.

Following our previous inspection in February 2015 we asked the provider to take action to make improvements as we found evidence of concern that people were not sufficiently supported with their nutrition and hydration needs.

During this inspection the provider continued not to protect people from the risks associated with inadequate nutrition and hydration.

Following the inspection we took action to restrict admissions until they had addressed the issues we identified. We also made a number of referrals to the adult safeguarding team which are currently being reviewed.

The service provides accommodation both residential and nursing care for up to 65 people who may or may not be living with dementia. The service has a registered 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.

During our inspections we identified differential care practices on the two floors with no effective monitoring of staff practice. We saw there were enough staff to deliver the care but this was not always the case and there was a reliance on agency staff. New staff had been appointed but induction processes were poor and staff shadowing new staff did not have the necessary competence and skills.

Risks to people’s health and safety were not fully documented and records were difficult to follow and people’s needs were not fully understood by all staff.

The home was not clean and there was a high risk of cross contamination.

Medication practices were good but records did not always show medicines had been reviewed, or give enough information about individual medicines prescribed.

Staff recruitment was satisfactory but once staff were employed there was little support or monitoring of their practice. Staff training was not adequate and there was no assessment of staff competencies. Staff did not have the necessary skills and there was poor leadership.

People were not supported to eat and drink enough. Poor records and poor evaluation of records made it difficult to see how people were adequately supported with their eating and drinking.

Similarly people’s health care needs were not always adequately recorded or documented.

Staff had not received or did not have sufficient understanding of the Mental Capacity Act 2015 and people were not adequately supported or consulted about their care needs.

We saw elements of caring practice but poor staff practice was left unchecked and staff were not clear about what the expectations were and their practices were not effectively monitored. There was no clear leadership or clear lines of accountability which resulted in variable staff practice. People were not always treated with respect or their right to choose respected.

Care plans were not written in line with people’s individual preferences and wishes and records were difficult to navigate through. Staff did not use records effectively to help them know what people’s needs were or how they could best meet them. People physical needs were met but there was not enough stimulation for people or recognition or promoting peoples’ emotional and psychological well- being.

Complaints were not always recorded so we do not know if actions taken were always proportionate or helped improve the service.

Quality assurance and clinical governance arrangements were inadequate and did not demonstrate how they improved the service or took into account peoples experiences of care.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we have told the provider to take at the back of the full version of this report. The overall rating for this provider 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. • Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the

Service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the

service by adopting our proposal to vary the provider’s registration to remove this location or cancel the Provider’s registration.