The inspection took place on 24 and 25 October 2017. The inspection was unannounced.

Maidstone Care Centre provides residential and nursing care and accommodation for up to 57 older people, some of whom may be living with dementia. The accommodation is arranged over three floors with a unit on each floor. Units are called Medway, Rochester and Pembury. People who required nursing care live on the ground and first floor units and residential care is provided on the second floor. A passenger lift is available to take people between floors. There were 48 people living at the service at the time of our inspection.

At our last inspection, in July 2016, we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the management of risk to individuals' safety, people’s care plans were not person-centred, activities were not available to meet people’s needs, notifications and safeguarding concerns had not been raised with the local authority or with the CQC, people were being unlawfully deprived of their liberty, people’s nutrition and hydration needs had not been met, staff had not been trained to meet people’s needs, recruitment practices were not safe and governance systems. This inspection took place to check that the registered provider had made improvements in these areas. We found that improvements had been made, and the breaches were now met.

There was a registered manager based at the service who was supported by a deputy 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.

People told us they felt safe living in the service with the staff that were supporting them. Staff and the management team had received training about protecting people from abuse, and they knew what action to take if they suspected abuse. Potential risks to people in their everyday lives had been assessed and recorded. The premises and equipment were maintained and checked to ensure the safety of people, staff and visitors. Accidents and incidents involving people had not been consistently recorded. Records showed staff had not always completed the required documentation or had the persons’ care records been updated as a result of an accident. Following our inspection the registered manager implemented a guide to inform all staff of the correct procedure.

People’s care plans were personalised and gave staff the information and guidance to meet people’s needs. Care plans contained information about people’s preferences and life histories. People were supported to participate in a range of activities to meet their needs. Independence for people was encouraged and promoted. People were supported to make choices and decisions and staff followed the principles of the Mental Capacity Act 2005.

People had access to the food that they enjoyed and were able to access drinks and snacks throughout the day. People’s nutrition and hydration needs had been assessed and recorded. People were supported to maintain their health with the support of health care professionals. Medicines were stored and administered safely.

Care and nursing staff regularly received training to ensure they had the skills and competencies to provide safe care. Staff received an induction when they joined the service. Staff completed training courses to meet people’s needs. The provider’s pre-admission assessment had not identified when people required any specialist support from staff. Following our inspection the registered manager updated the pre-admission assessment to include any specialist training that staff required.

People were treated in a kind and caring manner by staff who understood the importance of maintaining

The inspection took place on the 18 and 19 July 2016. The inspection was unannounced.

The service provides accommodation, nursing and personal care for 57 older people some of whom may be living with dementia. The accommodation is arranged over three floors with a unit on each floor. Units are called Medway, Rochester and Pembury. People who required nursing care live on the ground and first floor units and residential care is provided on the second floor. A passenger lift is available to take people between floors. There were 54 people living at the service at the time of our inspection.

The service had 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.

People told us that they felt safe. However, people’s risk assessments were not always comprehensive to mitigate the risks and in some cases there were no risk assessments in place. Risk assessments had not always been updated after people’s needs had changed. The service did not always respond to accidents and incidents appropriately and ensure proper records were maintained.

There were environmental risk assessments in place. People had Personal Emergency Evacuation Plans in place, however, these were not detailed to enable staff to support people safely from the building.

Recruitment practices were not always robust, with gaps in employment history not always being explored. Our observations identified issues with the way staff were deployed around the service and staff interactions with people. The registered manager used a dependency level tool that was completed for each person. We have made a recommendation about this.

People’s medicines were well managed. Staff were knowledgeable and knew how to administer medicines appropriately.

Staff had received additional training in managing and preventing pressure ulcers but it appeared that this training had not been embedded in practice. People were not receiving care and treatment in line with health care professional advice.

Staff had received mandatory training but had not completed some mandatory face to face training, placing people at risk of harm from unqualified staff.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. The registered manager understood when an application should be made. Decisions people made about their care or medical treatment were dealt with lawfully and fully recorded. One person did not have a DoLS in place when they needed to have one, however, the registered manager did action this following our inspection. The service did not notify the Commission when DoLS were authorised by the local authority.

