The inspection took place on 12 and 14 December 2018 and was unannounced.

St Michaels Court is a care home with nursing for up to 86 people, some of whom may be living with dementia. 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 home is a modern building over three floors. At the time of our inspection there were 71 people living within the home.

There was not a registered manager in post at the time of this inspection. 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. There was a manager in post who told us they had been there for two months, however this manager was no longer in post on the second day of our inspection visit.

Our last comprehensive inspection was carried out in August 2017, and we found that the service was rated as ‘Good’ overall.At this inspection we found that the service had deteriorated with widespread serious concerns and was rated ‘Inadequate’ in all areas. There were also seven breaches of regulations of the Health and Social Care Act 2008, and one breach of CQC Registration Regulations 2009.

The service was not safe. People were not adequately safeguarded from the risk of abuse and staff did not have thorough knowledge of safeguarding procedures. The provider had not ensured that safeguarding incidents had been investigated or reported to the appropriate authorities.

Risks were not adequately recognised, assessed and mitigated. This included risks associated with the development of pressure ulcers and people’s health such as choking or drinking enough, or their health conditions. People’s environment was not always kept safe as they did not always have safe equipment to use.

Topical medicines such as creams for skin care were not administered or recorded as prescribed and some were out of date. Some bottled items were not dated and in one areas of the home, stocks of oral tablets did not add up correctly which meant that people may not have received their medicines correctly. Protocols for some medicines required further clarification for staff around how and when to administer them.

There were not always good infection control practices in place, and some areas of the home and items of equipment that people used were unclean.

There were not enough staff to keep people safe and meet their needs. As a result, people were left unattended and uncomfortable for long periods of time. Staff were not available in communal areas so people could not get assistance when needed.

People were not always supported to drink enough and drinks were not always available to people. There was not always a good choice of food and drinks each day, but some options were not always available to people as the home often ran out of certain foods and drinks.

People were not supported to maintain their wellbeing through the involvement of relevant healthcare professionals and other agencies in a timely manner.

Staff did not always gain consent from people before delivering support and people’s privacy and dignity was not always upheld. There were times when staff supported people to maintain their independence, but not always.

People did not have access to opportunities to follow their hobbies or interests regularly, or engage in occupation or activity.

People and their families were not consulted or involved in the planning of their care. Staff did not always deliver care according to people’s own needs and preferences, and did not always know people’s needs well.

There were meetings for people and relatives, however people did not proactiv

This inspection took place on 21 and 22 June 2017 and was unannounced.

Our previous inspection in July 2016 identified breaches of three regulations. These regulations related to the provision of person-centred care, safe care and treatment and the governance of the service. This June 2017 inspection found that improvements had been made in all three areas and the provider was no longer in breach of any regulations. The July 2016 inspection had resulted in ratings of ‘requires improvement’ across all areas. This June 2017 inspection resulted in a rating of ‘good’ across all areas.

St Michaels Court provides accommodation for up to 86 people who require nursing and/or personal care. Some people may also be living with dementia. At the time of this inspection 75 people were living in the home.

A registered manager was in post. They were registered as the manager for two of the provider’s homes, with the second home they managed being approximately ten miles away. 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.

People felt safe living in the home and were cared for by staff that treated them with kindness and compassion. There were enough staff to meet people’s needs, but some people commented that staff did not always have time to chat with them. Recruitment procedures were thorough and people’s medicines were safely managed and administered to them.

Mental capacity assessments had been carried out appropriately. People and those acting on their behalf were involved in discussions and decision making about the care and support received. People were supported to have as much independence as possible. There was good access to health professionals when required.

People enjoyed the food and were offered choices. Staff were well trained and supported by the management team to undertake their roles.

The home was well managed which helped ensure people’s safety and welfare. There were systems in place to receive people’s views and to monitor the quality of the service that people received.

The inspection took place on 5 and 6 July 2016 and was unannounced. The service provided accommodation for persons who require nursing or personal care, including some people living with dementia. The home consisted of three units, one for nursing care, a residential unit and a unit for people living with dementia.

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.

We found three 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.

The management of medicines was not consistently safe. People did not always receive their medicines as the prescriber intended. The service had failed to maintain accurate and full records in relation to medicines administration.

People received enough to eat and drink and told us the food was good. People’s nutritional needs were met, although at times they were not positioned in a way that was ideal for eating. People’s hydration needs were not always met, as people were not always supported to drink.

Systems were in place, including staff training, to protect people from the risk of abuse. There were risk assessments that staff followed to help mitigate risks to individuals and their environment.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Although staff did not always have a good understanding of these areas, we found that assessments for people’s mental capacity were thorough and least restrictive methods were used in people’s best interests if they were to be deprived of their liberty.

