This was an unannounced, comprehensive inspection visit completed on 15, 16 and 21 August 2018.

Two Acres is a ‘care home’ providing nursing and residential care. 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.

The home is divided into four units. Three nursing units Rose, Lily and Iris and one residential, Fern unit. Rose and Fern units had shared bedrooms as well as single occupancy rooms. At the time of the inspection, there were 70 people receiving nursing care, and 13 receiving residential care.

The service had 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.’

At our last inspection on 5 and 6 September 2017, we rated the service overall requires improvement, with inadequate for the key question, well-led. We found breaches of regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed in relation to safe care and treatment, good governance practices and procedures and for sourcing consent from people living at the service.

Following this inspection, we took enforcement action and told the provider they had to send us monthly updates, linked to an improvement plan in relation to safe care and treatment. The required updates needed to cover nurse competency and implementation of training into practice, particularly in relation to medicines management and pressure care. Completion of four weekly audits of medicines management across the home were also required. Where concerns were identified as part of the provider’s medicine audit process, the conditions stipulated the need for the registered manager to implement management and contingency plans to mitigate risks.

During this inspection we identified repeated breaches of regulation and ongoing failings in the service's governance systems. We identified areas of concern in relation to staff competency in safe support of people experiencing dementia and complex physical health care conditions. There were significant shortfalls in the assessment and mitigation of risks to people using the service.

The service did not have robust governance processes in place for monitoring standards and quality of care provided. The registered manager and provider did not complete quality audits in areas such as documentation and equipment such as bed rails.

Staff were not consistently implementing training in the care and support of people living at the home. People’s records demonstrated a lack of consistent adherence to the Mental Capacity Act 2005. Concerns were identified around management of people’s food and fluid intake, with a lack of meal choices.

Low staffing levels impacted on people’s access to meaningful activities and care records lacked detail in relation to people’s hobbies and interests. There was not an up to date, daily activity timetable.

People were not consistently treated with care and compassion, and their privacy and dignity was not routinely protected. Staff did not consistently provide person-centred care to people living at the service.

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

Two Acres provides accommodation for up to 115 people who require nursing and personal care.

The home consists of four separate units, named Iris, Lily, Rose and Fern, set in landscaped grounds. At the time of our inspection Fern unit was closed for refurbishment and there were 69 people living in the home within the other units.

This comprehensive inspection included two visits to the home, which took place on 5 and 6 September 2017. The first visit was unannounced. The second visit was arranged with the registered manager to complete the inspection.

This home requires a registered manager as a condition of its registration. 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 2008 and associated Regulations about how the home is run. There was a registered manager in post who had been in post since April 2017.

We had previously inspected this service on 1 and 10 August 2016. We found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of two of the regulations which were for staffing and good governance.

At this inspection we found that the provider had taken action to ensure there were enough staff to keep people safe and provide them with basic care, therefore they were no longer in breach of this regulation. However, we found that although there were enough staff to keep people safe, there were not always enough staff to provide people with individualised care.

The provider had not taken the necessary actions to meet the requirements of the regulation relating to good governance. They had not adhered to their action plan they had sent us since the last inspection and were still in breach of this regulation.

We also found that the provider was in breach of a further two regulations during our most recent inspection. These were in relation to mental capacity and safe care and treatment. We found that people’s mental capacity assessments (MCAs) had not always been fully completed detailing specific decisions. There were no records of best interests meetings having taken place with regards to people’s care when they lacked capacity. Mental capacity assessments and DoLS applications had not always been reviewed and the conditions of DoLS were not always met.

People’s risk of developing pressure ulcers and the subsequent treatment of these pressure ulcers was not adequately recorded, monitored and understood. The ongoing risk assessment process when people had a pressure ulcer was not always thorough.

The systems in place for monitoring the service in order to identify areas for improvement and take action were not effective. We saw that where audits had been carried out and identified concerns, no further action had been taken. The registered manager and the provider had insufficient oversight of the effectiveness of the service.

People did not always receive person-centred, individualised care. There were not always plans in place to fully guide staff on people’s individual needs and preferences, and staff did not always have time to deliver person centred care according to these needs.

We found that most people’s medicines had been administered as prescribed, however we found that not all medicines had been managed safely. We found that medicines errors or omissions had not always been reported, and that there were not effective systems in place for ensuring the correct stock counts were in place. There were no actions taken when concerns had been found.

We found that staff did not always record people’s fluid intake where they needed full assistance to have drink, so the registered manager could not be assured that people received enough to drink across the home. People received

Two Acres provides accommodation for up to 115 people who require nursing and personal care. The home is situated in a residential area on the outskirts of the village of Taverham, near Norwich. The home consists of four separate units, named Iris, Lily, Rose and Fern, set in attractively landscaped grounds. Each unit has a number of single bedrooms with en suite facilities as well as communal sitting and dining areas. One kitchen supplies each unit with meals.

