Langford Park is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 35 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there.

At inspections in 2016 and 2017 the service was rated as Requires Improvement. We inspected the service in January 2018 and found that improvements had been made, therefore the service was rated Good. However, at our inspection in August 2018 we found that the improvements had not been sustained and the service was again rated Requires Improvement overall. Aspects of the management and recording of people's medicines required improvement. People did not always have the opportunity to engage in activities and social stimulation, and were at risk of becoming isolated and depressed as a consequence. Significant changes in the management structure and staff team had undermined the quality and safety of the service. New staff had not received the induction, training and supervision required to do their roles safely and there were concerns about poor recording, decreasing standards of personal care and housekeeping, and a lack of clarity around roles and responsibilities. We found breaches of the regulations related to person centred care; safe care and treatment; staffing and governance and served a requirement notice.

Following the inspection further concerns about the safety of the service were raised. Langford Park became the subject of a whole home multiagency safeguarding investigation in December 2018. Whole service investigations are held where there are indications that care and safety failings may have caused or are likely to cause significant harm to people. These concerns meant the local authority, with the agreement of the provider, placed a suspension on any further local authority placements at Langford Park. The provider also voluntarily agreed not to admit privately funded people to the home during this period. Improvements to the safety and quality of the service meant the whole home safeguarding process was concluded on 26 February 2019 and the placement suspension lifted. The service continues to be monitored and supported through the local authority ‘Provider Quality Support Process.’

Before the inspection we received concerns about the management and governance of the service. We carried out an unannounced focussed inspection of this service on 7 and 8 January 2019 to look into those concerns. We did not look at all the previous breaches and will report on those at the next comprehensive inspection.

While there had been some improvements, several issues identified at the inspection in August 2018, and in an audit completed by the provider in October 2018, had still not been addressed in January 2019. This included recording, risk assessing and training, for example in manual handling. The provider’s failure to address these concerns meant people had experienced harm, such as pressure area damage, and continued to be at risk of harm.

This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Langford Park on our website at www.cqc.org.uk can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Langford Park on our website at www.cqc.org.uk.

There was no registered manager at the service as the previous manager had resigned since the last 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

Langford Park is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there.

At inspections in 2016 and 2017 the service was rated as Requires Improvement. We inspected the service in 2018 and found that improvements had been made, therefore the service was rated Good.

However, at this inspection in August 2018, we found that the improvements had not been sustained. Aspects of the management and recording of people’s medicines now required improvement. Care plans did not consistently contain the guidance staff required to administer medicines safely, and when required. A member of staff was wearing a tabard to indicate they were doing the drugs round and should not be interrupted, but was undertaking other tasks. The manager was aware of the concerns and at the time of our inspection additional training in medicines administration had been arranged. In addition, a new clinical lead had been employed, along with two new nursing staff.

People did not always have the opportunity to engage in activities and social stimulation. Although some activities did take place, there was no activities programme. People told us they were bored and lonely. Two relatives told us their family member was becoming increasingly depressed and withdrawn because they were not receiving the support they needed to stimulate their mind or participate in activities. The manager was aware of this concern and action was being taken to address it. Two new activities co-ordinators were being recruited to work alongside the existing activities co-ordinator. The importance of interaction with people was being emphasised to staff.

Significant changes in the management structure and staff team had undermined the quality and safety of the service. These changes were intended to improve the service and provide better consistency, however at the time of the inspection they were not fully embedded. Many of the new staff had not worked in a care home before. They had not received the induction, training and supervision required to do their roles effectively. There were concerns about poor recording, decreasing standards of personal care and housekeeping, and a lack of clarity around roles and responsibilities. The provider had identified these issues through their quality assurance processes, and developed an action plan to address them. Emergency staff meetings had been held with clear guidance given to staff about expectations and the action required.

People told us they felt safe. Regular health and safety checks were undertaken at the service. There were effective infection prevention processes in place, the home was compliant with fire regulations and a programme of refurbishment was in progress. People were protected from the risk of abuse through the provision of policies, procedures and staff training, and an effective recruitment process.

There were systems in place to ensure risk assessments were comprehensive, current, and supported staff to provide safe care while promoting independence. The computerised care planning system, accessed by staff using handheld computers, ensured that information about people’s risks was shared efficiently and promptly across the staff team. This meant staff had detailed knowledge of people’s individual risks and the measures necessary to minimise them.