People’s social needs and personal preferences were not consistently met. There was little time for meaningful interaction with staff and very little provision of activities.

People told us staff were kind and caring. However, there were several occasions during our inspection where people were distressed and staff did not provide timely reassurance and comfort. We saw that staff did not always interact with understanding of people living with dementia. At times staff interactions were purely task-led.

People’s health needs had been identified, assessed and reviewed on a regular basis. Their care plans were individual to them and accurate, however lacked details of people’s personal interests and history. Staff did not always adhere to care plans.

There were some effective systems for monitoring and improving the service in place, and the registered manager had taken appropriate action in response to any complaints.

There were several areas where audits or observations had not picked up issues with regard to person-centred care and staff competency.

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

This inspection was carried out by two adult social care inspectors in response to information of concern that we had received from one person. In addition, we were also aware of a complaint that the home had received from a relative who had concerns about the care of their family member. We followed this up to see how the service had responded to this complaint.

During this inspection we spoke with the home’s acting manager, three other staff members, three people who lived in St Michaels Court and relatives of two further people. We reviewed six people's care records and other records relating to the management of the service.

This inspection was undertaken to establish whether we could substantiate the concerns raised with us. We reviewed the evidence we had obtained during this inspection and used it to answer 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?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

We had received information about a medication error that had occurred. During this inspection we identified the incident concerned had taken place in June 2014. We were satisfied that the service had dealt with this appropriately.

We were also able to establish that all staff administering medication had undertaken training and recent competency testing to ensure that they were safe to administer medication to people.

We discussed the potential implications to the service of the recent Supreme Court judgement relating to the Deprivation of Liberty Safeguards (DoLS) with the acting manager. These safeguards form part of the Mental Capacity Act 2005 and make sure that people are looked after in a way that does not inappropriately restrict their freedom. The acting manager was aware of this recent judgement and had sought advice from the local authority on making applications. The local authority had asked them to prioritise applications in the first instance. The acting manager had identified applications in respect of two individuals that were being made.

Is the service effective?

Staff told us that staffing provision was usually adequate to ensure people’s needs were met. The service had utilised agency staff more than usual in recent weeks to help cover holiday absence. Most people we spoke with felt that staff numbers were sufficient. One relative told us, “Staff are a bit more pushed sometimes at weekends, but it’s usually fine.”

Is the service caring?

We found that people were treated with respect and consideration by staff. We had received information suggesting that people living with dementia were gotten out of bed at 5:30 a.m. We found that this was not the case on the day of our inspection. We were unable to substantiate this concern that had been raised with us.

Is the service responsive?

We saw that in relation to the complaint we had received, the service had acted promptly to invite the person’s family to a meeting so that their views and concerns could be heard. This demonstrated that the service acted promptly when concerns were raised.

Is the service well led?

As a result of the complaint the acting manager was taking steps to improve the admissions process for people moving in to St Michaels Court. This showed that the service learnt from people’s complaints and used this information to improve the service people received. This was an indication that the home was well led.

Earlier in 2013, we visited St Michaels Court and identified issues with the way the service was running. We told St Michaels Court to make improvements, and in October 2013 we returned to the service to check they had made improvements

We found that relatives were now invited to a three month review of care records, where their views were documented. People using the service and their relatives were also invited to residents’ meetings, where they were able to express their views.

We found that people using the service had an assessment of their needs, detailed care planning and had risk assessments in place to protect them from harm. All of these documents had been updated within the three months prior to inspection to ensure the information was current. A relative we spoke with told us, "Things have improved a lot".

We found that there were now enough suitably qualified and experienced staff on shift to meet everyone’s needs. Staff had more time to engage with people and take part in activities. A relative we spoke with told us, "The activities are much better". Another relative told us, "The staff provide a good standard of care".

We found that the service had failed to improve the effectiveness of their audits, and as a result, issues with service provision were not identified.

We found that the service was now investigating complaints effectively and that care records were now written in legible writing and kept securely.

We inspected this service to assess compliance with Medicines Management following issues we identified and raised at our previous inspection in August 2013. We found appropriate arrangements for the recording, handling, storage and safe administration of medicines. We noted improvements had been made to the way medicines were administered to people and our checks found that overall, medicines were given to people correctly.

We inspected this service with our pharmacist inspector to assess compliance with Outcome 9 Medicines Management. We found there were not appropriate arrangements in place for the recording and safe administration of medicines placing the health and welfare of people living at the service at risk. There were improvements to information about people’s medicines. We noted there were appropriate arrangements for the storage of most medicines, however, medicines requiring refrigeration were not always being stored within the accepted temperature range and medicines stored in people’s rooms were still not secured placing them and others at risk.

