Appletree Court Care Home is registered to provide accommodation for up to 77 people who require nursing or personal care and treatment of disease, disorder or injury. 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. There were 43 people living at the service on the day of the inspection. Most of the people who live there are over 65 years old but the service also supports younger people with disabilities. The inspection took place on 22 February, 26 February and 7 March 2018 and was unannounced.

At the last inspection on the 26 September 2017 we found six breaches of the regulations. We issued three Warning Notices for breaches of regulations in relation to meeting nutritional and hydration needs, governance of the service and staffing levels. The other three breaches related to lack of risk assessments and not always involving health professionals as required, safeguarding people from abuse and treating people with dignity and respect.

At the last inspection the service was rated Inadequate and the service was therefore in ‘special measures’. Services in special measures are kept under review. We undertook this comprehensive inspection to check on the progress made by the provider, and to consider whether the service could be removed from special measures, our framework to ensure a timely and coordinated response, where we judge the standard of care to be inadequate.

At this inspection we found progress had been made in meeting nutrition and hydration needs, and dignity and respect. In other areas such as staffing, risk assessments and governance of the service, limited progress had been made. We found additional breaches of the regulations in relation to person centred care and medicines.

At this inspection there was no 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.

There had been several changes in management personnel at the service since the last inspection. A permanently employed manager had taken up post from the end of November 2017. Whilst the service had worked to make improvements, the impact of numerous changes in personnel meant that outstanding management actions remained and this meant there were still issues with the quality of the care. At the time of the inspection actions were not always taking place following quality audits, and not all quality audits were taking place in keeping with the provider’s policy.

Staffing levels had improved since the last inspection, but there remained a period in the early evening when people’s needs were not safely met. People and their families told us staff worked hard and were busy.

Whilst the service had undertaken a significant number of risk assessments since the last inspection, there remained areas in which there were gaps in risk assessments. This meant staff were not always provided with guidance in how to meet people’s needs safely.

People told us that staff were kind and caring, but the lack of care plans in place meant that the service could not evidence they provided person centred care.

At this inspection we witnessed an unsafe practice in relation to medicines management, and the provider had yet to establish a system for reviewing people who were administered medicines covertly. Medicine administration records were completed in line with best practice, stocks corresponded with records and medicines were stored safely.

The provider had made progress in ensuring people’s hydration needs were met and recorded and we found fluid charts were in place and monito

This unannounced inspection was carried out on 26 September 2017. Appletree Court Care Home is registered to provide accommodation for up to 77 people who require nursing or personal care and treatment of disease, disorder or injury. There were 61 people living at the service on the day of the inspection. Most of the people who live there are older but the service also supports younger people with disabilities.

This is the first inspection since the service was registered to the new provider in November 2016.

At the time of the inspection there was a manager who had only recently joined the provider and had been working at the service for less than a month. Consequently they had not applied to be a registered manager at the service at the time of the 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.

Following the inspection the manager left the service and a peripatetic manager took over the day to day management of the service. This person had previous experience working for the provider in a ‘troubleshooting’ role, and is referred to throughout the report as the peripatetic manager.

People’s hydration needs were not always met, as records did not always accurately reflect what people ate and drank. People said they were content with the food provided and we saw people receiving food intravenously safely.

The provider was not always ensuring people were kept safe from harm or abuse as we found instances of people with unexplained bruising. The provider had not investigated the causes in a timely way to ensure people were not at further risk of abuse. People who were able to communicate verbally told us they felt safe living at the service.

There were risk assessments in place for some risks identified but there remained some areas including managing people’s behaviours where staff were not always given guidance on how to mitigate risks. We were concerned that people with behaviours that challenged the service were not always receiving appropriate attention as their behaviour charts were not always analysed and the provider had not always sought the advice or intervention of mental health professionals.

We found there were insufficient staff to meet people’s needs and this impacted on the quality of care provided to people.

The provider undertook quality audits but did not always follow through in a timely way on actions identified. This meant people were left at risk of receiving poor care.

The majority of people were positive about the staff. Whilst we found the majority of care staff did support people’s dignity and respect, we saw one person left in an undignified state for a period which was of concern.

People received health care for physical health issues and we saw where people had pressure areas remedial action was taken to improve this, with appropriate health support requested by the service.

There was an activities co-ordinator working at the service who arranged some activities but as the service was split over three floors this meant there were limited activities taking place. There was a well maintained garden at the service which people enjoyed sitting in.

Medicines including controlled drugs were stored and administered safely. The service was clean throughout.

Staff were safely recruited so were considered safe to work with vulnerable people.

The service was working with the local authority to ensure all the necessary documentation was in place where people’s liberty was being restricted.

We found the provider was in breach of six fundamental standards. These related to the safe care and treatment of people using the service, safeguarding people from abuse and staffing. The provider was also i