Care plans were person centred and provided clear guidance for staff which enabled them to meet people’s needs according to their preferences. They had not always been formally reviewed in line with the provider’s own policy, h

Langford Park 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, and both were looked at during this inspection.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 32 people living there.

At an inspection on 18 and 22 February 2016 the service was rated as ‘requires improvement’ in all key questions and ‘requires improvement’ overall. We found no breaches of regulation. At the inspection on 06, 07 and 23 June 2017, significant improvements had been made. The service was rated ‘requires improvement’ in ‘safe’ and ‘well-led’, and ‘good’ in the other key questions. However we found breaches of the regulations related to safe care and treatment and good governance. The service was again rated ‘requires improvement’ overall.

We undertook an unannounced focused inspection of Langford Park on 15 and 22 January 2018. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our inspection on 06, 07 and 23 June 2017 had been made. We inspected the service against two of the five questions we ask about services: “Is the service safe?” and “Is the service well led?” We found significant improvements had been made and these two key questions were now rated good. No risks, concerns or significant improvement were identified in the remaining key questions through our ongoing monitoring or during our inspection, so we did not inspect them. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection.

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.

The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. They had acknowledged the areas in which the service needed to develop and improve, and had been proactive in making this happen. This had led to improvements in the quality and safety of the service. A relative confirmed, “There has been a gradual but firm process of improvement. My concerns have evaporated. It’s being properly managed”.

There were now effective quality assurance systems in place to help assess the safety and quality of the service, and identify any areas which might require improvement. The findings of the audits contributed to a service improvement plan, with clearly defined actions, responsibilities and timescales. The views of people, their relatives, and staff were actively sought to ensure the service was run in the way they would like it to be.

People told us they felt safe. Improvements to systems for the administration of medicines had been made, which meant people now received their medicines safely according to their individual needs and preferences. A computerised medicines administration system minimised the risk of errors and allowed the management team to monitor medicines on a daily basis. Regular medicine audits and spot checks were carried out by the provider.

There were now effective infection prevention processes in place, and a robust system to ensure that pressure relieving mattresses were at the correct setting for the person’s weight, to minimise the risk of skin breakdown.

There were systems in place to ensure risk assessments were comprehensive, current, and supported staff to provide safe care while promoting independence. The computerised care

This inspection was unannounced and took place on 6 and 7 June 2017. The provider was on leave during the inspection, so we met with them on 23 June 2017.

The previous inspection of the home was carried out on 18 and 22 February 2016. At that inspection the service was rated as ‘requires improvement’ in all domains and ‘requires improvement’ overall. We found no breaches of regulation. At this comprehensive inspection in June 2017 we found significant improvements had been made, however additional areas of concern and breaches of regulation meant further improvements were needed to ensure people’s safety. The service has therefore again been rated ‘requires improvement’ overall.

Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there, with one new person moving in on the day of the inspection. 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.

When we last inspected in February 2016, a whole service multiagency safeguarding process was underway to protect people's safety and well-being. The local authority safeguarding team, the commissioning team and the Quality Assurance and Improvement Team (known as QAIT) had been closely monitoring the home with regular visits, and providing training and support to help the provider and management team establish effective care and management systems. While we found significant improvements in the management and quality of the service, it was too soon at this stage to determine whether they would be sustained, and some improvements were yet to be implemented. This comprehensive inspection in June 2017 was carried out to check whether the improvements made had been sustained, and the service was now providing safe and effective care to people.

At this inspection we found that although there were systems in place to ensure people received their medicines safely, they were not always effective. For example, the member of staff doing the drugs round was distracted by the need to answer the door to visitors and provide support to other members of staff, which meant medication was administered late to people. Guidance had not been sought from the pharmacist on the safest method for administering covert medicines, in line with the service’s covert medication policy. Medication requiring disposal was observed on top of a cupboard in the nurses’ office, when regulations state that medication requiring disposal should to be stored in a tamper proof container and locked away. One person had three opened tubes of the same cream in use, one of which had no recorded expiry date.

