This inspection took place on 31 August and 1 September. The first day was unannounced and the second day was announced.

The Queen Charlotte provides accommodation and personal care for up to 51 people. There were 34 people living at the home at the time of inspection. The service is located in Chickerell and is a large detached four storey building. The accommodation offers bedrooms over three of the floors and has wheelchair accessible lifts for all levels. There are communal lounges and dining areas on three of the floors. There is also an accessible garden.

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.

People had access to a range of group activities but there were limited options for people who preferred one to one time with staff or who were in bed and not able to take part in the group opportunities offered.

Quality assurance measures were regular and used to identify gaps and trends. However this information was not consistently used to plan actions to improve the service.

Recruitment at the service was safe but there were some gaps in the consistency of information about applicants conduct in previous employment.

Risk assessments were in place and identified the risks that people faced and provided guidance about how to manage these. Staff knew peoples individual risks well and the service planned to build on the existing risk assessments to ensure they reflected the person centred details for people.

Some people had DoLS authorisations in place and one person had conditions attached to their authorisation which were being met. However another person had an expired DoLS which had included conditions which the home had not met. They advised that they would ensure that conditions for DoLS authorisations were consistently recorded and met in line with legislation.

People were protected from the risk of harm by staff who understood the possible signs of abuse and how to recognise these and report any concerns. Staff were also aware of how to whistle blow if they needed to and reported that they would be confident to do so.

There were enough staff available and people did not have to wait for support. People had support and care from staff who were familiar to them. Staff were consistent in their knowledge of people’s care needs and spoke confidently about the support people needed to meet these needs.

People received their medicines as prescribed and these were securely stored. Medicines were administered using an electronic system which alerted staff if a person had not received their medicines within two hours of the expected time.

The home had good links with health professionals and regular visits and discussions meant that people were able to access appropriate healthcare input promptly when required.

People were supported by staff who had the necessary training and skills to support them. Training was provided in a number of areas and refresher sessions were booked for certain topics on a regular basis.

Staff understood and supported people to make choices about their care. People's legal rights were protected because staff knew about and used appropriate legislation. Where people had decisions made in their best interests, these included the views of those important to the person and considered whether options were the least restrictive for the person.

People spoke positively about the food and had choices about what they ate and drank. The kitchen were aware about people’s dietary needs and where people required a special diet or assistance to be able to eat and drink safely this was in place.

Staff knew people well and interactions were relaxed and caring. Peopl

This inspection took place on the 7 and 8 July 2016 and was unannounced.

At our inspection in September 2015 we found issues with people receiving safe care and treatment and with staff deployment. Staff had not been trained to manage challenging behaviours and lacked an understanding of dementia. Staff did not have enough time for people resulting in a lack of empathy and dignity. Communication methods were not being used to support people who had a sensory or cognitive impairment and there was a lack of stimulation. We found limited detail and involvement of people in their care plans, no consideration of the compatibility of people living together and information not being shared with staff in a timely manner about people’s care needs. We found that audits were not effective as they had not included the delivery of care to people and staffing levels. We found at this inspection that improvements had been made although further improvements were required.

The service is registered to provide accommodation and residential or nursing care for up to 51 people. During the inspection there were 40 people living at the service many whom were living with a dementia.

The service comprised of a ground, first and second floor providing accommodation. Bedrooms had an en-suite toilet and sink. The ground floor had two lounge areas which gave access into a secure garden area, and a dining room. Both the first and second floor also had lounge and dining areas and kitchenettes. There was a lift and staircases to the first and second floor. The service had specialist bathrooms, a kitchen, sluice and laundry facilities.

The service did not have a registered manager. 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 manager was in the process of applying for their registration.

Staff understood the risks people faced. However risk assessments had been completed but care plans did not consistently include enough detail about the actions needed to minimise risk. The recording of incidents was not consistently taking place. Inconsistencies in record keeping and reviewing processes meant that at times risks to people and effective ways to manage risk were not able to be evaluated effectively. Some care plans did not reflect fully what we observed. This meant that if people had been supported by staff that didn’t have experience of caring for them they were at risk of receiving inappropriate care. Staff had a good knowledge of people. They told us that handovers happened each day and were detailed and included actions that needed to be carried over from the previous shift. Reviews included setting goals for people.

Medicine was stored and administered safely. Staff had a recognised tool to assess if people were in pain but we found this was not consistently being used. This meant that some people may not have received pain relief when they needed it.

There were enough staff to support in a timely way and at the pace of the person. Staff were being recruited safely and had employment and criminal checks in place. Processes were in place to manage unsafe practice.

Staff had received training and were aware of the signs of abuse and what actions they would need to take if they suspected abuse was happening. They received an induction and ongoing training that enabled them to effectively carry out their roles. Records showed us that the majority of staff had completed the provider’s mandatory training courses however a number had been slow in progressing through the e-learning programme.

Staff felt supported by the senior team in their day to day work. Formal staff supervision had not been happening regularly but there wa

We carried out this unannounced, focused inspection on 22 January 2015 to follow up on action we told the provider to take after our last inspection.

On the 21,22 and 23 September 2015 we carried out an unannounced comprehensive inspection of this service. We found breaches of legal requirements. This was because there was insufficient number of staff effectively deployed to meet the needs of the service users living at the home. People were not protected by effective quality assurance systems and that systems to report safeguarding concerns were not effective.

After that comprehensive inspection we told the provider to take action by issuing three a warning notices that required improvement in the numbers of staff and deployment within the home, the quality assurance systems and the reporting systems in use to safeguard people from harm by 1 January 2016. We also asked the provider to tell us how they would make improvements in relation to the other breaches of regulation identified. You can read the report from our the comprehensive inspection on 21,22 and 23 September 2015 by selecting the “all reports” link for “The Queen Charlotte Nursing home” on our website at www.cqc.org.uk.

