The Dell is a residential care home for 40 older people, some of who may be living with dementia. At the time of our inspection there were 37people living in the service.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of Good. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection. At this inspection we found the service remained Good.

The service had clear and effective governance, management and accountability arrangements. Staff understood their roles and responsibilities, were motivated, and had confidence in their management team. Moreover, they were supportive of each other to ensure people received excellent care. The management team placed a great importance on ensuring everybody was treated as an individual and giving them person-centred care. They also ensured the staff team felt valued. They had worked hard and established a strong and visible person-centred culture. The service was building links with the local community being actively seeking opportunities which would benefit people. They encouraged and sustained contacts with other resources and

support groups.

The staff and management teams showed a genuine and in-depth understanding and compassion for people they supported. They had a number of schemes and initiatives in place driving improvement and continuously encouraging innovation to benefit people in the service. The staff team always tried to enable people to express their own views ensuring people received the care they needed and wanted. People were encouraged to be as independent as possible. The management and staff team monitored people's health and wellbeing and took appropriate action when required to address concerns. The service had dedicated

champions for different areas of speciality such as infection control, hydration and diet and falls to effectively support people's health and wellbeing. They were constantly researching for creative and innovative ways to ensure people lived their lives to the full. The whole staff team were very responsive to the needs of the people and enabled them to improve and enjoy their life.

People were able to engage in a range of meaningful activities and maintain regular links with the community. This helped them avoid becoming isolated. People really enjoyed getting involved in activities and outings because it made them feel busy and useful. People could also spend time with their visitors or occupying themselves if they wished to. Their choices were respected by attentive and understanding staff. We observed staff were positive, respectful and considerate of people and their relatives. People and relatives confirmed staff always respected their privacy and dignity. People benefitted from living at a service that had a very open and welcoming culture.

The management team spoke with passion about the care and support they provided to people and their families. They worked hard to ensure this was also shared by the staff team. There was a great atmosphere in the service filled with lots of enthusiasm, laughter and friendliness. The management team encouraged staff to go the 'extra mile' when supporting people. Staff were motivated to provide care with kindness and consideration.

People felt safe while supported by the staff. Staff had a good understanding of how to keep people safe and their responsibilities for reporting accidents, incidents or concerns. Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe.

The management and staff team recognised, reviewed and explored better ways of working when things went wrong. The management team had planned and booked training when necessary to ensure all staff had the appropriate knowledge to support people. Staff had ongoing support via regular supervisions and daily communications. The

This inspection took place on 19 January 2016 and was unannounced.

Our previous inspection of 3 August 2015 had found breaches of legal requirements in relation to the care people received. This was in regard to medicines administration, risk assessments, staffing levels, the application of the Mental Capacity Act 2005, meeting people’s health needs and quality assurance processes. At this inspection we found that improvements had been made and the regulations had been met.

The Dell provides accommodation and personal care for up to 40 people some of who may be living with dementia. There were 21 people living in the service on the day of our inspection.

The service had a registered manager in place. 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 were safe because staff understood their roles and responsibilities in managing risk and identifying abuse. People’s care needs were identified and they received safe care that met their assessed needs. Risk assessments identified risk to people and put actions in place to minimise these risks.

There were sufficient staff who had been recruited safely and who had the skills and knowledge to provide care and support to people in the way they needed and preferred.

People received their medicines as prescribed. Staff were trained to administer medicines safely and effectively.

People were encouraged to take part in communal activities. Plans were in place to develop activities which were personalised.

There was an open culture and the management team demonstrated good leadership skills. Staff morale was good.

The management team had systems in place to check and audit the quality of the service. The views of people and their relatives were sought and feedback was used to make improvement and develop the service.

This inspection took place on 3 August 2015 and was unannounced.

Following our previous inspection in April 2015 we asked the provider to take action to make improvements as we found evidence of major concerns in relation to the assessment and monitoring of risk, staff training and competence, how the consent of people to the care provided was obtained, the handling of complaints and quality assurance monitoring at the service.

At this inspection we found that some improvements had been made. However, further improvement was required to ensure consistency and sustainability.

The Dell provides accommodation and personal care for up to 40 people. The service mainly provides care to people living with dementia. There were a total of 20 people living in the service at the time of our inspection.

The manager of the service was not registered with the Care Quality Commission but had applied to do so. 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.

A lack of records in some areas including some relevant individual risk assessments, monitoring tools and care plans meant that people may not always be supported consistently and in the correct way.

Plans were being implemented with regards to staff training and professional development in areas specific to people’s healthcare needs. This enabled staff to meet their needs more effectively. However this was not yet fully reflected across the service. This led to some inconsistencies in staff practice.

