We carried out a comprehensive inspection of this service in September 2015 and found the provider was not meeting the legal requirements in relation to standards of care and welfare for people who lived at the home. We served two warning notices against the registered provider requiring them to be compliant with Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as risks associated with people’s care within the home had not been assessed and there was a lack of clear accurate records and systems in place to monitor the effectiveness of the quality of the service people received. We also required the registered provider to submit action plans to tell us how they would address other areas of non-compliance we found at the home during this inspection. The home was placed into special measures following this inspection.

We carried out a focused inspection of this service on 9 May 2016 to follow up the warning notices we had served on the registered provider. At this inspection we found the home to be compliant with these Regulations although further work was required to embed this work.

We carried out a comprehensive inspection of this service on 5 and 6 October 2016 and found the registered provider was now compliant with all the Regulations. The home has been removed from special measures following this inspection.

The home provides accommodation, support and care, including nursing care for up to 40 older people, some of whom live with dementia. Accommodation is arranged over three floors with stair and lift access to all floors. At the time of our inspection 37 people lived 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.

People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately. Processes were in place to check the suitability of staff to work with people. There were sufficient staff available to meet the needs of people and they received appropriate training and support to ensure people were cared for in line with their needs and preferences.

Medicines were administered, stored and ordered in a safe and effective way.

Risk assessments in place informed plans of care for people to ensure their safety and welfare, and staff had a good awareness of these. External health and social care professionals were involved in the care of people and care plans reflected this.

People were encouraged and supported to make decisions about their care and welfare. Where people were unable to consent to their care the provider was guided by the Mental Capacity Act 2005. Where people were legally deprived of their liberty to ensure their safety, appropriate guidance had been followed.

People received nutritious meals in line with their needs and preferences. Those who required specific dietary requirements for a health need were supported to manage these.

People’s privacy and dignity was maintained and staff were caring and considerate as they supported people. Staff involved people and their relatives in the planning of their care. The home used closed circuit television to promote the privacy, dignity and safety of people. There were appropriate policies and procedures in place relating to this.

Care plans in place for people reflected their identified needs and the associated risks. Staff were caring and compassionate and knew people in the home very well.

Effective systems were in place to monitor and evaluate any concerns or complaints received and to ensure learning outcomes or improvements were identified from these. Staff encouraged people and their relativ

We carried out an unannounced inspection of this home on 14 September and 5 November 2015. Repeated breaches of the legal requirements were found in relation to; the assessment and management of risks associated with people’s care and ineffective systems to ensure a quality service was provided. We also rated the key question, is the service well led, as inadequate.

Following this comprehensive inspection we served two warning notices with respect to these breaches, on the registered provider of the service and the registered manager, requiring them to be compliant with the Regulations by 18 January 2016.

We undertook this unannounced focused inspection on the 9 May 2016 to check they had met the legal requirements and made necessary improvements in relation to the safe and well led questions. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Living Plus Healthcare Limited t/a Queen Anne Lodge on our website at www.cqc.org.uk

The home provides accommodation and nursing care for up to 40 older people including those living with dementia. At the time of our inspection 40 people lived at the home.

At the time of the focussed inspection a registered manager was 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.

We found improvements had been made, although further embedding was needed.

Knowledge of people and the risks associated with their care was good. Staff knew the support people required to reduce risks. Most areas of identified need that presented a risk had a plan developed to inform staff of what to look for and how to provide support. However, there were occasions when the care did not meet these plans.

Records had improved since the last inspection, although they were at times long and not all information was kept in a single place making it difficult to track.

Staff said they felt supported by the registered manager and said that this had improved since our last inspection. They said they felt listened to and able to approach the registered manager with any concerns they had. They said they felt the registered manager listened and would take action to address any concerns.

Feedback about the provider was mixed. Improvements had been made to the systems used to assess quality however, further improvements were required to ensure these were fully effective and embedded. We have made a recommendation about this.

We spoke with five people who lived at Queen Anne Lodge and six relatives during our visit. We received written feedback from one visitor after our inspection. People and their relatives told us they were happy with the care, treatment and support they received at the home. All relatives and visitors gave positive feedback about the service. Comments made about the service included, “I think they are brilliant”, “I am treated with complete kindness,” and “Life here is quite good and not controlled”.

We found that people received personalised care, treatment and support. The service worked in cooperation with other providers to ensure people who had dementia had their health and care needs met.

There was an effective system in place to ensure that the service was monitored effectively. We saw that appropriate action was taken when assessments identified changes or improvements needed to be made to the service.

We spoke with four people who lived at the Home. They all confirmed that their privacy and dignity was maintained at all times and that staff always knocked on the door before entering their rooms. People told us that their choices were respected, for example where they chose to eat their meals.

The people we spoke with were satisfied that their personal and nursing needs were being met and they had no concerns about the quality of care. Two of the people we spoke with told us that staff were very busy but did not feel that this had an adverse effect on care.