This focussed inspection report only covers our findings in relation to the action we told the provider to take in our warning notices. We will carry out another comprehensive inspection to check that other actions have been taken and that improvements have been sustained.

The provider is required to recruit a registered manager for this type of service. There was no registered manager in post but the provider had appointed a new manager who told us of their intention to apply to be registered. 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 and associated Regulations about how the service is run.

The home is registered to provide nursing care and support for up 51 people. The home was not at full occupancy and was accommodating 43 people.

The provider had looked at the staffing levels and the way staff were deployed in the home. As a result of this they had introduced a receptionist to answer the door to visitors on a Monday to Friday basis and were looking at how to cover this work over the weekends and evenings. The introduction of this post freed care staff up to support people living at the home. An activities coordinator had also been employed to help meet some of people’s social needs.

The systems in place to report safeguarding issues and protect people from harm were being fully used. The provider had carried out investigations as appropriate and informed the local authority and CQC as and when required. The staff told us they have confidence in raising issues with the management and confidence that any issue brought to the management’s attention will be addressed.

The provider had made arrangements to review peoples support needs and the quality of care being provided. From these reviews an action plan had been implemented and there was evidence that improvements were being made. People and those important to them had been consulted about the changes required and their views listened too.

At the time of the inspection a new manager had been appointed and was in the process of applying for registration. As such, the name of the previous manager will still appear on the report until such time as our records are amended.

We observed that staff treated people with respect using the person’s preferred name. Staff readily responded to requests for support quickly and discreetly. Visiting relatives told us that staff knew their loved ones needs and met them with compassion and empathy. One person told us that staff respected their wishes to occupy themselves throughout the day, but knew they would be supported to join others if they so wished.

Where people could not consent to care and treatment, the provider had systems in place to ensure any decisions taken on behalf of people was transparent and in the person's best interests.

The staff knew how to identify and report safeguarding adult concerns. The provider had made arrangements to ensure staff had opportunities to further their knowledge of safeguarding through training.

The provider had a system in place to monitor the quality of care it was providing. Both staff and people living at the home were consulted as to what the home could do better and plans were in place where issues were identified.

The care records provided staff with sufficient guidance to be able to meet people's needs in a way that they wished.

At the time of the inspection the registered manager had resigned. As such their name will still appear on the report until such time as our records are amended to reflect this change. An acting manager had been appointed and had been in post for the previous four weeks prior to this inspection.

People told us that staff looked after them well. One person told us they relied on staff to help them make decisions. However, due to their enduring mental health issues they could not describe in detail how their care and welfare needs were being met. The staff we spoke with were aware of people's needs and how they should be met.

The provider had made improvements to the environment. New fixtures and fittings had been purchased to address the issues noted at the previous inspection.

The provider had a system to monitor the quality of care at the home, however areas of this were being developed to ensure it was more robust.

The care records gave staff sufficient guidance to meet the needs of the people who lived at the home but issues relating to recording people’s consent to treatment were still apparent.

We used the Short Observational Framework for Inspection (SOFI) tool to help us see what people’s experiences were. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. This includes looking at the support that is given to them by the staff.

We observed that people were not treated with respect and dignity. They were offered choice with regards to their diet but this was not always provided. Staff were not aware of people's personal preferences and routines.

People told us that they felt that staff were approachable and would sort problems out for them. A visiting relative told us about concerns they had and that they felt the acting manager was making a positive difference by making themselves more accessible.

The provider did not have an effective quality assurance system which is required to monitor and improve the service offered at Queen Charlotte.

The care record system was not fully understood by all staff which can lead to people's needs not being understood or met in a timely way.

The inspection took place on 21,22 and 23 September 2015. The inspection was unannounced. The home is registered to provide nursing care and support for up 51 people. The home was not at full occupancy and was accommodating 43 people.

At the time of our inspection there was not a registered manager in post, the previous manger had left employment in December 2014. The provider had appointed a manager who had applied to become the registered manager. 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 service was last inspected on 11 February 2014 and found to be meeting the required standards. At this inspection we found that the provider was failing to meet the fundamental standards.

The provider did not ensure there was effective and responsive leadership within the home. The provider did not have an effective system to check the quality of care people received at the home.

There were insufficient staff effectively deployed to meet the needs of the people living at the home. The impact of this was that staff had little time to sit and talk with people or to meet their social and emotional needs. It also impacted on the staff’s ability to meet people’s needs in a dignified and respectful manner. People could not be confident of receiving care at the time they wished because there was not enough staff to meet people’s needs. People were left without social stimulation for long periods of time. People did not experience personalised positive care. Some staff failed to consistently show compassion when people were distressed.

People who had an identified risk of harm to themselves or others did not have the risk managed safely. Staff had been subject to verbal and physical abuse that was not consistently addressed. This put staff and people living at the home at risk of further abuse. Where allegations of abuse were made the provider had not made effective arrangements to investigate these concerns or give the local authority factual information regarding these concerns.

The risks people faced were not consistently acknowledged in people’s care records. When people were at risk of falls through health care conditions these were not acknowledged in their care records. This meant staff had insufficient guidance to meet their needs. Care records were not always accurate and the reviewing systems of these care records were unreliable.

Staff did not receive the training required for them to meet people’s individual needs. Staff spoke about their concerns that they had not received appropriate training. We observed a number of care practices that demonstrated staff required more training in order to support people in a dignified and individual way.

Medicines administered at the home were safely stored and dispensed appropriately.

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.

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