We carried out a comprehensive inspection in April 2017. We also carried out a focussed inspection on the 5 September 2017 following concerns relating to appropriate care of people who required nursing care input. Following that inspection, we received concerns and information received from the local safeguarding teams in July and August 2018 and the clinical commissioning group (CCG). In addition, we received concerns from the public and Lancashire County Council contracts monitoring team. We inspected the service against the key questions. ‘Is the service well led’ and ‘Is the service safe.’

This report only covers our findings in relation to the leadership of Guys Court and the safety of those who lived there. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Guys Court on our website at www.cqc.org.uk.

The inspection visit at Guys Court was undertaken on 20 August 2018 and was unannounced.

Guys Court is a ‘care home.’ 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, both of which we looked at during this inspection.

Guys Court Residential and Nursing Home provides nursing and personal care for 37 older people and people with dementia. It is a three-storey purpose built home, with a passenger lift to all floors. There is a separate dementia unit. Guy's Court is located in a residential area of Fleetwood, close to transport and local amenities. At the time of the inspection visit there were 25 people living at the home.

A registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 were in the process of registering a new manager with CQC.

At the last inspection we rated the service as good.

During this inspection, we found the provider did not ensure they met legal requirements and improvements were required. Furthermore, we made recommendations to ensure the safety of people was maintained.

We found the provider did not have sufficient information within their risk assessments to be able to keep people safe. In addition, risk was not managed well for people who required nursing care wound care management. This put people at risk of unsafe care and treatment.

You can see what action we told the provider to take at the back of the full version of the report.

At this inspection we found the provider did not have safe medication procedures in place to ensure people received their medication safely. This was because documentation was not accurate and up to date which put people at risk. This was contrary to current guidance 'National Institute for Clinical Excellence' (NICE) guidelines.

We have made a recommendation about safe medicine procedures.

Furthermore, we found audits had not identified issues that had we had highlighted during this inspection visit. For example, care plan audits did not always identify any mistakes and ensure people who lived at the home were kept safe and received the correct up to date support required.

We have made a recommendation about efficient monitoring and quality assurance systems.

We found the service did not have clear lines of responsibility and accountability. Changes in management had affected the running of the home and staff were not supported consistently.

We have made a recommendation about structured management systems to support staff in their roles.

Staff spoken with had received safeguarding training and understood their responsibility to report unsafe care or abusive practices.

We looked at staffing levels and skill mixes to check these were sufficient to

This inspection visit took place on 05 September 2017. The visit was unannounced.

The inspection visit was prompted by information we received from the local safeguarding team. They were investigating concerns following the death of two people who lived at the home.

The incidents are subject to a separate investigation and as a result this inspection did not examine the circumstances of the deaths. However the information shared with CQC about the incidents indicated potential concerns about the management of health issues and to ensure people were safe at Guys Court. This inspection examined those risks.

This report only details our findings in relation to the potential concerns in safe and well led.

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.

We found care records of people who needed assistance with personal care, potential skin breakdown and pressure sores were receiving support they required. This was in terms of up to date information of the person’s condition, repositioning charts to reduce the risk of pressure areas developing and appropriate body mapping documentation. Care plans, risk assessments and daily reports indicated checks had taken place. Repositioning charts to record the person's positional changes were used where needed. Pressure aids were in place where people were at risk of developing pressure sores for example special mattresses.

We looked at how staff received information and guidance. We looked at training records and found the registered manager had provided more training for staff in ‘pressure ulcer care’. This was to ensure staff had up to date knowledge of current care and guidance. Any care issues or changes were highlighted to staff in both individual supervision and staff meetings.

The service had introduced a number of systems to ensure correct recording and communication sharing was in place to reduce the risk of people who were vulnerable to pressure sores. For example a new all in one document, ‘handover sheet’ provided information about people’s diet, fluid intake and falls risk. This meant better communication and ensured information was documented.

Audits were frequent, documented and any issues found on audits acted upon promptly. They had introduced further auditing of care plans and pressure area support to ensure people were not at risk and kept safe. Support from the organisation regularly visited Guys Court who checked actions were taken where needed.

Guy's Court provides nursing and personal care to older people and people with dementia. It is a three storey purpose built home, with a passenger lift to all floors. There is a separate dementia unit. Registered for 37 people.

At the last inspection the service was rated ‘Good’. At this inspection we found the service remained ‘Good’.

The registered manager had procedures in place to minimise the potential risk of abuse or unsafe care. Staff spoken with were able to identify the different types of abuse and had received training in safeguarding adults. We confirmed this by talking with staff and looking at training records.

