The Care Quality Commission
  • Care Home
  • Care home

Archived: Angela Court

Overall: Inadequate read more about inspection ratings

Tipton St John, Near Sidmouth, Devon, EX10 0AG (01404) 812495

Provided and run by:
Alexis Care Limited

Important: The provider of this service changed. See new profile

All Inspections

17 and 22 December 2014 and on 05, 11 and 26 January and 1 February 2015

During a routine inspection

This inspection took place on 17 and 22 December 2014 and on 05, 11 and 26 January and 1 February 2015 and was unannounced. This was our fourth inspection during 2014. The inspection continued over several weeks because of the level of on-going concerns and in order to inform regulatory decisions about next steps. We brought forward the inspection because of concerns raised with us about people’s care and welfare and about staffing levels at the home. Previously, on 04 April 2014 we visited Angela Court and had no concerns. We visited again on 20 July 2014 because of concerns raised with us about staffing levels. We found a breach of regulations in staffing due to staff vacancies and high sickness absence. We issued a compliance action and the provider set out actions being taken to address our concerns. On 16 September 2014, we undertook a further inspection visit and found improvements in staffing levels had been made.

Angela Court is registered to provide accommodation for 37 older people who require nursing and personal care. Many of the people who were living at the home have advanced dementia and lack capacity, and are not able to communicate their experiences of care. Some have complex needs and require a high level of care and supervision from staff to keep them safe. A number of people display behaviours that challenge the service.

The home is required to have a registered manager as a condition of registration. Angela Court does not currently have a registered manager, the previous one last worked at the home in August 2014 and has since left and deregistered with CQC. There has been a series of interim management arrangements at the home since then. A new manager was recruited and started working at the home on 5 January 2015, and plans to register. 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 were not protected from abuse. This was because sufficient actions were not taken to keep people safe and prevent avoidable harm. Angela Court has been the subject of a whole home multiagency safeguarding investigation since 17 November 2014, the third such investigation during 2014. Whole service investigations are held where concerns about possible institutional abuse or neglect are being investigated. These are cases where there are indications that systemic abuse or care and safety failings may have caused or are likely to cause significant harm. On the 16 January 2015, the multiagency safeguarding meeting concluded the safeguarding concerns amounted to the neglect of people living at Angela Court.

As part of that process, a multi-disciplinary safeguarding protection plan was agreed with the provider, CQC, police and health and social care professionals to protect people’s safety and well-being. This included health professionals visiting the home regularly as part of the support plan and in a protection role.

People were not protected from unsafe and unsuitable premises. In particular, we highlighted burn and scald risks related to the central heating and hot water supply at the home. Following this, the provider took immediate steps to mitigate the risks, for example, displayed warning signs and where possible, put in place measures to stop people accessing hot water supplies unsupervised. Further plumbing and maintenance work was undertaken to address these concerns.

On three days of our visit, there was a strong smell of urine in the lounge, main corridor and dining room areas of the home. This was because cleanliness and hygiene standards in communal areas of the home were not being consistently maintained and because the carpets needed replacing. On 26 January 2015 when we visited, the carpet in the lounge area had been replaced and the odour had gone.

People’s health, safety and welfare were put at risk because there were not sufficient numbers of suitably qualified, skilled and experienced staff on duty at all times.

We were so concerned about some of the findings during our inspection visits that, on 13 January 2015, we wrote to the provider. We used our urgent enforcement powers to require them to provide an action plan and assurance to us by the 15 January 2015 about how they planned to ensure people living at Angela Court were being kept safe. The provider’s response acknowledged the concerns raised and gave a commitment to addressing them. The letter confirmed urgent action had been taken to manage the premises and protect people from risks related to hot water, hot pipes and other environmental concerns. It also outlined further actions being taken to improve staffing and skill levels as well as day to day leadership and supervision of staff at the home.

The staff training arrangements did not ensure staff had the knowledge and skills they needed to support people’s care and treatment needs. Staff needed more training to manage people with behaviours that challenged the service and to understand how to meet the needs of people living with dementia. We identified other gaps in training in relation to managing people with choking risks, the Mental Capacity Act 2005 and Deprivation of Liberty safeguards and in relation to nutrition, hydration and pressure area care.