People were supported to access routine health care which included GP, chiropodist and optician’s appointments. Appropriate referrals were being made to specialist healthcare professionals when needed.

The staff were caring although for some people there was a lack of engagement with staff which we observed on the first day of our inspection. Engagement with people was better on the second day of inspection but it was not clear this was because of being prompted from feedback by inspectors.

Staff knew how to be respectful and treated people with dignity. They knew about the importance of confidentiality and keeping records secure. However, not all records were maintained in a secure place.

People were not involved in the drawing up of their care plans. Care plans did not include people’s likes and dislike

This inspection was carried out by two inspectors over eight hours who worked to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic. There were enough staff on duty to meet the needs of the people living at the home. Each shift was led by a nurse and senior carer who could access records and respond to emergency situations. There was a plan in place to enable people’s care to continue should a foreseeable emergency occur, for example a power failure.

Care and treatment records did not contain all of the information required to ensure peoples safety. This was because we found that for some people their records were not being completed in such a way as to enable health issues to be followed up. Staff were not always kept informed of a person’s most up to date care needs. Compliance actions have been set for this and the provider must tell us how they plan to improve.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Policies and procedures were in place. However, we found that people’s human rights were not protected. This was because the manager of the service was not taking steps to ensure that staff were consistently following guidance. For example within the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). We saw that where appropriate people’s capacity was not always assessed. For example where a person’s liberty had been restricted the Deprivation of Liberty Safeguards process had not always been followed. This meant that it was not always possible for the manager to demonstrate that decisions were in people’s best interest. Compliance actions have been set for this and the provider must tell us how they plan to improve.

Is the service effective?

People told us that they were happy with the care they received and felt that their needs had been met. It was clear from what we saw and from speaking with staff that they understood people’s care and support needs and that they knew them well. We found that the records kept about people’s needs were not always kept up to date. We observed saw that staff were not always deployed in such a way as to meet people’s needs flexibly. People we talked with who used the service were generally happy with living there. One person said, “I do not have any problems, I like to get up early and the staff are friendly”. Others said “The staff are fantastic, they are polite and friendly”. One person told us that they were able to access the garden as they wished. Another person told us that they “loved to see people bringing in their dogs for people to see”.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people. We saw that staff interacted positively with people who used the service. People we talked with about the service told us that staff were caring and friendly. We observed staff offering people choices. We talked with five people who used the service including their relatives. All of the people we talked with who used the service were happy with the care they had received. They told us that the staff were caring, one person said “The staff are fantastic”. Another person said “I’ve never needed to complain; staff are always respectful and give me choices”.

Is the service responsive?

People’s needs had been assessed before they moved into the home. We saw that each person had a named key worker and that systems were in place that enabled care plans to be reviewed and updated. We observed that staff asked people for their views and permission before providing any care or treatment. Records confirmed people’s preferences, interests, aspirations and diverse needs had been recorded. However it was not always demonstrated that care and support had been provided in such a way as to ensure that it met their wishes. This was because people were not always being asked to sign and agree their care plans and assessments before the service was delivered. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

We asked the manager how their quality audits were analysed and how they had responded to people. The manager could not provide any information about how people’s comments on the quality of the service were collated and responded to.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. We saw that people who used the service were asked for their feedback about the service they received. People had opportunities to participate in residents and relatives meetings. People told us that they were confident that they would be listened to if they complained. Two people we talked with who used the service told us that if they wanted to raise any issues they could tell any member of staff, they said that “The manager of the service was nice and friendly”.

However, we had received information of concern about the number of managers that had left the service. The service commissioners told us that there had been five managers at the service in the last 12 months. We found that the service had not employed a registered manager since April 2013. It was a condition of the provider’s registration that they employed a registered manager at the location. We noted that the managers of the service had not been able to sustain compliance following previous enforcement action within the last year. Relatives of people who used the service had also raised concerns about why managers were not staying at the service. This meant that the provider could not demonstrate that the service was well led, at service level or at higher levels within the organisation.

