This inspection took place on 7 and 12 September 2018. The first day of the inspection was unannounced. This meant the staff and provider did not know we would be visiting.

Covent House is a ‘care home’. 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.

Covent House accommodates 63 people in one purpose built building. The home has five floors, four of which provide accommodation for people with nursing and personal care needs. Some of the people using the service were living with dementia.

The service did not have a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like 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 new manager was in post who had applied to be registered with CQC.

Covent House was last inspected by CQC on 1 August 2017 and was rated Requires improvement. At the inspection in August 2017 we identified the following breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 11 (Need for consent), Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment) and Regulation 17 (Good governance).

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Effective, Responsive and Well-led to at least good. At this inspection we found improvements had been made in all the areas identified at the previous inspection.

Accidents and incidents were appropriately recorded and investigated. Risk assessments were in place for people who used the service and described potential risks and the safeguards in place to mitigate these risks.

The manager and staff understood their responsibilities with regard to safeguarding and had been trained in safeguarding vulnerable adults.

Medicines were stored safely and securely. Procedures were in place to ensure people received medicines as prescribed and regular audits were carried out.

The home was clean, spacious and suitable for the people who used the service. Appropriate health and safety checks had been carried out.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant vetting checks when they employed staff. Staff were supported in their role via appropriate training and regular supervisions.

People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

People were protected from the risk of poor nutrition and staff were aware of people’s nutritional needs. Care records contained evidence of people being supported during visits to and from external health care specialists.

People who used the service and family members were complimentary about the standard of care at Covent House. Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

Care records showed that people’s needs were assessed before they started using the service and support plans were written in a person-centred way. Person-centred is about ensuring the person is at the centre of any care or support and their individual wishes, needs and choices are taken into account.

Activities were arranged for people who used the service based on their likes and interests, and to help meet their social nee

The inspection of Covent House commenced on 1 August 2017 and was unannounced. A second day of inspection took place on 2 August 2017 which was announced.

The inspection was prompted in part by a historical notification of an incident following which a service user may have sustained a serious injury. During the inspection the Commission became aware of a further incident were a service user died. As such a third day of inspection took place on 5 September 2017 to ensure the immediate safety of service users. These incidents are subject to criminal investigation and as a result this inspection did not examine the circumstances of the incidents.

However, the information shared with CQC about the incidents indicated potential concerns about the management of safeguarding concerns and medicines. This inspection examined those risks.

We last inspected Covent House on 17 June 2015 and found it was meeting all legal requirements we inspected against. We rated Covent House good in all domains at that time.

Covent House is registered to provide accommodation for up to 63 people who need nursing and personal care. It provides a service primarily for older people, including people living with a dementia related condition.

At the time of the inspection there were 57 people using the service.

The service did not have a registered manager. The current manager had been in post for five weeks prior to the inspection and had submitted an application to the Commission to be registered. The previously registered manager had left their post on 29 July 2013 but had failed to cancel their registration. Managers had been in post during this time but had not registered with the Commission.

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.

During the inspection we found areas of concern which constitute breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely safe care and treatment, safeguarding service users from abuse and improper treatment, the need for consent and good governance.

Medicines were not always managed safely for people and records had not been completed correctly.

A recent safeguarding incident had identified failings in relation to risk management, communication, documentation and training. Improvements were being implemented at the time of the inspection.

People were not consistently supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. This meant there was a failure to follow the principles of the Mental Capacity Act (2005) in relation to mental capacity assessments and best interest decisions.

Accurate, complete and contemporaneous records in respect of each person’s care and support had not always been maintained.

The provider’s quality assurance systems had not identified the concerns in relation mental capacity assessments, best interest decisions and some care documentation.

We have made a recommendation about the planning and assessment of care.

Complaints were investigated and there was a record that complainants were satisfied with the outcomes and action taken. The management of one complaint, with regard to a specific safeguarding incident, was being investigated.

The manager completed weekly audits, in addition to walk around checks and audits of medicines, the dining experience and care records. The head of compliance also completed an audit. An action plan was in place which had resulted in some improvements.