People’s care needs were not effectively communicated to staff and people did not always receive care in accordance with their individual care plans. Some people were not appropriately supported at mealtimes, which increased their risk of malnutrition and dehydration. Others were at increased risk of choking because speech and language therapist recommendations about how to support those people to eat and drink safely were not being followed.

The care provided at the home was very focused on supporting people with daily living tasks rather than in response to people’s individual needs and wishes. We saw examples of staff being caring and respectful of people. However, we also saw occasions where staff did not engage with people and did not treat them with dignity and respect.

People were at significant risk because accurate records about each person were not consistently maintained. We found gaps in people’s food and fluid charts, repositioning and personal care charts as well as in prescribed cream charts. We could not be assured from these records that people’s care needs were being met.

The quality assurance processes in the home were inadequate; some of them had lapsed and many of the concerns found were not identified by the provider’s own monitoring arrangements or had not been acted on. Many of the actions taken by the provider to protect people were in response to concerns identified by visiting professionals, and the inspection. This demonstrated the provider was reactive rather than proactive in managing risks for people. Where improvements were made, these were not being sustained and risks remained.

On 29 January 2015, the provider contacted CQC to inform us they had identified seven people who needed immediate transfer to an alternative more stable service. They confirmed they were working with the local authority and health professionals who were assisting them to facilitate those people's transfers in a safe and caring way. 

On 30 January 2015, CQC received notifications from Devon County Council and the Northern, Eastern and Western Devon Clinical Commissioning Group (CCG). These showed they had decided to give notice of the termination of the individual contracts for all people at the home for whom they had funding responsibility. This was due to the considerable concerns regarding the quality of care provided at the home and because people’s care and safety could not be guaranteed. They informed the provider of their intention to move people from Angela Court as soon as practicably possible. By 5 February 2015 the remaining people left Angela Court and currently, there is no one living at the home.

During the inspection, we identified a number of serious concerns about the care, safety and welfare of people who lived at Angela Court. We found 16 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, now replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People continued to be at risk of  harm because the provider’s actions did not sufficiently address the on-going failings. This was despite the significant amount of support provided by the multi-agency team to address those failings. There has been on-going evidence of inability of the provider to sustain full compliance since March 2011.

Notwithstanding the findings of this inspection, enforcement action was not necessary once we were satisfied that service users were no longer accommodated at this location and satisfactory action plans from the provider addressing the breaches were accepted by CQC.

11 October 2016

During a routine inspection

This inspection took place on 11 October 2016 and was unannounced. Angela Court is registered to provide accommodation for 37 older people who require nursing and personal care. We are not able to award a rating following this inspection. This is because, the service was not fully operational and there were not enough people using the service to gather sufficient evidence to demonstrate the systems used were embedded.

On the day of our visit there were six people living at the service which included two people receiving respite support. The people at the service were having their nursing needs met by the local health authority community nursing team. This was because the provider had made the decision to only admit people with who required personal care and had not employed registered nurses.

Previously we carried out an unannounced comprehensive inspection of this service during December 2014 and January 2015. Angela Court was at the time of the inspection, subject to a whole home multiagency safeguarding investigation. As a result, Devon County Council and the Northern, Eastern and Western Devon Clinical Commissioning Group (CCG) gave notice to the provider. This meant the termination of the individual contracts for all people at the home for whom they had funding responsibility. The provider also made the decision to give notice to people who held a privately funded contract with them. This meant that from 5 February 2015 nobody was living at the home. During the inspection, we identified a number of serious concerns about the care, safety and welfare of people who lived at Angela Court. We found 16 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, now replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider was meeting all of the regulations.

The provider worked with the Care Quality Commission (CQC) and kept us informed about their plans to reopen and the measures they would put into place to keep people safe.

In June 2016 the provider started admitting new people into the service. The Provider has recently developed and had begun to implement best practice care delivery based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This has resulted in the environment being divided into smaller houses to support small group living. Groups are determined based on the stage of the dementia of the person living at the home. The provider had employed senior consultants and a director with experience and expertise in developing this model of care for people living with or without a dementia.

The service is required to have a registered manager. A registered manager is a person who has registered with 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. A manager had been appointed and had submitted their application to CQC to become the registered manager at the service. The manager was very visible at the service and undertook an active role. They were very committed to providing a good service for people in their care and demonstrated a strong supportive approach to staff.

