This inspection took place on 18, 25 and 26 September 2018. The first day of our inspection was unannounced. The second and third days were announced to give the registered provider an opportunity to receive our feedback.

We had previously inspected the home in February 2018 and rated it overall as inadequate and the home was placed in ‘Special Measures’. Our key questions ‘safe’ and ‘well-led’ were both rated as inadequate and other key questions were all rated as requires improvement. We found breaches of the regulations concerning person-centred care, safe care and treatment, premises and equipment and staffing. We took enforcement action in relation to good governance. The registered provider sent us an action plan dated March 2018 which we followed up at this inspection.

Rockley Dene Residential 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. Rockley Dene Residential provides care and support for people with residential needs. The home has a maximum occupancy of 39 people. On the first day of our inspection, 26 people were living in the home and one was in hospital. On day two this number was 27 and on day three it was 26.

Due to their identified concerns, the local authority was visiting on a daily basis to check on the care provided and to ensure shifts were fully staffed. The local authority had taken the decision to suspend new placements at this home.

At the time of our inspection a manager was still registered with the Care Quality Commission. However, four weeks before our inspection, they left the home and were no longer in day-to-day control. Since the registered manager had resigned, a senior care worker had been temporarily appointed as the acting home manager within the home.

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.

On the second day of our inspection, we met the new home manager who had commenced their employment one day earlier. Throughout our report, we refer to them as the ‘home manager’. The home did not have a deputy manager in post, although this post had been offered to a candidate expected to commence employment in October 2018.

The registered provider had not ensured the acting home manager had the necessary skills and knowledge to be able to fulfil this role. We became aware of one incident which should have been reported to the Care Quality Commission which had not been communicated to us.

General maintenance in the building was not well managed. Two people living in the home had not had a hot water supply for several months. Certificates concerning the safe supply of water and lifting equipment had lasped. The supply of toiletries and disinfectant had been allowed to run out, despite this being identified beforehand. Some staff had purchased toiletries for people out of their own money.

Issues identified at the last inspection regarding locks on bathrooms and toilet doors not working had still not been resolved. This meant people were not supported to maintain their privacy and dignity.

Care plans did not reflect people’s needs as information was not consistently recorded throughout. There was a lack of evidence to show how people and their representatives had been involved in care planning. End of life care and planning for this had improved. The storage of archived records was chaotic and it took staff a long time to find the records we requested.

The management of medicines was not robust as not all staff had an up-to-date assessment of their competency. Some controlled drugs which were no longer ne

We carried out this inspection on 6 and 8 February 2018. The inspection was unannounced, which meant the people living at Rockley Dene and the staff working there didn’t know we were visiting. This was the service’s first inspection since the new registered provider had registered with the care quality commission (CQC) in December 2016.

Rockley Dene Residential Home 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.

Rockley Dene Residential Home accommodates 34 older people in one adapted building. This included people living with dementia. At the time of our inspection 33 people were using the service.

The service had 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.’

Staff we spoke with understood what it meant to safeguard vulnerable people from abuse, and they were confident management would take any concerns they had seriously and take appropriate action. However, issues we identified during the day did not support this and we submitted a safeguarding referral for one person to the local authority.

The registered manger used a dependency tool to determine staffing levels. However, we found this was not accurate as the dependency used the risk assessment scores and we found these were not reviewed effectively and therefore the staffing levels were not accurate. Staff also told us there was not enough staff on duty at certain times to meet people’s needs in a timely way.

Risks had been identified and management of the risks were documented. However, these were not reviewed correctly so the level of risk was not accurate.

Systems were in place for safe management of medicines. Staff received appropriate training and competency assessments.

People were not always protected by the prevention and control of infection procedures. We found some areas of the service and some equipment was not kept clean or hygienic to ensure people were protected from acquired infections.

We found procedures were followed for the recruitment of staff. Staff supervision took place and staff received an annual appraisal of their work. Staff received training. However we identified this was not always effective.

We found the service meet the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). staff we spoke with had a satisfactory understanding and knowledge of this, and people who used the service had been assessed to determine if a DoLS application was required. We also found where required some best interest decisions were made however there was not a consistent approach to ensure all decisions were made in people’s best interests.

People were offered a well-balanced diet. However, through our observations we saw people were not always supported to maintain a balanced diet. People accessed health care services when required. But we identified that referrals were not always made when people’s needs changed to ensure people’s safety.

People and relatives spoken with all said the staff were kind and caring. People also said staff respected them and maintained their dignity.

Care plans identified people’s needs and had good detail of how to manage people’s needs. However, we identified some documentation did not always reflect peoples current or changing needs.

People told us they were listened to by the management team and were confident any concerns would be dealt with by them.

Activities took place, people told us the activities were very good and they thoroughly enjoyed them.

There were processes