We undertook a responsive inspection of Bentley Court on 17 and 19 December 2018. This inspection was unannounced on the 17 December 2018 and announced on 19 December 2018. This inspection was carried out as we had received concerns about people’s safety from partner agencies.

At our previous inspection of Bentley Court care home on the 9, and 18 July 2018 we found the provider had breached some regulations. These breaches were due to a lack of assurance as to people’s consent being sought and systems in place that should have ensured the quality of service provision not being effective. Following the last inspection, we asked the provider to complete an action plan to show what they would do to address these breaches of regulation. We received an action plan but at this latest inspection, despite some improvements, we found there was still a breach of regulation in respect of the service’s governance. We also found further breaches of regulation in respect of deployment of staff and ensuring person centred care was delivered.

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.”

Bentley Court is a ‘care home’. 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. Bentley Court can accommodate up to 77 people in one purpose built property. There were two units, one for people with nursing needs and one for people that lived with dementia and nursing needs. The care home also accommodates people under retirement age. There were 65 people living at the home when we inspected.

At the time of our inspection there was a registered manager (who was present 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. We were informed at the inspection that the registered manager had given notice and was leaving the provider’s employment the same week.

People were not consistently protected as risk assessments did not always show how risk to a person’s safety was best minimised. There were occasi

We carried out this unannounced inspection on 09 and 18 July 2018. Bentley Court Care Home is a care home with nursing. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

This inspection was prompted in part by a notification of an incident when a person using the service died. This incident is subject to an investigation and as a result we did not examine the circumstances of the incident. However, as part of this inspection we looked to see if the risk to other people because of this incident had been mitigated.

Bentley Court provides care and support for up to 77 older people who require nursing or personal care, and who may be living with dementia. On the days of the inspection 69 people were living at the home. Bentley Court has two independent units. The ground floor provides nursing care to people and the first floor provides nursing care to people primarily living with dementia.

Since our last inspection the home has a new 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.

Although staff knew people’s risks care records were not always up to date or reflective of people’s needs. During day two of our inspection the provider had acted to ensure there were sufficient numbers of staff available to meet people’s needs. People told us they felt safe and staff understood their responsibilities to raise concerns regarding potential abuse. People told us they received their medicines as prescribed. People were protected from the risk of infection.

Not all staff had the skills and knowledge to meet people’s care and support needs. Staff lacked knowledge about which people were subject to a Deprivation of Liberty Safeguards [DoLS] and the application of DoLS by the provider was not effectively maintained. Staff missed the opportunity to engage with people as they were often focussed on tasks. People received adequate amounts of food and drink. We saw evidence people were supported to access healthcare professionals when required. People were not always treated with dignity and respect.

People had access to some activities. Care records were not reflective of people’s needs. People knew how to raise concerns or complaints and the provider had a system in place to investigate concerns.

The provider’s quality assurance systems were not always effective at identifying and addressing issues of concern that may affect people’s safety. People’s feedback in relation to the quality of the service was being sought. The registered manager understood their responsibilities for reporting incidents or events that occurred at the service to CQC. People and staff were positive about the new registered manager and said they were open and approachable.

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.

This inspection was unannounced and took place on 09 and 10 October 2017; at the time of our inspection 71 people were living at the home. The provider is registered to accommodate and deliver nursing and personal care to up to 76 people. People who lived there may have needs associated with dementia, old age or a physical disability.

At our last comprehensive inspection in April 2017 we found the provider was in breach of Regulation 12 of the Health and Social Care Act in relation to medicines management. We also found that other areas required improvement including levels of staffing, the availability of personalised care and activities and the provider’s governance arrangements. During this our most recent inspection we found that the necessary improvements had been made to medicines management to meet the breach of the regulations. However there were some areas that showed that the necessary improvements were not fully embedded.

There was no registered manager in post at the time of our inspection. The newly appointed manager had commenced in post two weeks prior to our visit and was being supported by the Operations Director. 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 sufficient level of improvement had been made to meet the regulations and satisfy the breach from our inspection in April 2017; however we found that there were some areas of medicines management that could be further improvement. Staff demonstrated a good awareness of their role and responsibilities regarding protecting people and were confident a member of the management team would deal with any concerns reported. People had risks relating to the care and treatment assessed and staff had guidance to refer to about how these should be managed. Sufficient staff were on duty to meet people's needs and forthcoming rotas had addressed and reduced the use of agency staff. Staff were employed through safe recruitment practices.

People were assisted to maintain healthy nutrition but choices about food on offer were not made readily available to support and involve people. Staff were well supported though supervision, the availability and variety of training and the quality of the induction provided to them. Systems in place ensured people were not deprived of their liberty unlawfully and people were appropriately supported to provide consent for the care they received. People were supported to access a range of healthcare services.