The premises and equipment were managed to keep people safe. The provider had refurbished the main communal area of the home. The ground floor wing referred to as, the ‘Otter suite’ was nearing the end of its refurbishment. The Otter suite had eight bedrooms with six having ensuite facilities. Plans for the future development of the other areas of the home were under discussion.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. Staff had been developing skills and knowledge to meet people’s needs. There were adequate staffing levels to meet people’s needs.

People felt safe and staff had a good understanding of what constituted abuse and how to report if concerns were raised. Measures to manage risk were as least restrictive as possible to protect people’s freedom. The manager was working with the local pharmacist to put in place systems to manage people’s medicines on their behalf.

Care plans were personalised and recognised people’s health, social and psychological needs. They contained detail regarding people’s wishes, backgrounds and goals. People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

The manager and staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA.

People were supported to eat and drink enough and maintain a balanced diet. The manager had been working closely with people and staff to provide a social inclusive dining experience which included staff joining people for meals. They were also developing a menu with people at the service. Staff relationships with people were strong, caring and supportive. Staff were motivated and inspired to offer care that was kind and compassionate. Staff spoke confidently about people’s specific needs and how they liked to be supported.

Staff supported people to follow their interests and take part in social activities. People had developed strong social groups within the home and the local community. The culture of the home was open, friendly and welcoming. The manager was taking the lead at the home and was working to delegate staff roles and responsibilities. The provider had a team of representatives who regularly visited the home to support the manager and staff. They used a range of quality monitoring systems to continually review and improve the service. There had been no complaints received. The manager was aware of the provider’s complaints policy and was open to people’s concerns and took action promptly to resolve.

16 September 2014

During an inspection in response to concerns

This was a responsive inspection. At the time of the inspection the service was the subject of a 'whole home safeguarding process', overseen by Devon County Council. There had been three incidents of concern raised in the past three months which related to the care and welfare of individuals at the home. We have chosen outcomes that relate to the concerns we received, namely the care and welfare of people using the service, recruitment processes and staffing levels.

The focus of the inspection was to answer five key questions: is the service safe, effective, caring, responsive and well-led?

Before our inspection we reviewed all the information we held about the home. We examined previous inspection reports and notifications received by the Care Quality Commission. We carried out this responsive inspection as at the last inspection in July 2014 we found that there were not enough qualified, skilled and experienced staff to meet people's needs. This area is now compliant.

On the day of our visit there were 30 people living at Angela Court and two in hospital. We looked at the care files of two people living there. We met with seven people living at the home to find out if the care and services they received met people's needs. Some people were living with dementia and unable to tell us directly about their experiences so we also spent time observing care in the communal areas. At the time of this inspection there was no registered manager in post. We spoke to the provider's clinical manager who was one of the acting managers until a suitable permanent manager could be appointed. A potential candidate was viewing the home during our inspection. We spoke to two registered nurses (one from an agency), the administrator, a team leader, three care workers, the maintenance person, housekeeper and the laundry person to find out if they the care and services they received met people's needs.

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.

Is the service safe?

The service was safe because people's health and care needs were understood by a trained and supported staff. Risks to people's health and welfare were understood and managed in line with their agreement. We saw that staffing levels had been increased appropriately when people's needs had changed requiring more input. External healthcare professionals were involved where necessary. We saw people looking relaxed and enjoying their day being cared for by attentive staff who knew them well. There was monitoring of events and incidents and measures were put in place to minimise a repeat of any issues.

Care plans included considerations of the Mental Capacity Act (2005) and staff demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and how they applied to their practice. We found the location to be meeting the requirements of the Mental Capacity Act (2005). People's human rights were therefore properly recognised, respected and promoted.

Is the service effective?

The service was effective because people's health and well-being was promoted. Care plans provided instructions to staff about the care each person wanted and needed. We saw evidence of multi-professional visits and appointments, for example GP, speech and language therapist, and community nurses. We also saw that the home had identified where people may be requiring additional support and clear records were kept to evidence people's changing needs to inform other health professionals.

Is the service caring?

The service was caring because we saw staff communicating in a warm and caring manner. For example, in the morning, we saw a member of staff sitting with a person helping them with a board game and also encouraging people living with dementia to join in activities that matched their abilities. Staff were very attentive to people's non-verbal language, managing behaviours which could be challenging to staff in careful, discreet ways.

Is the service responsive?

