Shiels Court 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.

The care home accommodates up to 40 people in one adapted building. At the time of this inspection there were 37 people living in the service. The service provides accommodation and personal care to people living with dementia and mental ill-health.

There was 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

When we completed our previous inspection on 13 and 14 February 2018 we found concerns relating to the deployment of staff throughout the home. We also found that staff were unclear when and how to apply the Mental Capacity Act (MCA) 2005.

At this inspection we found ongoing concerns relating to staffing, training and the application of the MCA. People using the service had been diagnosed with dementia or mental ill-health and most were unable to make safe choices relating to their wellbeing. Care plans did not show how decisions had been reached to ensure they were kept safe. Staff continued to show limited understanding of the relevant procedures and legislation. Some staff had still not received training to ensure they had the right skills and knowledge to meet the needs of people using the service.

We identified concerns around the management of people’s safety. Risk assessments relating to people’s care needs lacked detail and were not routinely updated. Measures identified to reduce certain risks in the home, such as exposed hot pipes, had not been put in place. Staff recruitment and safeguarding reporting was not consistently robust. Medicines were administered safely but medicine records were not always accurate. Staffing levels did not enable appropriate levels of support at meal times.

The provider had failed to respond to an action plan arising from the previous CQC inspection. This demonstrated shortfalls in the leadership of the service. The service’s governance systems required improvement to manage risks and drive improvement. Management did not routinely seek feedback on the service.

Staff did not always have time for meaningful interactions with people. For example, at lunchtime some people did not receive encouragement and support to ensure they ate their food. Care plans were not always up to date and did not contain information about people’s end of life care preferences.

Staff sought people’s consent before undertaking tasks and they offered people choice with their care. Staff also supported people to be independent where possible. Staff worked well with other healthcare professionals to ensure people’s health care needs were met. Referrals to specialist health care agencies were made promptly, as required. People and relatives reported that staff were kind and caring and they delivered care which responded to people’s needs and wishes.

We found four 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 the report.

This is the third time the service has been rated Requires Improvement.

This inspection took place on 13 and 14 February 2018 and was unannounced.

When we completed our previous inspection on 16, 22 and 24 December 2015 we found significant failings in the service. The service was rated inadequate and placed into special measures. The follow up inspection on 28 and 29 June 2016 found improvements had been made to meet regulations and the service was taken out of special measures. However, improvements were needed to ensure risks associated with people's health conditions were assessed and measures put in place detailing how these could be reduced. Additionally, people were at risk of not receiving consistent care, as staff did not have clear guidance to follow, including where people’s behaviour was challenging to staff to manage. At this time, managing behaviour that challenges was included under the key question responsive. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework, this topic area is included under the key question of safe. Therefore, for this inspection we have inspected this key question and the previous key question responsive to make sure all areas inspected validate the ratings.

At this inspection we found the required improvements identified in June 2016 had been made. However, we found further concerns in relation to staffing numbers allocated to the Coach House. These were not sufficient to meet people’s needs. We also continued to find staff were not clear about the application of the Mental Capacity Act (MCA) 2005 legislation and when this should be applied. At least 10 people using the service had been diagnosed with advanced dementia and or mental health issue, which affects their capacity to make decisions. There was no documentation in place to reflect how these people were supported to make day-to-day decisions. With the exception of best interest decision instigated by the Dementia and Intensive Support Team (DIST), there was no evidence to show there had been consultation with people’s family or other professionals, when making decisions about their care and treatment. We also identified not all staff had received training to ensure they had the right skills and knowledge to meet the specific needs of people using the service.

Before this inspection, we received information from a person using the whistleblowing process raising concerns about poor care, people having to wait for medicines, issues about the environment and poor infection control practices. At this inspection, we found people were happy with the care and support they received and they were positive about the staff. We saw people were clean, dressed in appropriate clothing, their nails were clean, hair was tidy and their glasses were clean. People were receiving their medicines when they needed them. Although infection prevention and control policies were in place, these were not always followed by staff to ensure essential elements of general cleaning were undertaken. Cleaning schedules were in place but were not being used effectively to keep the premises clean.

Shiels 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. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Shiels Court Care Home is one adapted building, with a self-contained dementia unit, referred to as the Coach House. The service accommodates up to 43 people. There were 37 people using the service at the time of our inspection, 11 of whom were living in the Coach House.

There is 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and asso

This inspection was unannounced and took place on 28 and 29 June 2016.

During our inspection of the home in December 2015, we found that the provider was in breach of nine Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. These were in respect of sufficient staffing, safe care and treatment, safeguarding service users from abuse, the need for consent, meeting nutritional and hydration needs, providing person centred care, statutory notifications and good governance. We placed positive conditions upon the provider and imposed a condition to restrict admissions. We also placed the service into special measures.

