This unannounced inspection took place on 01 December 2015. Ramsay Manor is registered to provide accommodation and personal care for 84 people, there were 18 older people living in the service when we inspected.

Ramsay manor was placed into ‘Special measures’ by CQC following the last inspection in April 2015 as they were not meeting the legal requirements. 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.

Following the last inspection the provider had sent us a detailed action plan which set out what they intended to do to meet the legal requirements. At this inspection we found that some improvements had been made but the provider had not achieved all that they said that they would do. We found that some actions had not been undertaken as planned and others had not been fully implemented. The service did not meet all the legal requirements for the 18 people currently living in the service. We were told that the provider was planning to admit more people and have concerns about the impact of increased numbers on the people already living at the service and the quality of care.

Since the last inspection a new manager has been appointed and has taken up post. They told us that they had applied to CQC to be registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that the service was only partly open; areas of the building were closed to people and staff as a refurbishment was underway. At the last inspection we found that the layout of the service and the on call system did not promote peoples independence or wellbeing. We found continued problems in these areas. The building also presented significant challenges in terms of staffing due to its size and layout. We found that staff were not always deployed effectively and people had to wait for assistance.

Safety checks were completed but the risk assessments processes were not always effective. We were concerned that the lack of clarity around moving and handling processes could lead to a risk of injury.

Medication was not safely managed. We found issues with the storage and the administration of medication. People did not always receive their pain relief as prescribed.

Since the last inspection significant recruitment had taken place and we found that the provider operated a safe and effective recruitment system. New staff however did not receive a comprehensive induction. Staff knew what abuse was and although they were not all clear about the role of the local authority they knew that concerns should be reported.

We saw that staff were supported to access ongoing training but their understanding of the subject and competency was not accessed. We identified shortfalls in staff understanding of consent, medication and moving and handling. The guidance for staff to follow to meet people’s health needs was not always clear.

People enjoyed their food and received a varied choice of nutritional meals. Support was available for those who needed it

Staff were caring and treated people with kindness. However people’s involvement in decision making was inconsistent. Dignity was not always well understood.

Care plans were in place but they were not always easy to use. This combined with the high numbers of new staff meant that people were at risk of not having their needs and preferences met.

Activities were being undertaken which was a positive development. However further efforts should be made to ensure that they are accessible to all the people living in the service, including those people with a diagnosis of dementia.

The new manager was being supported by an independent consultant and staff were largely positive about the changes that had taken place. Some efforts had been made to consult with people but audits were not well developed. The concerns which were identified at this inspection had not been identified by the registered person

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

Below is a summary of what we found during our inspection. The summary is based on our observations during the inspection. During the inspection we were supported by an 'Expert by Experience' (ExE). This is a person who has specific experience of dementia, we were also supported by two bank inspectors. We spoke with and spent time with people using the service. We spoke with six staff supporting people and the manager of the service. We also spoke with some people's relatives.

We looked at number eight people's care records. Other records viewed included staff training records and rotas, health and safety checks and staff and resident meeting minutes.

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 a summary of what we found;

Is it safe?

We found that people were not being supported in an environment that was safe, stimulating and homely. We found a number of environmental risk areas that we felt posed a risk to both people receiving the service as well as others.

We found that the service was not taking action to protect people from the risks of developing pressure areas. For example, we found that for one person whose records we reviewed, care planning for the prevention of pressure areas was not being followed by staff.

Care staff working in the service did not have access to sufficient information to provide safe and appropriate care to people. Care planning was not up to date, and for three people whose records we reviewed, did not accurately document their current care needs.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service was aware of new changes in the law with regard to DoLS. Where applications had needed to be submitted, appropriate actions had been taken to safeguard people's rights. Relevant staff had been trained to understand when an application should be made and how to submit one.

Is the service caring?

We found that staff always treated people in a caring and respectful manner. We saw that staff tried to work in a manner which did take into account people’s individual needs.

