We inspected Prema Court (formally known as Clifton House and Brook House) on 4 and 5 October 2018. The first day of the inspection was unannounced. This meant the service did not know we were coming.

Prema Court is a ‘care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Prema Court is owned and operated by Deepdene Care Limited and is registered with CQC to accommodate up to 44 people. At the time of this inspection, 33 people were living at the service with enduring mental health needs.

Accommodation is arranged over two units; Clifton House and Brook House, which were formally registered as a hospital. In April 2017 the provider made changes to their registration and service delivery, as Clifton House incorporated Brook House Hospital as part of their registration. This location is now called Prema Court. Brook House is a specialist unit within Prema Court providing nursing care and rehabilitation support for up to 12 adults experiencing high and complex mental health needs.

Our last inspection of Clifton House took place on 11 and 12 July 2016, when we rated the service good, with the well-led domain rated requires improvement.

At this inspection we identified seven breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We have made three recommendations.

You can see what action we told the provider to take at the back of the full report. We are currently considering our options in relation to enforcement in response to some of the breaches of regulations identified. We will update the section at the back of the inspection report once any enforcement work has concluded.

The service had a registered manager who had been in post for over seven years. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 was also supported by a deputy manager.

The premises were not maintained to a safe standard. During our tour of the premises we found the fire exit in the dining room was open, which led to an unsecure garden area, this potentially compromised people’s safety. A small number of people were under restrictions and were not free to leave the home independently, however the fire exit leading to an unsecure garden meant the provider could not assure people’s safety.

We noted some areas of the home that would benefit with being refurbished or re-decorated. The décor around the home appeared tired; the paintwork was scuffed and the carpets in high traffic areas of the lounge and downstairs corridor were showing signs of wear and discoloration. We discussed this with the registered manager who acknowledged our observations, but did not provide assurances that the home would be refurbished going forward.

The management of medicine was not always safe which put people at risk. The records about the stock and administration of medicines were kept electronically. When audits were done using these records they did not evidence that medicines were always administered as prescribed or could be properly accounted for.

Staff were not always working within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Information about people's care was not always being communicated effectively between staff.

The home did not comply with either the Mental Health Act 1983. We found there was an inconsistent approach detailing people’

We inspected Clifton House on 11 and 12 July 2016. The first day of the inspection was unannounced. This meant the home did not know we were coming.

Clifton House provides care and accommodation for up to 32 people with enduring mental health needs. At the time of our inspection there were 28 people living in the home. People were supported in one building over three floors. All 32 bedrooms were single occupancy and 11 had an en-suite toilet. Each floor had one or two communal bathrooms, a shared lounge and shared kitchen facilities. A sheltered smoking area was provided in the garden.

Our last inspection took place on 05, 06, 07 and 25 January 2016. At that time we rated the service as inadequate overall and for safe, responsive and well led. We rated the effective domain as requires improvement and caring was rated as good. As the previous inspection in January 2016 had rated the service as inadequate overall, we placed the service into ‘Special Measures’ because it was inadequate in three of the five domains.

At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall and good in caring, with no inadequate domains. This meant the service could come out of special measures.

We could not improve the rating from requires improvement because the provider needs to demonstrate that it can sustain improvements and consistently good practice over time. We will check this during our next planned comprehensive inspection.

The service had a registered manager who had been in post for over five years. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 the last inspection in January 2016 we found that support workers had not received the right training to ensure they provided care and treatment safely. This included training on how to manage people who may present behaviours which challenge. At this inspection we found all staff had received key mandatory training in areas such as safety and breakaway.

At the last inspection in January 2016 we found the registered manager had not reported all incidents to CQC as is required by the regulations. At this inspection we found systems had been developed to ensure incidents were reported to CQC in a timely manner.

At the last inspection in January 2016 a gas cooker was in use for nearly three months after it had been deemed unsafe to use by a gas engineer. The premises were not clean and various items of equipment and facilities, such as a washing machine and the lift, were out of use and had been for some time. At this inspection we found the kitchen had been upgraded in terms of cookers, ventilation and gas safety equipment and had been certified as fully compliant. Robust cleaning schedules had been introduced and we found all areas of the home clean and tidy.

At the last inspection in January 2016 support workers did not receive regular supervision and appraisal. Records showed that more than half of the regular support workers had not had supervision in 2015. At this inspection we found the provider had developed a new system ensuring staff received regular supervisions and appraisals.

At the last inspection in January 2016 we found that Clifton House was not supporting people to become independent; this was partially due to a lack of staff. We also found that care plans did not include people's goals and aspirations. At this inspection we found evidence that this had improved and people living at the home confirmed this. We also found that people’s care plans were person centred and people benefited from the services provided by the recovery team.

At the last inspection in January 2016 we found the home did

We inspected Clifton House on 05, 06, 07 and 25 January 2016. The first day of the inspection was unannounced. This meant that the service did not know we were coming.

Clifton House provides care and accommodation for up to 32 people with enduring mental health needs. At the time of our inspection there were 26 people living in the home. People were supported in one building over three floors. Nine people lived on the ground floor, eight people lived on the first floor and seven people lived on the second floor. All 32 bedrooms were single occupancy and 11 had an ensuite toilet. Each floor had one or two communal bathrooms, a shared lounge and shared kitchen facilities. There was a lift to all floors; however, it was out of order during our inspection. A sheltered smoking area was provided in the garden.

Clifton House had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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

Our last inspection took place on 30 September 2014. At that time the service was not meeting all the legal requirements. During this inspection we checked to see if improvements had been made.