We had carried out a scheduled visit in June 2013 when we had found serious shortfalls in staffing numbers and staff training. We had also found non-compliance with three other outcome areas. We had carried out a responsive inspection in August 2013 in response to concerns raised from anonymous sources. We had found that there was evidence of some improvement at this time from our previous visit in June. This inspection was carried out to assess if compliance had been achieved with all of the areas identified at the inspection in June 2013.

The inspection was carried out by two Inspectors over eight hours. We commenced the inspection at 07.00 so that we could meet and speak with night staff as well as with day staff.

During the visit we talked with people living in the home and with four relatives. We talked with 13 staff including the newly appointed manager and deputy manager. The regional operations manager was available in the home for much of the inspection and informed us about recent changes in the home prior to the appointment of the new manager.

People spoke positively about the home. Their comments included, “I am very happy and hope to spend the rest of my days here.” “It’s usually very good here.” “They look after us very well on the whole, I have no complaints.” A relative said “This is a good home. They are looking after my relative very well. The care is fine.”

We found that the home had a calm and relaxed atmosphere, and people living in the home spoke positively about their care and treatment. We saw that increased numbers of staff during “twilight” hours had made a significant improvement to meeting people’s needs at those busy times of day.

We found that the home had carried out reliable recruitment procedures for new staff, and they were being supported in their new posts.

We saw that new staff training programmes had been implemented. Newly recruited staff had received mandatory training, and most existing staff had completed updates in mandatory training. Staff were receiving training in other relevant subjects such as dementia care.

We found that reliable systems had been put in place to monitor the quality of care that people received.

We carried out an inspection visit in response to some concerns raised by two separate members of the public. The concerns were in relation to continued low staffing levels and inadequate staff training.

In accordance with information sharing policies we contacted Kent County Council Social Services and discussed the concerns raised. The visit was carried out by one Inspector and a Kent County Council Safeguarding Vulnerable Adults Coordinator.

On arrival we discussed the concerns with the Regional Manager who was in the building. We visited each unit and talked with people living in the home, and with staff. We viewed some records, including staffing rotas, staff recruitment files and staff training programmes.

A Care Quality Commission inspection had been carried out on 25th June 2013, and we had already found shortfalls in staffing numbers and staff training. We sent warning notices with a deadline for completion by 31st August 2013. Because of the nature of the concerns raised, we found it necessary to visit the home again before the deadline was due.

We did not make any changes to our judgements as a result of this visit, but will review the home again after the date of compliance has been reached.

The visit was carried out by two Inspectors over seven hours, and one expert-by-experience. During the inspection we talked with people living in the home; with relatives and visitors; and with 12 staff as well as the manager and regional manager.

We obtained a variety of responses from people living in the home and relatives about their view of the home. Some people said they were happy living in the home and did not have any concerns. Other people said that the staff were so busy and short of time that they did not have time to care for people properly.

We found that care planning was generally up to date on computer systems but not on paper versions.This meant that care staff were not aware of people's specific needs. Care plans tended to be generic and non-specific.

People said that the food was good and they were provided with a suitable variety.

We inspected medication procedures and found them to be well managed.

Staffing levels were inadequate on all units for day and night staff. This was having a major impact on the quality of the care being given.

Staff training was not up to date. This impacted on people’s care, as staff lacked the knowledge they needed to provide effective care.

We found that a new manager was providing strong leadership in the home. The staff were growing in confidence in sharing their views.

Complaints management had improved and we saw that complaints were responded to appropriately and were properly addressed.

During our last visit in September 2012, we found that there was only one activities co-ordinator to assist 57 people living in the home with their choice of activities. We found that Pembury unit, for older people with dementia, included people who were often up early and who needed stimulation and observation throughout the day.

The manager sent us an action plan to state that the company had decided to employ a second activities co-ordinator for the mornings in Pembury unit.

At this visit we looked at staffing rotas and discussed them with the deputy manager; and we talked with four staff on duty in Pembury unit, and two other staff. We observed care and activities for a short time in this unit.

