This inspection took place on 14 and 20 February 2018. The first day was unannounced. This meant no-one at the service knew we were planning to visit.

On 14 February 2018 the dementia unit was closed to non essential visitors due to a flu outbreak. When we returned on 20 February 2018 the dementia unit had reopened and we were able to conclude this inspection.

We checked progress the registered provider had made following our inspection on 9, 10 and 16 March 2017 when we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were Regulation 9, Person-centred care, Regulation 12, Safe care and treatment and Regulation 17, Good Governance.

Following the last inspection, we asked the registered provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, responsive, caring and well-led to at least good. We found improvements had been made in some areas, however the service continued to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Regulation 9, Person-centred care and was now also in breach of Regulation 14, Meeting nutritional and hydration needs.

Manor 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. Manor Park is a purpose built care home that provides both residential and nursing care for up to 75 people. There are three separate units within the home divided into nursing care, residential care and care for people living with dementia. At the time of this inspection there were 67 people living at Manor Park.

The manager had been at Manor Park for approximately six months at the time of this inspection. She was in the process of registration with CQC. 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 saw people were not always given a choice of what to eat and drink at mealtimes. On the first day of this inspection some people were not offered any food or were not supported to eat it when required.

Staff told us they knew what it meant to treat people with dignity and respect. However, we saw this did not always happen in practice, particularly when some people were being supported to eat.

Activities were advertised as taking place at Manor Park. Some people and their relatives told us they would like more activities and of a wider variety.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. However, we recommend the registered provider considers ways to improve care staff’s understanding of Deprivation of Liberty Safeguards (DoLS) and the implications for day to day practice.

The service had systems in place to help keep people in safe. However, these were dependent on staff recording all concerns, incidents and accidents so managers could follow up any outstanding actions, track progress and identify any wider trends.

People and their relatives told us there were not always enough staff employed to safely meet people’s care and support needs in a timely way.

People had detailed electronic care records, which contained risk assessments and care plans covering all areas of daily living, such as mobility and personal care. However, the information recorded was not always accurate or consistent.

Staff were knowledgeable about how to protect people from harm and what they would do if they had any safeguarding concerns. They

The inspection took place on 9, 10 and 16 March 2017 and was unannounced. The service provides accommodation and nursing care for up to 75 people, some of whom may be living with dementia. There were 53 people living at the home at the time of the inspection.

There was no registered manager in post, although the peripatetic manager was in still in place at the last inspection remained in post. The peripatetic manager had applied to be the registered manager until a new manager could be appointed. 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 our previous inspections in August 2016 we found three breaches in regulations, for good governance, safeguarding service users from abuse and improper treatment, and staffing. At this inspection we found improvements had been made, although there remained some shortfalls in the recording systems and in the systems for medicines management. This inspection indicated the home was continuing to make improvements.

Staff had an understanding of the safeguarding and whistleblowing procedures to follow to ensure people were protected from harm. Safeguarding information was available for all people in the entrance should they have concerns and wish to report them.

Risk assessments for individual potential hazards were still lacking in detail or conflicting in some people’s care records for staff to be able to support people safely.

Staffing levels were appropriate to meet people’s needs, which had improved since previous inspections, although the deployment of staff was not always effective, such as at staff break times and a member of agency staff had not received any basic information prior to starting their shift.

People were supported patiently with their medicines and staff gave good explanations to ensure people knew what each medicine was for. Systems for managing medicines with regard to topical creams, covert medicines and the storage of medicines no longer needed were not robust.

Continued improvements were ongoing with regard to the temperature in some parts of the home to ensure people’s comfort although it was particularly warm on the nursing unit.

Training was evident and staff felt supported to gain relevant skills and competencies for the role they did. Staff had an improved understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) which affected people’s care. The manager had worked hard since the last inspection to ensure all DoLS authorisations were in place or renewed for people.

