About the service: Donness Nursing Home is a residential care home that was providing personal and nursing care to 23 people aged 65 and over at the time of the inspection. The home is registered to support 34 people.

In 2017, the home was rated as 'good' by CQC. The appointment of a second registered manager had helped drive improvement in the home. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as 'inadequate' and 'requires improvement' following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017. In July 2018, there was a further inspection and the service was rated as ‘inadequate’. This showed the

provider was unable to sustain the improvements made. A team of multi-disciplinary health and social care professionals provided further input to support the provider. The provider chose to employ an interim management team to help them make improvements, who were working at the home at the time of this inspection.

People’s experience of using this service:

• The level and standard of activities and meaningful occupation did not meet the social needs and well-being of everyone living at the home.

• The recruitment process was not robust with some required information not in place before staff started work.

• The interim management team were committed to improving the experience of people living at the home. They ensured the provider was updated about progress and barriers to improvement by the completion of a service improvement plan.

• There were on-going problems with equipment to help staff keep in touch with one another, such as radios/pagers. The provider had not addressed these issues in a timely manner.

• Concerns were not routinely responded to in a consistent manner so people were unclear about the outcome and if action had been taken to address their concerns.

• Fire drills did not take place regularly which put people at risk in the event of a fire as staff may not be competent and confident to respond appropriately.

• Maintenance issues, such as hot water temperatures and hot water availability, were not monitored in an adequate way to maintain people’s safety and promote good hygiene practice.

• The staff training matrix showed some staff had undertaken little training and there was low attendance at some sessions. There was mixed feedback about whether staff were paid to attend training. Staff competency in a person-centred approach was variable.

• A sluice door was not locked on one occasion, which put people at risk of potential harm.

• On one occasion, medicines were left unsecure, which put people at risk of potential harm.

• The main lounge and a person’s bedroom were malodourous, which undermined people’s dignity.

• Work was continuing to embed improvements in the way the home was run to benefit the people living there. Staff were positive about the support they received to carry out their job and the role of the interim management team.

• People’s nutritional needs were identified and monitored. Nutritional care plans contained details to instruct staff on how to support people in relation to eating and drinking.

• People received their medicines in a safe and caring way, although there were some areas of medicines management that needed improving.

• Plans were in place to increase the competency of staff to run shifts and delegate effectively to benefit the experience of people living at the home.

• People’s health, safety and welfare was improved because there were sufficient numbers of suitably qualified, skilled and experienced staff on duty.

• We saw positive interactions between people and staff. We saw staff were kind, friendly and patient when assisting people. However, some staff were not skilled in their approaches w

An unannounced comprehensive inspection took place on 16, 29 June and 4 July 2018. It was carried out by one inspector, who was accompanied by an expert by experience on the second day. There was a second inspector on the second and third day.

In 2017, the home had been rated as ‘good’ by CQC. The appointment of a second registered manager had helped drive improvement in the home. A team of multi-disciplinary health and social care professionals had also provided intensive support to the service to address a previous lack of staff training, poor record keeping and poor management. This high level of support had been instigated when the service was rated as ‘inadequate’ and ‘requires improvement’ following CQC inspections in 2016. The second registered manager left shortly after the inspection in 2017 and the outcome of this current inspection shows the provider was unable to sustain the improvements made.

Prior to this inspection, CQC were contacted by two people who raised concerns about the quality of the care at the home and the poor practice of some staff. This inspection was brought forward due to concerns about staff practice and the care at the home.

Donness Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as 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. Donness Nursing Home provides accommodation for up to 34 people; 27 people were living at the home during our visit. The service provides care for older people; most people are living with dementia. The bedrooms are on all three floors, which can be accessed by a passenger lift.

A registered manager was 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’. The registered manager is also the home owner. 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 is also the provider.