At this inspection we found that support workers had not received the right training to ensure they provided care and treatment safely. This included training on how to manage people who may present behaviours which challenge.

The registered manager had not reported all incidents to CQC as is required by the regulations. A representative of the provider said that the home would review and improve their notification procedure.

A gas cooker was in use nearly three months after it had been deemed unsafe to use by a gas engineer. The premises were not clean and various items of equipment and facilities, such as a washing machine and the lift, were out of use and had been for some time.

Support workers did not receive regular supervision. Records showed that more than half of the regular support workers had not had supervision in 2015.

At our last inspection we found that Clifton House was not supporting people to become independent; this was part

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service 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.

This is a summary of what we found:

Is the service safe?

People who used the service and relative told us they felt safe at the home. People made comments such as, "Yes I feel safe" and "The staff keep an eye on everyone". The four people we spoke to told us they felt respected by the staff at all times.

We spoke with three staff, two told us that they felt the staffing levels were insufficient to meet people's needs. Staff told us that they often had to attend to emergencies or support people with behaviour that challenged the service. Staff told us they were required to diffuse situations which required them to give people one to one attention. This lead to one less person on the floor for some time and being under staffed, putting people who used the service and staff at risk.

Is the service effective?

We saw the service was not adequately effective in supporting the people to develop goals and work towards their future. When reviewing peoples’ independence it was found there was insufficient evidence to show the provider was encouraging and working with people to assist them in gaining life skills and making them more independent.

Is the service caring?

Clifton House operated a key worker system that allowed people to build positive relationships with their key workers who provided them with one to one sessions. The provider may like to note, the four people we spoke with who used the service all told us they felt they needed more one to one sessions and activities to do during the day. They all said they were very happy with the staff and treatment provided. The people we spoke to told us the staff we “Very good” and “Great.”

Is the service responsive?

We saw that the manager conducted monthly ‘residents meetings’ to discuss the menu and trips out. We saw that people were all happy with the menu on the previous monthly meeting. The four people we spoke to said the food was “Very good” and “Excellent”. We saw that trips had been suggested previously and these trips had been undertaken. Although the provider might like to note, people told us there were not enough activities. People had not made suggestions to improve the service during this meeting. The provider did however offer them a private and confidential way of leaving suggestions which was through a suggestion box near the entrance.

We saw that a care plan audit had been undertaken through an action plan which informed staff that they had to be more vigilant about signing entries made into the care files. There was no template for the audit so it was unclear what had been reviewed when the audit was undertaken. The manager told us they completed a medication audit however this was a stock check. We saw all stock was accounted for.

Is the service well-led?

The manager lead a monthly staff meeting in which they discussed any ongoing issues with any people who used the service, trips out, any incidences, root cause analysis and improvements for next time. The minutes of the meeting were too vague to see what staff had suggested as trips and any improvements. We were unable to determine if the manager responded to staff suggestions.

We asked people who lived at the home and staff about the manager and their ability to deal with concerns. They all felt the manager dealt with any issues very promptly and everyone we spoke with gave positive comments about their management style and personality for example, "He is always available" and "Good manager".

We observed staff positively interacting with people, acknowledging people in communal areas, prompting and encouraging. We noted that staff knocked and waited to be invited into people’s rooms.

People living at Clifton House told us: “It is welcoming and caring, they (staff) prompt and encourage you.” “It is not my choice to be here, but while I am it is OK, I have seen my care plan and staff listen to me.” “Staff support me in the community as I struggle to walk.” “As part of my plan for independence I am supported to cook my own meals.” “I have more motivation here than when I was living in my own house, I was isolated.” “I have a more positive attitude here, you see other people who live here going out and participating in the community. I have a very positive relationship with staff and other residents.”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. In the three care plans we sampled consent was clearly documented, we noted that people had signed a consent form.

Staff received appropriate professional development, and had support to gain a Diploma in Health and Social care. We noted that eight staff were enrolled on the level three diploma and one member of staff enrolled on the Level five.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on

People living in the home made some positive comments about the service they received. They said, "I receive my medicines at the correct time" "I am happy with how staff support me" and "We are asked if we like the food and if we want to make any suggestions to go on the menus. I get enough to eat and drink." However, when we asked three people what they would be doing on the afternoon of our visit they responded, "Oh not much really" "Nothing" and "I'll probably stay in my room."

We found that care plans were incomplete in relation to recording signed consent and nutritional risk assessments and records of staff training and supervisions were not available during the inspection. Three members of staff told us that they had not received regular supervisions and appraisal or training in care planning.

Complaints and incident recording systems were robust and complaints and incidents occurring in the home had been managed appropriately.

Staff told us that minimum staffing levels had not always been maintained when support staff were absent due to sickness. Staff commented that this had a negative impact on meeting people's social needs, particularly if they needed an escort to access community activities. However, the provider confirmed that their minimum staffing levels had been maintained at all times.

We found that robust systems were in place to ensure that people using the service received their medicines exactly as prescribed by their doctors.

People using this service told us that staff provided the right level of information and support for them to make informed choices and decisions about things that were important to them. Support plans provided further evidence that staff placed importance on providing care and support in a dignified, respectful and private manner.

Support plans recorded each person's preferences for how they would like to be supported. People living in Clifton House said they sat down with their key workers regularly to discuss and agree any changes that were needed.

We were told by people using this service that they liked and trusted the staff. They said that staff listened to their views and took them seriously. People told us they felt safe living in the home and in a recent satisfaction survey the home scored highly in the areas of cleanliness, security and personal safety.