During the inspection we found that the management of clinical waste was not safe, which put people at risk due to the potential for the spread of infection. Two open bags of waste, including used disposable gloves, were left on the floor in the laundry.

At the last inspection in February 2016 we found that improvements were needed in relation to the assessment of risk, particularly related to falls and accident and incidents. At this inspection we saw there were now effective systems in place to assess and minimise risks, supported by a new computer based care planning system. However, further improvements were needed to ensure staff had the information they needed to keep people safe, specifically related to the safe use of pressure relieving mattresses.

At the last inspection the provider did not have adequate systems in place to monitor and review the quality of care and ensure the service co

This inspection was unannounced and took place on 19 and 22 February 2016. The previous inspection of the home was carried out on 17 and 19 August 2015 where we found breaches of regulations. These related to safe care and treatment, safeguarding service users from abuse and improper treatment, and assessing and monitoring the quality of service provision. The service was rated as ‘requires improvement’ and the provider was required to submit a monthly action plan explaining what they were doing to meet the legal requirement to improve the service.

We carried out this inspection in February 2016 to check whether these improvements had been made. Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability. At the time of this inspection there were 29 people living there. 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 significant improvements in all aspects of the management of the service since the last inspection. There had been input from the local authority safeguarding team, the commissioning team and the Quality Assurance and Improvement Team (known as QAIT) since the last inspection. These professionals had closely monitored the home with regular visits and provided training and support to help the provider and management team establish effective care and management systems. This input had been welcomed and the providers and management team had worked closely and constructively with them to keep people safe and improve the quality of the service. However, it was not possible at the time of the inspection to determine whether there was consistency in the effectiveness of the care, treatment and support people received, or whether this would be sustained, as the changes had been so recent. In addition, some improvements had yet to be implemented.

At the last inspection we identified that risks to people’s safety had not been fully assessed, recorded or reviewed. At that inspection we found staff did not have access to written information about potential risks or the actions they must take to reduce those risks. At this inspection we found improvements had been made and there were systems in place to minimise risks. However further improvements were needed in relation to the assessment of risk, particularly related to falls and accident and incidents.

At the last inspection we found there was no information to show how people had been involved in the planning and review of their care. Since that inspection a new care plan system had been introduced in the home and staff were writing new care plans for everyone. However not everybody we spoke to had been consulted. The new care plans required additional information, especially about people’s history and background. People’s end of life wishes had not been consistently discussed with them or their families and had not been recorded. This meant there was a risk they may not receive the care they and their families wish for at the end of their life.

There had been a large turnover of staff which had made it difficult for people to build relationships with the staff who supported them. One visitor said, “The biggest issue is the turnover of staff. You’re never sure who will be here when you visit”.

At the time of the inspection staff had not been receiving regular individual support and supervision. Managers recognised they had lost confidence during the safeguarding process and were feeling under scrutiny and demoralised. They wanted to provide constructive and positive support to help them feel more motiva

At the time of the inspection there were 32 people living at the service; we met with or saw the majority of people. We spoke in depth with nine people to hear about their experiences. People told us they were happy with the level of care and attention they received. Comments included, “This is the right place for me”, “I am happy enough here. The staff are friendly”, “We are pretty well cared for here” and “It’s very good here. Staff are gentle and caring. This was definitely a good decision for me to move here”.

We spoke with five relatives, eight visiting health professionals (including members of the stroke rehabilitation team, dieticians, palliative care nurses and a tissue viability nurse) and the Devon County Council contracts team. Relatives told us, “X’s condition has improved since coming here”, “I am happy with everything so far”, “We like it here. X is settled. It is friendly and welcoming” and “Things are really good here”.

Visiting professionals told us that the service always referred people appropriately and in a timely way. One physiotherapist told us, “It appears to be good care and support for people here”. Other comments from professionals included, “There have been major improvements over the past year or so”, “They (staff) know what is going on for people. They have some fab nurses” and “They have complex service users but we have no concerns about the care”. Devon County Council contracts officer told us there were no current concerns about the service.

We spoke with six members of staff, including the registered manager. Staff told us they felt well supported and they felt they had access to a good range of training to help them do their job safely and competently.

