Dene Court is registered to provide accommodation with personal care for up to 28 people who may have needs due to old age, sensory impairment, physical disabilities, dementia, learning disabilities, autism or mental health needs. 24 people were living in the service at the time of the inspection. 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.

At the inspection of the home carried out in November 2015 we found breaches of regulations. The service was then rated as 'inadequate' and placed into special measures. The special measures process is designed to ensure there is a timely and coordinated response where we judge the standard of care to be inadequate.

At the next comprehensive inspection of the service in April 2016, we found significant improvements. There were no breaches of legal requirements at that inspection, but there had been insufficient time for new management systems to be embedded. Therefore we rated the service as ‘requires improvement’.

On 31 August 2017 and 5 September 2017 we carried out an unannounced focussed inspection to look specifically at the safety of the service and to check that improvements had been maintained. We confirmed this was the case and the service was safe.

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. They, along with the provider were committed to the improvement and development of the service and had continued to make significant changes which had a positive impact on the safety and quality of the service.

At the inspection in April 2016 we found the quality monitoring systems in place to ensure the home ran smoothly were not yet fully established. At this inspection we found there was a comprehensive system of audits in place which scrutinised all aspects of service provision and the environment. People, relatives and staff were invited to express their views of the service through satisfaction surveys and at staff and residents meetings. The information from the quality assurance processes was used to drive improvements at the service.

There were systems in place to ensure risk assessments were comprehensive, current, and supported staff to provide safe care whilst promoting independence. The computerised care planning system, accessed by staff using hand held computers, ensured that information about people’s risks was shared efficiently and promptly across the staff team. This meant staff had detailed knowledge of people’s individual risks and the measures necessary to minimise them. Care plans were comprehensive and reviewed monthly; however we had mixed views from people and their relatives about how the service involved them in this process and decisions about their care. We raised this issue with the registered manager who was already looking at ways to improve communication with families and provided reassurance they would take action to involve people and their relatives more in reviewing their care plans.

People had mixed views about the food at the service. Most said they enjoyed the food, but would prefer more choice. People had sufficient to eat and drink and received a balanced diet, and care plans guided staff to provide the support they needed. The service supported people with special dietary needs, for example a diabetic or pureed diet. However one person expressed concern about the availability of food appropriate for their specific dietary needs and staff understanding of their condition. The registered manager told us they had been working with the pe

We carried out an unannounced focused inspection on 31 August 2017 and 5 September 2017 to look specifically at the safety of the service.

Dene Court is registered to provide accommodation with personal care for up to 28 people who may have needs due to old age, sensory impairment, physical disabilities, dementia, learning disabilities, autism or mental health needs. At the time of this inspection there were 27 people living there, which included two people on a respite stay.

At the inspection of the home carried out on 10 and 13 November 2015 we found breaches of regulations. The service was then rated as 'inadequate' and placed into special measures. The special measures process is designed to ensure there is a timely and coordinated response where we judge the standard of care to be inadequate.

The last inspection took place on 4 April 2016 when we found significant improvements. There were no breaches of legal requirements at that inspection, but we were concerned there had been insufficient time for new management systems to be embedded. Therefore we rated the service as ‘requires improvement’.

We carried out this focused inspection to check that improvements had been maintained. We also wanted to ensure people were receiving safe care following anonymous concerns shared with us about the quality and safety of the service. Prior to the inspection the provider had investigated the concerns and provided reassurances that people were not at risk. At this inspection we confirmed this was the case and found the service was safe.

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.

The registered manager, and the provider, had worked constructively with the local authority quality assurance and improvement team to improve the quality and safety of the service. A comprehensive service improvement plan had been developed which demonstrated that improvements had been made in a range of areas including care plans and risk assessments, recording, safe staffing levels, environmental safety, quality assurance and the development of an open and transparent culture where people, relatives and staff would feel able to raise any concerns.

The staffing structure at Dene Court provided clear lines of accountability and responsibility. The registered manager was very visible in the home and proactive in observing and monitoring the quality and safety of the care provided. Quality assurance systems were comprehensive and ensured the service met people’s needs safely and effectively.