The service was responsive because people's likes and dislikes were taken into account. For example, the home involved families and/or advocates to create a person centred care plan for individuals that ensured their needs were met. The staff we spoke with understood each person's needs. They were able to describe people's preferences and showed sensitivity to each person's needs. Care files were regularly updated and provided staff with sufficient information about each person's needs to ensure their health and welfare needs were met safely. Staff also identified changes in a timely way and sought appropriate advice.

Is the service well-led?

The previous registered manager had recently left. Whilst the home were seeking to employ a new permanent manager two acting managers were in place. Staff knew who to go to for support and told us they felt well supported and listened to. One staff member said 'The care and attitude is very good here'. The acting manager showed us monitoring forms and processes which provided evidence of regular checks carried out to ensure all aspects of the service were safe and ran smoothly. Staff meetings and staff supervision sessions were held monthly. All meetings were minuted and this showed that people and staff could raise matters about the service and know their views were valued.

20 July 2014

During an inspection in response to concerns

Our inspection was unannounced and was completed by one inspector on Sunday 20 July 2014 and lasted approximately five hours. The inspection was responsive rather than scheduled. It was triggered by two concerns regarding poor staffing numbers at the home, CQC decided to carry out an inspection. The focus of the inspection was to check on the care and welfare of the people living at the home and to ensure staffing numbers at the home met people's needs.

We found on the day of our inspection people living at Angela Court were having their care and welfare needs met. The people were being supported by a nurse and seven carers in line with the assessed staffing levels told to us by the registered manager.

We were told by staff the staffing levels at the home had been inconsistent. We found by looking at records of the homes staff rota on 17 days out of 46 days before the inspection the staffing levels at the home had fallen below the recognised levels assessed by the registered manager. We were told and saw records confirming the shortages were due to staff sickness. We saw there were not sufficient contracted staff hours employed by the home to fulfil the level of staffing required to meet people's needs.

4 April 2014

During a routine inspection

Summary

We considered our inspection findings to answer 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.

On the day of our inspection there were 32 people living at Angela Court.

The summary is based on our observations during the inspection, we spoke with five people using the service, the registered manager, and six staff supporting them. We also spoke to two visitors and one health professional involved with people using the service to ask their views.

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

Is the service safe?

The registered manager ensured there were staff on duty with the appropriate qualifications, skills and experience required to ensure people's needs were met. People were supported by staff who had received appropriate training in the skills required to perform their roles.

The registered manager understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty safeguards ( DoLs). Although no DoLs applications had been made, the manager was able to describe the circumstances when an application should be made and knew how to submit one.

A visiting G/P told us that he had seen improvements at the home, he felt well informed regarding changes to his patients and that the home had followed guidance and instructions that he had given.

The provider had suitable arrangements in place to reduce the risks of people receiving inadequate nutrition or becoming dehydrated.

The home was clean and had processes in place to maintain a clean environment.

Is the service effective?

People's health and care needs were assessed and their care plans and assessments were reviewed monthly. Specialist dietary, mobility and equipment needs had been identified in care plans where required. This showed that people were having care delivered effectively or in accordance with their assessed needs.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well. One person told us 'I am looked after well, if I wasn't happy I would tell them'.

Is the service caring?

People were supported by staff who were understanding and sensitive to their needs. We saw that staff showed patience and gave reassurance and encouragement when supporting people.

Visitors told us that they had no concerns about the home and that their friend always looked well cared for

Is the service responsive?

We saw that learning from incidents and investigations took place and appropriate changes were implemented.

People knew how to make a complaint if they were unhappy. Complaints that had been received since our last inspection had been acted upon promptly and in line with the homes complaints policy and procedure. One person told us 'I am looked after well, if I wasn't happy I would tell them'. People can therefore be assured that complaints are investigated and action is taken as necessary.

Is the service well-led?

The service had appropriate systems in place for gathering, recording and evaluating information about the quality and safety of the overall service. Systems were in place to make sure the manager and provider learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

Systems were in place to make sure that the manager and staff learned from complaints, concerns and investigations carried out by the home. We looked at how complaints had been dealt with, and found that the responses had been in line with the homes policy and were open, thorough and timely.

The provider worked with the registered manager and the staff to ensure the standards that people expected at the home were maintained.