During our inspection, we contacted the local authority safeguarding team and made safeguarding alerts for five individuals because we were concerned about their safety and well-being. Following the inspection, we met with the provider and a group of health and social care professionals, which included commissioners. At this meeting, the whole service met the threshold to be monitored under the local authority’s safeguarding process. This meant health professionals began to visit the home on a daily basis to monitor people’s care and well-being and to review people’s care needs to ensure they were being met. Commissioners have taken the decision not to move new people to the home and the provider has agreed not to admit new people.

Staffing arrangements were poorly planned and potentially put people at risk. Rotas were not organised to provide consistent cover. This was despite people with complex physical and mental health needs and end of life care needs living at the home. Low staffing levels impacted on the safety of people at risk of falls as communal areas were not staffed in the early evening. People who had been abused by a person living at the home were not protected as staff did not ensure they monitored people’s whereabouts or observed communal areas in the early evening.

Staff training was not well managed and systems were not in place to ensure all staff practiced in a safe and caring way. There were examples of good care, with staff showing affection and compassion towards people. However, there were also practices which undermined people’s dignity. This was because improvements were needed in staffing levels, skills and knowledge in supporting people living with dementia. People did not always experience meaningful and caring i

This inspection took place on 8 and 14 March 2017 and was unannounced on the first day. The service is registered to provide care and support for people who may have nursing needs. The service is registered for 34 people; during the inspection there were 17 people living at the home.

We last inspected the service on 14, 15 and 23 June 2016 when it was rated as Requires Improvement overall. At that inspection, we found three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the running of the home, supporting staff and notifying CQC about incidents that affected the running of the service. The provider had produced an action plan to ensure improvements were made and sustained. Following the last inspection, the provider worked with local health and social care professionals and with the local authority quality monitoring team to improve the service as part of a whole home safeguarding process; this process is now closed because of the improvements that had been made to reduce risk to people’s safety and well-being.

At this inspection, we found that improvements had been made and the breaches were met. We made two recommendations linked to staffing and the environment.

People said they felt safe and secure living at the home. People were protected from potential abuse and avoidable harm. Staff had undertaken safeguarding adults training and understood their responsibility to reports concerns immediately.

Since the time of the last inspection, a second registered manager had been appointed. We have referred to them as the day to day manager in the report. They were present on both days 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.

The service had two registered managers; one was in day to day charge of the running of the home and had been in post for approximately six months. They said they had worked closely with the provider in the running of the home. The second registered manager was also the provider. They visited the home two to three times a week and provided support for policies, procedures and managed the budget. Neither of the registered managers were practising nurses, although one had a nursing qualification. The service had a designated ‘clinical lead’ nurse to oversee and advise on clinical decisions at the home. There was also a deputy manager.

The registered manager who was in day to day charge of running the home was leaving at the end of March 2017. In preparation for their departure, they were developing the deputy manager to take on increased responsibilities. They had delegated some duties to them, for example auditing care records. The provider said they were considering what changes they would make to the management team following the registered manager’s departure.

People described their relationships with the staff as positive. For example, speaking about a staff member, one person said, “She is a lovely girl”, another person described staff as “kind and gentle” and a third person said staff were “very good.” People looked relaxed with staff. This included staff who worked as part of the housekeeping, activities and catering team. Care staff were able to describe their practice to ensure they respected people’s dignity, for example when supporting people with personal care.

People's safety and wellbeing was promoted because there was sufficient staff to keep people safe and meet their needs at a time and pace convenient for them. The atmosphere in the home was not rushed and organised; staff worked in an unhurried way and were able to spend time with people. However, we have made two recommendations to the provider to

We carried out an unannounced comprehensive inspection on 2, 9 and 11 December 2015. 13 breaches of regulation were found and we served two warning notices, relating to staffing and good governance. The overall rating for this service was ‘Inadequate’ and the service was placed in ‘Special measures’. The provider provided CQC with an improvement action plan to say what they would do to make improvements to the service.

