About the service:

Priory Gardens is a residential care home that was providing personal and nursing care to 42 people at the time of the inspection.

People’s experience of using this service:

People told us they felt safe and were happy living in Priory Gardens. Many told us of the improvements they had seen since the previous inspection. They felt staff were knowledgeable and confident in their role and were happy and friendly in their approach. Staff had received regular supervision and training and told us they felt valued. They worked well as a team.

People were safe as staff understood how to manage any risks to their wellbeing. Guidance was well documented to help staff to keep people safe, and staff adhered to the guidance in most instances. Recruitment checks were more robust and staff received an appropriate induction. There were enough staff to meet people’s needs, although people told us they sometimes had to wait for staff. We did see some periods of unattended communal areas as staff were always busy, although the general atmosphere was calm and organised.

Medicines were administered safely and the home was clean. The registered manager was pro-active in responding to incidents and accidents, and evidenced learning from such events where necessary.

The registered manager used evidenced based guidance to improve the service. They displayed sound understanding of best practice and used feedback from a variety of sources to continuously improve care. There had been fewer complaints and none about care provision which showed an improving service.

People were supported to eat and drink and visual options helped people to choose. Records for those people at risk of a poor diet were not sufficiently detailed. We recommend records where people were at nutritional risk needed to evidence what measures were in place to address these rather than generic statements. People accessed health and social care services as needed.

There had been significant improvement in obtaining people’s consent to care and treatment. Some records needed updating where people could not consent to their care and treatment. We recommend the capacity assessments are reviewed to ensure people with the relevant legal authority were involved in decisions. People’s privacy and dignity was respected.

There was a comprehensive activity programme for people to engage with in communal areas. We saw people involved and animated during various events.

Care documentation had been made more person-centred and reflective of people’s needs. It was regularly reviewed and audited to ensure it was still current.

The registered manager had worked hard, along with the staff team, to improve the experience of living at Priory Gardens. By using the tools for quality assurance they ensured each aspect was considered in depth regularly and any actions responded to quickly. There had been significant improvements in the culture at the home but more work was needed to ensure this became embedded.

This service has been in special measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection this service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

Inadequate (Report published 15 August 2018)

Why we inspected:

This was a planned inspection based on the rating at the previous inspection. The service had previously been in breach of five regulations which resulted in three warning notices and two requirement notices. At this inspection we found improvements had been made.

Follow up:

The service will continue to be monitored in line with our inspection progr

The inspection of Priory Gardens took place over two days, 15 and 21 May 2018 and was unannounced on both days. At the previous inspection in March 2017 the service was rated requires improvement with two breaches of regulation for safe care and treatment and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good.

Priory Gardens is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Priory Gardens accommodates 72 people in one adapted building divided into three units. One of the units, Grace, specialises in providing care to people living with dementia. Nightingale supports people with predominantly nursing needs and Symphony supports people requiring assistance with daily living. On the days of the inspection there were 46 people living in the home.

There was no registered manager in post at the time of the inspection. The home was being supported by a relief manager, an area director and an area quality director. 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 and relatives told us there were insufficient staff to provide safe and effective care. Many relatives advised us they came in to assist staff otherwise their relation would not be cared for properly. Staff were extremely busy, and became task-focused in their roles due to the continuous demands on their time. This was to the detriment of team work on occasion. Staffing rotas did not reflect the amount of staff needed in relation to people’s true dependency levels.

Risk management was not consistent and while some had been improved, the correlation between care plan guidance and risk management had not been identified.

Staff were confident in how to report any concerns. We found reporting of such incidents was mostly timely but evidence of lessons learned was limited, partly due to the new management team.

Medication management was not always safe as people had missed medication and records were sometimes incomplete.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not always support this practice. The provider had allowed legal safeguards to lapse with incomplete records of people’s mental capacity, and staff’s understanding of these safeguards was poor.

Although people had regular food and fluid, their experience was not in line with best practice in every instance and relatives were relied on to assist people.

Staff had received induction, supervision and training although we found some issues with recruitment records and records of agency staff. The manager relied on resources from the provider to keep abreast of current practice.

Most staff treated people with kindness and consideration on an individual basis. However, the pressures of too much to do showed on occasion when people’s needs were ignored as staff were dealing with others. Dignity and privacy was promoted in most instances and we saw some discreet interventions when people needed more personal care.

Care documentation, whilst still being amended, was not always consistent or accurate in the new records. There was a lack of cohesion in some records with staff not always being aware of what was contained in them. The delivery of care was task-driven rather than based on person-centred involvement.