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

Staff meetings and supervision meetings were more consistent and there was clear support and direction for staff overall. The system for handover of information between shifts was much more detailed and thorough since the last inspection. There were much clearer lines of accountability and systematic reporting to the manager of key risks. However, the nursing unit leader had recently left and the home manager was monitoring the nursing risks until a unit leader was appointed. However, due to the home manager's primary role of running the home, there were weaknesses in the oversight of key risks on the nursing unit.

People mostly enjoyed the food and there were improved opportunities for people to drink and stay hydrated. However, we noted a concern on the nursing unit on the first day of the inspection which we raised with the manager. People’s weight was more closely monitored and appropriate referrals were made to other professionals where weight loss was identif

The inspection took place on 23 and 31 August 2016 and was unannounced on the first day. The service provides accommodation and nursing care for up to 75 people, some of whom may be living with dementia. There were 59 people living at the home at the time of the inspection.

There was no registered manager in post, as the previous manager had left and a peripatetic manager was temporarily in place. The peripatetic manager had applied to be the registered manager until a new manager could be appointed. 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.

Manor Park Care Home was previously inspected in March 2016 and there were five breaches in the regulations. We found improvements had been made, although we identified continued breaches in two of the five beaches highlighted at the last inspection and a further breach of regulation. Our concerns were in relation to the general nursing unit.

Staff had an understanding of the safeguarding and whistleblowing procedures to follow to ensure people were protected from harm.

Risk assessments had improved although were still lacking in detail in some people’s care records.

Staffing levels on the nursing unit were at times insufficient to meet people’s needs, which was an ongoing concern from previous inspections. Continuity of nursing staff was poor, as was communication between shifts.

Systems for managing medicines had improved since the last inspection; medicines were stored correctly and there were more thorough audits. However, not all nursing staff were confident in the recording of medicines on electronic records, which meant there was potential for errors to be made.

Improvements had been made to ensure the temperature in some parts of the home was comfortable for people, although there was a communal area in the dementia unit that was too warm. There were plans in place to address this.

Training had improved to ensure staff felt supported to gain relevant skills and competencies. Staff had a basic understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which affected people’s care. However, not all authorisations were in place or renewed for people.

Staff had regular staff meetings and there were improving supervision meetings to discuss their role. However, handover documentation lacked detail and there was a lack of clear direction for staff on the nursing unit, particularly where agency staff were deployed, for them to understand the requirements of their role each shift.

Attention to nutrition and hydration had been given priority to ensure people’s good health, especially on the nursing unit. People mostly enjoyed the food and they had many opportunities to drink.

Staff consistently displayed a kind and caring attitude and they were patient and friendly in their approach to assisting people. Staff showed respect for people’s dignity and there was evidence this was continually monitored and reinforced by managers.

Care documentation had improved since the last inspection, although this still lacked detail and accuracy. Where people were nursed in bed, there was a clear reason and this was regularly reviewed and monitored.

Quality assurance systems were more robust to address key aspects of people’s care and support, and address concerns identified at the previous inspection, although there were still weaknesses in the leadership on the general nursing unit.

At the last comprehensive inspection this provider was placed into special measures by CQC. This

inspection found that although some improvements had been made, there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory res

The inspection took place on 10 March 2016 and was unannounced. The service provides accommodation and nursing care for up to 75 people, some of whom may be living with dementia. There were 60 people living at the home at the time 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.

Manor Park Care Home was previously inspected in August 2014 and was non-compliant in all areas inspected at that time and there were six breaches in the regulations. We found continued breaches in five of the six beaches identified at the last inspection.

Staff understood the safeguarding and whistleblowing procedures to follow to ensure people were protected from harm.

Risk assessments were incomplete and conflicting for some individuals.

Staffing levels were insufficient to meet people’s needs, particularly on the nursing unit. This was a concern at the previous inspection.

Systems for managing medicines were ineffective; some medicines were not stored correctly and there were inaccuracies in stock balances.

The premises were well maintained overall, although the temperature in some parts of the home was too high for people’s comfort.

Staff training was regular, although this was not always effective enough to ensure staff had the right skills and competencies. Not all staff had a secure understanding of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which affected people’s care.

Communication between staff was regular in staff meetings and supervisions, although staff handover documentation was poor between shifts.

