We inspected Francis Court on the 8 November 2016. Francis Court provides care and support to people with personal care and nursing needs, many of whom were living with dementia. The service was arranged over three floors and offered residential and nursing care based on people’s particular needs and requirements. The service provided care and support for up to 87 people. There were 76 people living at the service on the day of our inspections. Francis Court belongs to a large corporate organisation called Care UK. Care UK provides residential and nursing care in many services across England.

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’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We saw that regular meetings took place and people were encouraged to ask questions, discuss suggestions and address problems or concerns with management. However, we identified concerns in relation to feedback being acted upon by the provider. People, relatives and staff told us that they were not always satisfied with the service provided and that communication was not always good. Although some staff spoke positively of the culture and how they all worked together as a team, feedback from other staff was mixed and indicated that there was a lack of cohesion and a negative culture in the service. We have identified these as areas of practice that need improvement.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. One person told us, “The relaxed atmosphere makes me feel safe”. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding and what action they should take if they suspected abuse was taking place.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, caring for people with dementia and palliative (end of life care). Staff had received supervision meetings, and formal personal development plans, such as annual appraisals had been implemented. One member of staff told us, “Since [the registered manager] has been in post I get regular training. I wanted training around moving and handling and I got it, and I wanted to do an NVQ (National Vocational Qualification) and I’m on it”.

People were encouraged and supported to eat and drink well. There was a daily choice of meals and people were able to give feedback and have choice in what they ate and drank. One person told us, “The carers have to mash my food and the chef knows that I like parsnips, so he does them for me”. Special dietary requirements were met, and people’s weight was monitored, with their permission. Health care was accessible for people and appointments were made for regular check-ups as needed.

People chose how to spend their day and they took part in activities

We carried out this inspection because we had received concerns about inadequate staffing levels at the service. In line with their responsibilities, the provider had also notified us of four incidents which had occurred. These had involved agency members of staff and included two medication errors.

We spoke with nine people who used the service. They told us that they were happy with the care and support that they received at Francis Court. One told us, “It’s very good, the people are nice”. Another said “I am very well cared for. I have no concerns”. We observed that staff had a good rapport with the people they were supporting. They were available and responded quickly to meet their needs. We also spoke with three relatives who were visiting the home on the day of our visit. They were equally complimentary. One said, “The carers are lovely” and, “It’s personal, the carers take time with them”. Some people mentioned that they were often cared for by new members of staff. They said that this could be frustrating as new staff were not always aware of how people preferred to be supported.

We spoke with the new manager, two representatives of the provider and 15 members of staff, including eight permanent staff and seven employed through agencies. Some permanent staff told us that they felt frustrated and demoralised by the instability in the staff team. One said, “We have the numbers of staff needed but having new agency makes our work more difficult”. Others spoke more positively. One said, “They’re getting things on track and things have improved”. Another told us, “It’s definitely picking up, the vibe is lifting slightly”.

We looked at the processes, procedures and records held by the service relating to the use and management of medicines. We found that there were appropriate arrangements in place to manage medicines.

The home used a significant number of agency staff in order to maintain their staffing level. Many of the agency staff worked in the home on a regular basis, which provided continuity for the people they were supporting. We found, however, that the provider did not check the skills and experience of agency staff before they came to work in the home. This meant that they could not ensure there were enough suitably qualified and experienced staff available to meet the needs of people living in the home. We also found that agency staff were not always given a suitable induction to the home. This meant that they were not adequately supported to fulfil the tasks expected of them and had the potential to impact on the care that people received. One relative said, “If they can only get the staff settled, that’ll be the thing”.

In October 2013 we undertook an inspection over three days which identified serious concerns about the way that people were being cared for at Francis Court. In particular, we judged that people who required nursing care were being placed at serious risk of harm. Following the inspection, we took urgent enforcement action against the home. This action included reducing the number of people who could be accommodated at the home from 87 to 49. We also placed a restriction on the provider's registration which prevented them from admitting anyone else into this service.

Since our last inspection, we have liaised closely with our health and social care colleagues to ensure the safety of the people who used the service. We have also been in constant contact with the provider who took immediate steps to improve the quality of care provided. This action included implementing a new management team at the home and increasing staffing levels. The purpose of this inspection was to assess whether the action taken by the provider had reduced the serious risks previously identified in October 2013.

This inspection was carried out by three Inspectors, one of whom was a pharmacist Inspector for the Commission. Our inspection was also supported by a specialist nurse advisor who was able to give us an independent view about the nursing care provided at Francis Court. We found that the quality of care at Francis Court had been significantly improved and that there was no longer evidence of a major risk to people's health and well-being.

We found that the interim manager was knowledgeable about people’s needs and in control of the daily running of the home. They closely monitored the direct care and support provided to people by permanent and agency care staff. This meant that the risk associated with the use of temporary staff was lowered because agency staff were supported by someone who understood the needs of the people who used the service. The interim manager was supported by a new clinical lead and a team of senior staff from Care UK. This provided sufficient management cover to the service and enabled change to be effected quickly.

We found that staffing levels had been significantly increased, with the number of registered nurses who worked on each shift having doubled. This meant that there were now sufficient staff to meet the complex needs of people which ensured that they were properly supported. The home was still heavily reliant on the use of agency staff, although it was evident that many of these staff now regularly worked in the home. We found evidence of an active recruitment drive and nine new staff members were undertaking induction training at the time of this inspection. We also saw that existing staff had completed key training since our last inspection. This meant that the provider had taken appropriate steps to increase staffing levels and competencies at Francis Court.