The manager had a strong leadership style with a positive vision for the future of Covent House. Staff were complimentary of th

We inspected Covent House on 17 June 2015 and the visit was unannounced. We last inspected the service in January and February 2015. At that inspection, we found breaches of legal requirements in five areas; management of medicines, consent to care and treatment, assessing and monitoring the quality of service provided, safeguarding people who use services from abuse and staff recruitment practices. We asked the provider to take action to make improvements and they told us they would be fully compliant with the regulations by 15 May 2015. On this visit we found improvements had been made in all of the regulations that had been previously breached and the registered provider was now meeting current regulations.

Covent House is a care home which provides nursing and residential care for up to 63 people.

Care and support is provided for older people, some of whom are living with a dementia related condition. At the time of the inspection there were 55 people living at the service.

The service did not have a registered manager, as the manager who had been in post since February 2015, was awaiting the outcome of their application for CQC registration. 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.

Employment procedures now ensured that appropriate recruitment checks were undertaken to determine the suitability of individuals to work with vulnerable adults. Appropriate risk assessments had now been completed following Disclosure and Barring Service (DBS) disclosures.

Improvements had been made to the management of medicines. Medicines records were accurate, complete and medicines were managed safely. People’s medicines were stored securely.

People using the service told us they were well cared for and felt safe at the home and with the staff who provided their care and support.

The home was clean, tidy, well maintained and no unpleasant odours were evident in any part of the home. The home was well appointed, furnished and decorated. It was also suitable and adapted to meet the needs of people living with a dementia related condition.

Staff members had a good understanding of safeguarding adult’s procedures and knew how to report concerns. A whistleblowing policy and information was available for staff to report any risks or concerns about practice in confidence within the organisation.

Staffing levels were sufficient to meet people’s needs. Staff were attentive when assisting people and responded promptly to requests for assistance or help. Risk assessments were in place to ensure risks were assessed and appropriate support, treatment and care was identified.

Accidents and incidents were reviewed and analysed regularly to identify possible trends and to prevent reoccurrences. Duty managers were available out of hours for advice and in the event of a crisis. Detailed and up to date personal emergency evacuation plans described how people should be evacuated from the home in the event of an emergency.

Improvements had been made in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Detailed information was available for staff. The requirements of MCA were followed and DoLS were appropriately applied to make sure people were not restricted unnecessarily, unless it was in their best interests.

All new staff received appropriate induction training and were supported in their professional development. People received care from staff who were provided with effective training to ensure they had the necessary skills and knowledge to effectively meet their needs. Staff received regular supervisions and annual appraisals were carried out.

People were asked their permission and offered choices before care or support was delivered. People were supported to make sure they had enough to eat and drink and their nutritional needs were met to ensure they stayed healthy. They told us they enjoyed the food prepared at the home and had a choice about what they ate.

People were supported to have access to healthcare services and referrals had been made to health professionals for advice and guidance where required.

People spoke positively about living at the home and told us staff treated them well. We observed warm, kind and caring interactions between staff and people. Staff were patient, unhurried and took time to explain things to people clearly.

Staff acted in a professional and friendly manner and treated people with dignity and respect. We observed staff supporting people and promoting their dignity. Staff regularly checked on people to see if they needed support or assistance. There was a warm, calm and relaxed atmosphere throughout the home. Staff interacted and had a good rapport with people.

People’s relatives were involved in the care and support of their family member. Care records confirmed the involvement of people in care planning and reviews.

Relatives we spoke with told us communication with the service was very good. Advocacy information was accessible to people and their relatives. Surveys were undertaken and people’s feedback was acted upon.

A complaints policy and procedure was in place. People and their relatives felt able to raise any issues or concerns. Complaints received by the service were dealt with effectively and the service had recently received a number of compliments.

People’s care records were up to date and accurate and were detailed from pre-admission to present day. They contained up to date and accurate information on the needs and risks associated with people’s care. Health and social care professionals were involved in the review process where applicable.

Care staff were responsive to the needs of the people they cared for and supported. People and their relatives told us regular activities were organised throughout the home. We noted a comprehensive activities and entertainment programme was available. Regular meetings were held for people and their relatives.

The service was well-led. The service had recently appointed a new manager who had applied for registration with the Care Quality Commission. People, their relatives and staff all told us noticeable improvements had been made to the running of the home which had made a positive impact on the quality of service provided. They also told us the manager was approachable, supportive and listened to suggestions made to improve the service.

Up to date and accurate records were kept of equipment testing. Other equipment and systems were also subject to checks by independent assessors or companies. Management regularly checked and audited the quality of service provided and made sure people were satisfied with the service, care and support they received.