Staff told us they were clear about their roles and responsibilities. They told us 'It's a great place to work, very rewarding but also extremely challenging' and 'The other staff are all wonderful people, it takes a certain type to work here. It can be difficult meeting people's needs as they are complex'.

Relatives and supporters of people living at the home had completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed. This helped to ensure that people received a good quality service at all times.

During an inspection looking at part of the service

Our visit was unannounced and took place over two days with three inspectors. 24 people were living at Angela Court. We met with 12 people living at the home and one person visiting the home. We spoke with eight staff and observed the practice of staff members.

This inspection report is in addition to the initial report written for a scheduled inspection on 15 and 16 May 2013. Please read the initial report in conjunction with this report as it covers a number of other outcomes. This report has information relating to staff training and notifications. These were both found to be compliant. This report has been written from evidence collected on 15 and 16 May 2013. However, the information did not appear in the correct sections in the original report so this report has been created to address this issue.

15, 16 May 2013

During a routine inspection

Our visit was unannounced and took place over two days with three inspectors. 24 people were living at Angela Court. We met with 12 people living at the home and one person visiting the home. We spoke with eight staff and observed the practice of staff members. We looked at care plans for people living at the home and quality assurance records. We followed up on previous concerns linked to care and the environment. We also collected information as part of a thematic review about the preparation and training of care workers. We used a tool called SOFI 2 (Short Observational framework for Inspection) to help us make a judgement about people's experiences of using the service. This was because some people could not comment directly on the service.

There was a marked improvement since our previous inspection in December 2012 when we had highlighted significant shortfalls in the way the home was run and how people were cared for. We met with the provider in January 2013 to ensure they understood the level of non-compliance and our serious concerns.

All the outcomes areas that we inspected were compliant. The provider had taken action to address areas of non-compliance. We saw that people's dignity and respect was maintained. Their health and wellbeing was assessed and care was provided in a way that suited people's individual needs. The environment had improved, as had staff training and medication management. Quality assurance processes were more robust and effective.

13 December 2012

During a routine inspection

We carried out this unannounced inspection over three days, with three inspectors including a pharmacist inspector. During our inspection, we spoke with 18 people but most people were unable to comment directly on the care they received. So we spent time in communal areas observing their experiences and how staff interacted with them. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us about their experience of care.

We spoke with eight relatives during the inspection about their views on the quality of care provided at the home and their views were generally positive. However, these opinions did not reflect our judgements on the quality of care. Some areas of the service needed to be significantly improved to enhance the lives of people living at the home. We also spoke with 12 staff to gather their views on how the home was run, their role and how people living at the home were cared for.

We pathway tracked six people during our inspection; this meant that we met with them, looked at their health care, social care and medication records and spoke with staff about their care needs. We also looked at areas such as how staff kept people safe, the maintenance and quality of the environment, staff training and quality assurance to help us make a judgement about the experience of people living at the home.

We had asked the provider to send us some additional information following the inspection, to help us make our judgements.

The home does not currently have a registered manager but we have been advised that the provider was actively interviewing people for the post. The previous registered manager resigned in August 2012.

16 August 2012

During an inspection looking at part of the service

We (the Care Quality Commission) carried out an unannounced inspection at

Angela Court on 16 August 2012. At our previous inspection in June 2012, we identified that improvements were needed in relation to seven outcome standards.

The purpose of this inspection was to check whether the provider had made the required improvements in relation to outcome 7, Safeguarding people who use services from abuse. At our last inspection we identified concerns about whether people living at the home could be confident that risks to them from other people were being well managed to protect them from abuse. Following that inspection, the provider was required to send a written report detailing all actions being taken to address identified areas of non compliance and when they would be compliant. We will follow up the remaining outcome standards at the next inspection.

Angela Court has been part of a whole home safeguarding concern, which meant that commissioners, health and social professionals have been reviewing and monitoring the quality of care provided. The provider has continued to work with all agencies involved to make the required improvements.

On the day we visited, there were 28 people living at the home. Most of the people we spoke with were unable to give us feedback about living at the home because of cognitive difficulties related to their dementia. Instead, we observed people in communal areas of home and looked at how staff interacted with people. We also spoke to one relative who visited the home whilst we were there. We spoke to eight staff including the registered manager, deputy manager and a representative of the provider and asked about people's needs and how they were being met. We looked at five people's care records, two staff files, staffing rotas and reviewed all accidents and incidents reported since our previous visit.