At this inspection, we found that the necessary improvements had been made. Therefore the provider is no longer in breach of these Regulations. However, improvements were required to make sure that people consistently received care that was well planned and ensured that their needs were met at all times.

Shiels Court Care Home is a service that provides accommodation for up to 43 older people, many of whom may be living with dementia. On the day of inspection, there were a total of 30 people living at the home.

There was a manager employed at the home who had recently applied to become the registered manager. They had been in post since December 2016, when the previous manager left suddenly. 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.

The provider had recently put systems in place to protect people from the risk of abuse and risks to peoples safety had had been assessed. However, these systems had not yet become fully embedded and were not used consistently for all people living in the home. The home and equipment that people used was clean.

There were enough staff to meet people’s care needs safely, and people received their medicines when they needed them. Staff had received appropriate training and supervision to provide them with the necessary skills and knowledge to provide people with effective care.

People were treated with dignity and respect by staff that were kind and compassionate. People were asked for their consent about their care, staff understood how to support people who were unable to consent to this.

People received enough to eat and drink to meet their individual needs and timely action was taken by staff when they were concerned about people’s health. However systems that had been put in place to monitor people’s intake of fluid were not always completed. We brought this to the attention of the manager who made changes regarding the overview of these records immediately.

People’s individual care needs and preferences had been assessed. However the records used by the provider contained out of date information and had not been regularly updated with changes. The provider had taken action to address this, but progress was very limited. People were able to participate in a wide range of suitable activities, both in the home and within the local area.

The staff were happy working in the home and felt supported in their role. They were clear about their individual roles and responsibilities. However, some staff lacked the confidence and experience to interact with people with communication difficulties when providing one to one support. People, their relatives and staff were positive about the changes the new manager had made. People told us that the manager was very approachable and were confident that planned improvements would continue to be made.

Any complaints or concerns that were raised were listened to and dealt with. The provider had recently purchased a system to monitor the quality and safety of the care provided which was to be introduced shortly.

A single inspector carried out this inspection. The inspection followed up on concerns we had found at our inspection carried out on 30 May 2014, concerning the number of staff on duty at the time of our inspection. We focused on the key question relevant to this inspection: Is the service safe?

Below is a summary of what we found. The summary describes what people’s relatives and staff told us, what we observed and the records we looked at. We did not speak with people using the service on this occasion. If you would like to see the evidence that supports the summary, please read the full report.

Is the service safe?

We looked at the staff duty rotas that covered a period of one month and saw that sufficient staff were employed each day to ensure that people received safe care in a timely manner. We saw that the staff names recorded on the duty rota for the day of our inspection complied with those staff on duty.

Our observations showed that people were being supported by staff in an unhurried way. Staff were kind and attentive and spoke to people in a respectful way. The atmosphere throughout the communal areas was calm and relaxed, with people sitting where they chose and engaged in some activity such as reading the newspaper, entertaining their visitors or having coffee and biscuits. One visitor spoke about the staff and said, “I haven’t met a bad one yet.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. At our inspection carried out on 30 May 2014, we established that proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

A single inspector carried out this inspection. The focus of the inspection was to answer the five key 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?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports the summary, please read the full report.

Is the service safe?

We inspected the staff rotas which showed there were insufficient staff on duty to meet the needs of people on the day of our inspection. We observed people receiving a poor lunchtime experience because there were not enough staff available to support those who needed assistance to eat their meal.

People were cared for in an environment that was safe, clean and hygienic. Regular health and safety audits took place to ensure all equipment and systems were working safely.

We spoke with staff and this demonstrated to us that people were cared for by staff who had the skills and experience needed to support people appropriately. One person told us, “Staff help me, they are very good.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care service. While no applications have needed to be submitted, proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to employing sufficient skilled and experienced staff at all times.

Is the service effective?

People we spoke with told us they were happy living in Shiels Court Care Home. They told us they received the care and support they needed. They described how staff always asked permission before giving them any assistance. One person said, “They always ask first.”

Staff explained how they communicated with people who were not always able to understand what they were saying because they were living with dementia. They were able to tell us about individuals’ preferences, their health requirements and how they effectively supported people to be as independent as possible.

Is the service caring?

The people we spoke with told us that staff treated them with care and consideration. Our observations showed that people were supported by kind and attentive staff. Care workers were warm, friendly and respectful and they offered choice and encouragement to people. However, there were not enough staff available to ensure that people received uninterrupted care and attention at lunchtime.