The provider had strengthened quality assurance and governance systems which enabled them to have a clearer oversight of the service being provided. They were working towards addressing the issues previously identified to drive improvement. However not all improvements had been fully implemented in some areas and we were unable to fully assess if they had taken effect and were being sustained.

A complaints procedure had been put in place and the one complaint received since its inception had been dealt with effectively.

Staffing levels at the service were not sufficient to ensure people received their assessed care needs. The provider did not have an effective method to assess the number of care staff required.

People were not protected from social isolation. They were not supported with individual interests and hobbies.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The Regulated Activities are now subject to the following conditions imposed by the First Tier Tribunal (Care Standards):

(i) There should be a registered manager as required by the existing registration certificate.

(ii) Quality assurance audits are to be undertaken by the home to include the audit of management which is to be undertaken by Fennell Solutions. This condition shall subsist until 31 December 2015.

(iii) The home shall not admit any new residents until 1 November 2015 and then only at 2 per month. The condition will subsist until 31December 2015.

The overall rating for this provider is ‘Requires Improvement’. However because on two consecutive inspections one of the Key Questions has been rated as Requires Improvement, the service has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:

• Ensure that providers significantly improve
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
•  Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The overall rating for this service is ‘Requires Improvement’. However, the service has been rated as ‘Inadequate’ in a key question over two consecutive comprehensive inspections and is therefore in ‘Special measures’. The ‘inadequate’ rating may not be in the same question.

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.

We carried out this inspection took place on 28 April 2015. This was an unannounced inspection.

The service is registered to provide personal care for up to 40 people. On the day of our inspection there were 21 people living in the service.

The service is required to have a registered manager. On the day of our inspection there was no registered manager in place. A manager had been appointed by the provider two weeks before our inspection and told us it was their intention to register 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.

Previous inspections of this service dating back to February 2013 found the service was not ensuring the care and welfare of people, was not managing people’s medicines safely, did not have sufficient staff who were appropriately supported to carry out their duties, did not assess and monitor the quality of the service effectively and did not maintain appropriate records.

At this inspection staff were able to describe to us what constituted abuse of adults but they were not able to tell us how they would report this abuse. Not all staff had received training in safeguarding adults. This meant we could not be sure that people were kept safe by staff who knew what to do when safeguarding concerns were raised.

We found that medicines were stored safely. The service carried out audit procedures to ensure the administration of medicines was recorded correctly. However, we found that one person was receiving their medication covertly and the correct procedures had not been carried out in accordance with the Mental Capacity Act 2005.

There were sufficient staff. However, staff new to the service did not undergo an induction to ensure they were providing effective care. Staff had not received training to ensure that the care they provided was based on best practice and did not receive regular supervision and appraisals.

The service approach to risk assessment was generic. Some risk assessments in care plans were duplicated and other risk assessments were carried out when an assessment had not identified a risk. Care plans were not person centred and contained generic information not relevant to the person. They were not regularly used by care staff to support the care they provided. Audits and quality monitoring procedures carried out by the service were not effective and were not used to drive improvement.

People were not involved in making decisions about their care and treatment. Care plans were not person centred and contained a number of generic documents which were not relevant to the person.

The service did not operate an effective complaints procedure which was accessible to people and their relatives.

People were referred, when needed, to health and social care professionals to make sure they received appropriate care and treatment. People told us the quality of the food was good and that their were choices available.

Staff had good relationships with people who used the service and were attentive to their needs. Staff respected people’s privacy and dignity and interacted with people in a caring and respectful manner.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We inspected this service because we had information of concern. In addition we wanted to see if any improvements had been made to the standards of care people received since our last inspection. We found that improvements had not been made.

We considered our inspection findings to answer 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 what we found;

Is the service safe?

The service failed to learn from incidents and accidents, and put in place measures to protect people in the future. We saw that people did not have the care they needed delivered to ensure they were safe and their welfare was protected.

Is the service effective?

People's care records we reviewed were inconsistent, and did not always reflect their current needs. This meant that the service could not demonstrate through its records that it took prompt and appropriate action to ensure people received the care they needed.

Is the service caring?

Records we reviewed did not evidence that people were receiving care that met their needs. People's hydration and nutrition records showed that people who needed support to eat and drink had low intakes of food and fluid in the month prior to our inspection. This meant that we could not be assured that people were well supported.

Staff we spoke with had a poor or limited knowledge of people's needs which meant that although their approach was kind they did not understand fully how their needs should be met.

Is the service responsive?

The service had failed to take action where people continued to lose weight and refer them to specialist services such as the dietician.

The service had failed to seek support for people developing pressure areas from specialists such as the district nurse.

Is the service well-led?