We found that the service had made improvements with care planning; however, some people were still not receiving care and treatment in line with their individual plan. A relative told us, "It has got better, but there is still a way to go".

We found that significant improvements had been made at meal times. People were encouraged to make choices about food, drink and where they would like to eat their meal. However, one relative told us "Breakfast is not always served on time; sometimes you wait until eleven am before it arrives".

We found that the service did not have an adequate system of audit in place to identify issues in quality and the delivery of care. Complaints were not always investigated in line with policy and one relative told us, "I never received an outcome of my complaint."

In April 2013, we inspected St Michaels Court and told them they needed to make improvements with regard to respecting and involving people, meal times, staffing and record keeping. We visited St Michaels Court in June 2013 to see if they had made the improvements we asked them to make.

We found that the service had failed to make improvements with involving people in care planning, and maintaining people's privacy and dignity. We spoke with the relatives of four people using the service. One relative told us, "My mother went to hospital, the hospital said she was dirty". One other relative told us, "Her clothes keep going missing and I’ve found her dressed in another person’s clothes". Another relative told us, "She wants a bath but staff said they don't have time. She hasn't had one in a year".

We found that the service had failed to make sufficient improvements with regard to nutrition and hydration. People were still not given sufficient choice at meal times and people's needs at meal times were not always met.

We found that the service had made sufficient improvements with regard to staffing, having put in place two extra members of care staff so they could better meet the needs of people living in the home.

We found that the service had not made the improvements necessary with regard to record keeping. The service was still not maintaining care records for people that were accurate, fit for purpose and kept securely.

We visited St Michaels Court to see if they had achieved compliance with a warning notice we issued in May 2013. We found that the service had failed to make the improvements necessary to achieve compliance which meant that the safety and welfare of people using the service was at risk.

We found inconsistencies in care planning, needs assessments and risk planning which could lead to confusion for staff using people’s records to help them understand individual care requirements. This could result in inappropriate care or treatment being delivered to the individual, which would put them at risk.

We identified major concerns about the way in which the service was managing the pressure care of people using the service. We found that the service was not always putting in place preventative measures to lessen the risk of a person developing a pressure sore. We also found that people's pressure needs were not being cared for in line with what was specified in their care plan.

We spoke with three relatives of people using the service and one person using the service. One relative told us, "There's no continuity of care, staff don't know people well enough to look after them properly". A person using the service told us, "I don't really get cared for as such, I'm left to care for myself really, and struggle". Another relative told us, "I've had to change dressings on my mum’s pressure wounds because they've been dirty. There's no record of when they were last changed".

We inspected this service to assess compliance with Outcome 9 Medicines Management. We found appropriate arrangements in place for the recording of medicines but some information about people’s medicines was not accurately recorded. We noted there were appropriate arrangements for the storage of most medicines, however, medicines stored in people’s rooms were not secured placing them and others at risk. At the time of our visit some members of staff authorised to handle and administer medicines had not received recent training or were not yet assessed as competent to undertake medicine management tasks.

We looked at the care records for twelve people and found that in eleven of these care records there was no evidence that the person using the service or a relative had been involved in the planning of care.

People told us that the dignity and respect of their relatives was not being maintained. One person told us, "On occasions we have found him dressed in dirty clothing". One other person told us, "I found my dad dressed in someone else’s clothes that were too small for him".

We found that care planning was basic and the service was not protecting people from harm through the assessment and planning of care. People told us that they were receiving poor care. Two visiting health professionals told us they felt people were not being well looked after.

We found that people were not being properly supported to make choices about nutrition and hydration. People told us that the food was not of good quality and that menu's were repetitive. People did not have a choice of where they would like to dine.

We found there were not enough staff to meet the needs of people living in the home. Four staff members we spoke with felt that the service was consistently understaffed, as did two visiting health professionals. People living in the home felt there needed to be more staff.

We found that care records were at times incomplete, inaccurate or missing. There was not sufficient information held about people so that staff could sufficiently meet their needs.

This visit to St Michaels Court was a follow up unannounced inspection undertaken on 19 November 2012. We looked at records and spoke to the manager during our visit to ascertain whether the service had become compliant. We did not speak to people or visitors during this visit.

We looked at care plans for people specifically those living with dementia situated on the first floor of the building. We selected at random some care plans to check the service had completed assessments of people who lacked capacity and check that appropriate risk assessments had been put in place specifically regarding nutritional needs.

We checked whether improvements to reduce the noise level of the call bell had been put in place and whether regular quality audits had been carried out. We spoke with the manager who provided us with the majority of the information.

