This was an unannounced inspection that took place on 4, 5 and 7 December 2018.

The West Gate 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.

There were 43 people living at the service when we inspected. Many people needed support with personal care, eating, drinking safely and with mobility.

We last inspected this service in October 2017. Breaches of regulations were found. We issued requirement notices in relation to safe care and treatment, medicines management and shortfalls in keeping accurate and up to date records. We asked the provider to take action. The registered manager sent us an action plan telling us what action they would take to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements.

At this inspection, there had been improvements but more are needed.

People's care plans stated their fluid intake needed to be monitored. Staff did not effectively record the amount people drank. Some staff were recording the amounts and others were not. There was no oversight or accurate record of the amount that people drank to make sure they remained hydrated.

A risk assessment for catheter care was not completed or had not been fully captured or completed on the system. People could be at risk of not receiving care and support appropriate to their needs.

Audits and checks had not been fully effective in identifying and remedying shortfalls.

There was a registered manager in post at the time of the inspection. They had been at the service since April 2018. 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 and associated Regulations about how the service is run. The manager was supported by a clinical lead, and team of clinical nursing staff and care staff. The manager told us there was still issues with the electronic system they were using which collated all the information about the care and support that people needed.

Before people decided to move into the service their support needs were assessed by the manager or clinical lead.

Improvements had been made to make sure people received their medicines safely and when they needed them. PRN (‘as and when’) medicines that were given covertly had the necessary risk assessments and accurate records of when creams and ointments were applied displayed on body maps.

The management and staff knew how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests Deprivation of Liberty Safeguards (DoLS) had been applied for by the manager when it was necessary.

People were supported to have a nutritious diet. Their nutritional needs were monitored and appropriate referrals were made to specialist teams such as dieticians when it was necessary.

Staff were familiar with people's life stories and were very knowledgeable about people's likes, dislikes, preferences and care needs.

We saw many positive interactions and people enjoyed talking to the staff. Throughout the inspection people were treated with dignity and kindness. People's privacy was respected and they were able to make choices about their day to day lives. When people became anxious staff took time to sit and talk with them until they became settled.

Accidents and incidents were reported and responded to.

Staff knew how to keep people safe from abuse and neglect. The registered manager referred incidents to the local safeguarding authority.

The safety of the premises was assured by regular

This was an unannounced inspection that took place on 23 October and 25 October 2017.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 39 people living at the service when we inspected.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff.

We last inspected this service in October 2016. Breaches of regulations were found. We issued requirement notices in relation to safe care and treatment, medicines management and shortfalls in keeping accurate and up to date records. We asked the provider to take action. The registered manager sent us an action plan telling us what action they would take to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found improvements had been made but there were continued breaches of the regulations.

Since the last inspection the registered manager had left the service. There was no registered manager working at the service at the time of this visit. 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 and associated Regulations about how the service is run. There was a manager in post who had applied to register with the CQC and was awaiting their fit person’s interview. The manager was supported by a nurse manager, and team of clinical nursing staff and care staff.

The manager told us there was still issues with the electronic computerised system they were using which collated all the information about the care and support that people needed. Information about people had been transferred to the electronic system including care plans and risk assessments. However the system was not formulating all the information needed to make sure there was an accurate account and guidance of the care and support people needed. The manager and other staff had highlighted their concerns to the provider about the electronic system and they were working together to improve its efficiency. In the meantime some records were not accurate.

Risks had been identified and assessed for people's health and welfare but full guidance to make sure all staff knew what action to take to keep people safe and manage risks was not always available. Staff knew people well and were able to explain what action they would take to make sure risks to people were mitigated. However, when new staff were working or when agency staff were covering there was a risk of people not receiving the interventions they needed to keep them as safe as possible.

Before people decided to move into the service their support needs were assessed by the manager or nurse manager to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan was personal to them. The care plans were written to inform staff about how people preferred to be supported and cared for.