There was no effective quality monitoring process in place. This meant that the management of the service was unable to identify risks and put in place measures to protect people.

The management of the service failed to make the necessary improvements to safeguard people from harm. This meant we were not assured that the service was well-led.

During our inspections of 2013 and earlier 2014 we identified and raised issues in relation to how the service managed people’s medicines. At this inspection our pharmacist inspector again assessed if people’s medicines were being managed safely and if arrangements were in place to protect people against the risks associated with the unsafe use and management of medication.

We looked at how information in medication administration records and care notes for people living in the service supported the safe handling of their medicines. We found that not all medicines could be accounted for numerically and so we could not be assured people’s medicines were being administered as intended by their prescribers. We found there to be evidence that some people did not receive their medicines as scheduled and we found failings and inaccuracies in supporting records which could have led to people not receiving their medicines appropriately and as intended by prescribers. We found people were at risk of accessing external medicines in their rooms with the potential for causing themselves harm. We noted that the competence of staff handling and administering people’s medicines had not recently been assessed.

We carried out this inspection to check if improvements had been made since our last visit in April 2014. We found that there continued to be serious failings in the care people were receiving, and this was putting people at risk. This was because care was not being delivered in a way that was meeting people’s needs or keeping them safe from risk.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service effective? Is the service well-led?

This is a summary of what we found;

Is it safe?

We found that people were not being protected against the risks of malnutrition, because the service was not taking appropriate action to meet people's needs. We saw that the service was not identifying where people were losing weight and needed to be referred to a dietician.

We found that the service was not taking action to protect people from the risks of developing pressure areas. For example, we found that for six people whose records we reviewed, care planning for the prevention of pressure areas was not being followed by staff.

Care staff working in the service did not have access to sufficient information to provide safe and appropriate care to people. Care planning was not up to date, and for three people whose records we reviewed, did not accurately document their current care needs.

Is the service caring?

We found that staff did not always treat people in a caring and respectful manner. During our inspection we overheard a staff member shouting to another staff member that they were, “Going to toilet [a person using the service].” This did not promote the dignity of this person. We saw that staff worked in a task orientated manner which did not take into account people’s individual needs.

Is the service responsive?

We found that the service did not take prompt action to refer people to other health professionals where appropriate. For example, people using the service who had lost weight were not referred to a dietician in a timely manner, and were therefore put at risk. We also found that where offers of support from external agencies or bodies had been made, these had not been acted on or accepted. This meant that we were not assured that the service was acting in a responsive and communicative way.

Is it effective?

We found that the service did not have an effective process in place to identify issues and put these right to protect people from risk. There were no effective systems in place for auditing the quality of the care delivered to people, and significant failings in this care were not identified prior to the inspection.

Is it well-led?

Between October 2013 and January 2014, the service was issued with three warning notices by The Care Quality Commission (CQC). The management of the service failed to ensure that sufficient improvements were made to the service in order to comply with the terms of these notices. In addition following a meeting with CQC in January 2014 reassurances given about development and timescales for improvements were not adhered to. The management of the service failed to make improvements within a two month period between our inspection visits in April and June 2014. This meant that people continued to be put at significant risk. This told us that the service was not well-led.

During a previous inspection, we found that the provider was not meeting this standard. We warned the provider and told them that they had to be compliant with this standard by the 20 October 2013. While we found improvements in the arrangements for the management and safe administration of medicines, people were not fully protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording of medicines.

Prior to our inspection a number of concerns were raised with the Care Quality Commission. The purpose of this inspection was to respond to these concerns. However, one safeguarding concern is currently being investigated by the local authority safeguarding team and the overall review of this matter has not yet been concluded.

The majority of people who used the service were living with dementia and had limited ability to communicate with us verbally their views of the service. We spoke with two people who told us they were satisfied with the standard of food that was provided. However, they also told us that there was limited choice of meals provided. We also found there was limited snacks and drinks available during the day.

We looked at the care records of eight people who used the service. We found major shortfalls in the assessment, planning and management of risk for people who had a diagnosis of diabetes and those at risk of malnutrition. Following our observations and findings during this inspection we took action and made a referral to the local authority safeguarding team for them to investigate our safeguarding concerns. The overall review of this matter has not been concluded.

We looked at the premises and found the all communal areas including bathrooms to be clean and tidy. We found that the provider had implemented a schedule of cleaning of the premises and equipment.

We looked at the provider’s complaints policy. We saw that they had a system in place to receive and respond appropriately to concerns and complaints. Investigations were seen to be thorough and outcomes were recorded.

We observed staff interactions with people and for the most part found the interactions to be positive. However, we observed one incident where one person’s request for a drink went ignored by care staff who told us they were too busy to respond.