People told us they felt safe living at Dene Court. A relative said, “I’m very grateful my family member is somewhere safe.” Staff had the knowledge and skills required to meet people’s needs, and sought specialist advice from external health and social care professionals where necessary.

There were sufficient numbers of staff to keep people safe. During the inspection we saw that in addition to supporting people with tasks and daily routines, staff spent time sitting and chatting with people. The registered manager told us they now had a stable staff team, which meant agency staff were no longer needed. People therefore received consistent support from familiar staff who knew them well.

People were protected from the risk of abuse through the provision of policies, procedures, robust recruitment and staff training.

Risks in relation to people’s physical and mental health were assessed, monitored and managed well. Risk assessments were comprehensive and reviewed regularly. They provided clear guidance to enable staff to meet people’s needs according to their individual needs and preferences, promoting their rights and indep

This inspection was unannounced and took place on 4 April 2016. The inspection was carried out by two inspectors. The previous inspection of the home was carried out on 10 and 13 November 2015 where we found breaches of regulations. These related to the safe care and treatment, care and welfare of people who use services, assessing and monitoring the quality of service provision, consent to care and treatment, and records. The service was rated as ‘inadequate’ and placed into special measures.

Dene Court is registered to provide accommodation with personal care for up to 28 older people. At the time of this inspection there were 20 people living there (one person was in hospital). . There was a manager in post who was not yet registered. They have submitted an application for registration and we are currently processing this. 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 found significant improvements in all aspects of the management of the service since the last inspection. There had been input from the local authority safeguarding team, the commissioning team and the Quality Assurance and Improvement Team (known as QAIT) since the last inspection. These professionals had closely monitored the home and provided training and support to help the provider and management team establish effective care and management systems. We have been kept informed and updated about progress towards achieving the provider’s action plan. Staff and people living in the home told us the home was now well-managed.

Improvements had been made in all aspects of safety. While we were satisfied the home was safe and fully compliant in all areas of safety at the time of this inspection we have yet to see that safety standards have been embedded and can be sustained.

Risks to people’s health and safety had been assessed, monitored, and there were systems in place to ensure risks were minimised where possible. At the last inspection we found people experienced a high number of falls. During this inspection we found the incidence of falls had decreased significantly. This was due to a number of factors, including improved monitoring of fluid and food intake levels, increased staffing levels which meant staff were able to monitor people’s whereabouts more closely, and increased activities and stimulation. Where people had previously experienced anxiety or displayed aggression the staff had worked closely with relevant professionals to find solutions, and we saw examples where this had resulted in positive benefits for people.

New staff had been employed following safe procedures. Staffing levels had increased and this meant there were sufficient staff to meet each person’s needs safely. People received care and support from a staff team who had received relevant training and qualifications. Staff had the knowledge and skills needed to enable them to meet each person’s mental and physical health needs. Communication systems had improved and staff were kept well informed about any changes to people’s needs through staff meetings and handover sessions between each shift. Staff received supervision regularly in line with the provider’s supervision policy. Staff told us they were well supported and there were good systems of communication.

Staff knew how to recognise possible abuse, and the actions they should take. They were confident any suspicions of harm or abuse would be listened to and acted upon appropriately. Staff told us “It’s so much better here. We feel we can do a good job and keep people safe and the work is more rewarding.”

People’s social needs had been assessed and actions had been taken to provide activities and social stimulation for each pe

We found that that the concerns we raised about some aspects of medicines handling at our last inspection on 1 November 2012 had been acted upon. Medicines were stored safely and in line with current legal requirements. Suitable arrangements were in place for the safe handling of medicines. We did not speak to people using the service as part of this follow up inspection.

We spoke with 10 of the 25 people living at the home on the day we visited, and with a relative of one of these people. We also spoke with two community-based professionals who supported people living at the home.

People’s privacy, dignity and independence were generally respected. They were cared for by staff who were supported to deliver care safely and to an appropriate standard. People confirmed that they saw staff treated other less mentally or physically able people kindly and respectfully. One person added “Everybody gets treated well.” Another said “We have a good bit of fun” when discussing how staff supported them. Someone who described themselves as a ‘worrier’ told us that staff always took time to reassure them. However, we found the provider did not have appropriate arrangements in place to manage people’s medicines safely.