The manager had formed links with other organisations to improve their knowledge, share good practice, and ensure the home was up to date with current national best practice standards and improve the overall care people received. This had helped improve everyone’s understanding and awareness of dementia related conditions.

A monthly newsletter had been introduced to keep people, their relatives and staff up to date and informed about forthcoming events and items of interest. A reward scheme for staff was in place to acknowledge good performance and reward their accomplishments.

We received positive feedback from people, their relatives and staff about the management team and how the service was managed and run. Staff meetings were held regularly. Staff were asked their opinions in an annual satisfaction survey.

People were positive about the care provided at Covent House. Comments included,

"I am looked after very well here", "The staff are very good to my mother” and “If I need anything I get it”.

We saw people were cared for effectively and care was planned to meet the needs of individuals.

We found there was sufficient qualified and experienced staff on duty to provide care and support for people.

We found records were accurate and up to date. They were secure and stored appropriately.

We carried out this inspection after we were told about concerns regarding the service.

We found people had received inappropriate or unsafe care as the planning and delivery of care did not ensure people's welfare and safety. We found people's personal care needs had not been met.

There was not enough staff to meet people's needs. We found during staff breaks there was often only one member of staff available on a floor to provide care for people.

We found people's personal care records were inaccurate and up to date. People had not been protected from the risks of unsafe or inappropriate care because accurate and appropriate records had not been maintained.

We found the provider had taken appropriate measures to ensure that the environment was suitably designed and adequately maintained for people to live and work in.

Some people we spoke with told us they were happy with the care provided. One person said, “I couldn’t ask for more, the staff are lovely. I’m well helped.” A relative said, “The care is very good.” However some people did raise concerns with us. One relative said, “I’m not convinced she gets bathed as much as she would like. That’s where they fall down".

Following this inspection and prior to the issue of this report the provider sent us an action plan which described the action to be taken to address the issues identified at this visit. In this action plan the provider told us they would be compliant by the 31st October 2013.

Staff promoted choice and obtained consent before offering personal care. Family members and care professionals helped with decision making. People received the care they needed and said they were happy with this. One person said, “Everything’s super, I love the place.” A relative told us, “If anything happens they’re straight to hospital, no messing.”

We observed people being cared for with compassion, dignity and respect. Staff were busy, but well organised. Some people stated the home would benefit from more staff on duty. Staff said they were sufficiently resourced. There was a calm and relaxed atmosphere.

Equipment was available on all floors to help meet people’s care needs. We found equipment had been serviced to keep it safe.

People told us they were happy with the staff who worked with them. One person stated, “The staff are all lovely.” Another comment was, “The staff are very good.” Visiting relatives we spoke with made similarly positive comments. These included the comment, “I respect the staff, they work very hard.” We found pre employment references and other checks were in place before staff started work here.

People told us they knew how to complain and were confident any concerns they might have would be looked into and addressed. One comment we heard was, “If anything’s not right I’d speak to the girls or the manager … things are going alright.” We checked relevant records and found complaints were acknowledged, investigated and responded to.

We used a number of different methods to help us understand the experiences of people using the service, because some people using the service had complex needs which meant they were not able to tell us about their experiences of using the service.

We observed care; spoke to six people who use the service, two visiting relatives, three visiting professionals and six members of staff. We also reviewed care records for people using the service.

We saw good examples of personal choice and care provided by staff. We saw that people were safe and protected from abuse. We reviewed records which showed the provider effectively monitored the performance of the home. We found that the staff at the home was suitably experienced and qualified and that the staffing levels at the home were sufficient to meet the needs of the people who use the service.

One relative we spoke to said the service was, "Absolutely fantastic, anybody could take anybody into there" and” The staff are extremely caring. I just come in anytime and staff are always the same. Some of them are so caring I would give them a gold medal if I could."

This inspection took place over three days, 27 and 29 January and 9 February 2015. The first two days of the inspection were unannounced. We last inspected Covent House in October 2014 as we had received anonymous concerns. These related to staffing levels at the home. We found the home was meeting all the regulations that we inspected.

Covent House is registered to provide accommodation for up to 63 people who need nursing and personal care. It provides a service primarily for older people, including people living with dementia. At the time of the inspection there were 56 people living at Covent House.