One relative told us how a person needed support with all aspects of their care and said their needs were being met. They said 'things have improved' in relation to their main concern which was about staffing levels.

We observed how staff bent down and made eye contact with people who were sitting down in order to talk to them. We also saw that care workers encouraged people and praised them for their achievements. When staff spoke to us about the people they cared for, they talked about people as individuals and demonstrated they had a good knowledge of people's needs and how to care for them.

We followed up what improvements had been made since our last visit to protect vulnerable people. We were told how staffing levels were reviewed and had been increased during the day. This meant staff were better able to monitor and check each person as they moved around the home to ensure they were kept safe.

We saw that people were being safely managed and any potential conflict was swiftly dealt with. For example, we observed that one person started to shout and became aggressive in the lounge area. We saw how a staff member dealt with them quickly by talking to them and asking them what they would like, which distracted them. This meant they calmed down and other people were not frightened by their behaviour.

We were also told how practice was reviewed in relation to the care of some people during the night, who had a tendency towards aggressive behaviours and were resistant to having help with their personal care. This resulted in their care plans and risk assessments being updated and changes made in the way their care was managed. We were told how personal alarm systems were provided to staff so they could more easily call for help, if needed. We were also told that door alarms had been ordered for some rooms to alert staff when people left their room at night.

Accidents and incidents were monitored and measures were identified to reduce risks of recurrence and to monitor any trends. We were told about additional training being organised to help staff manage people with challenging behaviours more confidently and to try and reduce the risks of injury to staff.

We concluded the provider had taken action to identify which people posed risks to others and implemented measures to protect people from abuse. We found that concerns about suspected abuse were investigated and measures taken to protect people from harm and improve care through staff training and supervision.

We found that the provider was meeting the standard related to safeguarding people who use services from abuse.

29 June 2012

During a routine inspection

Our unannounced inspection at Angela Court Nursing Home took place over two days on 20 and 29 June 2012. The visit lasted in total over 22 hours. On the first day we arrived at 6.30am and on the second day we stayed until 8pm. This helped us understand what it was like for people living and working at the home at different times of the day.

We spent the majority of our time in communal areas. On both days, two inspectors visited the home enabling each inspector to focus on different areas of the home.

We spoke with four people living at Angela Court Nursing Home who were able to comment directly on their care. However, most of the 21 people we met were not able to comment directly on their care so we spent time with them to help us understand what life was like at the home. This meant we spent time observing care and people's interactions with staff in communal areas to see whether they had positive experiences. To do this we used the Short Observational Framework for Inspection (SOFI 2). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us about their experiences of care.

On a previous inspection in February 2012, we had made compliance actions about the standard of care, the environment and staffing levels. On this visit, we visited 31 bedrooms to see how they were maintained. We looked at a range of written records including care assessments, care plans, minutes of meetings, menu records and staff rotas.

We were given a list on our first day that showed 28 people were living at the home and we were told that three people were in hospital. On the second day, we were told that 28 people were living at the home and we were told that two people were in hospital. During the inspection, we spoke with the manager, who is registered with the Care Quality Commission, and the provider. We also spoke to 25 staff members about their roles and their work and with three relatives who were visiting the home.

We gave detailed feedback to the manager and the provider at the end of the inspection to ensure that they could begin improvements immediately. Prior to the inspection, we had met with the nominated individual for PSP Health care Limited on 11 May 2012 to discuss the improvements outlined in the action plan that was completed for the inspection for February 2012.

Angela Court was part of a whole home safeguarding concern, which meant that commissioners, health and social professionals were reviewing and monitoring the quality of the care that was provided by the service.

People generally looked well cared for. When staff spoke to us about the people they cared for, they talked about people as individuals and some staff showed they knew people well by referring to their past achievements, which matched with information in their care records. However, from our two days at the home, we saw that there was not a consistent approach to maintaining people's dignity and choice.

We saw that most staff were caring in their approach and that some recognised the importance of person centred practice. Some people enjoyed each others company, which staff respected and supported. Some people received more attention than others from staff, while quieter people had less interaction from staff. We saw feedback from a relative that praised the work of the activities co-ordinator and the management of large celebrations, such as the Jubilee garden party. There was a lack of general interaction and stimulation between some staff and people living at the home.