This comprehensive inspection included two visits to the home, which took place on 1 and 10 August 2016. The first visit was unannounced. The second visit was arranged with the registered manager to complete the visit and provide full feedback.

This home requires a registered manager as a condition of its registration. 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 2008 and associated Regulations about how the home is run. There was no registered manager in post. The provider had appointed a manager who had been in post for two years. They were in the process of submitting an application to CQC to register as manager of Two Acres. The manager was on holiday during our first visit to the home.

Staff had undergone training and were competent to recognise and report any incidents of harm. Potential risks to people and to their health were assessed, recorded and managed so that people were kept as safe as possible. Medicines were managed safely so that people received their prescribed medicines.

The provider had followed a recruitment process that ensured that required checks had been undertaken before new staff started work. There were not enough staff on duty to ensure that people’s assessed needs were met.

Staff had undertaken a range of training courses and received support so that most staff were equipped with the knowledge and skills to do their job well.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS), which apply to care services. People’s capacity to make decisions for themselves had been assessed. Appropriate applications had been made to the relevant authority to ensure that people’s rights were protected if they lacked mental capacity to make decisions for themselves. DoLS authorisations were handled well.

People were supported to maintain good health and their healthcare needs were met by the involvement of a range of healthcare professionals. People were not always given sufficient amounts of food and drink and the nutritional needs of people who required special diets were not always met.

There was a range of quality in the care provided. Most staff showed that they cared about the people they were looking after and treated people with kindness, warmth and compassion. Some staff did not show respect for people and people’s privacy, dignity and confidentiality were not always upheld. Visitors were welcomed to the home at any time.

Care records included care plans which gave staff guidance on how to meet people’s needs. Care plans were not always personalised and had not always been updated to reflect each person’s current needs. Staff were not always able to fully meet each person’s needs as they did not have enough time.

People and their relatives knew how to complain and complaints were responded to in a timely manner. Some activities, outings and events were arranged for people but people did not always have enough to do to keep them occupied and stimulated.

People and their relatives were encouraged to share their views about the service being provided to them in a number of both formal and informal ways. Staff were also given opportunities to share their views about ways in which the service could continue to improve. Staff understood the provi

Our inspection team consisted of two inspectors. We considered our inspection findings to answer the following questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found.

Is the service caring?

Through observations, inspection of records and talking with staff and management we found the staff and managers knew the people living there well and had ensured the care offered was correct for the individual.

We listened to respectful discussions that showed staff were acting in the best interest of the person they were supporting. Explanations on what was happening were given slowly and people were given time to understand.

Comments from relatives were positive. They told us the home was caring and that they would not want their loved one living anywhere else.

Is the service responsive?

At the last inspection the provider produced an action plan showing how the environment was to be improved. During this visit the action plan had almost been completed.

In care records we noted individual support from health professionals was gained quickly when a concern was identified. For example, we read referrals to dieticians or continence advisers within 24 hours of a record stating a concern.

Is the service safe?

The home was split into four separate units. Due to the complex needs of the people living there outer doors had a key pad locking system. In some units, where the people were more mobile, sensor equipment was used to monitor when someone was up and out of bed or when they moved through their bedroom door. This could be turned off when not required. Risk assessments were completed to ensure these were managed correctly and safely according to the need of the individual person.

The home had recently needed to work with the local safeguarding team and quality monitoring officer in the local authority. We spoke with one of these professionals who assured us that the situation of concern had been fully investigated and that people concerned were safe.

Walking around the home we did not see any concerns regarding environmental safety. Staff told us they had health and safety checks carried out and any damage or building concerns would be dealt with. Fire officers had visited the building in January 2014 and a few changes to the property were required. Door strips had been put in place and rewiring in one area was planned.

Is the service effective?

The four buildings were of varying sizes and shapes. According to their individual needs people are placed in the most appropriate building. For example, one unit had a much bigger lounge and dining area that could accommodate people in wheelchairs and specialist chairs. One unit was smaller but had better areas for people who were mobile and preferred to walk.

We noted that staff interaction and the methods used were effective when a person did not understand or was unwilling. This ensured that people who may challenge the need for care and support received that support appropriately.

Clear records of assessment, care needs, outside professional support and risks were tailored to meet the individual needs of the person the plans of care belonged to. This ensured they had the correct and effective support required.

Is the service well led?

Staff told us that the home had improved in recent months and that the manager listened to what was said. The manager told us she worked shifts on the staff rota to observe the work taking place on the units. This ensured any concerns or issues could be addressed quickly.

We read the complaints system records and noted that action to address complaints or concerns were timely and appropriate.

We read the most recent questionnaire sent to families who praised the service. Where some concerns were highlighted the manager had started to act upon them.

We spoke with staff who were happy with their work and felt they were supported well with training, supervision and guidance.

