This comprehensive inspection took place on 25 July 2018 and was unannounced. Old Shenfield Place 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. Old Shenfield Place provides accommodation and personal care for up to 31 older people. There were 17 people living at the service at the time of our inspection. The service is registered to provide nursing care but on the day of inspection there was not anyone assessed as requiring nursing care.

A manager was in post that had completed an application to register, this was confirmed during this inspection process. 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 the last comprehensive inspection on 21 March 2017 the overall rating of the service was, Requires improvement. We found that there were three breaches of the regulations. This was because there were shortfalls in the arrangements that had been made to provide people with safe care and treatment. Risks to people were not always reflective of their current care needs, insufficient numbers of skilled staff were deployed to ensure people's needs were met at all times, and systems to assess, monitor and improve the quality and safety of the services were not effective.

We told the provider to send us an action plan stating what improvements they intended to make to address our concerns. After the inspection the provider told us that they had made the necessary improvements.

Whilst we found improvements had taken place in some areas, people remained at risk of unsafe care and treatment and the provider had not done enough to mitigate these risks. The rating of the key questions, is the service safe and is the service well-led, as well as the overall rating for this service, remains requires improvement.

During this inspection, we found the registered manager had not communicated with us openly or taken appropriate action to ensure that medicine errors reported to them had been dealt with in a timely manner.

This was a continued breach of Regulation 17 good governance.

At the last inspection on 21 March 2017 we found that people's risk assessments were not always reflective of their current risks and did not guide staff on how to care for people. At this inspection we found the provider had made the necessary improvements and risks to people were now well managed.

There were enough staff deployed to work in the service who had been suitably recruited. Training was available for staff to ensure they had the skills and knowledge to provide effective care for people. Staff had received regular supervision and appraisals. The registered manager now had a good oversight of training and supervision.

There were procedures for safeguarding people from abuse and the provider worked with other organisations to investigate and respond to allegations of abuse.

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 gave us positive feedback about the quality of the food. They were provided with sufficient food and drink.

People received support from caring staff who gave people time to make choices and decisions. Staff treated people with dignity and respect. People were supported to maintain their independence. Relatives and visitors were made welcome at the service by staff who knew them.

People received care that met their preferences. People's past lives, cultural and diverse needs were assessed and

The inspection was completed on 21 March 2017 and was unannounced.

Old Shenfield Place provides accommodation and personal care for up to 31 older people. There were 24 people living at the service at the time of our inspection. The service is registered to provide nursing care but on the day of inspection there was not anyone assessed as requiring nursing care.

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.

Staff understood the principles of keeping people safe, but in practice these had not been followed. We found some risk assessments in place to meet their needs, but for some people relevant risk assessments were not found or up to date. This meant there were risks associated with people's care which staff were not aware of.

Staff told us they did not think there were always sufficient numbers of staff on shift to meet people’s needs in a timely way. There were mixed views on staffing from people using the service. Some told us there were not enough staff and this would mean they would have to wait for support at times.

Care staff had not all had the training required, and staff had not received regular supervision of their conduct or practise.

There were quality assurance processes in place to monitor the quality of the service and to make improvements however, these were not sufficiently robust to make sure all shortfalls were identified promptly. The manager had been working to an action plan, which did not provide sufficient detail of any remedial actions taken.

Care plans were in the process of being updated and reviewed however some of the information in people's care records lacked detail. People's healthcare needs were monitored and advice and guidance was sought from healthcare professionals when needed.

Although the manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS), some staff had a limited understanding of the MCA and DoLS.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns.

People were supported to eat and drink sufficient amounts to meet their nutritional needs. People were able to choose alternative meal options if they did not like the choices offered on the daily menus.

People were treated with dignity and respect by caring staff. Staff knew the people they were supporting well. Although staff reviewed peoples care plans, sometimes they were not up to date or did not contain sufficient information about people's needs to be reliable for staff to follow when providing care.

An activities co-ordinator was in post who offered a range of activities to people through the activities programme in place.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of this report.