People told us they could spend their time where and with whom they pleased. One person described to us how they liked to spend time in the quiet lounge, where they could read their newspaper and watch the television. They spoke about staff always being about if they needed them. They told us that staff were, “Good.”

Is the service responsive?

People knew how to make a complaint and the complaints process was displayed on the back of each bedroom door. A further copy of the process was to be put in the entrance to the home so that it was available to all visitors. We saw from the home’s complaints records that all expressions of dissatisfaction were investigated.

People’s needs were assessed on a monthly basis. Where they changed we found that the service responded promptly and sought advice from health professionals. Care records showed that the service worked well with other agencies and services to make sure people received their care in a joined up way.

Is the service well led?

The service last sought the views of people in December 2013 to ensure they were providing a quality service that met people’s expectations. Staff assisted people to complete their questionnaire where necessary. Actions were taken where possible in response to people’s comments.

Staff told us they were clear about their roles and responsibilities. They understood the ethos of the home and had access to training and development that enabled them to provide appropriate care and support. This helped to ensure that people received a good quality service.

We spoke with four people and one visitor and also used the Short Observational Framework for Inspection (SOFI). One person said, "It's nice here, I like everyone". Another person told us, "You don't have to wait long for staff", and said they were offered choices every day. One person described how they liked to go to their room but that they could spend the day wherever they liked. People agreed that staff were available if they needed them and they were always very kind and helpful. One person said, "The staff are alright". They said they could see the doctor if they needed to and said he was, "Very nice".

People said they would speak with the manager if they were unhappy about anything. They agreed that they felt safe at the service and felt able to join in with the various activities that took place.

We looked at staff files and saw that the service followed robust procedures when recruiting new staff. Checks were in place to ensure that only appropriate people were employed.

We saw that staff were patient and kind to people, speaking with them in a calm and friendly way. Staff demonstrated that they understood the individual needs of people by the way they responded to those who were unable to articulate their needs. We saw one person become distressed and staff immediately gave the reassurance the person needed.

This inspection took place on 16, 22 and 24 December 2015 and was unannounced.

Shiels Court Care Home is a residential home providing accommodation and care for up to 43 older people, many of whom are living with dementia. At the time of this inspection 37 people were living in the home.

The registered manager had left the service in November 2015. 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. The then deputy manager had taken on the manager’s role and was leading the service with support from the provider two days a week. They are referred to as the manager throughout this report.

At this inspection we found major shortfalls in many areas of the service and identified that people were at risk of harm. We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and two breaches of the Care Quality Commission Registration Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

We found that there had been longstanding failures in identifying and notifying relevant authorities about safeguarding incidents. Incidents and accidents were not always recorded. When they were recorded the information from them had not been utilised to identify patterns in risks to people’s welfare. This prevented the manager from understanding where the risks to people were in how the service operated.

Risks assessments provided little guidance for staff on how to support people safely and did not always cover the risks to people we identified during the inspection.

People’s medicines were not always available and were not always administered in a timely manner to ensure that people would benefit from the relief they provided.

Insufficient staff numbers were deployed to meet people’s needs throughout the home. In The Coach House, the home’s unit for people requiring a high level of support, people were unaccompanied for significant periods of time, putting their welfare at risk. There were up to 15 people in the main lounges but very often staff were not available to meet the needs of the people there.

The manager and provider had a poor understanding of the Mental Capacity Act 2005 (MCA). The service was not acting in accordance with this legislation. This had led to decisions being made without people’s consent.

The new manager had improved accessibility to staff training and a substantial training programme was underway. However, no staff had been trained in the MCA. Supervisions and appraisals needed to be fully implemented to ensure staff were able to support people effectively and safely.

People’s nutritional and hydration needs were not being met. Staff did not understand the nutritional screening tool they were using and did not follow the related guidance when people were deemed as at risk. Food and fluid charts were not informative and actions were not taken to ensure people were supported with their nutrition by health professionals.

We observed both good and poor staff interactions with people living in the home. Staff were well meaning and caring, but some lacked insight into how their actions or comments could be perceived.

People’s needs had not been identified and planned for. Several people had significant health conditions which were not reflected in their care plans. Risk assessments had been combined with care plans. There was little detail to show how risks were to be mitigated and the guidance for staff to follow was minimal. There was little for people to do during the day. Most people spent their days asleep, watching others or walking about the home.

The service was poorly managed. The quality management in the service was lacking in several areas and was not identifying issues when they arose. Notifiable events had not been reported to CQC for a considerable period of time.

The staff were supportive of the manager and provider and there was an open culture in the home which benefitted people living there and staff alike. The provider and manager had recognised that there were a lot of improvements that needed to be made, but until this inspection had not been aware of span of issues in the home that required addressing.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still 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 this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.