Is the service responsive?

We saw that staff consulted with people and offered them choices in their daily lives. People's choices were taken in to account and listened to.

We saw that staff were responsive to people's changing wishes and needs and supported them well.

People told us that they felt able to raise any issues they might have and felt that the service would act upon their concerns.

Is it effective?

Staff working in the service were supported through induction, on-going training and supervision to offer people care and support to meet their needs. Staff were positive about their role and felt that teamwork in the service was good.

We found that the service did not have an effective process in place to identify risk? particularly relating to the environment and put these right to protect people from harm. There were other systems in place for auditing the quality of the care delivered to people.

Is it well-led?

When we arrived at the service our identification was checked and we were asked to sign in the visitor's book. This meant that appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service and that they would speak with the staff if they had concerns. People had the opportunity to express their views about the service through meetings and one to one discussions.

Staff allocation systems ensured that they were accountable and that practice could be monitored. Staff also had lead areas to monitor practice in aspects such as health and safety and infection control.

Service reviews had not picked up the environmental issues that have been reported on elsewhere in this report. This meant that the service did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of the people who used the service and others.

As part of the inspection we checked on standards that were not met at our last inspection in April 2013. These related to care and welfare, supporting workers and assessing and monitoring the quality of the service. At this inspection we found that the provider had made considerable improvements in these standards and we found that they were now met. We did not speak with people living in the home during this follow-up inspection.

We had conversations with four people living in the home and one relative who was visiting at the time of our inspection. A relative of a person who was recently deceased was full of praise for the end of life care that their relative had received, describing it as “excellent”. The four people we spoke with told us that they were happy in the home and found the staff “very helpful”. Although two people were happy with the food, one person described it as “average” and another person said: “The food has deteriorated.” There was evidence, however, that staff tried to meet people’s individual dietary needs and preferences.

As part of this inspection we checked on the standards that were not met at our last inspection in June 2012. These related to staff training and record keeping. We found that the provider had an appropriate range of records in place, therefore we judged this standard was now met. However, the care plans and risk assessments were not being kept up to date following changes in people’s medical condition and care needs. This meant that staff would not be able to use the records to plan and provide a consistent standard of care.

We found that there were still gaps in staff training, which meant that the people living in the home could not always be assured that their needs would be met by appropriately trained staff. The service had a quality assurance programme but greater analysis was needed for it to be fully effective.

During our inspection we had conversations of various lengths with six people living in the home and with two relatives who were visiting at the time of our inspection. The majority of people we spoke with felt well supported and were very complimentary about the staff. People were generally positive about the choices on the menu and the quality of the food. One person described the food as “excellent”.

A person told us “The home has improved a lot since they (the current owners) took over.” Another person said “It’s a wonderful home, it must be one of the best in Essex.” A relative described “very positive” staff interactions with people in the home and said that care was matched to individual needs. Another relative told us “The staff are absolutely fantastic. X is doing really well in the home.”

We did not speak with anyone who uses the service about the way their medicines are managed.

We carried out an unannounced inspection at Ramsay Manor on 29 February 2012 in order to follow up concerns identified at our last inspection, on 23 November 2011, and to follow up safeguarding concerns raised since our last inspection.

During our inspection we had conversations of various lengths with five people living in the home and with one relative who was visiting at the time of our inspection. People told us that they were very concerned about the frequent changes of staff over the past few months. They were particularly unhappy about the fact that six staff from Ramsay Manor had been swapped with six staff from other Southend Care homes and they had not been consulted about the moves. One person said “They didn’t tell us that these staff were coming here.” Another person told us “These new staff work differently and changed the routine without telling us.”