Two people were able to tell us that they felt safe at the home. One person told us that a person of the opposite sex regularly came into their room uninvited. They told us that they used the call bell and staff responded quickly to remove the person. We saw from records that some people do regularly go into other people's rooms without being invited. A third person also told us that this was a problem, particularly at night.

We saw a number of people moving freely around the lower floor of the building and choosing where to sit. We saw that the home was surrounded by well maintained grounds. The provider told us that people use the gardens regularly but this was not recorded in activities records.

We saw most staff gave eye contact, reassurance and showed compassion and concern when people became anxious. However, this good practice reduced when staff were busy and we heard some staff give instructions to people in a manner which was too quick and hurried.

We spoke with four people who were able to comment directly on their care but most people were unable to express their views on the care they received. Two people told us they were satisfied with the standard of care and the support staff gave them. One person said 'very happy here, wouldn't swap it for anything'.

3 February 2012

During an inspection in response to concerns

This review was carried out as a result of information we (the Commission) received about Angela Court. The information suggested that the service might not be compliant with some of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which describe the essential standards of quality and safety that people who use such services have the right to expect.

We carried out an unannounced visit to the home on 2 February 2012, returning for the afternoon of the next day to complete our information-gathering. We were assisted fully by the registered manager and the staff.

There were 34 people living at the home, 14 of who had nursing needs. We observed how people were being cared for, talked with people who use the service, talked with staff, looked at records of people who use services and checked the provider's records. We pathway-tracked three people living at the home. This means we followed up in more detail the care and support they received. They had differing types of needs, and included people with nursing needs.

Many people living at the home were not able to comment directly on the service because of their memory problems. We therefore used a formal observation method during our visit to help us understand their experiences. This involved observing people in the main lounge-dining area, for an hour and a half. We observed their mood state, how they engaged in activities, and interacted with staff members, other people, and the environment. This helped us assess the well-being of people who were unable to comment directly on the care they received. It also helped us to make judgments about how people occupied themselves during the day, and the skills of the staff who supported them.

Four people who lived at the home spoke with us to give us some of their views. We also spoke with visitors related to four people who were unable to answer our questions because of their memory problems or frailty.

The people we spoke with were positive about the support they received. One was recovering from a bout of ill health, and they confirmed that they were being looked after well. We saw staff speaking respectfully with people and responding to people's body language, offering assistance. People seemed at ease with the staff around them. When we asked one person if they thought the staff treated less able people well, they replied "I think the staff are marvelous," confirming they meant with regard to how the staff treated people when they were confused.

One of the visitors told us things had improved at the home since they had raised concerns in previous months. Another was very positive about the care provided to their relative, comparing it more favourably to that provided in the person's previous care setting. However, we found that the planning and delivery of care did not always ensure that people received the care, treatment and support they needed. And that there were not enough suitably skilled and competent staff employed to achieve this, in part due to staff changes in recent months.

A visitor was positive about the amount of communal space for people to use at the home, and two people we spoke with confirmed that they were happy with their bedrooms. The environment was not always maintained or refurbished in a homely and timely way, however, with heating problems and malodours in areas of the home.

14 September 2011

During an inspection looking at part of the service

People were generally treated with respect by staff, and in a kindly way, with consideration shown for people as individuals. We saw care and domestic staff engaged with people as they passed them, acknowledging them and making eye contact, some stopping to chat. We heard staff talking with people as they assisted them, seeking their views and agreement before continuing with their support. Staff lowered their body position to talk to people face-to-face, or sat beside them when assisting them with their meal, rather than standing over them.

We used a formal way of observing people, during this visit, to help us understand their experiences. We noted good or neutral interactions from staff, rather than poor communication, although we discussed with the manager one less appropriate communication we heard.

People we met looked as though their personal care needs had been attended to. During the day, we saw the domestic staff engaging helpfully with people, and alerting care staff to assist them with personal care if necessary. Care staff attended promptly in such situations. People were encouraged to do what they could for themselves, such as two staff taking time to assist someone to walk to the dining table rather than using a wheelchair to move them more quickly.

We saw some picture signage around the home, to help people identify certain rooms (such as toilets) or areas. We noted some people benefiting from the handrails fitted in corridors, using them to get around more independently and more safely. Areas of the home still needed attention, to improve facilities and provide a more pleasant environment throughout.