The staff told us that the employment of an additional staff member in the mornings had made “a big difference”, as this was the busiest time of day. They said that the activities co-ordinator was able to provide ongoing activities during the morning while care staff were assisting people to get up.

We talked briefly with some of the people living in the home, and they responded cheerfully. We saw that they were enjoying taking part in different activities, or were watching others.

This inspection was carried out to follow up a compliance action given at the last inspection visit, in regards to Outcome 4, “Care and welfare of people who use services”.

At the last visit the Inspector had found shortfalls in the care planning system, in that the care plans reviewed did not show people’s preferences for how their personal care should be provided. This omission compromised the dignity of people who used the service.

At this visit, we looked at eight care plans, and talked with five people and three relatives and visitors. We also talked with seven members of staff, as well as with the manager.

During the visit, we noticed that there was only one activities co-ordinator to provide activities for 57 people accommodated on three floors. We asked further questions about care staff numbers and found further concerns about the numbers of care staff employed for duties in the residential dementia unit (Pembury).

People using the services were able to tell us that they liked living in the home. They told us that the staff were friendly and caring. We were able to talk to four people about the care received in the home.

One person told us, ‘I like it here. I like the people. Support is there when you need it’.

Another said, ‘It is clean and nice here and I can have a laugh with the staff’.

We visited all the units in Maidstone Care Centre, although the majority of our visit was spent on the Pembury unit, which was for people with dementia. Not everyone using the service was able to tell us about their experiences and so to help us understand these we used a method of observation called SOFI (Short Observational Framework for Inspection). This allowed us to spend time watching what was going on, how people spent their time, the type of support they got and whether they had positive experiences. Some people that use the service were able to tell us about their experiences and we also had the opportunity to speak with a large number of visitors to the home.

Visitors spoke positively about the service provided. One person told us that the home was “Absolutely outstanding with superb staff” and said that “The improvement has been quite vast for [my relative] just by coming here.” Another visitor described the home as having “a lovely feel, like a family” whilst one person said “Day to day the staff will always go the extra mile”. People that use the service told us that the staff gave them the help they needed and one person commented that “they never rush me.” Relatives told us that “The staff always stop and talk to people when they walk past” and “They take time to plump peoples’ cushions as they go past.”

People that use the service told us that they were always given a choice of what to eat. A visitor told us that “Everyday [my relative] is asked what they want to eat. It’s not just dished up in front of them”. People told us that that they enjoyed the meals provided and one person said “The meals are always cooked to perfection”. Another person said “I always have the option of a cooked breakfast every morning.” Some people told us that there were not always enough staff around to help people eat their meals and that this meant that sometimes a staff member had to help more than one person at the same time. We saw this happen during our visit to the Pembury unit.

People told us that their health needs were met quickly and that they could see a doctor or nurse if they needed to. One person said “nothing is too much trouble”. People told us they always got their pain killers on time and could ask for more pain relief if they needed it. A relative described how they had overheard the night staff explaining someone’s medication to them and said this was “an example of how brilliant the staff are”.

People using the service told us that they enjoyed most of the activities that were provided, but that they would like them to happen more often. One person said “There is an exercise session, but it’s a bit babyish for me” and “There is not much going on during the day as the activities organiser went and hasn’t come back.” One relative explained that there was a lack social activities at the moment as there was no one to organise these. Relatives described the garden as beautiful and one visitor told us “People go outside in nicer weather. We had a lovely family day in the garden with [my relative] and the staff bought us tea.” Some people told us that they would like to be able to go out in the garden more often, but that they needed staff to help them do so and that the staff did not always have the time.

People said that generally they thought there were enough staff to meet their needs and they did not have to wait long for help with their personal care, however several people commented that more staff were needed at mealtimes and to provide activities. One person said “Sometimes it seems as if they need a few more hands to help, but they cope very well.” People told us that they liked the staff and one person commented “The staff are really good. If [my relative] wants them they come straight away”. Another person told us that the “Staff members are genuinely caring, they enjoy their job and it makes such a difference.”