Improvements had been made to make sure people received their medicines safely and when they needed them, however there were areas that needed further improvement. These areas included ‘as and when’ medicines that were given covertly and keeping accurate records of when creams and ointments were applied.

Staff understood how to kee

This was an unannounced inspection that took place on 31 October and 1 November 2016.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There is a lift to the first and second floors. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 34 people living at the service when we inspected.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff.

We last inspected this service in April 2016. We found significant shortfalls and the service was rated inadequate and placed into special measures. The provider had not ensured that care and treatment was being provided in a safe way. People were not receiving appropriate care and treatment to meet their health care needs. Staff had not ensured the proper and safe management of medicines. Care plans lacked detail and at times were contradictory. Care plans were not consistently updated when people's needs changed. People's assessed needs were not always regularly reviewed and properly assessed before they moved into the service. Staff were not suitably competent and skilled to manage risks to people safely. People were not protected from abuse, harm and improper treatment. Staff had not received appropriate support, training, professional development and supervision, as was necessary to enable them to carry out the duties they were employed to perform. The provider had not ensured that the systems and processes that were in operation to assess, monitor and improve the quality and safety of the service were consistently applied. The provider failed to maintain accurate and complete records in respect of each person.

We took enforcement action and required the provider to make improvements. This service had been placed 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. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that improvements had been made in many areas. There were still areas were improvements were required.

The service had a newly appointed registered manager who was available on the days of the inspection. 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 registered manager was supported by a clinical lead whom had recently been appointed.

The provider had recently installed a new computer system where all people’s information was being transferred to. Staff said that the system would be effective when it was ‘up and running’ properly but they were having a few initial problems with how the information was stored and generated. They were sorting these out but at the time of the inspection some records on the system were inaccurate and not consistent. The registered manager said that progress was slower than they hoped because of these initial ‘teething’ problems.

People’s records relating to the care and support they needed were not always accurate or completed. The registered manager and staff team were aware of this and were working to make sure all records were updated and in place. This was a work in progress.

Risks to people had been identified and recorded but guidance was not alw

This was an unannounced inspection that took place on 27 and 28 April 2016 and 05 May 2016.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There is a lift to the first and second floors. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 42 people living at the service when we inspected.

We last inspected this service in July 2015. At this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. We issued two warning notices in relation to good governance and safe care and treatment. We issued requirement notices relating to person centred care, staffing, safeguarding service users from improper care and treatment and the need for consent. We asked the provider to take action and the provider sent us an action plan.

The provider had not completed all the actions they told us they would make. In particular, they had not met the requirements of the warning notices we issued following our last inspection. As a result, they were continuing to breach regulations relating to fundamental standards of care.

There was no registered manager when we visited as required by regulations. The last registered manager left the position in March 2014. 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. There was an acting manager in post who was in the process of applying to become the registered manager. The acting manager was supported by two clinical managers who were registered nurses.

People had suffered avoidable harm and pain. The nursing staff had not acted appropriately or in a timely way to make sure people were safe and getting the care and treatment that they needed. Nursing staff had not taken appropriate action when people’s health deteriorated.

People were at risk of neglect and were at risk of receiving improper treatment. Risks to people were not being well managed and reduced. People’s weight loss, pressure areas, diabetes and catheter care were not managed consistently. Medicines were not always available for people when they needed them.

People were not supported effectively with their health care needs. There had been delays in accessing health care specialists when they were needed. When people needed to see a doctor because their health was deteriorating the staff did not always recognise signs and symptoms of ill health and doctors or other professionals were not always contacted.

Recruitment processes were in place to check that staff were of good character. Information had been requested about staff’s employment history, including gaps in employment. There were enough staff on duty to meet people’s needs. Staff had not received all the training they needed to meet the needs of people. Staff did not receive the supervision and support they needed to carry out their roles effectively.

The provider had a complaints policy and process. Complaints were not always managed effectively to make sure they were responded to appropriately, in a timely manner and in line with the policy. People and their relatives told us they would speak with the acting manager or staff if they had a concern and they would be listened to.