Throughout the inspection the manager gave us information and an understanding that assured us she knew the people and staff in the home well. A night manager had been introduced recently to ensure the night shifts were supported by management as well as during the day. The manager explained how this leadership had helped with the 24 hour service provision.

At our last inspection in May 2012 we identified concerns that included how the needs of people living with dementia in two of the home’s living units were met by their environment. At the time of this inspection we found that there were plans in place to close one of these units by the end of 2012. A refurbishment programme was in progress in the other unit in question. We were unable therefore to fully assess improvements made relating to the environment on this unit. However, we followed up our remaining concerns by visiting three of the four living units; by talking with staff, people and their visitors; by looking at the records of care and support and observing how people were supported by staff. We found that appropriate improvements had been made and, where improvements were ongoing there were arrangements in place to ensure that they were completed.

Visitors told us that they were happy with the care and support provided by the service and that people experienced a good range of meaningful activities. One person described the care as “…wonderful.” They said that the staff kept them "…up to date” with their relative’s progress.

Before our inspection we had received concerns from two people about the about the care needs of people living in the home not being met. These concerns related to personal care; activities; the use of communal spaces; staff attitudes; how people’s clothing was managed; the use of wheelchairs; how concerns raised were listened to or addressed; and staffing. We had also received some concerns from healthcare professionals about the support provided to one person to enable them to eat sufficient food to maintain a healthy weight.

During our visit we sought the views of visitors to the home. We were told that they felt involved in their relatives care planning and that staff were meeting their relatives needs commenting that “Staff are very kind and they are meeting mum’s needs as far as I am aware” . However concerns were raised from this visitor about the management of their relatives clothing, the activity provision and staffing levels.

We were unable to directly communicate with many people living at the home due to their cognitive impairments so we spent some time observing the care and support being delivered. Our findings demonstrated that staff were not always quick to respond to peoples needs and that people lacked social stimulation.

People who used the service, their representatives and staff were asked for their views about the care and treatment provided at the home. Feedback from relatives about the approachability of staff was positive. However, not all survey respondents were happy with the way people’s views were listened to and acted upon. An analysis of the survey also identified some areas for improvement.

We received information from an unnamed source, that staff were not able to deal safely with the challenging behaviour being displayed by a person living at the home. We were not given any names for the people about whom the source was concerned. We visited the service and looked at how they deal with people who had behaviour that challenged other people and staff.

We did not speak to people using the service during our visit on 02 December 2011. However, we spent time observing practice and speaking with staff. We also briefly spoke with visitors to the home.

We saw that people were relaxed and the atmosphere was calm. People were engaged in various activities and some people remained in their rooms. Some people were watching television. Where possible, people were moving about the unit independently. All areas of the communal space were in use. There was no planned activity taking place during our visit.

People visiting the home were satisfied with the care given to their relatives. One person said the care was “First class.” We were also told that they were “Made welcome” by staff. People were encouraged to be involved in their relative’s care. For example, relatives arrived at the home in time to help people to eat their meal.

Two Acres is registered to provide accommodation and nursing care for up to 115 people some of whom may be living with dementia or mental health problems. There are four units on the site; Rose, Lily, Fern and Iris. There were 96 people living in the home at the time of the inspection.

This unannounced inspection took place on 09 and 21 July 2015. The previous inspection was undertaken on 23 April 2014 and we found that the provider was meeting all the legal requirements that we assessed at that time.

 The current manager had been in post managing the service since December 2013 and was in the process of applying 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 provider’s recruitment process had not always been followed to ensure that people were only employed after satisfactory checks had been carried out.

The quality of care plans varied and didn’t always give staff the information they required to meet people’s needs. Not all care plans had been reviewed effectively to ensure that when people’s needs had changed the care plan reflected this.

The requirements of the Deprivation of Liberty Safeguards (DoLS) were being followed. This meant that where people were being restricted from leaving the home on their own to ensure their safety, this had been done in line with the legal requirements. However, not all staff had an understanding of the Mental Capacity Act 2005 (MCA) or how this should be applied.

People received their medicines as prescribed and safe practices had been followed in the storage, administration and recording of medicines. When there had been any errors in the administration of medicines these had been recorded and dealt with appropriately.

People felt safe and staff knew what actions to take if they thought that anyone had been harmed in any way.

There were enough staff available to meet people’s needs. Staff were kind and compassionate when working with people. They knew people well and were aware of their history, preferences, likes and dislikes. People’s privacy and dignity were upheld.

Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed. People were provided with a choice of food and drink that they enjoyed. Special diets were catered for.

There was a complaints procedure in place and relatives of people living in the home felt confident to raise any concerns either with the staff or the registered manager.

The manager obtained the views from people that lived in the home, their relatives and staff about the quality of the service and action was taken if any improvements were needed.

We found two 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.