People’s nutrition and hydration was not sufficiently managed and monitored to ensure their good health, particularly within the nursing unit. Some people were unhappy with the quality of the food and there were insufficient opportunities for people to have a drink. This was also an issue at the previous inspection.

Staff demonstrated a kind and caring approach and they were patient and reassuring when assisting people. Staff respected people’s dignity in personal care, although at times they spoke about people over their heads and this was not always respectful.

Care documentation was incomplete and computerised information was not easy to locate. A large number of people were nursed in bed, with no clear information about the reason for this.

There was a new activities coordinator who had lots of ideas for engaging with people, although those who remained in bed were under-stimulated.

Some quality assurance systems were in place although these were not robust enough to address key aspects of people’s care and support, or the breaches identified at the previous inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special Measures’.

The service 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.

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

The inspection visit was carried out by two inspectors and an expert by experience. During the inspection, we spoke with the quality manager, the deputy manager, four care assistants, the maintenance person, three kitchen staff, 14 people who lived at the home and 5 relatives of people who lived at the home. Not all of the people we spoke with who lived at the home were able, due to complex care needs, to tell us about their experience of living at the home. We observed care given to people in the communal areas, including lunch, and in their bedrooms. We also also looked around the premises, observed staff interactions with people who lived at the home, and looked at records. There were 72 people living at the home on the day of the inspection, this included 21 people living with dementia.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

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

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

Is the service safe?

Care was not planned and delivered in a way that ensured people's safety and welfare. There were insufficient numbers of suitably qualified staff to meet people’s needs. We have asked the provider to make improvements.

People were cared for in an environment that was not clean and hygienic. This meant people may not be protected from the risk of infection because appropriate guidance had not been followed.

One person’s relative told us, “There are no staff to watch people in the main lounge of the nursing unit. People are unable to summon help if they need it”.

We observed an incident occur on the unit for people living with dementia. Staff did not take appropriate action to prevent a reoccurrence, did not document the incident in a timely manner, or refer the incident to the local authority safeguarding team in a timely manner.

Peoples’ medicines were stored in rooms which were above the required temperature and medicines were not managed safely. This meant vulnerable elderly people were being put at risk.

Is the service effective?

The service was not effective. The home did not promote a good quality of life for the people that lived there.

We looked at six people’s care files. We saw that some important documents within people’s care records had not been completed.

People were not supported with diet and fluids to support their health. This meant people were not protected from the risks of inadequate nutrition and dehydration.

Audits were not effective; they either failed to identify issues or failed to follow up on issues when they were identified. This meant peoples’ care needs were not being met.

Is the service caring?

On the unit for people living with dementia, we saw people were supported by staff who did not appear to have the necessary skills to meet their care needs. However we did see some staff to be patient and encouraging when supporting people.

Relatives we spoke with told us they were not happy with the care provided at the home. One person’s relative told us, “The staff here are not good. I’d say about 90% of them do not care. We have raised concerns with the manager and nothing changes. It’s not nice when you come to visit and your relative smells and has dirty finger nails. It’s just not good enough.”

One person who lived at the home when asked what they would do if they were unhappy said “I wouldn’t bother saying anything, I don’t think anyone would care.”

We saw some people displaying signs of distress but staff did not intervene. One care assistant said to us “That one just says ‘nurse’, ‘nurse’, ‘nurse’ over and over.”

Some care assistants we spoke with told us they felt frustrated at the restrictive practices in place at the home. For example, on the unit for people living with dementia people’s toiletries had to be stored in a cupboard and not in the person’s bedroom. People also had to have their meals and drinks out of plastic plates, bowls and cups. However, when we looked in people’s care records we saw there were no risk assessments in place to address this.

When we looked around the residential unit of the home we saw people’s bedrooms had been personalised and contained personal items such as family photographs. However, on the unit for people living with dementia we saw people’s rooms were stark with very little in them. We were told by staff on this unit that people’s bedroom doors were locked on they had got up in a morning and people had to ask staff to let them back into their rooms. They told us this was to ensure people did not wander into other people’s bedrooms. However, for people living with dementia this may be difficult and meant they were limited to where they spent their time.

