The inspection took place on 16 and 21 October 2018. Both days of the inspection visits were unannounced.

Canning Court is a purpose built home which is registered to provide residential and nursing care for up to 64 older people living with dementia. The home has two floors, a ground floor unit called Hamlet, and the first floor unit called Gower. Most people who lived at Canning Court had limited mobility and/or a diagnosis of dementia. At the time of our inspection there were 51 people living at Canning Court.

Canning 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.

Canning Court is required to have 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 and associated Regulations about how the service is run. At the time of this inspection, this service did not have a registered manager in post. A new manager had been appointed and had been in post for four months. The new manager was in the process of completing their application for registration with the CQC when we visited.

We previously inspected the service in June 2017 and the rating after that inspection was 'good'. This inspection was prompted following concerns from local commissioners which included information related to people falling, a lack of permanent staff and poor record keeping. During our inspection visit we found there were areas where the provider needed to improve the service. We changed the rating of the service to 'Requires Improvement'. We identified a breach of the regulations and you can see what action we have asked the provider to take at the back of the full version of the report.

On the first day of our inspection visit there were enough staff to keep people safe. However, there were often occasions when staffing levels as identified by the manager based on people’s assessed needs were not maintained, which impacted on the ability of staff to provide safe, responsive care. A lack of clarity around staffing levels meant senior staff were not aware of when they needed to follow the provider’s policies to report low staffing levels in the home.

The provider had systems in place for auditing the service to monitor and identify trends and better respond to risks to people using the service, but these had not always been effective and had not consistently identified risks to people living at the home. The provider was working towards a quality improvement plan in response to the concerns that had been identified.

The provider had taken action to improve the management of identified risks to people’s health and wellbeing. However, people in their bedrooms did not always have access to their call bells which put them at risk.

Staff monitored people’s health and referred them to other healthcare professionals if a need was identified. People received their medicines as prescribed and in accordance with good practice. The home was clean and tidy and staff followed good hygiene and infection control practices.

New staff had an induction into the home, however, the high turnover of staff meant the provider was constantly training new staff who needed time to gain the skills to provide effective care. Staff did not always feel supported but said their opportunity to speak to senior staff had improved recently.

People's consent was sought consistently by staff and the provider had made applications to the local authority for any restrictions that may be a deprivation of a person's liberty.

People were supported to eat and drink enough to maintain their health and staff were aware of those people who ha

We inspected this service on 6 and 9 June 2017. The inspection was unannounced.

Canning Court provides residential and nursing care to older people with dementia. It is a purpose built home which is registered to provide care for 64 people. the home has two floors, a ground floor unit called Hamlet, and the first floor unit called Gower. At the time of our inspection there were 61 people living at the home.

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.

This service was last inspected on 19 and 20 December 2016 and we found three breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. Procedures and processes to keep people safe were not always followed or effectively implemented, the deployment and management of staff did not ensure people who used the service were kept safe at all times and systems or processes were not robust, established and operated effectively to ensure people were consistently provided with a good quality service. We gave the home an overall rating of requires improvement. The provider sent us an action plan, setting out the actions they planned to take to improve the quality of the service. At this inspection we looked to see if the provider had responded to make the required improvements in the standard of care to meet the regulations. We found they had made improvements and they were no longer in breach of the regulations.

Since our previous inspection, the registered manager had recruited additional staff. There were enough suitably skilled and experienced staff on duty to meet people’s care and support needs safely and effectively. Staff felt more confident because the management of shifts had improved.

People felt safe living at Canning Court. The process to report potential safeguarding incidents to ourselves and the local authority safeguarding team had improved. Risks to people’s health and welfare had been assessed and care plans developed to minimise the identified risks. Staff understood how to support people identified as being at risk.

Staff had received training and felt this gave them the skills and knowledge they needed to effectively meet people’s needs. Staff particularly felt they had benefited from training that had given them the opportunity to understand the sensory experiences of a person who lived with dementia.

