What life is like for people using this service.

• People were not always kept safe from harm. We were concerned that one person was not safe and made a referral to the local safeguarding authority and police as we were not reassured the service knew how to best support this person.

• There were not enough staff to meet the complex and changing needs of people. We saw people placed at avoidable risk of harm. There were not enough staff to support people to effectively prevent incidents such as falls.

• There were few activities for people to follow. People were not supported to lead lives that were meaningful to them. We saw three people with needs for positive behavioural and emotional support wandering around the home, showing periods of distress and confusion. They received minimal interaction from staff.

• Medicines were not always managed safely. Care staff were administering medicines in a patient and caring way and recording the medicines given with no gaps. However, there were no protocols in place for covert medicine administration or when it was appropriate to administer a medicine prescribed ‘as needed’. Some controlled drugs were not safely stored.

• Care plans and risk assessments were not up to date with people’s needs, placing people at risk of inappropriate care and treatment.

• People’s preferences were not being met. Choices were offered to some people but care staff did not always offer a choice to those people who might not be able to verbalise their preferences.

• Daily recording and monitoring frequency did not match up to care plans and there were gaps in records. We were concerned some people were not being repositioned as often as they should be and some people who required hourly monitoring to remain safe were not being checked on by care staff regularly enough.

• People were not empowered to have choice and control in their lives. They were not invited to contribute to the running of the home, either through their ideas or taking part in domestic tasks to introduce a feeling of purpose.

• There was insufficient manager and provider oversight into the day to day running of the home. There was a lack of senior staff presence on the floor. We had to intervene and ask for managers to assist after two incidents took place in a short space of time.

• Quality assurance was lacking and did not pick up on some of the issues we found during the inspection.

• The service had not always notified the Care Quality Commission of important events or significant incidents by sending in legally required notifications.

• People were supported by staff who cared about their welfare and spoke fondly of them. Relatives told us care staff were kind. We saw care staff approaching people gently and being patient.

• There had been some efforts to make the environment homely and there were planned redecoration and other maintenance works taking place during our visit.

• People had drinks within reach and were offered warm drinks throughout the day. There was a balanced diet on offer. Some people were not happy with the presentation of the food.

• Staff felt supported and informed by the provider on changes that were taking place. Supervisions were starting to take place. Training had been booked for future dates as there were gaps in staff knowledge and training relating to people’s needs.

• The provider, who had taken over in May 2018 was open to suggestions and had a programme of improvements for processes, the building and staff support planned.

• We found breaches of legal requirements in eight regulations relating to safeguarding, safe care and treatment, recruitment, staffing, consent, person centred care, good governance and notifying us of significant events.

• The service met the characteristics for inadequate in three of the five domains we inspected and the overall rating is inadequate.

• More information is in the Detailed Findings below.

Rating at last inspection.

This was the first inspec