St Peters Court is a 'care home'. People in care homes receive accommodation and nursing and personal care as a single package under a contractual agreement with the local authority, health authority or the individual, if privately funded. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Peters Court is registered to accommodate up to 24 people, including people who live with dementia or a dementia related condition, in one purpose built building in the grounds of St Peters Hospital, Maldon. St Peters Court is a large detached property and the premises is set out on one main floor. Each person using the service having their own individual bedroom with communal facilities available for people to make use of within the service. The building is split into two zones with named corridors depicting street names for residential and nursing service users. At the time of our inspection there were 19 people using the service with one person in hospital,

This was the services first inspection under a new provider. At the time of inspection we found the service to be requires improvement. We found four breaches of regulation relating to regulation 12 - safe care and treatment, regulation 9 – person centred care, regulation 18 – staffing and regulation 17 - good governance. Additionally, we have made recommendations with regard to, meaningful activity provision, visiting rights in care homes, DoLs applications and environmental building works.

A registered manager was not in post at the time of this inspection. At the time of this inspection the office manager had been covering the service as acting manager for one month. We were advised a new manager was being recruited and they were due to start on 1st October 2018 which was the day before our second day of inspection. 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 and associated Regulations about how the service is run.

Additionally at the time of this inspection the registered provider had enlisted the help of an external quality audit company to help ensure the service was compliant in the five key areas of safe, effective, caring, responsive and well led. Whilst this mitigated some risk our inspection still identified areas which required action which we have outlined in the main report

Staff were not always effectively deployed. There was not always enough staff to care for people safely and effectively. In some instances where people had received funding for one to one care this had not happened.

Staff did not always follow safe practice in regard to the administration, storage and recording of people's prescribed medicines. People did not always have their medicines administered and reviewed in a timely safe manner.

Systems for monitoring accidents and incidents were not effective. The provider could not evidence that incidents were always investigated appropriately, or that lessons were learnt and shared and actions taken to mitigate future risks.

Some improvements were required to ensure infection control legislation was followed at all times. This required the registered provider to address some improvements in the service.

Risk assessments did not always provide clear guidance to staff as to how to manage identified risks associated with people's needs.

improvements were required to ensure DoLs authorisations were submitted in a timely manner and people should be fully supported to have maximum choice and control of their lives

People received enough specific food and drink to meet their dietary needs.

Care plans contained some information about what was important to people and about how their needs should be met. However, this often lacked sufficient detail to implement res