Relatives told us that they were always made to feel welcome when they visited the home and they described the manager and staff as approachable. People told us that where they had needed to raise any concerns about the service these had sorted out instantly by the manager. People told us that there were regular meetings for people that use the service and their relatives to share their views. One person told us that at the last meeting a small minority of relatives were critical of the care provided, but wanted to point out that “this is certainly not the representative view of the rest of us.” Another person told us that the relatives’ meetings were well attended and whilst some had negative comments they did not feel these were fair. The person went on to give very positive comments about the care provided.

Relatives we spoke with told us that they felt the communication between the home and themselves was good and one person commented “The team leaders are fabulous, they always call straight away if there are any concerns.”

People told us that they were very happy with the care that they received. One person said, "The carers are very good, happy and friendly."

We spoke to people who use the service on Medway (residential and nursing care unit). They told us that they were had no complaints and felt that they were getting a good service. One person said, "It's very clean and nice. The staff are great and I can choose how I spend my time. There are quite a few things going on every day."

We saw that care staff attended to people's needs and requests promptly. They were courteous in their manner and took time to listen to people. One person told us, "The staff are very nice, when I ring my call bell someone comes quickly." Another person told us, "I couldn't fault them. They are very dedicated."

People told us that they felt safe in the service and that they are supported by caring and respectful staff who attend to their needs promptly.

People told us that they received the care and support that they need when they need it. They said that the care staff were respectful of their wishes and were knowledgeable.

One person told us, "The carers are lovely, I can't fault them". Another person said "The staff are very helpful."

The inspection was carried out on 9 & 10 March 2015 and was unannounced.

At our previous inspection on 15 April 2014 we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The breaches were in relation to the application of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS), the effectiveness of the quality and risk monitoring systems in the service and the completion of records. The registered manager sent us an action plan telling us they would be meeting the regulations by 3 September 2014. At this inspection we found that improvements had been made and they were meeting the regulations.

The service provided accommodation, nursing and personal care for older people some of whom may be living with dementia. The accommodation was arranged over three floors with a unit on each floor. Units were called Medway, Rochester and Pembury. People who required nursing care were in the ground and first floor units and residential care was provided in the second floor unit. A passenger lift was available to take people between floors. There were 56 people living across the three units in the service when we inspected.

There was a registered manager employed at the service. 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 Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice.

People felt safe. Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. The registered manager responded quickly to safeguarding concerns and learnt from these to prevent them happening again.

The registered manager and care staff assessed people’s needs and planned people’s care to maintain their safety, health and wellbeing. Risks were assessed, recorded and reviewed.

Incidents and accidents were recorded and checked by the registered manager to see what steps could be taken to prevent these happening again. The risk in the service was assessed and the steps to be taken to minimise them were understood by staff.

Managers ensured that they had planned for foreseeable emergencies, so that should they happen people’s care needs would continue to be met. The premises and equipment in the service were well maintained.

People had access to qualified nursing staff who monitored their general health, for example by testing blood pressure. Also, people had regular access to their GP to ensure their health and wellbeing was supported by prompt referrals and access to medical care if they became unwell.

Recruitment policies were in place. Safe recruitment practices had been followed before staff started working at the service. The registered manager ensured that they employed enough nursing and care staff to meet people’s assessed needs. Staffing levels were kept under constant review as people’s needs changed.

There were policies and a procedure in place for the safe administration of medicines. Nursing staff followed these policies and had been trained to administer medicines safely.

Staff received training that related to the needs of the people they were caring for and nurses were supported to develop their professional skills.

People and their relatives described a service that was welcoming and friendly. Staff provided friendly compassionate care and support. People were encouraged to get involved in how their care was planned and delivered.

Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected. People’s care was responsive and recorded.

Staff supported people to maintain their health by ensuring people had enough to eat and drink. All of the comments about the food were good.

If people complained they were listened to and the registered manager made changes or suggested solutions that people were happy with.

People felt that the service was well led. They told us that managers were approachable and listened to their views. The registered manager of the service, nurses and other senior managers provided good leadership. They ensured that they followed best practice for people living with dementia. This was reflected in the positive feedback given about the service by the people who experienced care from them.