The provider had not taken appropriate steps to ensure they had oversight and scrutiny to monitor and support the service. There was a lack of continuity in the management of the service, which had impacted on people, staff and the quality of service provided.

Care staff were clear about their ro

The inspection team was made up of two inspectors. We spent time in the home looking at care records, talking to staff and people who used the service. The previous registered manager at the service, Mrs Annelli Chatfield, no longer works at

The Hockeredge but has not yet deregistered with CQC. The provider has put an acting manager in place who is in the process of applying to be registered.

We looked at people’s plans of care, staffing records and quality assurance processes. We set out to answer our five 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 is based on our observations during the inspection, discussions with people using the service, their relatives, the staff supporting them and looking at records.

Is the service safe?

People were treated with respect and dignity by the staff who focused on positive risk assessment to support people to maintain their independence. For example, risk assessments were focused on what people could do and managing risks as far as was possible, rather than focusing on limiting peoples abilities because of the level of risk. People told us they felt safe and we observed that staff demonstrated that they understood how to protect people’s rights and safeguard the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people who used the service and helped the service to continually improve.

We found that the service was safe, clean and hygienic. Equipment was well maintained and the service was going through a renovation programme to ensure that the environment continued to meet people’s needs safely.

People’s care needs and the qualifications, skills and experience of the staff were taken into account when making decisions about staffing numbers required to the meet the needs of people who used the service.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People who used the service and their relatives said that they had been involved in the planning of their care and that the care plans reflected their current needs.

People’s needs were taken into account with signage and the layout of the service, enabling people to move around freely and safely. The premises were undergoing renovations and were in the process of being adapted to continue to meet the needs of the people using the service.

Is the service caring?

People were supported by kind and attentive staff. We used the Short Observational Framework for Inspection (SOFI 2). SOFI 2 is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed that care workers showed patience and gave encouragement when supporting people. People commented, that staff were courteous One person told us “On the whole it is very nice here. The atmosphere is friendly and one of acceptance. The staff are very good.”

We found that people’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People regularly completed a range of activities of their choice both in and outside of the service. We found that surveys were regularly sent to people who used the service, relatives and professionals. We saw that the feedback the service received was acted upon.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home. This helped to ensure that the quality of service was maintained.

On the day of the inspection we met with the two directors, the deputy manager and the estates manager. We also talked to several staff and observed people in the home talking to them where either possible or appropriate. One of the staff told me people were like ‘jigsaw puzzles’. The joy of the job came from occasional breakthrough scraps of information and putting these scraps together to learn about people’s lives and stories.We spent time with one of the activity coordinators who told us how the week activities were planned with input from people and staff. We observed a group painting. We also saw the newly opened ‘living memory room’ and the ‘Hockeredge Arms’ an English pub simulation – a popular place for lunch.

We saw a lunch service and were shown the Food Safety and Nutrition leaflets which included the corporate policy, sample menus, training schedules and a ‘must tool’. This tool showed the five step screening plan to enable identification of malnutrition concerns. It was used as an audit tool as well as part of the daily care planning process.We looked at staff planning and support with a training framework. We also talked through the complaints process looking at the policy, the complaints folder and reached an understanding of the process.

There were 46 people using the service when we completed our inspection. We met and spoke with some of them, we also spoke to the manager, staff and visitors. Everyone we spoke to said they were happy with service the Hockeredge provided. One person told us, “The staff have time for the people using the service and treat them with respect”.

People told us that they felt safe and well looked after. People looked relaxed, comfortable and at ease with each other and staff. One staff member told us, "I have been given the skills and experience to keep people safe."

We observed that staff were respectful and caring to people who used the service and spent time talking to them. People were encouraged to make choices for themselves including what and where they ate their meals.

The service had participated in a recent dementia care improvement project and had changed the ways in which they worked in accordance with published research and guidance.

Staff we spoke with were committed to working in a person centred way and had knowledge and understanding of people's needs and knew their routines and how they liked to be supported.

