The inspection took place on 2 October 2018 and was unannounced. The inspection was brought forward due to concerns raised by professional visitors to the service around issues such as falls and medicines errors. There had been some recent changes in the management of the home and the new manager had only been in place for a matter of weeks. The home had an improvement plan in place and were working closely with the local authority and the clinical commissioning group (CCG) to implement improvements. The home had put a voluntary suspension of placements in place whilst improvements were being made.

The last inspection was undertaken under the previous provider registration on 6 December 2016 when the service was rated good in all domains and overall. At this inspection we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment, nutrition, dignity, person-centred care and good governance. We also made recommendations with relation to implementing overviews of safeguarding concerns and falls and ensuring activities were person-centred.

Shannon Court Care Centre 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.

Shannon Court Care Centre accommodates up to 78 people in one adapted building. The service provides nursing and personal care in three separate units over three floors. One of the units specialises in providing care to people living with dementia. At the time of the inspection there were three vacancies and two people were in hospital.

There was an acting manager in place at the home who was in the process of registering with the Care Quality Commission. 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.

Leadership at the service had been inconsistent for a period of time. Documentation was poor and there was a culture of ineffective responses to people’s basic needs and dignity. There was a lack of guidance for the staff around the importance of providing person-centred, respectful care for all the people who used the service.

Systems were not always effective in ensuring medicines were administered, recorded and stored safely. There were appropriate safeguarding and whistle blowing policies in place and staff had a good awareness and understanding of them. There were enough staff on duty and recruitment systems were satisfactory.

Risk assessments were completed but individual risk assessments were not always effective. Health and safety measures were in place and accidents and incidents were recorded.

Staff completed an induction on commencing work at the service. However, we noted that some sections of the induction booklet were incomplete. Staff had completed essential training and refresher training was ongoing. Staff would benefit from more in-depth dementia training. The premises were not as dementia friendly as they could be.

The food choices were limited and there was a lack of fruit and vegetables on the menu. Pureed food was unappetising, and the lunchtime experienced could have been improved with more attention to detail.

The home was working within the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Staff were hard working, cheerful and caring. They worked as a team and were friendly and respectful. Communication between relatives and the home was good. Independence was encouraged and there was evidence within care plans of the involvement of the person and their relatives with care