During the inspection in December 2015, we shared our concerns about staff practice and staffing levels with the local authority safeguarding team, commissioners and clinical commissioning group. They reviewed and monitored people’s care as part of a whole home safeguarding process. A further CQC inspection took place in March 2016. This was to check on the warning notice for staffing which we judged was not met as there were low staffing levels on some night shifts.

Services in special measures are 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. This inspection on 14,15 and 23 June 2016 took place because the home was in ‘Special Measures’. At this inspection, we found they were progressing with their improvement action plan and had met the majority of legal requirements.

However, there had been occasions when the registered manager had not notified us about issues that impacted on the running of the service. For example, changes linked to nursing arrangements within the home and when there had been problems with staffing levels on shifts. This meant the CQC was not being kept up to date with issues relating to risk. This also meant that this regulation had not been met since it was first reported on after an inspection in December 2015. We also found the warning notice served following the inspection in December 2015 had not been fully met. Records to ensure people received safe and good quality care needed further improvement. Quality assurance systems were not yet embedded as part of the regular quality assurance system because they had not been fully established and were not fully effective.

In the last six months, there had been significant changes in the home including the staff structure and the staff working at the home. The action plan had identified multiple areas for improvement and most of these had been addressed. We have made recommendations in relation to the design of the building for people living with dementia and the use of a nationally recognised staffing tool to assess staffing levels. We recommended improvements were made to ensure there was a consistent approach to induct new care staff following nationally recognised current induction standards.

Donness Nursing Home provides accommodation for up to 34 people who require personal care with nursing; 22 people were living at the home during our visit. The service provides care for older people, some people who are living with dementia. The bedrooms are on three floors, which can be accessed by two passenger lifts.

There was 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’. The service is owned by a provider, who is a registered person. 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 Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. We discussed DoLS with the registered manager and looked at records. We found t

Our inspection team was made up of an inspector who spent one day at Donness Nursing Home. We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 27 people living at Donness Nursing Home. The summary is based on conversations with three people using the service, five staff supporting them, two people’s families, two health care professionals, the registered manager (known as matron), observation and records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was safe because staff had a good understanding of people's needs and ensured those needs were met. This included close monitoring of diet, blood sugar levels, falls and psychological needs. Advice was sought appropriately and within a reasonable timescale. Necessary equipment was provided. People who had been admitted with pressure sores or whose diet was a concern were making considerable improvement.

Care plans included considerations of the Mental Capacity Act (2005) and staff demonstrated an understanding of the Mental Capacity Act (2005). People were protected through the Deprivation of Liberty Safeguards (DoLS) which were properly managed so as to protect people from being deprived of their liberty unlawfully. The registered manager had taken advice about an application under DoLS the day before our visit.

The service was safe because checks were completed prior to new staff starting work at the home. This ensured those staff members were suitable to work in a care home environment. There were sufficient staff to meet people’s needs in a safe way but this was marginal some nights whilst an additional night care worker was being employed.

The service would be safer if all accidents were better recorded and investigated in a timely manner.

Is the service caring?

The service was caring because people’s individual needs were understood and met. For example, one person had decided they wanted to stay in bed permanently. They were made comfortable and protected from risks from inactivity. They appeared happy and settled when we visited them.

Staff were attentive to people’s needs and dignity. We saw care workers act quickly when one person started removing their clothes. Other care workers were discreetly monitoring a person’s diet. That person’s family told us “They care. They go beyond the basic needs. It’s about mum as a person”.

We heard and saw staff interact with people in an unhurried and respectful way. One person told us “Most staff are caring”.

The service was caring because people’s well-being was seen as the priority. People appeared to be comfortable and relaxed at the home.

Is the service effective?

The service was effective because people’s health and welfare were promoted. People received an assessment of their needs prior to admission. Risks were assessed and risk management planned. The person’s care plan was then completed and updated as the person settled into the home. The care plans were reviewed monthly following discussion with the person and/or their family representatives and health professionals. One person’s family told us "I feel the staff are geared to his needs".

Health professionals had no concerns about the standards of care provided.