The provider had systems to monitor the service's quality and manage risks to those who used the service or others. People’s views and experiences were taken into account. Those we spoke with felt able to make a complaint if necessary.

A recent survey by the home showed excursions and bedding as areas for improvement. The manager told us that new bedding had since been obtained. People had indicated general satisfaction with the facilities, their room, privacy, food, and how their clothing was dealt with. Their comments included “Nice and always clean”, “Definitely staff available at all times”, and “Brilliant home.”

We carried out an inspection on 2 and 3 August 2012 to review improvements made by the service following the inspection that took place on 12 January 2012. At that inspection compliance actions were issued for outcomes 8, 9, 12 and 16.

A new provider took over the home at the end of September 2011, and they were at the home for part of our visit. During the inspection we also spoke with the manager, the deputy manager, two care workers, a district nurse who was visiting people living in the home, a training assessor from an independent training agency, and a director of a company who regularly visited the home to provide activity sessions.

There were 26 people living in the home on the first day of this inspection. During our visit we spoke with three people individually in their bedrooms and we also joined a musical activity session where we observed interactions between care workers and many of the people living in the home. We also observed care workers sitting and talking with people in lounges, and saw them supporting people to move around the home. The atmosphere was happy and relaxed. We heard laughter and saw lots of smiles. Care workers talked to people while they were assisting them, explaining the care tasks they were carrying out. People were supported in a respectful and dignified manner.

People told us they were happy living in the home. They praised the care they received. Comments included “The staff are lovely – very good. Always pleasant”, and “It’s a happy place. You can do what you want. The staff are always nice, always helpful.”

We saw evidence of many improvements that had been carried out in all areas of the home and gardens in the last six months to improve the environment. We saw evidence, and heard about, plans for further improvements in all areas of the home that the providers expect to carry out in the next 18 months.

Two people told us they liked their bedrooms and found the rooms homely and comfortable. One person said they were happy with the way their room was kept clean, and said the room was vacuumed every day. Another person told us they liked to keep their own room clean and polished, although the cleaning staff always vacuumed the room every day for them. All areas of the home appeared clean.

We asked two people if they had been asked for their views on the home. They said they did not remember being asked to complete any questionnaires, or attend any resident’s meetings. They said that there staff often sat and talked with them, either in groups in one of the lounges, or individually, and they felt they could raise suggestions, concerns or complaints at any time with the manager, deputy manager, or the staff. They said they could not think of anything that could be improved. We talked to the provider about the way they involved people in the home and how they sought people’s views. They showed us their quality audit procedures and their future plans to implement surveys and systems for seeking people’s views.

This visit was carried out after we received information suggesting that the home might be non-compliant with some of the essential standards of quality and safety that registered services must meet.

There were 26 people living at the home on the day we visited. We spoke with nine people who were able to give us their views, and met one person who chose not to speak with us. Three other people we met were unable to give us their views because of their mental health needs and memory problems, so we observed some of the support they received during our visit.

A new provider took over the home at the end of September 2011, and they were at the home for part of our visit. The manager, who registered with us when the new ownership began, was also present.

People we spoke with were happy living at the home. They appeared to be at ease with staff, and confirmed that staff were respectful. One person told us, “I’m independent-minded and they’re very good – they let me do what I can.” We asked another person if they felt the home was run for the residents or for the staff, and they replied that residents and staff fitted in with each other.

We were told that staff ensured people's privacy when they were in their bedroom, or if assisting them to bathe. We heard staff communicating with people in a polite but friendly way and speaking discreetly at times, which upheld people's dignity.

People felt that they had enough to do with their time. We saw some reading, sitting or walking outside, and knitting. One said that staff sat down and chatted with people. We saw that people enjoyed conversations with each other also, with two telling us that they had known each other before they moved to the home. The home had two cats, which some people told us about and clearly enjoyed having around.

Though people were satisfied with the support they received, they were not always aware of the care records kept about them, such as their care plan. These records sometimes lacked details which would help to ensure they continued to receive the care they wanted or needed.

