This inspection took place on 25 and 26 September 2018 and was unannounced.

The last inspection was carried out in December 2017. The overall rating for the service was Inadequate. We found the provider was in breach of Regulations 12 (safe care and treatment), 9 (Person Centred Care) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During our comprehensive inspection in September 2018, the home demonstrated to us that improvements had been made. The home is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Kent House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a 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. Kent House is registered to accommodate a maximum of 40 people with dementia. At the time of our inspection 28 people were living at the home.

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 2008 and associated Regulations about how the service is run.

Overall there was a system to ensure that people were safe and protected from abuse. Staff knew how to recognise abuse and how to report allegations and incidents of abuse. There was evidence risks to people had been identified and assessed. However, we found the content and quality on some of the risk assessments to be variable. In some examples, risk assessments had understated risk. Although there had not been any immediate effects, this potentially posed a risk. Safe recruitment procedures were in place. We saw that pre-employment checks had been completed before staff could commence work. There were sufficient numbers of staff to support people to stay safe. We also saw there were systems in place to protect people and staff from infection. There were suitable arrangements for the recording, administration and disposal of medicines.

Staff had not received regular supervision and appraisal. Furthermore, although staff had received relevant training, we found that their capabilities were not assessed to ensure that they could effectively use relevant tools to identify adults at risk of malnutrition. Since the previous inspection, improvements had been made to ensure people were supported to have choice and control of their lives. Their care records showed relevant health and social care professionals were involved in their care. The home was working within the principles of the Mental Capacity Act 2005 (MCA). Care records held best interest decisions including details of people's relatives who were involved in the decision-making process. The home also followed the requirements of Deprivation of Liberty (DoLS), which meant that people were not deprived of their liberty unlawfully. There were arrangements to ensure that people’s nutritional needs were met.

People’s privacy and dignity were respected. Staff understood the need to protect and respect people's human rights. We saw they had received training in equality and diversity. People’s spiritual or cultural wishes were respected. Representatives of local churches visited the care home regularly for prayers with people. People received compassionate and supportive care when they were nearing the end of their lives. Selected staff had attended ‘End of Life Care Champion’ and a ‘Palliative Care’ training provided by a local hospice.

This inspection took place on 5 and 8 December 2017 and was unannounced on the first day and announced on the second day.

Kent House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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. Kent House is registered to accommodate a maximum of 40 people with dementia. At the time of our inspection 28 people were living at the home.

There was no registered manager in post at the time of our inspection. The current manager was in the process of applying to become the 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.

This was the first comprehensive inspection of Kent House since it was re-registered under the provider, GCH (South) Ltd in May 2017. Prior to this the service had been inspected in May 2017 under the previous provider, GCH (Kent) Ltd, at which time it was rated 'Requires Improvement’'..

At our last inspection in May 2017, we found two breaches of regulations. We found medicines were not managed safely and that the provider did not effectively assess, monitor and improve the quality and safety of the service provided. At this recent inspection we found improvements had not been made and we identified further areas of concern.

Prior to this inspection CQC had received intelligence from external sources, including professionals, raising concerns for the safety of the people residing at Kent House. We looked into these concerns as part of our inspection.

We found the leadership of the home to be weak and inconsistent. Kent House has had four managers since 2016. People’s relatives expressed concerns about the constant changes of managers. They told us there was a general lack of continuity. We also found there was a general low level of staff satisfaction because the absence of a stable management team meant that staff did not always receive consistent support.

There was no evidence of learning, reflective practice and service improvement. Although there was an internal audit system in place, we found this to be unreliable and irrelevant because shortfalls were either not addressed or identified. This meant we could not be assured that the audit process was effective.

Risks to people had not always been identified and managed appropriately. There was limited action to assess, monitor or improve the safety of the service. Where risks had been assessed plans were not clear or coordinated. In other examples, there were no plans in place to instruct staff on how to safely manage those risks. At times information about risks to people was not passed on to the staff and others who needed it. A few staff members were not aware of specific risks to people.

The service did not regularly review its staffing levels to make sure that it was able to respond to people’s changing needs. Although the levels of staffing described by the provider were mostly maintained during the week, this was less so during the weekends. We saw records of people who now had higher needs since moving to the home, but this had not been taken into account in staffing decisions.

People were at risk because staff did not administer medicines safely. In some examples we found people did not receive medicines as prescribed. This was a repeated breach, as we saw no improvements since our last inspection in May 2017.

Accidents and incidents were not competently managed. We found the approach to reviewing and investigating causes to be insufficient and slow. We found people with documented history of falls but no effective action had