Staff worked within the principles of the Mental Capacity Act 2005 when supporting people with personal care. They sought people's consent and respected the decisions they made. The registered manager had applied to the supervisory body when it had been assessed that people did not have the capacity to understand the risks associated with any restrictions to their liberty.

People were supported to maintain a balanced diet according to their needs and to enjoy their meals. Staff monitored people’s weight and nutritional intake and referred them to other health professionals if they had any concerns. People were supported to take their prescribed medicines by trained staff.

People were supported by kind and caring staff who demonstrated a commitment to want to care and enhance people’s lives. Staff regularly worked with the same people so they knew them well and understood how they wanted to be cared for.

Care plans were detailed and reviewed regularly to ensure they met people's changing needs. Essential information was handed over between staff shifts so people's needs were met consistently and responsively.

People had opportunities to engage in activities that were of interest to them and improvements had been made in the social engagement with people who were cared for in bed.

The inspection took place on 19 and 20 December 2016. The first day of our inspection visit was unannounced. We told the manager we would be returning the following day.

Canning Court provides residential and nursing care to older people with dementia. It is a purpose built home which is registered to provide care for 64 people. The home has two floors, a ground floor unit called Hamlet, and the first floor unit called Gower. Most people who lived at Canning Court had limited mobility and all but one of the people had a diagnosis of dementia. At the time of our inspection there were 62 people living at Canning Court, which increased to 63 when another person was admitted on the second day of our inspection visit.

Canning Court is required to have 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 and associated Regulations about how the service is run. At the time of this inspection, this service did not have a registered manager in post. A new manager had been appointed and had been in post for seven months. The new manager was in the process of completing their application for registration with the CQC when we visited.

Whilst people generally felt safe living at Canning Court, some people expressed concern because other people would frequently walk into their bedrooms uninvited. We were told staffing levels were set by the provider based on an assessment of the level of care each person required. However, the assessment tool did not take into account the spacious layout of the home. The deployment and management of staff meant there were times when there were not enough ‘eyes and ears’ to monitor people safely as they walked around the home and interacted with each other.

Staff and the manager knew how to report allegations of abuse and previous safeguarding notifications showed the provider had acted as required. However, we identified occasions when people had been pushed over or hit by others which had not been reported to the local authority or ourselves as potential safeguarding incidents.

Medicines were managed safely and people received their prescribed medicines. Staff were responsive to fluctuations in people’s health needs and people had good access to health care professionals when required.

Staff received an induction and on-going training to carry out their role effectively. The manager had planned further dementia care training to provide staff with further skills and knowledge in this area. Staff told us they had opportunities to talk about their roles within the home at one to one meetings with senior members of staff.

Staff understood the principles of the Mental Capacity Act 2005 and assumed people had capacity to make everyday decisions. Staff sought people’s consent before supporting them. Mental capacity assessments had been completed where it was believed that a person did not have the capacity to consent to a specific decision.

The provider had identified people whose care plans contained some restrictions to their liberty and had submitted the appropriate applications to the authorising authority in accordance with the legislation.

People were treated with kindness and thoughtfulness by staff who knew them well. Staff understood people’s behaviours and attitudes and supported people as individuals which helped manage their anxieties, emotions and behaviours.

Staff employed to organise activities were able to provide opportunities for engagement and stimulation for people, but other staff had little time to respond to people’s social needs as they were busy completing other care tasks. People cared for in bed had little to do to keep them occupied or to stimulate them.

Many of the people who lived at Canning Court, whilst having a diagnosis

The inspection took place on 7 October 2014. It was an unannounced inspection.

Canning Court provides residential and nursing care to older people with dementia. It is a purpose built home which is registered to provide care for 64 people. The home has two floors, a ground floor unit called Hamlet, and the first floor unit called Gower. People who lived at Canning Court had limited mobility. At the time of our inspection there were 61 people living at Canning Court.