At this inspection we found that the provider was meeting all of the outcomes we looked at. The service was responsive to people’s care and support needs and people told us they felt the staff were caring, and that they felt safe at Langford Park. We received many positive comments about the registered manager. People living at the home, relatives and professionals told us the service was well managed.

We spoke with five people about how the service involved them in consent to care and treatment. People told us that they were consulted with about their care needs on a daily basis. People said that staff explained any procedures to them and asked for their permission before undertaking interventions. One person told us, “Staff always ask how I want things done. They listen to me and do as I ask”. Another person told us, “I have been given a copy of my care plan to read. I have spoken with the staff about the support I want. I am happy with it. It is a fair assessment. I can direct my own care”.

We found that improvements had been made since our last inspection. Arrangements were in place to ensure that valid consent was obtained from people in relation to the care and treatment they received. There were appropriate arrangements in place to protect people who may lack capacity.

We (the Care Quality Commission) spent two days conducting unannounced visits to Langford Park as part of a planned inspection of the home. During this inspection we had an opportunity to look at concerns raised with us about the care and support people receive at the service. We also checked that action had been taken to achieve compliance following the inspection of November 2011.

During our visits we met with or saw the majority of the people using the service. Some people were unable to tell us what it was like to live there due to communication difficulties. However, we spent a lot of time observing the care and support delivered to people. We had conversations with three people using the service and met with four people's relatives. We also spoke with a visiting health professional, one visiting social care professional, five care workers, three nurses, the registered manager and the recently appointed manager.

People told us, “The staff are decent”, “On the whole staff are respectful”, “All staff understand what’s wrong with me”. Another person told us that their care needs were met but that they sometimes had to wait for attention if staff are busy. People we spoke with told us they felt safe at Langford Park. One person told us, “Staff are fine. They are not rough or rude. I have a good relationship with staff”.

Overall comments about the food were positive. One person told us, “The chef really looks after me”. Another person told us that the food was “good” and that they were offered a choice.

Visiting relatives told us that they were happy with the general care at the home. They told us they had no concerns about the way staff treated their family members. One person told us, “X has settled well. Staff are polite…” Another relative told us, “I feel X is totally safe here” and “X is treated with respect and kindness. I have never seen anything of concern or heard staff being rude. They are always polite”.

We visited the home on 20 and 26 April 2012. On the morning of 26 April we used our SOFI (Short Observational Framework for Inspection) tool to help us see what people’s experiences of spending time in main lounge was. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time and whether they have positive experiences. This includes looking at the support that is given to them by the staff. We spent 90 minutes watching and we found that people had a mix of both positive and negative experiences. There was some friendly and sensitive interaction between care workers and people using the service and people often smiled when staff approached them. However, we also saw one person with dementia being unnecessarily disrupted by a care worker from activity that was meaningful to them and one person’s request to use the toilet was ignored.

A new manager was appointed in January 2012. People using the service, relatives, visiting professionals and staff spoke highly of the newly appointed manager. People had confidence in her ability to improve the overall service provided at Langford Park.

The newly appointed manager told us that there were some current weaknesses at Langford Park, which were in the process of being addressed. The manager recognised that it “would take sometime”. CQC recognised that some improvements had been made since the last inspection. People living at the home told us about the improvements made, which included regular meetings to allow people to share ideas and express views. These meetings had resulted in ideas being put into practice. Relatives and visiting professionals also told us about the improvements made at the home since the appointment of the new manager.

However, we found that there was no consistent system in place to assess if people had capacity to give consent or make meaningful decisions about the care and support they receive.

We found that care plans did not always contain up to date and detailed information about peoples' assessed needs and preferences. This means that people might be at risk of receiving care or treatment that is inappropriate or unsafe.

We found that staff had not received the training necessary to enable them to meet people’s diverse needs; however there was a training plan in place which covered all the necessary areas.

We carried out this review after receiving information of concern directly and through the local authority's Safeguarding team, in relation to care of three people who had used the service in 2011. We visited the home unannounced on 26 October 2011, and returned the next day to complete our inspection.

As the registered manager was on holiday, we were assisted during our visit by the deputy manager and one of the company’s managers, as well as by the staff. The registered manager and the nominated individual (the provider's representative) came to the home on the second day, for discussion of our findings.