People received a nutritious diet which they told us they were happy with. Comments included "Food is pretty good" and "Not too bad. Quite good".

Is the home responsive?

The registered manager (matron) was clearly well known to people and their families who felt they were able to take any issues to them, the office manager and the staff. The home also sought staff and people’s views through an annual survey of opinion.

The home had responded to changes in people’s needs and circumstances. We saw how people’s needs were reviewed and their plan of care amended where necessary. We saw how people’s health had improved since admission to the home.

Is the home well-led?

The home was well-led because the service was monitored. For example, we saw how a missing record had been highlighted as an issue. People’s views were sought and audits undertaken. There were efficient arrangements for communication between the registered manager (matron), office manager, nursing, care and support staff at the home. However, we saw matron did not always act quickly enough and one staff said “or show us that she has acted”.

We saw the registered manager was “very approachable” and people using the service, their families, health professionals and some staff wanted to tell us this. However, some staff members did not take issues they had to the manager.

The home was well-led because it ran effectively and there were contingency plans in place for any foreseeable emergency.

We visited Donness Nursing Home to check whether people’s consent to care and treatment was confirmed so that their rights were being upheld by the home. We found that consent was always sought and that staff understood how to support people who did not have capacity to make decisions about their own welfare. Staff told us “…I always ask if they would like to get out of bed.”, “…..Every day I ask people what they wish to do, even those I know don’t have capacity, I still ask.”, “….everything we do is always in the person’s best interest, always.”

We looked at whether people received the care and treatment required to maintain their health and safety. Most people were unable to tell us their experience of living at Donness Nursing Home but we saw staff providing appropriate care in an unhurried way. We saw that people's personal care needs were being met and that people looked comfortable and had equipment in place for their safety, such as pressure relieving mattress. We found that staff were knowledgeable about people, people’s care was planned according to their individual needs and delivered in a safe way.

We looked at whether there were enough staff to meet people’s needs and whether those staff were skilled and competent in their work. We found that care workers had a clear understanding of people’s needs, had been trained to meet those needs and there were sufficient staff for the number and needs of people receiving the service.

We looked closely at the care of four people who used the service and also spoke to one visiting family. We observed staff providing care and support to people. We spoke to staff.

People told us, “They look after me very well”; “Good staff here. Well organised” and “It’s lovely; when you ring the bell the carer will answer it.”

Work towards ensuring people consented to their care and treatment had not adequately led to consistent or properly documented evidence that their consent was always sought and recorded. This meant that people might not always be at the centre of their care arrangements.

People's care and welfare needs were being met by competent, knowledgeable, kind and thoughtful staff.

People benefitted from staff whose training needs were being better organised and completed. We were told, "The staff are excellent. They really look after you” and “The staff are nice.”

Service improvements were evident, such as risk better managed, an example being accident monitoring. People confirmed that any concern would be dealt with promptly by the registered manager. One person told us, "(The Matron) is very good. Any ideas you have got - they listen."

Two staff said that record keeping had improved and we saw that care and medication records were detailed, complete and available to inform staff and monitor people's care. Improved record keeping protected people from unsafe or unsuitable care.

We met two people living in the home who were able to speak with us and were able to observe 12 others. We also met with two people who visited the home regularly.

At our last inspection in February 2013 we found that people were not protected against the risks associated with medicines. We issued a warning notice. The provider sent us an action plan to show how they would address this. During this inspection we saw that action had been taken to address the issues raised in the warning notice.

We looked at people’s care plans and found that they had been re-written recently with good guidance for staff in how people liked their care to be provided. We saw good practice with respect to people’s care and welfare. One person told us the family had chosen this home for their relative because it was smaller than others in the area and offered the quality of life that suited them.

We found that staff were not always clear about how decisions should be made when a person was not able to decide for themselves. However, we found that staff offered choice and asked people what they wanted.

