About the service: The home is registered to provide nursing and personal care support for up to 60 older people. At the time of our inspection 40 people were receiving personal care and support from this service across two units.

People’s experience of using this service:

•Care plans and risk assessments were not always updated to reflect changes in people’s care needs. •Risks to people were not always identified and risk management plans were not in place to manage risks safely.

•Monitoring charts, including close observation charts, elimination charts and food and fluid charts were not always completed to help ensure people's safety.

•People's medicines were not always safely managed.

•Incidents were not appropriately logged or investigated to reduce the risk of repeat occurrences.

•Staff were not effectively deployed and were not always aware of their responsibilities. Staff training was not up to date and staff were not always supported through supervisions to ensure they carried out their roles effectively.

•The provider had not followed safe recruitment practices when recruiting new staff.

•People were not always supported and encouraged to eat a healthy and well-balanced diet

•People and their relatives told us and we saw staff were not always kind and did not always respect their privacy, dignity or promote their independence.

•People were not involved in planning their care and support needs.

•People who could not communicate were not provided with information in a format that met their needs.

•The provider’s quality monitoring systems were not effective.

•The registered manager had a lack an understanding of their regulatory responsibilities as they had not reported incidents to the local authority safeguarding team or CQC where required.

•People and staff commented that the registered manager was not visible and did not provide adequate leadership and support.

•People told us they felt safe. There were appropriate adult safeguarding procedures in place to protect people from the risk of abuse.

•People were protected from the risk of infection because staff followed appropriate infection control

protocols.

•Assessments were carried out prior to people joining the service to ensure their needs could be met.

•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 had access to healthcare professionals when r

This unannounced inspection took place on 20 November 2018. Gallions View is a care home that provides nursing and personal care and support for up to 60 older people. 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 time of our inspection, 47 people were using the service across two units - Squires and Hutton, the majority of whom were living with dementia.

At our previous inspection on 15 and 16 February 2018 we found breaches in our legal requirements in relation to identifying risks to people and detailed guidance not being in place for staff to be able to manage these risks safely. Incidents were not always logged and investigated appropriately. People and their relatives were not involved in planning their care needs and care plans were not always reviewed on a monthly basis to reflect people's current needs. There was a lack of activities on offer throughout the day for people to take part in. Regular staff and resident meetings had not taken place to give people information about the provider, who was new at the time. Audits were not always effective in identifying shortfalls in the safety and quality of the service There was a lack of leadership and staff did not feel listened to and morale was low.

At this inspection we found that whilst the provider had attempted to address some issues, there remained shortfalls, and little improvement had been made. At this inspection we found we found continued breaches of the Health and Social Care Act 2008 (Regulated Activities 2014). Medicines were not safely managed. Staff training was not up to date. People’s observation chart which included turning charts and elimination charts were not always completed to ensure people’s safety. There were not enough staff deployed to meet people’s needs in a timely manner and the provider had not followed safe recruitment practices when recruiting two members of new staff. We found people who communicate were not provided with information in a format that met their needs. Complaints made by relatives were not always logged and investigated in a timely manner. The registered manager had a lack an understanding of their regulatory responsibilities as they had not reported incidents to the local authority safeguarding team or CQC where required.

We found improvements were needed as staff were not always supported through regular supervisions and appraisals. People's diverse needs including, cultural food were not recorded. We found that not all staff were caring. Feedback from residents and relatives had not been analysed and used to drive improvements. We found the ethos of the home was not being delivered which was to provide people with a comfortable life and concentrate on delivering individual support to meet their care needs. People’s end of life wishes were not always recorded in their care plans.

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 inspecting 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 act 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 if they do not improve.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the s

This inspection took place on 15 and 16 February 2018 and was unannounced. This was the first inspection of the service after it was taken over by a new provider, HC-One Oval Limited.

Gallions View is a care home that provides nursing and personal care and support for up to 120 older people. 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 time of our inspection, 40 people were using the service across two units, the majority of whom were living with dementia.

At this inspection on 15 and 16 February 2018, we found breaches of the Health and Social Care Act 2008 (Regulated Activities 2014). This was because we found identified risks to people did not always have detailed guidance in place for staff to be able to manage these risks safely.

Incidents were not always logged and investigated appropriately detailing the incident and the outcome.

People and their relatives were not involved in planning their care needs and care plans were not always reviewed on a monthly basis to reflect people’s current needs.

Regular staff and resident meetings had not taken place to give people information about the new provider.

Audits were not always effective in identifying shortfalls in the safety and quality of the service, such as issues we found during this inspection.

There was a manager who had been in place for three weeks prior to this inspection. The manager had applied to be 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.

There was a lack of leadership and staff did not feel listened to and morale was low.

The service had appropriate safeguarding procedures in place and staff were aware of the action to take if they had any concerns. Medicines were safely managed. Medicine records were completed and showed that people received their medicines as prescribed.

The manager and staff understood the Mental Capacity Act 2005 (MCA) and asked for people’s consent before they provided care. People received support from staff to eat and drink and records confirmed dietary advice had been sought from healthcare professionals, where appropriate. People had access to a range of healthcare professionals when required such as GPs, district nurses and speech and language therapists.

Staff respected people’s privacy, dignity and independence. People were encouraged to be as independent whenever possible. People were provided with information about the home prior to moving in so they knew what facilities and services the home offered.

People knew about the service's complaints procedures and how to make a complaint. Complaints were logged and investigated in line with the provider complaints procedure. People's cultural needs and religious beliefs were recorded to ensure that staff took account of people's needs and wishes, for example their faith or cultural needs. People’s care plans contained a section on end of life care and their preferences and choices for their end of life care was documented.