There were 29 people living at the home, and we were told that 21 residents were over retirement age. We spoke with 11 people who lived at the home who were able to give us their views to varying degrees. We also spoke with a relative and a care manager for two of these people. We met other people who, because of frailty or mental impairment (such as caused by dementia), had a limited ability to give us their views. We relied more on observation to find out about the safety and quality of the service they received.

There was a lack of evidence in people's care records, including those who had dementia, to show that their capacity to make decisions for themselves or give valid consent had been formally assessed. This meant that staff could not be certain if consent given by someone, regarding their care or medication for example, was 'valid' - that is, that they can make an informed decision about their care and so on.

People we spoke with felt in general they received the support and care they wanted, with the exception of recreational opportunities. We also received mixed views about the food provided, and we were told that a new part-time cook was being employed in response to people's comments. People were treated respectfully and most felt staff ensured their privacy, but they were not fully involved in discussions about their care and their diverse needs were not always met. For example, regarding use of people's free time - although one person said they were going out a lot more than they used to, people raised week-ends particularly as a matter of concern. Comments included that week-ends were “boring”, and “Sundays are depressing”. A visitor told us their relative’s health had improved since they moved to the home, which they felt this was due to care the person had received at the home. Yet they also had concerns about aspects of care, despite speaking with staff about these. Systems had not been established to effectively assess and improve the quality and safety of the service people received.

People appeared relaxed in the company of staff. People's comments about the staff included that they were good, and "All very nice, very good". One person told us some staff were better than others, which they felt was a training issue, as well as being due to individual personalities. We found the training needs of some staff hadn't been identified or acted on, though the staff team as a whole were trained and supervised to provide a safe basic level of care. People considered staff to be caring, when we asked about this. We saw there were friendly yet professional relationships between the staff and people living at the home. People were safeguarded from abuse because staff knew their responsibilities regarding this, although systems to protect people's property need strengthening.

We carried out an unannounced comprehensive inspection on 17 and 19 August 2015. Langford Park is registered to provide accommodation, nursing and personal care support for up to 34 older people, people living with a dementia and younger people with a physical disability.

We last inspected the service on 9 and 14 May 2014 when we found that the service was in breach of Regulation 21 HSCA 2008 (Regulated Activities) Regulations 2010. The provider did not operate an effective recruitment process to ensure people were protected from unsuitable staff. The provider sent us an action plan in August 2014 which explained what they would do to meet legal requirements in relation to improving their service. At our inspection on 17 and 19 August 2015 we judged that the selection and recruitment of staff was now satisfactory.

There was a new manager in post. A registered manager application had been submitted to the Care Quality Commission but the registration process was still in progress. 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 new manager was open and honest about the strengths of the service and areas for improvement. Everyone was positive about her, and felt she was approachable, caring and committed to the improvement of the service and the well-being of people there.

The service did not ensure staff had the information they needed to provide safe care. Risk assessments and care plans were not always kept up to date. This put people at risk of not having their current needs met, particularly if staff were new or from an agency, and did not know the people they were caring for. Care plans did not always record whether people had been consulted when their plans were being drawn up and reviewed.

The service did not always manage people’s medicines safely. Recommendations made by a visiting pharmacist in March 2015, related to the development of a comprehensive ‘Medication Management Policy’ and the safe storage of oxygen had not been carried out. Oxygen cylinders were not stored in a portable trolley or safe container and could cause injury if they fell over. Regular auditing of medication administration records (MAR) was not being undertaken. This meant that there was a risk that medication errors may not be picked up promptly and people may not receive medicines as prescribed.

The service was not using an effective programme of audits to monitor and review the quality of care, and ensure the service continued to meet people’s needs effectively.

The manager and deputy manager recognised that the service was not fully meeting its requirements in relation to protecting people’s human rights, where people lacked the mental capacity to make certain decisions about their care and welfare.

Following a period of high staff turnover at the service there was a relatively new but stable staff group, and sufficient numbers of staff to care for people. Staff met people’s needs appropriately and promptly and treated people with dignity and respect.

People were supported to take part in a range of social activities if they wished, inside and outside the home, and in the local community.

The provider actively sought the views of people, their relatives and staff through staff and residents meetings and questionnaires to continuously improve the service. There was a complaints procedure in place and the manager had responded to concerns appropriately.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.