The previous registered manager had left the home in February 2014 and was no longer managing the regulated activities at the location. However they were still a registered manager on our register at the time of the inspection. A proposed registered manager had been in post since April 2014; however they left the service in November 2014 prior to registering with the commission. 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 told a new manager had been recruited and was due to commence their employment in February 2015.

Staff recruitment practices at the home did not always ensure that appropriate recruitment checks were carried out to determine the suitability of individuals to work with vulnerable adults, placing service users at risk of harm. Satisfactory reference had not been conducted, information on application for employment forms was incomplete. Where DBS disclosures revealed details of convictions, cautions, reprimands, final warnings or other information, a risk assessments of the applicants’ suitability to work with vulnerable adults had not been undertaken. Security checks had been made with the Disclosure and Barring Service (DBS) and these checks help employers make safer recruitment decisions and prevent unsuitable persons working with vulnerable people.

People’s medicines were stored securely. However we found that medication records were inaccurate and the service’s arrangements for the management of medicines did not protect people.

Staff understood what abuse was and knew how to report abuse if required. We also noted the service had a whistleblowing policy. This meant staff could report any risks or concerns about practice in confidence with the provider.

We saw staffing levels were appropriate. We noted there were sufficient staff to provide a good level of support to people and to meet their needs. People using the service told us they were well cared for and felt safe with the staff who provided their care and support.

We found that there was limited understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) so that the code of practice was not applied consistently, or appropriately. This meant people were at risk of their human rights to make particular decisions was being denied to them. The service did not follow the requirements of the Mental Capacity Act 2005 (MCA). MCA assessments and ‘best interests’ decisions had been undertaken by the relevant supervisory body where there were doubts about a person’s capacity to make decisions.

The providers’ representatives were aware of the legal changes widening the scope of DoLS. However, they told us that at the time of the inspection people had not been assessed. We saw for a number of people living in the home, a ‘Deprivation Checklist’ had been completed. We noted this was prior to the legal changes and therefore did not encompass new guidelines relating to DoLS.

All new staff received appropriate induction training, received the training they needed and were supported in their professional development. However, we found that regular supervision sessions and appraisals were not currently being conducted.

Staff were knowledgeable about their roles and responsibilities. They had the skills, knowledge and experience required to support people with their care and support needs. People were also supported to make sure they had enough to eat and drink and told us they enjoyed the food prepared at the home and had a choice about what they ate.

People were supported to keep up to date with regular healthcare appointments. We noted where referrals were needed for external professionals to support people; this was done in a timely manner.

Meetings for people using the home and their relatives were currently not being held. The last relative’s meeting was last held in November 2014 and no further meetings had been held, as relatives had been informed they would recommence when the new manager was in post at the end of February 2015. Advocacy information was not always easily accessible to people and their relatives. Advocacy ensures that people, especially vulnerable people, have their views and wishes considered when decisions are being made about their lives.

Relatives told us they were involved in the care and support their family member received. Care records confirmed the involvement of relatives in care planning. This helped ensure that important information was being communicated effectively and care was planned to meet people’s needs and preferences.

Staff acted in a professional and friendly manner and treated people with dignity and respect. We observed staff supporting people and promoting their dignity wherever possible.

People told us that staff treated them well and we observed kind and caring interactions between staff and people using the service.

A complaints policy and procedure was in place and people told us they felt able to raise any issues or concerns. However, we found the provider’s policy was not always followed. We found complaints were not accurately recorded. We also found there was no evidence available to confirm some complaints had been investigated, resolved, or any response had been provided to the complainant.

Care plans were regularly reviewed and evaluated. We saw health and social care professionals and relatives were involved in the review process where applicable.

People and their relatives were complimentary about the range of activities available at the home and we noted the service had recently received a number of compliments, which included, “We've found the staff to be helpful, compassionate and very effective,” “I appreciate the care and support they gave her,” and, “'I feel very comfortable knowing he is being well looked after.”

Quality monitoring systems currently being used did not always ensure the service was operating safely and effectively. Quality assurance audits were not being undertaken. A medicines audit recently conducted had failed to identify discrepancies and shortfalls identified in the service’s management of medicines.

The provider was not considering best practice in relation to meeting the needs of people using the service.

Care staff we spoke with told us the current management team were approachable and there had been noticeable recent improvements at the service. The majority of staff we spoke with said they felt equipped and supported to carry out their role.

During our inspection we identified a breach in five regulations. You can see what action we told the provider to take at the back of the full version of this report.