People we spoke with were satisfied with the cleanliness of the home. However, we found systems for ensuring its cleanliness needed to be established, and their effectiveness monitored. Similarly, people were happy with the way staff managed their medication for them but there weren’t effective systems in place to ensure this was always done safely.

People didn’t recall if the home had asked for their views on the service they received, although the manager told us that meetings were held for people who lived at the home. One person told us that though they weren't asked about their care or the service, they could always speak to someone if they had a suggestion to make or a complaint, which reflected other people’s views.

Work was being carried out to improve various areas of the home’s environment. There was a programme to refurbish all bedrooms, particularly to refresh and update the decor. We were told that people would be able to choose the colour scheme for their room. Garden areas were being made more accessible and safer. The manager told us that one person who lived at the home who had sensory impairment had helped to choose some scented flowers and other plants, in readiness for the new garden in spring.

This inspection was unannounced and took place on 10, 13 and 26 November 2015. The inspection was carried out by two inspectors on the first day, one inspector on the second day and two inspectors on the third day. The previous inspection of the home was carried out on 27 January and 6 and 10 February 2015 where we found breaches of regulations. These related to the care and welfare of people who use services, assessing and monitoring the quality of service provision, consent to care and treatment, and records. During this inspection we found some improvements had been made, but these were not fully effective and required further action. We also found some new breaches of regulations.

Dene Court is registered to provide accommodation with personal care for up to 28 older people. There is 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. The manager is also registered to manage another home owned by the provider, and their working week was shared between the two services.

There were insufficient staff to meet each person’s needs safely. On the first day of our inspection neither the manager or deputy manager were on duty. There were four care staff on duty to meet the needs of 25 people living there. The demands on the care staff were high and this meant staff were unable to meet some people’s needs fully. Staff had insufficient time to provide adequate care and support to people with high levels of care needs in particular in relation to protecting them from falls, managing depression and anxiety.

Staff had no time to provide activities or meaningful engagement and we saw some people remained in their chair all day with very little interaction from the staff. We saw evidence that people living in the home and staff had raised concerns about staffing levels being too low but their concerns had not been investigated or actioned. On the second day of the inspection staffing levels had increased. The deputy manager was on duty plus five care staff and this meant staff were more relaxed and had more time to interact with people. However, people currently had high levels of need, for example the daily handover sheet indicated that at least 17 people needed regular checks for mobility, whereabouts and mood. There were no instructions for staff as to how this was managed other than to do “regular checks.” Staff told us they “Kept an eye out” and could not say what “regular checks” entailed. People’s records showed a high level of falls. After the inspection the provider told us they were in the process of recruiting more staff.

There was insufficient evidence of regular social activities or how social stimulation, engagement and social isolation was managed within the home or the community. Individual social needs had not been assessed and there was no plan to show how these would be addressed. Daily records showed no evidence of these needs being met although highlighted people being low in mood, asking to go out, wandering/exploring the home or identified as requiring to be kept busy. These were not addressed and most people spent their time without social stimulation for long periods other than during personal care tasks and meals. There were some visits each month from visiting entertainers and activity providers, but these were infrequent. People were rarely supported by staff to go out of the home, and instead relied on relatives or friends to take people out.

Systems to assess and regularly monitor risks to people’s health were not fully effective. Where risks had been identified these were reviewed on a monthly basis, for example tissue viability and weight loss (the frequency of reviews had improved since the last inspection). However, where the reviews identified changes in the level of risk this information had not always been transferred to the main part of the care plan. This meant the care plans did not always provide up-to-date information. For example, one person’s care plan said they were independently mobile but the review said they required two staff and were non-weight bearing at times and at high risk of falls. There were no instructions to staff on the actions they should take to minimise any identified risks such as falls and weight loss. Daily records did not always show that staff had provided adequate care to reduce risks such as falls, dehydration, anxiety and low mood. Therefore people remained at risk. Staff identified risk and informed health professionals but did not then devise an action plan of how to further minimise risk.