We noted that people had their morning medication in a more timely way (over the breakfast time) than on our last visit. One person was able to tell us that staff brought them medication for their pain promptly when they asked for it.

We noted staff knocked before entering people's bedrooms, and kept doors closed when assisting people with personal care, promoting privacy. A visitor told us they sometimes asked staff to assist their relative to more appropriate seating, if necessary for better or more private conversation during their visits. They said that staff were very willing to help in this way.

We found that people's advocates or representatives were given relevant information so they could be involved in decisions about the person's care, when individuals no longer had the mental capacity to make such decisions themselves. We met relatives who confirmed that the home kept them informed about changes in the person's health and that they were involved in care planning for the person. We noted, however, that someone's bedroom was still being used to store hoists, without evidence about how the decision had been reached to use this person's room for storage of the home's equipment.

Clergy from various Christian denominations visited regularly. Families and friends, as well as people from the local area, had attended the home's summer fete. We saw letters on display from local charities that had been helped by the home's fund-raising efforts at their fete and so on. We read in the minutes of the last Residents/Relatives meeting that there had been a trip to the local donkey sanctuary. These links help to make the home part of the community that surrounds it.

Visitors we spoke with told us that they felt able to speak to staff or the manager if something was wrong or they were not happy about the care their relative was receiving. One relative told us that they did raise concerns at times, and confirmed that they were not treated badly as a result of speaking up.

17, 25 March 2011

During a routine inspection

When we asked people who lived at the home for their views of it, their comments included 'They look after us very well,' and 'They don't talk down to you.'

People's capacity to make various decisions had been assessed, and this was used to inform care planning and the support they were offered, with the views of their relatives or other advocates taken into account. We saw that people were generally treated with respect for them as individuals, and with respect for their human rights. Occasionally, staff did not communicate well so opportunities for people to express their views or make choices were missed or denied.

The home arranged sight checks, chiropody and dental care for those living at the home. Some people had received support from mental health nurses and community nursing services. Aids and adaptations were provided to promote people's independence safely. Someone who used a walking stick said they got around well enough, without encountering any hazards.

The activity programme included events that could help people's physical and mental well being ' such as darts, a 'movement' session, and manicures. A visitor said their relative particularly enjoyed the musical events, music having been their lifelong interest. People living at the home told us they used the garden in the better weather.

Staff we spoke with clearly knew people's current individual needs, preferences and care, though we saw a very small number of staff were less skilled at individualised support. Issues relating to medication management, written care planning, accident prevention and how people are safeguarded mean that people may not always experience safe and appropriate care, treatment and support. This is detailed in the report.

When we asked someone about the food provided, they replied 'It's glorious!' A visitor also told us that their relative always said the food was nice. People confirmed that they were weighed regularly, one person adding 'They're very particular about that.'

Comments about the cleanliness of the home included 'The appointment of a Housekeeper / supervisor made a big difference', and that the home was kept clean enough. Visiting community nurses told us they had no concerns about infection control practices there.

One person told us staff cleaned their room 'by arrangement', so that the person was able to put away anything if they wished beforehand. Some people had a key for their bedroom door, also promoting privacy. We noted people were not always offered the opportunity to move somewhere private or more suitable if they had visitors.

Action had been taken to try to personalise individuals' rooms, make them more homely, and to try to address persisting malodours. This action needed to be ongoing. Those we asked confirmed their bedroom facilities were satisfactory, including that their bed was comfortable and warm enough.

Regarding the staff, one person commented, 'The people [staff] here are lovely.' Appropriate recruitment procedures were in place to safeguard them from unsuitable staff. Visitors said that staff were usually in the lounge but it was easy to find them otherwise, which was reflected by people living at the home. Care assistants we observed did not rush people, and provided timely assistance.

People who we asked felt staff knew what they were doing, and knew what support or help they needed as individuals. Staff training had been arranged which was directly related to people's needs, with the aim of improving the support and care they received. One person told us that the manager dealt with staff politely but firmly if he thought they are not doing something right, thus guiding their practice in their daily work.

We asked some people what they thought about how the home was run. One person said there had been a great improvement since the new manager arrived; another said they thought things were getting better. A visiting professional also thought aspects of the care and the home had improved in recent months. People told us they would speak to the manager if they had a complaint or if something was not as they would like. Those who had raised concerns with him told us their concerns had been addressed or he was currently endeavouring to resolve them.