Staff had been recruited safely, appropriately trained and supported. This was confirmed by records looked at and discussions with staff the management team and people who lived at the home. They had the skills, knowledge and experience required to support people with their care and social needs. Staffing levels were observed to be sufficient to meet the needs of people who lived at the home. The management team monitored and regularly assessed staffing levels to ensure sufficient care and nursing staff were available to provide support people needed.

Risk assessments had been developed to minimise the potential risk of harm to people during the delivery of their care. Care records showed they were reviewed and any changes were recorded.

We looked around the building and found it had been maintained, was clean and hygienic and a safe place for people to live. We found equipment had been serviced and maintained as required

Medicines had been checked on receipt into the home, given as prescribed and stored and disposed of correctly. We looked at medication administration records of people who lived at Guys Court and found them to be correct and up to date.

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

We observed lunch served which was a relaxed social occasion for people. There were aids to help people be as independent as they could. During the morning period the chef spoke to everyone before lunch to ask what they wanted for lunch to ensure people got what they wanted. Comments were positive about the quality of food and included, “All home made food fabulous” Also, “The food is great plenty of choice.”

Relatives and people who lived at the home told us staff and the management team had a caring manner and kind attitude to support people. Comments from people who lived at the home included, “The staff make me feel I'm at home here. They are very friendly and we like to have a laugh together.”

Following the recommendation from the previous inspection in March 2015 action had been taken to address the issues. Care records had now been reviewed and updated since the previous inspection when we recommended any treatment or support identified must be recorded and carried through as planned. A staff member said, “We ensure any concerns or action taken in relation to a persons health is followed through.”

People who lived at Guys Court and relatives /friends knew how to raise a concern or to make a complaint. The complaints procedure was available and people said they were encouraged to raise concerns.

The registered manager used a variety of methods to assess and monitor the quality of care at Guys Court and told us they were supported by the organisation. These included regular audits of medication, care plans. Also and staff and ‘resident’ meetings to seek the views of people about the quality of care being provided took place on a regular basis. Any suggestions to improve the service were acted upon.

The inspection visit at Guys Court took place on 24 March 2015 and was unannounced.

Guy's Court provides nursing and personal care to older people and people living with dementia. It is a three storey purpose built home, with a passenger lift to all floors. There is a separate dementia unit. At the time of the inspection there were 33 people living at the home

There was a registered manager in place. 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.

At the last inspection on the 6th January 2014 the service was meeting the requirements of the regulations that were inspected at that time.

People who lived at the home told us they felt well cared for, safe and secure. People’s care and support needs had been assessed before they moved into the home. Care records we looked at contained details of people’s preferences, interests, likes and dislikes. Relatives we spoke with told us they had been consulted about their relative’s care and were informed of any changes that occurred. People who lived at the home told us their views and choices were listened to by the staff and registered manager.

We observed staff interaction with people during our visit, spoke with staff, people who lived at the home and relatives. We found the deployment of staff were sufficient to meet the needs of people and keep people safe. Staffing levels were sufficient to ensure peoples safety and meet their needs.

The registered manager had safeguarded people against unsuitable staff by following their recruitment policy and all checks were in place before staff started work. One recently employed staff member said, “The recruitment process was good all checks done before I started work.”

We observed medication being dispensed and administered in a safe manner. We observed the nurse administering medication and dealt with one person at a time to minimise risks associated with this process. We observed the nurse had a very caring attitude towards people and ensured the person took their medicines as directed.

We observed staff assisting people at lunchtime to eat their meals. They were kind and patient, engaging with the person they were attending to in conversation and making the lunchtime meal a pleasant and relaxing time. Comments about the quality and quantity of food were positive. One person who lived at the home said, “The food is excellent and there's plenty of choice. However staff appeared to be rushed in the dementia unit. The registered manager may look at the way staff were deployed at mealtimes. This would ensure people who lived at the home were supported to have their meals in a timely manner.

The care plans we looked at were centred on people’s personal needs and wishes. Daily events that were important to people were detailed, so that staff could provide care to meet their needs and wishes. People we spoke with were confident that their care was provided in the way they wanted.

Records showed that staff members had completed key training in all areas of safeguarding vulnerable adults, Infection control, dementia awareness and moving and handling techniques. These were mandatory training courses. Staff members we spoke with told us that training was discussed with the registered manager at supervision meetings which were held on a regular basis. There were no restrictions to develop their role in terms of access to training courses and further professional qualifications.

There were a number of people living with dementia at the home. There were specific staff responsible for organising meaningful activities designed to stimulate people with dementia. Staff were seen to be playing various games in the afternoon. We saw the activity coordinator was organising reminiscence sessions in the specially designed area for people living with a dementia condition.