Some staff training had been delivered recently but there were significant gaps in training provision, management support and supervision for staff which meant that we could not be confident that people would always have their care provided by staff who were competent to meet their needs

We met with three people who lived in the home and observed eight others in the lounge and dining room. We met with five staff on duty and the registered manager, and were supported by a staff member to look round the home.

One person told us, “You couldn’t have people wait on you better.” Staff told us that people joined in keep fit sessions and a musical entertainer visited regularly.

However, we found that care planning and risk assessment had not been carried out consistently. Guidance for staff was not updated and accurate. Staff did not always record accurately what they had done and in some instances there was no evidence that they had done what the care plan said was needed. We saw staff moving a person from their wheelchair to an easy chair in a way that might cause the person harm.

Recording of medications was unreliable. It was not always clear that people had been given medication according to the instructions from the prescriber. We found instances of unsafe practice when staff had given medication without carrying out a check that was necessary beforehand.

We found that there were insufficient checks in place to ensure that the home was run in a safe way. This included a lack of medication reviews, to ensure that people were being given the correct medicines to promote their well being and lack of evaluation of accidents and incidents to see whether there was anything more that could be done to prevent people falling.

We carried out an unannounced inspection on 27 September 2012. On the day of our visit we were told that there were 23 people living at Donness Nursing Home. We spoke with six people who lived at the home, four staff members, and the registered manager and looked at three people’s care files.

We saw that staff treated people with consideration and respect. We saw that staff quickly responded to people’s care needs to ensure that they were kept comfortable and informed about what was happening, such as discreetly assisting someone to the toilet and informing them about when lunch would be.

Staff had knowledge of privacy, dignity, independence and human rights. For example, how to maintain privacy and dignity when assisting with personal care. They showed an understanding of the need to encourage people to be involved in their care. For example, staff recognised the need to explain tasks to people before assisting them.

Care plans that we saw reflected people’s health and social care needs and demonstrated that other health and social care professionals were involved.

We spoke with staff about their understanding of what constituted abuse and how to raise concerns. They demonstrated a good understanding of what kinds of things might constitute abuse, and knew where they should go to report any suspicions they may have.

A responsive review of Donness Nursing Home was completed on 27th July 2011. This was in response to safeguarding alerts relating to:

• how pressure area care is managed

• how well the nursing home cares for people with complex needs

• how infection risks are managed

• how medicines are managed and whether this is done safely

• how staff are recruited and whether this protects people

• whether the staffing levels meet the needs of people.

CQC received an action plan from the registered providers about how they intended to comply with regulations, and we continued to be part of the multi agency strategy meeting which was then closed.

We carried out a further unannounced inspection at Donness Nursing Home on 26 January 2012 to check on compliance of outcome 4 (care and welfare) and outcome 13 (staffing). We wanted to check whether the service was following their action plan to meet the regulations in these outcomes. We also looked at improvements the service had made so we have included outcomes 8 (infection control) and outcome 12 (recruitment) in this review. Overall, we saw that there have been a lot of improvements made at Donness Nursing home so that compliance has been achieved with outcomes 4 and 13.

We looked at two care plans in detail to see what information had been gathered relating to people’s care and welfare. We also looked at handover information used each shift to pass on details about care needs for people.

We spoke with three people currently living at the service, two of whom were people whose records we looked at. Overall comments from people we spoke with were very positive and included, ‘there have been a lot of new staff, which is better” and “they’re very kind and always check on how you’re doing”.

We observed the care and support of eight people for short periods of time and spoke with six care workers. We saw that care workers interacted well with people and that care and support was delivered promptly and in a kind and respectful manner. People enjoyed a lively exercised class in the lounge whilst we were visiting and this catered for everyone’s needs and abilities.

People looked clean and neat and tidy in their own clothes. The home was spotlessly clean.

Changes had been made to the way needs are recorded for people. These had been streamlined making them accessible, easier to follow and more person centred.

People did not tell us anything about the recruitment of care workers. However, the provider sent us information about this and we saw that there has been improvement in the way checks are done, which ensured that people are protected.