Some care plans had been improved since the last inspection while others continued to provide only basic information on the person’s daily routines and lacked detail on how they wanted staff to support them. It was unclear how people had been involved in drawing up and agreeing their care plan. Some relatives had been asked to check and agree the care plans for example for people who were living with dementia. The records did not clearly show each person’s capacity to make decisions about their daily needs, or explain how staff were expected to involve the person or seek their consent before providing care. Where restrictive equipment was in place, such as pressure mats to indicate to staff when someone was mobilising and may require assistance, there was no record of any best interests discussions or effectiveness.

Some aspects of medicine storage and administration were potentially unsafe. The pharmacy that supplied medicines to the home had recently changed the way they supplied medicines. Medicines were no longer supplied in four –weekly monitored dosage packs, and instead were supplied in bottles and packets and therefore it was important that effective recording systems were followed. However, we saw unexplained gaps in the medicine administration charts with little or no evidence to show these had been investigated or actions taken to check the medicines had actually been administered. Administration records of prescribed creams and lotions were poor, with many unexplained gaps. The management team had carried out spot checks on the medication administration processes and had identified some problems, but they had failed to investigate these fully or take actions to address the problems.

Staff did not receive supervision regularly in line with the provider’s supervision policy. The policy stated that all staff should receive supervision six times a year but the supervision records showed that on average staff had received supervision twice in the previous ten months and some had only received formal supervision once. Staff meetings were held regularly and these were minuted.

Overall the home was maintained to a good standard and was equipped to meet the needs of each person living there. However, there were some areas where redecoration and updating needed some further attention. For example some paintwork was scuffed and scratched, a ground floor shower room was being used as a storage area and needed repairs, and a cupboard door with a sign saying ‘fire door keep locked’ needed adjustment as it could not close. Some furniture and equipment appeared scuffed and worn. The deputy manager told us replacement items were on order. After the inspection they showed us systems they had put in place immediately after our inspection to monitor decoration and maintenance issues and make sure these are completed promptly. The home provided a range of equipment included nursing beds, handrails and bath hoists to help people move safely and as independently as possible.

The provider had monitoring systems in place to ensure the home ran smoothly but these had failed to identify the issues we found during this inspection such as high risk of poor nutrition and falls. Therefore, people were at risk of weight loss and continued falls. For example, care plans had not been fully checked to make sure they contained sufficient information about each person’s needs. There were no audits to oversee falls, for example to establish any patterns and again no actions put in place to minimise risk effectively. One person had been identified as being at risk of falls and they were moved to a ground floor room, however no further actions were put in place and this person continued to fall. Systems to consult and involve people in planning their care needs or seeking their views on the services they received were not fully effective.

Some daily records for individuals indicated there had been incidents where there had been behaviour that could be challenging for staff. For example, one person had hurt their finger, one person had gone into other people’s rooms at night and another person had shaken another resident. We had not been informed of these and actions had not been put in place to minimise these risks.

We discussed our concerns about our findings with the local safeguarding and quality team throughout our inspection who were now working with the home to help them make improvements.

Since the last inspection the registered manager had sought legal authorisation for those people who lacked capacity to make important decisions for themselves, and who may be deprived of their liberty. This meant they had addressed the breach of regulations we had found at the last inspection.

Most people we spoke with, and their relatives and visitors, were positive about the home. Comments included “I love it here!” and “It’s alright.” A relative told us “She looks better in here that she did when she was at home. I think that’s because she is eating properly now.” A community nurse who visited on the first day of our inspection told us they had no concerns about the support given to people to meet their health needs. However, we spoke with a social worker after our inspection who raised concerns about the care provided to one person. This matter was referred to the local authority safeguarding team.

People received care and support from a staff team who had received relevant training and qualifications. This meant staff had the knowledge and skills needed to enable them to meet each person’s mental and physical health needs.

During the inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk from harm because the provider’s actions did not sufficiently address the on-going failings. There has been on-going evidence of the provider to sustain full compliance since 2011. We have made these failings clear to the provider and they have had sufficient time to address them. Our findings do not provide us with confidence in the provider’s ability to bring about lasting compliance with the requirements of the regulations. We are taking further action in relation to this provider and will report on this when it is completed.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Services placed in special measures will be inspected again within six months.

• The service will be kept under review and if needed could be escalated to urgent enforcement action.