Although activities were organised in some areas of the home, there w

The inspection of Priory Gardens took place on 6, 7 and 13 February 2017. We previously inspected the service on 26 July and 2 August 2016, at that time we found the registered provider was not meeting the regulations relating to safe care and treatment, good governance and staffing. We rated them as inadequate and placed the home in special measures. The purpose of this inspection was to see if significant improvements had been made and to review the quality of the service currently being provided for people.

Priory Gardens is a nursing home currently providing care for up to a maximum of 72 older people. The home has three separate units which provide care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 49

people were living at the home.

The service had a registered manager 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.

People told us they felt safe and staff understood the potential signs of abuse and how to report any concerns.

Peoples moving and handling records were not robust and needed further work to ensure they addressed all aspects of peoples care and support including any equipment they used, for example to access the bath or specialist seating. Where people were at risk of falls, their care plans needed more information as to how the risk to their safety was being reduced.

People had a personal emergency evacuation plan (PEEP) in place and there was a system to ensure all staff received regular fire drills. External contractors were used to service and maintain equipment, and internal maintenance checks were made on the premises and equipment to ensure the home was safe.

Staff were recruited safely. Changes had been made since the last inspection to the staff numbers and skill mix. During our inspection we identified further concerns with the staffing levels but the registered provider assured us they were taking steps to address this.

Staff who had responsibility for the management of medicines received training and audits were regularly undertaken on peoples medicines to highlight any concerns at an early stage. We found issues identified at our previous inspection had been addressed but improvements were still needed to the management of people’s creams.

The home was generally clean but we identified some areas of uncleanliness which we informed the registered manager about. We also noted on the dementia unit staff were not adhering to good practice as hoist slings were not being used on an individual basis.

Relatives felt staff had the skills they needed to do their job. New staff completed an induction but this was not always completed in a timely manner. There was a programme in place to provide staff with training in a range of topics. However, we identified staffs knowledge of other methods which may be deployed to effectively support a person with behaviour which challenged others, was limited.

Staff understood people had different abilities in regard to making decisions about their daily lives. We saw evidence of mental capacity assessments in peoples care plans but we identified aspects of some peoples care where they were unable to consent yet there was no evidence of a capacity assessment or that best interest’s decisions had been made.

People received their meals in a timely manner. Although we identified one person who was not provided with adequate staff supervision to reduce the risk of choking while drinking. Staff recorded the food and fluid intake for some people and although we found the standard of recording had improved since our last inspection they were not yet consistently accurate.

Each o

The inspection of Priory Gardens took place over two days, 26 July and 2 August 2016. We previously inspected the service on 21 and 23 September 2015. The service was not in breach of the Health and Social Care Act 2008 regulations at that time, however, we did identify areas where improvement was required. During this inspection we checked to see if improvements had been made.

Priory Gardens is a nursing home currently providing care for up to a maximum of 72 older people. The home has three separate units which provide care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 51

people were living at the home.

The service has not had a registered manager in place since July 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.

Medicines were not managed safely. We found evidence one person had not received a prescribed medication on a number of occasions. A care plan recorded one person was allergic to a medicine but this information was not recorded on the medicine administration record. We could not evidence topical medicines were administered correctly. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Personal emergency evacuation plans were not all fully completed. Information regarding the correct settings for individual pressure mattresses was not completed. The information in care plans and risk assessment regarding peoples moving and handlings needs was inconsistent and did not always reflect the practices we observed. Positioning records for people failed to evidence people received pressure area care appropriate to their need. We noted a person’s blood sugar had been recorded at 26mmol but was no evidence to suggest staff had rechecked this to see if they required medical attention. This was a breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were bathed although not always to the frequency they preferred. People’s daily care record was task orientated and contained gaps regarding the care of people’s nails and teeth. Food and fluid records did not evidence people always received sufficient to eat and drink and snacks were not consistently recorded. This was a breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People who lived at the home and staff, told us there were not enough staff on duty. This concern had been raised in resident meetings but no action had been taken by the registered provider. People on the nursing and dementia unit did not receive their lunchtime meal in a timely manner. Staff received regular training but one to one supervision of staff was not completed on a regular basis. New staff had not received a thorough induction to their role. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe and staff had completed training in safeguarding adults. Staff were aware of how to raise concerns about harm or abuse. Where people were deprived of their liberty, the home had requested appropriate authorisation from the local authority in order for this to be lawful and to ensure a person’s rights were protected. Mental capacity assessments were in place but lacked sufficient detail to ensure they met all the requirements of the Mental Capacity Act 2005.

A programme of refurbishment had been completed at the home. This had enabled people in the dementia and residential unit to access the garden.

Staff were caring. Interaction between staff and peop

We carried out this inspection to follow up on three compliance actions we had made following a scheduled inspection in July 2013.The compliance actions related to outcome 4 (care and welfare), outcome 9 (medicines) and outcome 13 (staffing).