Canning Court is required to have 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 and associated Regulations about how the service is run. At the time of this inspection, this service did not have a registered manager in post and had not since June 2013. An interim manager had been in post for one week at the time of our visit and the process for completing their registration application to the CQC had started.

People who lived at Canning Court, relatives and staff told us they thought people were safe. There were systems and processes in place to protect people from the risk of harm. These included robust staff recruitment, staff training, a safe environment and appropriate equipment. Risks to people were minimised because they received their care and support from suitably qualified staff in a safe environment that met their needs.

People told us staff were respectful and kind towards them. We observed staff were caring to people throughout our visit. We saw staff protected people’s privacy and dignity when providing care to people.

People told us there were enough suitably trained care and nursing staff to meet their individual care needs. There was a system in place that reallocated staff to ensure people’s needs continued to be met. We saw staff spent time with people, provided assistance, support and reassurance to people who needed it.

Staff understood they needed to respect people’s choice and decisions if they had the capacity to do so. Assessments had been made and reviewed about people’s individual capacity to make certain care decisions. Where people did not have capacity, decisions were taken in ‘their best interest’ with the involvement of family and appropriate health care professionals. This meant the service was adhering to the Mental Capacity Act 2005.

The provider was meeting their requirements set out in the Deprivation of Liberty Safeguards (DoLS). We found the provider did not notify the Care Quality Commission when referrals had been approved. The Area Manager told us they would ensure future approvals were notified to us.

People’s health and social care needs had been appropriately assessed. Care plans provided accurate, detailed and up to date information for staff to help them provide the individual care people required.

There was a safe and effective procedure in place for managing people’s medications safely.

There were systems in place to monitor and improve the quality of service people received. The recently appointed manager had identified areas that required improvements. We saw plans were in place to ensure the effectiveness of regular checks would be maintained. Staff told us they felt supported by colleagues and managers and if they had any concerns, these would be listened to and acted upon.

We met with ten people who lived at Canning Court. Due to the complex needs of people, some were unable to verbally share their experiences of what it was like to live at the home.

We spoke with three relatives and one visiting professional to obtain their views about Canning Court. We also spoke with the regional manager, the nurse in charge, the cook, three care staff and the administrator.

We observed staff interaction and talked with care staff about how they met the needs of people they supported.

Staff demonstrated a clear understanding of people's needs and engaged with people in a positive manner. People appeared relaxed and happy in the company of the staff and were not hesitant when they approached them.

We saw consent to care had been obtained for people who lived at the home.

Most of the relatives we spoke with told us they were happy with the care at Canning Court.

We looked at the care planning documentation and we found that care plans were very detailed and demonstrated that staff treated each person as an individual based upon their needs.

Staff told us they were supported by the manager and had access to regular training.

We saw that systems were in place to monitor the quality of the service.

We went back to Canning Court Nursing and Residential Home to follow-up on progress made against the two compliance actions we identified during the May 2012 visit to the home. Concerns relating to staff shortages, the impact on people's care and involvement in prearranged activities had been identified. Some environmental risks which could put people at risk were also found.

Discussions with staff and people's relatives confirmed staffing levels had improved. We were told that care worker recruitment had been successful. The home was continuing to advertise for some trained nursing staff. Staff confirmed they were happy and felt supported by the new manager.

During the inspection we toured the home to ascertain whether the areas identified as requiring development had been actioned. These areas related to the availability of hoist slings, garden maintenance, equipment storage and high environmental temperatures in the kitchen and laundry areas.

We found the garden had been well maintained. Hoist slings had been identified for people requiring them and an order placed for additional slings to allow people to have their own and avoid cross infection. The BUPA regional manager confirmed that improved storage for equipment was being put in place. We saw temperature monitoring of both the kitchen and laundry facilities had taken place. We were told a BUPA senior manager meeting was due to take place to identify the way forward in relation to this issue.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke with the relatives of five people using the service; ten staff from the home and reviewed the Autumn 2011 home survey.