During our visit we spoke with seven people who use the service and one relative. Some people told us that they felt well cared for and were having their needs met. Other people said that they did not always get the support they needed due to a lack of staff. Some people said that had not been always been involved in the planning and review of their care. However, they felt that they were involved in the day to day decisions about their care.

Other people who use the service said that they felt well looked after and received good support with their daily health and care needs. They said that staff respected their wishes but at times their choices were limited by the number of staff on duty. One person told us that staff were good and treated them well. They said that sometimes there were not sufficient numbers of staff on duty which meant they had to wait to have their needs met. One person told us that they were “fed up” they didn’t always get a good bath and didn’t always get their creams applied at night. Another person said they liked living in the home and they get well looked after. One other person we spoke with said that they were not clear about their plan of treatment and care and had not been involved in any review of their care. They said that they didn’t think good care was provided consistently and expressed some concern about the lack of staff to properly meet people’s needs. However, they also said that staff were pleasant and helpful.

We spoke with a relative who told us they were happy with the service their relative received and any problems were quickly resolved.

People we spoke with said the quality of the food was good. They said they enjoyed the food and there was always choice and a sufficient quantity.

People who we spoke with did not express any concern about the cleanliness of the home. People said they were happy with their accommodation.

Many people we spoke with expressed concern about the number of staff available to support them when needed. One person told us that on occasions there was a long delay in having their call bell answered. Another person told us that because there were not enough staff on duty in the morning they had to stay in bed longer than they wished. However, many people told us that they had their needs met but may have to wait longer than they would have liked.

We spoke to six people living at St Michael's Court, two visitors, four staff, the manager and the associate director of the company. The majority of people were satisfied with the care and treatment they received at the service.

Each of the three floors were visited and it was observed that various activities were organised during the morning.

People were observed sitting in lounges or staying in their own room or taking part in various activities or rehabilitation. One person was going out with their visitors with staff support.

Other observations showed staff speaking to people in a friendly and dignified manner and a member of staff making drinks for people was heard asking if they would like biscuits with their drink and, if so, what sort they would prefer.

People with whom we spoke told us they knew there were records written about them, and generally the majority of people were spoken with staff when there records were reviewed.

One person spoken with said 'The nurse comes to sit with me to discuss what I have planned to do next with my rehabilitation, and I see the physiotherapist every week'.

Another told us 'One of the staff chats about any changes I would like making with my care'.

One person who we spoke with at length said "The staff are marvellous and would do anything for me if I asked, they are very willing to help".

We followed up concerns that had been sent to us regarding equipment and staffing numbers on the top floor prior to this visit. While walking round the building we did hear the call bell ringing constantly and found this was connected on all three floors. People did not seem to notice the noise levels although this could be an irritation to people living at St Michael's Court and was discussed with the manager to reduce this.

We reviewed the evidence we had obtained during our inspection and used this to answer 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?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

The service had made substantial improvements which ensured people were safe from the risk of ingesting harmful substances. People were cared for in accordance with their care plans and systems were in place to ensure this continued.

We found the home to be clean which meant that the risks of infection were minimised. People told us the home was always as clean as we found it to be during our inspection. One person told us, “They’re always cleaning here. See how nice my room is.”

We spoke with the service manager about the Deprivation of Liberty Safeguards (DoLS). They told us they had been in contact with the local authority to enquire whether an application would be appropriate in respect of one person. This demonstrated to us that where there were concerns that the appropriate action would be taken.

Is the service effective?

People we spoke with told us they were happy living in St Michaels Court and they had everything they needed. Staff explained how they communicated with people who were unable to communicate verbally and described how they supported people living with dementia. They were able to tell us about individual’s preferences, health requirements, what things worried people and how they alleviated their concerns.

Is the service caring?

People we spoke with were clear that staff treated them or their family members with care and consideration. One person told us that their family member had “….always been treated with great respect.” We found that people were relaxed in the company of staff and noted that staff took time to speak with people’s visitors. One person told us, “It means so much to me that staff here say hello and chat with my family when they come in. It’s so nice.”

Is the service responsive?

The service was organised to ensure people’s needs were met. People’s needs were assessed and reviewed on a monthly basis. Where they changed we found that the service responded promptly and sought appropriate advice from health professionals when necessary. People had requested access to a wider range of denominational services and this had been organised. Information was available in several areas of the home about this. Upcoming meetings were widely publicised throughout the home. We were told that attendance at these meetings was increasing.

Is the service well led?

People we spoke with were keen to tell us how much the service had improved in recent months. We heard nothing but praise for the service managers from people living in the home, their relatives and staff. Staff we spoke with told us that they were proud to work at St Michaels Court.

The service managers carried out regular checks to make sure that people’s care and welfare was assured and carried out correctly. Where areas for improvements were identified action was taken and the effectiveness of any action reviewed.