People were supported to be comfortable and at ease and their care was provided with dignity and respect. Further work was needed in relation to how people’s sexuality was supported and explored as part of personalised care planning. People were supported by staff that were caring and respected their right to privacy. Staff treated people with dignity and respect. People and their representatives wherever possible were involved in making decisions about their care. Written information and contact numbers were not available for people about how to access and receive support from an independent advocate, although staff knew how to direct people.

People were actively supported to take part in a range of activities; in addition the environment had been improved in order to stimulate people’s interest. Staff demonstrated they were knowledgeable about people's individual needs and preferences. People's care records were written in a person-centred way and had been developed with the person or their relatives/representative. Complaints received by the provider were acknowledged, investigated and responded to complaints in line with their own policy.

The home had on-going governance issues and had failed to provide the necessary evidenc

This unannounced inspection took place on 11 and 12 April 2017. Bentley Court is registered to provide accommodation with nursing for up to 77 people. At the time of our inspection there were 68 people living in the home.

At our last inspection the home was rated as requires improvement in all the domains.

There was a registered manager, however, at the time of our inspection we were informed the registered manager had left and the home was being run by an interim manager who had started the day before our inspection and would be in post until a replacement could be found. 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.

Although people told us they received their medicine when they needed it, we found improvements were needed in the management of people’s medicine to ensure required medication was available so that people received their medicines as prescribed.

People told us there were times when there were insufficient staff to meet their needs. We saw there were sufficient staff available for people who chose to spend their time in the lounges however some people had to wait when they were nursed in their bedroom. People were supported by staff who knew how to manage risks to their health and safety and we saw staff put into practice their knowledge when supporting people. The provider operated a safe recruitment system which meant people were supported by staff who were suitable to work with vulnerable people.

People who lived at Bentley Court told us staff had been trained to meet their needs. Staff told us they received good training to help them support people and we saw them put into practice the training they had received. People’s rights were protected through effective use of the Mental Capacity Act. Where people were deprived of their liberty the provider had made the appropriate applications to the local authority for this deprivation to be authorised. People’s nutritional needs were met. People had access to other healthcare professionals when their health needs changed.

People told us staff respected their privacy and dignity. People told us they were supported by kind and considerate staff. We saw staff knew people well and positive relations had developed between people who lived at Bentley Court and the staff who supported them. We saw people had choices about their care, and staff respected the choices people made.

People told us and we saw people’s care was not always responsive to their individual needs. People did not have access to meaningful activities. People and their relatives were happy to raise complaints about the care they received and told us when they had complained they had been listened to.

The registered manager had left their post and where concerns had been highlighted action had not always been taken to ensure people got the care they required to meet their needs. Staff told us they were not always supported in their role. Prior to leaving the service the registered manager had given people and their relatives the opportunity to be involved in the running of the service. The provider had ensured that they had notified us of events that had taken place within the service.

During this inspection we found a breach 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.

The Inspection took place on 14 and 15 December 2015 and was unannounced. Bentley Court is registered to provide accommodation with nursing for up to 77 people. At the time of our inspection there were 68 people living in the home. This was the first inspection under the new provider who took over the home in May 2015.

At the time of our inspection the home had 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.

Medicines were not always managed safely. For example, people did not always get their medicines on time and medicine errors were not always recorded.

People told us and we saw there were insufficient numbers of staff to support people and keep them safe. Risks to people’s safety were not always managed appropriately.

People told us they felt safe. People were protected from the risk of harm because there were safe recruitment practices were in place to ensure staff were suitable to work in the home. Staff knew how to recognise and report any potential abuse.

People’s rights were not always protected. When people lacked capacity to make decisions for themselves the principles of the Mental Capacity Act had not always been followed. People told us they were supported by staff who had received appropriate training to meet their needs. Staff were supported in their roles and received training when they needed it.

People told us they enjoyed the food they received and that they were given choices at mealtimes. People who had special dietary requirements were catered for. People had access to outside healthcare professionals when their health needs changed.

Staff did not always have the time to spend with people and there were missed opportunities for interaction. People’s privacy and dignity was not always respected by staff.

People were not always supported to follow their leisure activities. We saw people were supported by staff who knew their individual needs and preferences but this was not always reflected in their care plan. People told us that they were encouraged to maintain relationships that mattered to them. People and their relatives knew how to complain. A system was in place to respond to people’s complaints when they had reason to complain.

Quality assurance systems were in place to improve the service for people however they were sometimes ineffective because they did not identify some of the shortfalls in the home. People told us that they were not always involved in the running of the home. Staff felt supported by the registered manager. We saw that that there was an open culture within the home.