People said they liked living at The Hockeredge. They said they had been involved in discussions about the help they needed and their preferred day to day routines. People said they had enough to do and could join in with activities if they wanted to. They said they were happy with the support they received, that the staff were kind, caring and on hand to help when needed. People said they liked the food, there was a choice of menu and that they chose where to eat. They said they knew who to speak to should they have any concerns.

This was an unannounced inspection that took place on 16 and 20 July 2015.

The service provides accommodation with nursing and personal care for up to 47 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There is a lift to the first and second floors. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 42 people living at the service when we inspected.

There was no registered manager when we visited. 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.

A number of shortfalls were identified during our visit, some of which had been recognised by the provider. An action plan was in place with timescales and named staff that would be responsible for making these improvements. The operations director was overseeing the management and running of the service and was supporting staff to make the improvements. However, there was still work to be completed.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. There were restrictions imposed on people that had not been assessed, consented to and reviewed to be the least restrictive option. This included a locked door policy and managing people’s cigarettes. DoLS authorisations had started to be applied for to the local authority but there had been a delay in ensuring they were applied for when people were having their liberties restricted unlawfully. When people lacked the capacity to make decisions staff were not following the principles of the Mental Capacity Act 2005 to ensure any decisions were made in the person’s best interests. The administration of covert medicines had not been assessed to ensure this was the best way to ensure people received their medicines.

People were at risk of not having their health care needs met. Wound care treatment plans were not completed so people’s skin was not monitored effectively to prevent the risk of further breakdown. Some people did not have the support they needed to manage their continence. Some people had diabetes and needed their blood sugar levels monitoring. This was not happening.

People could choose from a range of different meals and specialist diets were catered for. However, people who had lost weight should have a treatment plan to help improve their weight. These were not always in place and some people continued to lose weight.

Management of risks was inconsistent and risk assessments were not all up to date to give staff guidance of how to manage some risks safely. Accidents and incidents were recorded, but not monitored, reviewed or analysed to prevent or reduce the likelihood of reoccurrence.

People’s care needs were not always assessed before they moved in. Care plans had not all been reviewed and kept up to date to ensure that staff were aware of people’s current needs. There was an action plan in place to address this, but this work was still in progress.

People and their relatives thought that staff made sure they were kept safe, although some relatives did have concerns that some people could get agitated at times and this could have a negative impact of their relatives. Staff understood the importance of monitoring people to ensure that other people were not put at risk. Staff had a good awareness of what abuse was and knew about the importance of whistle blowing.

Routine prescribed medicines were managed safely and people received their medicines when they needed them. The records for the returned / destroyed medicines were not properly maintained and there were no protocols for ‘as and when’ (PRN) medicines.

There were shortfalls in staff training and not all staff had received supervision. There was an action plan in place to address this and a staff supervision programme was in place. Staff felt well supported and had the opportunity to attend regular staff meetings. Recruitment checks were carried out for new members of staff.

There were enough staff on duty to meet people’s physical needs, although staff were busy and did not have much time to spend with people. Staff did not always notice that people needed support to go to the toilet.

There were some processes to support people to have a say about the service and give their opinions, but these were not consistently in use. There were limited opportunities for people to take part in different pastimes, although they could choose from some arranged activities available.

Audits were not carried out to make sure the quality of the care provided was monitored, assessed and reviewed. Records were kept about the care people received and about the day to day running of the service. Some records were not accurate and were not always up to date.

There was an on-going refurbishment programme. There was a lack of suitable signage to help people find their way around. There were risk assessments and safeguards to keep people safe in the environment.

There was a complaints procedure. People and their relatives felt confident that any concerns they had would be acted upon and resolved.

The provider had a clear vision for improvements for the service and was supporting staff by providing additional resources to make improvements.

We have made recommendations that the provider consider best practice guidance for the environment and developing activities for people living with the dementia.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 You can see what action we told the provider to take at the back of the full version of this report.

We have issued two formal warning notices to Bedstone Limited telling them they must take action to address the safe care and treatment of people and the good governance systems in the service.