During this inspection we spoke with the registered manager, three relatives, six people who lived in the home and five staff.

We found improvements had been made to care records and people were receiving the care and support they needed from staff. People we spoke with who lived in the home told us they were satisfied with the care they received. Comments included:-

“I’m well looked after here”

“I get the help I need”

“Staff are lovely, I’ve no concerns”

We found improvements had been made in the management of medicines. People were receiving their medicines as prescribed and records were maintained. The home was in the process of moving to a new medication system and staff were receiving training on the day we visited.

We found more staff had been recruited and staffing levels had consolidated. A new management team was recruited following the last inspection and staff were now allocated to specific units which provided people with better continuity of care.

We visited Priory Gardens and spent time on all three units in the home. We spoke with four people who used the service, four relatives, seven staff, the registered manager and the quality assurance manager.

We found the home was clean and comfortable. We saw that staff treated people with respect, offered them choices and maintained their privacy and dignity. One person said, “Staff are lovely and treat me with respect”.

We found people were generally well cared for but found shortfalls in the care documentation which we considered could impact on the care people received.

We identified concerns with some of the medication systems and practices in place, which meant some people had not received their prescribed medication.

We found there were not always enough staff to meet people’s needs due to the dependency levels and layout of the building. We found staff had access to ongoing training and development and there were supervision and appraisal systems in place. There were systems in place to monitor the quality of service people received.

We carried out an inspection in June 2012 and found the provider was compliant with the outcomes we looked at, however we received concerns about staffing levels and two incidents with regard to two people who lived at Priory Gardens. We reviewed this information and decided to carry out a visit to the home to assure ourselves that people were being cared for properly.

The manager was not available when we visited but we spoke with her the following day and she provided information for us on our request.

We found that there had been some difficulties with appropriate staffing levels but this had now improved.

The incidents reported to us had been investigated by the manager and appropriate steps had been taken to remedy them.

People with Dementia are not always able to tell us about their experiences so we have used a formal way to observe people in this inspection visit to help us understand. We call this the ‘Short Observational Framework for Inspection’ (SofI).

Overall we found staff interactions with people were warm and positive with care staff demonstrating knowledge of people’s preferences and care needs.

People were observed being treated with dignity and having their wishes respected at all times. The empathy and experience and communication skills of staff ensured that people remained safe and free from any kind of abuse.

People say they like the people caring for them. One person said the carers are ‘brilliant’ and ‘very caring’. Another says ‘there is always someone there when you need them’.

People say they like the people caring for them. Some people we could not communicate with were happy and positive relationships were observed being fostered between those living in the home and those caring for them.

People living in the home say they like the people caring for them. People we could not communicate with were relaxed and comfortable with those supporting them.

The inspection of Priory Gardens took place on 21 September 2015 and was unannounced. We also visited a second time on 23 September 2015 and this visit was announced. We previously inspected the service on 30 July 2014. The service was not in breach of the Health and Social Care Act 2008 regulations at that time.

Priory Gardens is a nursing home currently providing care for up to a maximum of 72 older people. The home has three distinct units providing care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 52 people were living at the home.

The service did not have a registered manager 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. The previous manager had left the organisation in July 2015 and the home was currently being managed by a ‘turn around’ manager.

Everyone we spoke with, told us they felt safe and staff we spoke with were aware of their responsibilities in keeping people safe from harm.

We saw evidence that equipment was serviced and maintained, and there was a procedure in place in the event of a fire.

People told us there were not enough staff. The manager had reviewed the staffing levels at the home and some changes had been made.

People were protected against the risks associated with the use and management of medicines.

We saw evidence staff received regular training and supervision relevant to their role. New staff were supported when they commenced employment.

People told us staff gained their consent prior to undertaking care related tasks, but, where people lacked capacity, there was a lack of documented evidence regarding the decison making process.

People were offered a choice of where to eat their meal and asked what they would like to eat and drink. Two people’s food records were incomplete which meant we could not evidence they had received adequate nutrition.

We saw evidence people received input from other healthcare professionals.

Building and refurbishment work was still ongoing at the home when we visited. Relatives told us the registered provider had written to them to advise them of this work. The décor of the dementia unit was designed to enable people who were living with dementia to navigate their way around.

We observed staff were kind and caring in their approach to people. Staff spoke about the people they cared for in a professional manner and were knowledgeable about people’s needs, likes and dislikes.

People’s care records provided the details staff required to enable them to meet people’s individual support needs. However, the quality of information recorded about people’s life history, hobbies and interests was inconsistent.

Complaints were recorded, including a record of the action taken to resolve the issues raised.

Senior managers also visited the home at least monthly. There was a system in place to continually monitor the quality and safety of the service people received. This included management reports, staff meetings and service user’s feedback.

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