We found examples where the home had responded to changes in people’s needs. We saw referrals had been made to external professionals. For example a referral had been made to the General Practioner (GP) when one person had lost weight over a period of time. However the action plan informed us the person required to be weighed weekly. This was not consistent, as the care notes told us three weeks had passed by without the person being weighed. This could put people at risk of not receiving appropriate care that had been identified.

People who lived at the home were encouraged and supported to maintain relationships with their friends and family members. Relatives we spoke with told us they were always made welcome at any time.

We found a number of audits were in place to monitor quality assurance. Records demonstrated identified issues were acted upon in order to make improvements. The registered manager and provider had systems in place to obtain the views of people who lived at the home and their relatives.

We made a recommendation that the service ensures records are kept up to date of actions identified in care plans to ensure people were receiving the right care at the right time.

When we last inspected this service we had concerns about the lack of staff interaction with people and leisure activities available in the dementia unit. We found staff were not encouraging people to drink their mid morning drinks. Some moving and handling practices observed were unsafe. Staff supervision was limited and meant that staff were unaware what people were doing for some of the time. We also found the medication policy was not always adhered to, increasing the risk of errors.

During this inspection we found our concerns had been addressed. A structured activities programme had been devised and implemented on the dementia unit. We saw a number of people participating in armchair exercises during the morning. They appeared to be having fun and getting on well with the staff. During the two hour period we spent on the unit we saw constant interaction between the people being supported and staff on duty. We saw staff encouraging people to drink their mid morning drinks. Assistance was provided if required.

We saw staff assisting people with mobility problems. The staff were patient and took care to ensure the people being supported were assisted safely. The staff members we spoke with confirmed they had received mandatory moving and handling training.

People we spoke with said they were happy with their care. One person said, “The staff are lovely caring people”.

We spent time in the unit specialising in the care of people with dementia and in the larger nursing area. There were 24 people in the nursing areas and 10 people in the dementia unit when we inspected. We spent time observing how staff interacted with people in both units. We also talked with people living in the home throughout the inspection.

Some people had limited verbal communication and understanding and were unable to hold a conversation with us. To help us understand their experiences of living in the home we observed the care they received and the interaction by staff.

People living in the home and relatives said they felt staff were caring and supportive. One person said, “I am happy here. The staff are kind.” A relative told us, “Without the care given here my relative would not be alive.”

We saw staff engage with people in the nursing areas. Staff checked if people needed anything and supported them. There were also some activities available. There was little staff interaction with people or leisure activities available in the dementia unit. Neither did staff encourage people to drink their mid morning drinks. Some moving and handling practices were unsafe. Staff supervision was limited and meant that staff were unaware what people were doing for some of the time.

The medication policy was not always adhered to, increasing the risk of errors. The home had identified this in a recent audit and was starting to take action to deal with this.

Systems were in place for monitoring the quality of the service people received. People living in the home and relatives told us that they were well supported by the manager and staff team. A relative said, “You can always speak to the manager, she always makes time for you.”

We spent time in the unit specialising in the care of people with dementia and in the larger nursing unit for older people. People living in the home that we spoke with told us staff were kind and respectful and asked how they wanted staff to support them. One person said, “The staff are very polite and explain things to me.” A relative said, “The staff here are great, they always involve me in decisions. They are brilliant.”

People living in the home said they were involved in making decisions about their care and that routines in the home were flexible. Relatives said they were kept informed and involved in what was happening with their family member and in the home generally.

We observed staff interacting with people in both units during our visit. We talked with six people living on the Dementia unit and observed their care and talked with four people on the nursing unit. People living in the home were complimentary about the care and support they received. One person said "The staff are very nice. I like it here." Another person said, “The staff are so kind, nothing is too much trouble.”

As well as talking with people we used the short observational framework for inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people who had communication difficulties or difficulties in understanding. We found that staff interacted well with people. They assisted people sensitively, chatting as they carried out tasks and activities with people. We saw staff encourage people who had limited communication to be involved in discussions and activities. We also saw staff assist people with personal care promptly when they asked for help.

We also spoke with two relatives. One relative said, "The staff are excellent, so caring, they are great." Adding, "They made it possible for me to ‘let go’ a little." Another relative said "I am glad that we came here.”

People living in the home said the staff were kind, patient and helpful and they felt safe at Guy’s Court. They told us that they would tell staff or their relatives if they were upset about anything and they would deal with the problem.

The people living in the home said they were well supported by the staff team at Guy’s Court. They said they could tell them if they wanted their care provided in a different way or if they were unhappy about anything. People living in the home, relatives and staff said that the manager was approachable and willing to listen.