Two people’s relatives described experiences at the home as it has ‘‘got better as time has passed and everyone’s great!’‘ and ‘‘I think it is getting better!’‘ One person said since the arrival of the new manager in May 2012 things had improved.

Relatives told us they had been able to express their views and had been involved in making decisions about their relative’s care and treatment. Three relatives said they had attended two-monthly meetings held at the home where they had been able to identify any concerns.

A number of concerns were raised by both staff at the home and relatives in relation to staffing levels at the home at night and during the afternoons. Some nursing staff and carers said that although they had identified concerns relating to staff shortages these had not been reported through the home‘s incident reporting system.

When we visited Canning Court we were able to speak with one person who was using the service and eight relatives. Family members and friends of the people using the service are welcome to visit them at anytime and we had brief discussions with people who were visiting at the time.

The one person using the service that we spoke with told us that staff cared for them ‘nicely’ and that staff were ‘kind’. They told us that ‘generally’ they could go to bed when they wanted to but usually got out of bed early in the morning as they had to take some medication at a specific time. They told us they liked the food but they usually ate their meals in their bedroom as it could be noisy in other areas of the home.

Most people using the service were not able to talk to us about their care because of their health condition, however when we spoke to them about this they smiled and nodded. People were smartly dressed and well groomed, although some people walked around the home without their shoes or slippers on. This was mostly due to their mental health and not being able to recall where they had placed their footwear. We noted care workers on occasion promoting people to wear their footwear.

People in general, although in some cases distressed by the effects of their condition, appeared to be comfortable in their surroundings and with the attentions of the staff.

Most relatives we spoke with were complimentary about the care provided to their family member. They told us that staff ‘worked hard’,were ‘caring’ and that care of people’s clothing had improved.

Relatives told us that they had opportunity to discuss any concerns about the care delivered with the manager at their relatives meetings. One relative told us, ‘Relatives meetings have given us a bit of a voice. Some things have been attended to but not everything.’ One relative told us ‘we are listened to but things are still hectic’.

Many relatives we spoke with felt that there had been improvements in the home over the past few months. One person told us, ‘It is better, although I am not sure they are managing drinking, falls and diabetes.’ Other comments from relatives we spoke with included,

‘We are notified if there is any trouble’.

‘The home is clean, they eat and drink well’.

‘Could do with more people to look after them – not a complaint, just feel it would be a good investment’.

Many people living in the home had little communication; this was because of their condition and care needs. Some people smiled and nodded their heads when we asked them what it was like living at Canning Court.

We spoke with relatives who told us they were happy with the care their family member was receiving. People told us the staff at the home kept them informed about their family members care. People felt they could discuss any concerns they had about the care service.

People told us the staff always treated their family member well and that their privacy was respected. People were complimentary about the home's environment, the staff that worked at the home and the quality of the food.

Relatives told us that they were happy with the care support in the home. They told us the staff listened to people using the service and spent time with them, talking and carrying out activities, as well as providing care.

Some relatives told us about the concerns they had about people being vulnerable at mealtimes. They were worried that their family member may not have staff support to eat their meals as staff were busy at mealtimes supporting people with difficult behaviours.

Some people were concerned about the way their clothing was being laundered.

Comments from people who use the service about the standards of care and support and their experiences included:

'Very pleased. Rate the care as excellent, he is happy.'

'Some staff do miss the little things like switching the light on when it gets dark.'

'We have no concerns about the care and staff are very caring.'

'Care – generally no concerns.

'The kitchen try hard, more fruit & veg would be nice. We have afternoon cakes and fruit in the summer.'

'Good food.'

'The food is a bit repetitive, could do with meat & veg but there is always a choice at mealtimes and a roast dinner on Sundays.'

'Could do with a choice of dining room so I can sit at a table with my relative when they are eating – too noisy in the current dining room.'

'Staff are good.'

'Staff are helpful and kind.'

'Staff are fantastic.'