The home employed an activities co-ordinator who worked every weekday and provided social activities in addition to escorting residents out on day trips. People could influence what activities were undertaken either informally or through residents and relatives satisfaction questionnaires.

We also spoke with one relative who visited the home regularly, always unannounced. We were told that the care given was good but staff were very busy.

We observed that people had their own copy of a Service Users Guide which outlined people’s rights and the provider’s responsibility in protecting them.

To help us understand the experience of people using the service, we used our Short Observation Framework for Inspection tool (SOFI). This allowed us to spend time watching what was going on in a service and to record how people spent their time, the support they got and whether or not they had positive experiences. Using this, we found that staff found the necessary time and skills to care for people well.

People told us that they are happy with the care and support they receive. They spoke positively about the staff team and how they are treated as individuals. People told us that they have been asked about the quality of the services being provided to them.

Staff told us that they are receiving training to carry out their roles and report further

People told us that they are happy with the care and support they receive. They spoke positively about the staff team and how they are treated as individuals. People are pleased with the work carried out to improve the décor, fixtures and fittings in the home.

Staff told us that they do feel more supported by the new manager and the home is more organised but training has still not taken place.

Portsmouth City Council’s safeguarding team continue to monitor the home but report better communication with the home and that no new concerns have been raised about the home.

Healthcare professionals also told us that the home is managing the care of people well and there are currently no concerns about the care and treatment of people who use the service receive.

People who used the service expressed mixed views about the home. People told us that overall they are happy living in the home but there is a lack of choice in the meals provided and activities are limited and irregular.

Some people told us that they are very happy with the staff that support them, others expressed concern that because staff do not interact with them they feel they are not liked.

Staff told us that they have not had training and support to carry out their roles and meet the needs of people who use the service. Staff expressed concerns about the staffing levels and the impact this has had on the choices people who use the service can make.

Portsmouth City Council’s safeguarding team told us that they have concerns about the current staffing levels in the home particularly the number of trained nurses available to meet people’s needs. They have also received information of concern that people have been exposed to abuse that has gone unreported to either the safeguarding team or the Commission.

This comprehensive inspection took place on 14, 15 September and 5 November 2015. The inspection was unannounced.

Living Plus Health Limited t/a Queen Anne is a registered care home and provides accommodation, support and care, including nursing care, for up to 40 people, some of whom live with dementia. There were 35 people living in the home at the time of our visit. The home is built on four levels and there is a lift between the floors. There is a communal lounge and separate dining room on the ground floor where people can socialise and eat their meals if they wish.

At our previous inspection in October 2014 we identified concerns in relation to the provider’s compliance with the regulations. They were not able to demonstrate safe recruitment practices and staff were not supported effectively through supervisions and training. Plans of care were not always personalised and reflective of people’s needs. At times they were unclear and confusing. Medicines were not always safely managed and the provider was not able to demonstrate they sought and acted upon peoples consent to their care. We required the provider to take action to address these concerns. The provider wrote to us in April 2015 to say what they had done to meet legal requirements in relation to these breaches. We also made a recommendation at this inspection that the provider seek professional support for the registered manager as well as embedding a robust auditing system.

A change in the registered manager had taken place since the inspection in October 2014 and the service had had a new registered manager in place since June 2015. 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 this inspection we found the provider had taken action to make improvements. However sufficient action had not been taken to meet our regulations and further improvements were required.

People confirmed they felt safe and staff demonstrated a good understanding of how to protect adults at risk. The management of medicines had improved. However, risk associated with people’s care were not always appropriately assessed and plans had not always been developed to ensure that staff met people’s needs consistently and reduced risks.

Recruitment practices had improved and appropriate pre-employment checks were undertaken. Staffing levels were appropriate to meet the needs of people. Improvements to supporting staff had been made. Supervisions were taking place although not as frequently as the policy stated. Some improvements in the training staff received had been made, although there were still significant gaps in training that would support staff to effectively deliver care.

Observations demonstrated people’s consent was sought before staff provided care. People confirmed staff involved them in making decisions. Staff and the registered manager demonstrated a good understanding of the Mental Capacity Act 2005. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service had submitted applications for DoLS for some people living in the home to the supervisory body.

People described staff as kind and caring. They felt they were treated with respect and dignity. Most observations reflected this. Whilst staff knew people well, care plans and care records were not always personalised, accurate, up to date and reflective of people’s needs and preferences.

People and their relatives knew how to make a complaint and these had been investigated. However records did not always follow the provider’s policy. We have made a recommendation about this.

Systems were in place to gather people’s views. Staff described the registered manager as open and approachable. They were confident any concerns would be addressed and staff and people felt listened to. A system of audits was in place although this was not always fully effective. However, the provider was introducing a new system to support the auditing of the service.

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.

The overall rating for this service is ‘Requires Improvement’. However, we are placing the service in 'Special Measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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 inspected 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 take action 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 within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.