We carried out this responsive review in response to an overall multi agency safeguarding strategy which is being coordinated by Devon County Council. The alert focuses on key themes, which include:

• how pressure area care is managed

• how well the nursing home cares for people with complex needs

• how infection risks are managed

• how medicines are managed and whether this is done safely

• how staff are recruited and whether this protects people

• whether the staffing levels meet the needs of people.

We carried out a responsive review with two inspections to Donness Nursing Home on 21st and 27th July 2011 and because of the concerns we looked outcomes 4, 8, 9, 12 and 13.

We were not investigating this alert because this is being looked at as part of the safeguarding process. The purpose of this review was to check compliance in these five key outcome groups for people currently living in the home.

We looked at the records of four people in detail; and where possible we spoke to the individual and or their carer. We observed other people being attended to whilst we were visiting. We also spoke to different care workers including nurses and care assistants.

People who were able to tell us said that their needs were being met and commented that care workers are "friendly" and "thoughtful". However, we observed that people with cognitive impairment did not always have the consistent attention they require to promote their well being or safety because there has been a reduction in the numbers of care workers on duty.

We have identified some key areas of concern where lack of assessment and care planning could place people at risk. We did not find that outcomes for people were poor, but we did find that care plans were not being reviewed and monitored sufficiently to ensure appropriate care and treatment was consistent.

People looked clean and neat and tidy in their own clothes. The home was spotlessly clean.

People are cared for by skilled and experienced care workers. We saw that when people did have attention care workers always had good eye contact with them. We also saw that care workers initiated conversations with people and treat them as individuals.

People did not tell us anything about how new staff are recruited. However, we suggested that improvements be made to the recruitment process, to ensure that it is robust and protects people.

We have set two compliance actions and two improvement actions and we will be reviewing these again in the near future with a further unannounced visit to the nursing home.

We carried out an unannounced comprehensive inspection on 2, 9 and 11 December 2015. 13 breaches of regulation were found and we served two warning notices, relating to staffing and good governance. During the inspection in December 2015, we shared our concerns about staff practice and staffing levels with the local authority safeguarding team, commissioners and clinical commissioning group. They are currently reviewing and monitoring people’s care. There is a whole home safeguarding process in place.

After the comprehensive inspection we received concerning information from several sources.  This information suggested that people's physical and emotional needs were not being managed appropriately because of low staffing levels. There were also allegations of poor practice by some staff. We raised these additional concerns with the local authority safeguarding team. We visited the home on 11 February and 9 March 2016 for a focused unannounced inspection to look at how staff were deployed in the home. The date by which the service should be compliant with the warning notice relating to staffing was 15 February 2016. During this inspection, some staff practice led us to raise concerns with the provider regarding how people’s privacy and dignity was maintained.

On the first day of the inspection, we arrived at the home at 4.30am to check on the staffing levels at night and to see how people were being supported by staff. On the second day of the inspection we arrived at 3.30pm to judge how people’s health and social care needs were being met and to check on staffing levels.

We judged that although there had been some improvements the warning notice had not been met. This was because some shifts were operating at lower levels than the provider’s assessed level even when people’s care needs had increased. The approach to replacing staff when they rang in sick was still not consistent. New staff were not provided with an induction which enabled them to shadow experienced staff before working as part of the shift. Care records did not consistently demonstrate people experienced regular care in line with risks to their health and their well-being. There was still no system for staff to check each other’s location in a building with bedrooms based over three floors, apart from using call bells in people’s rooms.

Following the focussed inspection, CQC were contacted by a relevant professional regulatory body who informed us that a staff member working at the home had not been registered with them for a number of years. This meant the staff member had been working in the role of a health professional when they did not hold the appropriate registration. We contacted the provider and local authority on the same day as receiving this information. The provider told us the staff member was no longer working at the home. We are taking further action and will report

on this when it is completed.

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.