A relative told us that they were “very happy” with the care provided. People we spoke with were generally satisfied with the standards of care but considered that staff did not always give them genuine choices. One person told us “I get up when they come and get me up and that’s it. They take it for granted that I’m going to get up.” People said that staff were sometimes “rushed” and did not check up on them regularly when they were in their rooms. One person told us “The carers don’t come in and have a few words like they did before, to check that you’re all right.” Another person said “The staff are always very nice but they haven’t got a lot of time and we sometimes have a long wait before they come.” The manager told us that a comfort check form had recently been introduced to ensure that staff checked people’s needs on a regular basis.

People told us that there were choices at every meal time and that they were generally happy with the standard of food provided. One person told us “We get lots of cups of tea, they’re very good at that.” However, two people considered that portion sizes had recently been reduced until they had complained about this. One person said “They weren’t giving us enough to keep a cat alive” but confirmed that portion sizes had now improved. One person commented on the lack of support for people at meal times and said “Carers don’t sit down and encourage people to eat.”

People told us that they wanted more to occupy them in the home. One person told us “I feel alone quite a lot of the time. I’d like someone to have a chat to me and not sit here by myself.” Another person said “There’s nothing to do here. They advertised that they had days out here but there haven’t been any trips out in the past few months. I thought we might have gone out at Christmas.” A third person told us “They used to have regular entertainments but they don’t have them so much now.” The manager told us that monthly entertainments were now booked and that there had been a number of events over Christmas, including a Christmas bazaar.

People living at Ramsey Lodge had a wide range of needs. Some people had varying levels of dementia and different communication needs. We were therefore unable to fully understand everybody's specific issues.

We met with people who were confused as to time, place and person. They were relaxed and smiling and happy to converse with us about where they felt they were and who they were with.

Those people with whom we spoke were generally complimentary about the service and the care they received, they told us that staff were kind and respectful, one person said "I am fortunate to have such kindness shown to me."

Another person told us that since their admission they have improved both mentally and physically.

Everybody expressed satisfaction with their bedrooms and most areas of the home and were impressed with the improvements being made. One person said "We have seen improvements but we need more staff, there are long waiting times for assistance and sometimes it is too late, staff do their level best to help me." Another person told us that it can be some time before they see any staff.

Everybody said that were able to get up when they wanted to and go to bed when they wanted to.

People told us that during the summer months some people were provided with several opportunities to go out and that they attended a fete held at another of the providers care homes and had afternoon tea; visited Walton on the Naze and had a picnic, had a fish and chip lunch at Mistley and visited a small animal sanctuary.

Some people with more complex needs said that there were limited things to do one person told us that they found the boredom difficult to cope with.

Although people said that the food was good; the vegetarian menu and choice was limited and uninteresting.

This unannounced inspection took place on 13 and 17 April 2015. Ramsay Manor provides accommodation and personal care for up to 84 people, many of whom were living with dementia . There were 36 people living in the service when we inspected.

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 the location or cancel the provider's registration.

A registered manager was in post. 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.

After an inspection in July 2014 we asked the provider to take action to make improvements to the environment, care and welfare ,staffing, and how the quality of the service was monitored. Following this inspection the provider sent us an action plan to tell us the improvements they were going to make, which they would complete by September 2014. During this inspection we looked to see if these improvements had been made, but they had not all been completed.

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

People’s safety was being compromised in a number of areas. This included how well the environment was being maintained and how well equipment was cleaned and maintained as well as how well medicine’s were administered.

People’s health care needs were assessed. However, people’s care was not planned or delivered consistently. Although people told us they felt their privacy and dignity was respected and made positive comments about staff, we saw that care was mainly based around completing tasks and did not take account of people’s preferences, it was not individualised and did not promote independence where possible.

The provider did not have a system to assess staffing levels and make changes when people’s needs changed. This meant they could not be sure that there were enough staff to meet people’s needs. Furthermore, everyone we spoke with raised concerns about low staffing levels. There were not enough staff to meet people’s needs.

The process for monitoring the quality of care was still not effective; it had not picked up some of the significant problems we found so had not led to the necessary improvements.