We found that significant improvements had been made to the way medicines were managed by the home. The increased number of nursing staff meant that people now received their medicines in a more timely way and that medication records were now better maintained. We also identified that medication guidelines had been reviewed with appropriate medical professionals as necessary. This ensured that people were better protected by the medication systems in place. We found some areas of medication could be further improved, but there was no longer the serious risk of harm which had previously been identified.

We talked to people and their relatives about the care they had received. We observed care practice during the eight hour inspection and looked at the care records of twelve of the seventeen people who had received nursing care at Francis Court. We found that each person now had a plan of care which reflected their current support needs. We also found evidence that information about the care provided was now being recorded most of the time. There were still risks associated with the fact that not all staff were able to access all of the information necessary to support people effectively. This risk however, had been reduced by the increased management presence in the home.

There were 49 people who used the service at the time of our inspection. In June 2013 nineteen people were permanently admitted to the service, this was due to the closure of another nursing home. This inspection was undertaken because we had received several anonymous concerns about inadequate staffing levels at the service. We spoke with three people who used the service, two relatives, six staff and the registered manager.

We observed that staff had a good rapport with people who used the service and their visitors, which promoted a relaxed atmosphere. We saw interactions between staff and people which were sensitive and respectful. A person told us “All the staff are so helpful and kind to me I can’t fault them, I just wish there was more of them to help the ones that shout out a lot” a relative told us “Mum is very happy here, much better and safer than other places she has stayed in we have always found the staff to be really helpful”.

There were not always sufficient numbers of qualified staff to meet the needs of people who used the service which meant that people were placed at risk of inappropriate care. Staff told us: “This is the best week of staffing we have had in months, there is actually three nurses on duty which means we can provide much better care as we can support the care staff better” and “There have been days when you are the only experienced member of care staff on duty as its new or agency staff.”

Staff did not always receive appropriate professional development or support in order to help ensure they could deliver consistent appropriate care and support.

On the day of our inspection there were 31 people living in the home. Due to their complex needs, not everyone who used the service was able to speak with us about how their care was provided. We talked with seven people who used the service, two relatives and two visitors. We also spoke with three members of staff, the registered manager and a representative from the management team.

People told us that they felt well cared for and that there were enough staff on duty to meet their needs. “It’s very nice here. The carers are good” said one person. Another person told us “This home is as good as you’ll get in every respect”.

People told us that staff understood their needs and provided appropriate care and support. One person said “Carers are very caring and very well trained.” We observed that staff were responsive when people asked for assistance and offered people choices about how their care was provided.

People felt safe and good arrangements were in place to safeguard people. Sufficient numbers of staff with the relevant training, skills and experience were employed to meet peoples’ needs. The service took account of peoples’ views in how the service was provided. The service monitored the quality and safety of the service provided and took action where needed.

The inspection took place on 4 and 5 March 2015 and was unannounced.

Francis Court is registered to provide nursing and residential care for a maximum of 87 people but this number was restricted to 52 due to a condition imposed on the provider’s registration. At the time of this inspection there were 52 people in residence including people who had general and complex nursing needs and people living with dementia, mental health and physical needs. The service provides long term and respite placements. Prior to this inspection we had received an application from the provider to remove this condition. We are considering the application in light of our inspection findings.

The service 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. The manager had been in post for approximately four months and was newly registered. After a period of significant change, people, relatives and staff spoke positively of the new registered manager and the stability she had brought to the home.

People told us that they enjoyed living at Francis Court and that they received good support from staff. One described the staff as, “Top class”. Another told us, “Everybody looks after us so well”. Of the management, one person said, “I know the manager and she will talk on any issues and is very approachable”. A member of staff told us, “The management is good. The team leaders and nurses they are all good to us”. A significant number of new staff had been recruited and the home had reduced their reliance on agency staff to cover shifts. This had a positive impact on people as they were familiar with the staff supporting them. One member of staff told us, “So far everything is going in the right direction”. A relative said, “In every way I am very pleased”.

People, their relatives and staff felt involved in decisions relating to the home. The culture was one of collaboration. Staff felt empowered and this created a positive atmosphere. The management team listened to views and were quick to respond to suggestions or concerns.

There were enough staff on duty to meet people’s needs safely. Staff were clear on what was expected of them and received training and supervision to help them deliver care to an appropriate standard. The registered manager was aware that staff were not up to date with their training and that supervisions and appraisals had fallen behind. This was being addressed and a clear plan of action was in place.

People were treated with kindness and respect. One person told us, “The staff talk to me and they would help without any doubt”. There was a friendly atmosphere at the home. People and staff were seen to enjoy each other’s company, to joke and laugh together. People were involved deciding how they wished to spend their time and staff were quick to notice when they required assistance or reassurance. Staff understood how people’s capacity should be considered and had taken steps to ensure that people’s rights were protected in line with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

Staff understood local safeguarding procedures. They were able to speak about the action they would take if they were concerned that someone was at risk of abuse. Risks to people’s safety were assessed and reviewed. Any accidents or incidents were recorded and reviewed in order to minimise the risk in future. Medicines were managed and administered safely. People had been involved in planning and reviewing their care and detailed care plans were in place. Where necessary, external healthcare professionals had been involved and their advice had been incorporated into the care plans.

Lunchtime was a sociable experience for most people. A menu was available for them to choose from and people told us that they enjoyed the food. People who required assistance to eat were supported. There was a varied activity programme and some events were attended by people from the local community. The home had recently arranged the use of a minibus and staff had taken their tests ready to take people on outings.

The home was well-led. A system was in place to monitor the quality of the service delivered and to ensure that necessary improvements were made. This included audits by the home and representatives of the provider.

We have made a recommendation regarding the system for tracking staff training, supervision and appraisal.

We have made a recommendation concerning how people’s care and support needs are recorded.