Is the service responsive?

We heard call bells going off for long periods during our visit. We also saw several call bells which were out of reach in bedrooms and bathrooms we looked in. We noted that call bells were not in reach of people in the lounge areas. Two visitors told us they have seen people in wheelchairs have to wheel themselves to the call bells to summon help for people who are not able to mobilise.

All of the people we spoke with, including relatives and visitors, told us that there were not many activities for people to engage with. One person said, “There’s not much to do except watch TV.” One relative said, “I’ve never seen much going on in the way of activities. When we asked people who lived at the home about what they did to pass the time. None were enthusiastic in their responses. One said “Sometimes there’s bingo, I go to that if I feel like it. I don’t know whether it is on today, though.” Another person said “I would love to dance sometimes.” We asked whether anyone ever put music on and encouraged them to do this. They said “No, never. But that would be lovely.”

We asked people in the upstairs lounge about their access to the garden. One said “I’d like to go out there, especially when it’s warm. We don’t get to do it very often though.”

Several people who lived at the home used the word “Boring” to describe their experience of living in the home. One said “I’m bored to tears. I just want to get out of here.”

We found the complaints system at the home was not effective. Comments and complaints people made were not responded to appropriately.

Is the service well-led?

The service was not well-led. People were not protected against the risks of inappropriate or unsafe care. The provider had a system in place to assess and monitor the quality of the service people received however, when issues were identified through audits we were unable to see that actions had taken place. This meant the system of audit within the home was not effective. The leadership on the unit for people living with dementia and the nursing unit at the home did not assure the delivery of high quality, person centred care. When we asked care assistants why some practices were in place they said it was just what they had been told to do.

We spoke with five visiting relatives to find out about their views of the home. They all spoke positively about how the staff involved people in decisions about their treatment and care and how they acted in accordance with their wishes. Relatives told us that communication with the home was good. One relative explained: “We were involved in reviewing the care plan recently. This is done every year and the staff speak to us about anything new in between to keep us up to date.”

We saw the home had a medicines policy in place. Medicines audits were completed by staff working at the home to measure the safe handling of medicines, in line with the homes policy and current guidance.

Staffing levels were reviewed and increased during our inspection based on the dependency levels of the people living in the home. Manor Park Care Home agreed to keep the Care Quality Commission (CQC) informed of any changes in staffing. The CQC will continue to monitor the staffing levels within this home.

People spoken with said they had no concerns or complaints about the home at this time. They said they knew who to speak to if they had a worry or concern. They told us they felt able to make comments and were confident the staff or manager would do all they could to put it right. One relative said: “I have only needed to complain once about [my relative] not being smartly dressed. This was sorted out immediately I mentioned it and I’ve never had to complain again.”

We undertook this visit to follow up a specific concern identified at a previous inspection relating to fluid balance charts. We did not obtain the information from people who use the service on this occasion.

We spoke to people who use the service and relatives as part of this inspection. They told us that the staff are 'excellent' and that they feel the home is clean and that they like the food that is provided. People told us that staff did not always have time to stop and talk to people as they were very busy.

We used a number of different methods to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences so we spent time with people in the lounges. We spoke to some people who used the service, their relatives and staff about the care and support provided at Manor Park. Two inspectors carried out this inspection over two days.

We spoke with six relatives who all told us that staff were excellent; very kind and caring but people did tell us that they felt there were not enough staff on duty and there were times when people had to wait to be attended to. Our observations indicated that staffing levels needed to be reviewed in order to ensure people’s needs are met and to ensure the safe running of the home.

We asked people about making complaints if they were unhappy about any aspect of the service and without exception the people we spoke with said they would talk to a member of the management team and they felt confident that any complaints would be dealt with swiftly.

We spoke to seven members of staff who told us they enjoyed working at the home but they struggled to complete their duties because there were not enough staff on duty.

We returned to the home for a second day in order to spend more time assessing staffing levels and to meet with the manager who was unavailable on the first day.