In February 2013, we carried out an inspection and found that the service was not compliant with three standards of quality and safety. The provider sent us an action plan to tell us when they would be compliant. We returned to check if they were meeting the standards.

We spoke with five people, one relative and seven staff. One person told us, “This is a good place, the staff are kind and helpful.” Another person said, “I am happy here.” A further person told us, “The care is good, they look after me well.” One person said, “I tolerate it here.” One relative said, “X is being cared for ok.”

We saw that people who lived at the service had access to various healthcare professionals such as doctors and district nurses when they needed them. However, some people experienced inappropriate or unsafe care. People’s care needs were not always being regularly reviewed. The manager had plans in place to review each person’s needs.

The management of medication had improved. However, further improvements are required to ensure that medicines are managed safely.

The number of staff had been increased since the last inspection and plans were in place to recruit more staff however, we saw that there were not always enough staff to assist people in a timely manner.

Some people’s care plan records contained inaccurate information and were not always being regularly reviewed. The manager had plans in place to review each person’s care plan to ensure that they were accurate.

We carried out an inspection because concerns were raised with us regarding the safety of people using the service, staffing levels and medication administration. We spoke with four people using the service. Where people were unable to give us their views, we spoke with their relatives. We also spoke with two staff.

People gave us their views regarding living at the Dell. One person said, “It’s ok.” Another person told us, “I like living here, it’s nice.” People told us that they were satisfied with how the staff cared for them. One person said, “On the whole they (the staff) are pretty good.” A relative told us, “I am happy with the care, the staff are lovely and know my (relative) well.”

However, people told us that there were not always enough staff to meet their needs. One person said, “When you ring the bell they don’t come very quickly.” A relative told us, “There’s not enough staff, they do what they can.”

We looked at the management of medication. We found that this was stored appropriately however, we could not be assured that all medication was being administered as intended by the prescriber.

We looked at three care plans and found that the documentation was inconsistent and that some risk assessments had not been reviewed. This meant that not everyone who lived at the service had risks to their care and welfare regularly assessed.

The service had not always informed the appropriate authorities in relation to safeguarding issues that had occurred.

People we spoke with told us that staff were kind and considerate, that they were well looked after, and that they could make choices about their daily routine.

We did not speak to anyone who uses the service about the way that the home manages their medicines.

We received concerning information which led us to carry out an inspection on 13 November 2014. During the inspection, we identified serious shortfalls in the care being provided to people using the service. As a result we made referrals to Suffolk County Council who are responsible for safeguarding adults.

We visited the service again on 20 November to ensure that the provider had taken action to address the shortfalls. We found that despite support and monitoring from external organisations, the management of the service were unable to show that they had taken sufficient action to ensure people were receiving adequate amounts of food and drink.

A pharmacist inspector visited the service on 26 November 2014 to follow up a warning notice for the administration of medications, which was issued in September 2014. A warning notice is part of the CQC’s enforcement framework. It allows us to give the provider a short timescale within which to make improvements. We found that whilst some improvements had been made, errors were still identified which the service had not picked up on.

We spoke with three people who used the service. We also spoke with the owner of the service, the manager and care staff. We observed the care and support provided to people to check that people received care that met their needs. We looked at twelve people's care records. We considered our inspection findings to answer 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?

Is it safe?

We found that the management of the service failed to ensure that those people who needed support to eat and drink were provided with sufficient and consistent help. We observed that staff were often unaware of what a person had eaten, even when being monitored, and records reflected the amounts people had eaten inaccurately. The service had not taken appropriate and timely actions to safeguard some people from further weight loss.

Is it effective?

During our inspection visits, we found that the management of the service was continuing to fail in this area. This was because people using the service were not supported to eat and drink sufficient amounts. Staff were not deployed in a way that ensured people’s needs were met.

Is it caring?

We saw some positive and caring interactions between staff and people using the service. However we also observed staff who displayed poor practice which did not ensure people were consistently treated with dignity and respect.

Is it responsive?

Observations did not demonstrate that staff delivered the care people needed in line with their plan of care. This meant that people using the service could not be assured of receiving the appropriate care in a timely manner.

Is it well-led?

Following our first visit we contacted the provider to share our concerns about the service. We also requested information to assure us that action was being taken to address shortfalls we had identified. The provider was unable to provide all the information in the timeframe we gave them so we inspected again the following week to check if improvements to the care provision had been made.

The provider was present during the second day of our inspection. They shared information on how they were addressing the concerns we had raised. In addition they told us how they were planning for the future oversight and management of the service.

Despite this we found the management of the service did not have in place an effective and robust system to identify shortfalls in staff practice and in service provision before they were identified by us. This meant that we were not assured that the service was well-led.