Dalton Court Care Home

Dalton Court Care Home is a residential care home providing personal and nursing care to up to 60 people. The service provides support to older people and people living with dementia and physical disability. At the time of our inspection there were 52 people living at the service.

The home accommodates people across two separate floors, each of which has separate adapted facilities. One of the floors specialises in providing care to people living with dementia.

People’s experience of using this service and what we found

People received safe care to meet their needs. Staff were kind and patient in their approach, to which people responded positively. People were protected from the risk of abuse and neglect. Risks to people were assessed and plans put in place to guide staff in how to support people safely whilst respecting their wishes and preferences.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service had a positive culture that was person-centred. Managers were committed to people receiving high quality, safe care. People and staff had opportunities to provide feedback on the service to inform changes. The service had clear and effective governance and management arrangements in place to ensure people received consistent and good care. The provider and registered manager were committed to making ongoing improvements at the service to benefit people’s wellbeing.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 August 2022). There was a breach in regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out as part of our response to winter pressures in the NHS. We reviewed the evidence we held about the location, which suggested the rating may have improved to at least good and that an improved rating would create additional capacity within the service.

This report only covers our findings in relation to the Key Questions Safe and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dalton Court Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Dalton Court Care Home is a residential care home providing personal and nursing care to up to 60 people. The service provides support to older people and people living with dementia and physical disability. At the time of our inspection there were 41 people living at the service.

The home accommodates people across two separate floors, each of which has separate adapted facilities. One of the floors specialises in providing care to people living with dementia.

People’s experience of using this service and what we found

People were at risk of harm as recommendations relating to the health and safety of the service had not always been acted on or addressed responsively. The provider gave assurances action had been taken following our inspection.

People were supported by sufficient numbers of staff, who were knowledgeable about risks to them. Relatives were confident that their family members were safe living at the service. One relative said, “I know that [person] is safe and being looked after.” Staff knew how to identify and escalate any concerns about people’s safety. Visiting arrangements were in place to ensuring family and friends were able to visit their loved ones, whilst being mindful of infection transmission risks.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The registered manager and provider’s quality assurance systems had not been effective in identifying the health and safety issues we found. An action plan was in place to support improvements at the service and enhance people’s quality of care. Relatives and staff felt engaged in the running of the service. People received person-centred care from staff who were focused on promoting their quality of life.

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

Rating at last inspection

The last rating for this service was good (published 21 February 2020).

Why we inspected

This focused inspection was prompted by a review of the information we held about this service. This report only covers our findings in relation to the key questions Safe and Well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dalton Court Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment at this inspection. Please see the action we have told the provider to take at the end of this report.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service and what we found

Since the last inspection the newly formed senior management team and staff team had turned the service around to ensure people received consistent and effective care and treatment. The provider had improved its systems for monitoring older adult services and greater scrutiny and support had been given to the home. Significant improvements were seen at this inspection. Relatives told us how pleased they had been with the improvements. One person summed this up by saying, "I feel confident now to leave my relative. They are in safe hands.”

People were safe and protected from abuse and avoidable harm. Risk assessments helped protect the health and welfare of people. People received their medicines when they needed them from staff who had been trained and had their competency regularly checked. The service was providing safe and consistent staffing levels. Infection control was well managed and the home was clean and free from hazards.

Staff were well trained and supported for their role so that they could meet people's assessed needs. People's rights were protected as the staff team understood their responsibilities under the Mental Capacity Act. People told us they enjoyed meal times and were offered a variety of good quality meals. People's health and nutritional needs were being well met. The home worked effectively with external healthcare professionals.

People’s equality and diversity was respected by a caring staff team. People told us they judged the staff team to be caring and respectful. Staff gave people their time and understood this was important in supporting people’s well-being. They knew the importance of encouraging people to maintain their independence, wherever possible.

The staff team knew people well. They planned and provided care to meet people’s needs and to take account of their preferences. People's views about the quality of care and any complaints were used to make improvements. People had a wide range of organised activities and entertainments to chose from. Relatives were made welcome and included as part of the care team.

The home was being well-led by the registered manager, who was described by staff as being very supportive, approachable and set high standards. Everyone we spoke with told us they would recommend the home and were ‘delighted’ with how the home had improved. Team morale was high, staff felt valued and enjoyed working at the home.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 18 December 2018). We needed to be assured improvements were fully embedded and would be sustained. We made a recommendation in relation to the safer recruitment of staff. We found no breaches of the law.

Why we inspected

This is a planned re-inspection because of the issue highlighted above.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Since the last inspection a new manager had been appointed and they had applied to become the registered manager with us, CQC. 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.

This unannounced inspection took place on 4 & 18 December 2018. We carried out this inspection to check people were receiving safe care and treatment and to see what improvements had been made following our previous inspection of 4 July 2018.

The findings of previous visits, December 2017 and 4 July 2018, led us to rate the home as inadequate on both occasions and the home was placed into our 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.

We had serious concerns about the providers ability to run the home in a manner that was safe and to meet people’s needs. We took the ratings history of the service into account and we judged it necessary to take higher legal action following the July 2018 inspection in order to protect people. To check that this was still the right course of action we carried out this inspection of 4 December 2018.

On this inspection, 4 December 2018, we looked at all the areas where the home had breached the regulations and other areas to ensure that we carried out a fully comprehensive inspection. We did make a recommendation in relation to the safer recruitment of staff.

The breaches the service had not met at the last inspection included: meeting people’s health and welfare needs; record keeping; responding to safeguarding; managing risks; staffing levels and staff training; assessing and monitoring the quality of service and not having a registered manager.

The overall findings and outcome of this inspection, December 2018, was that there had been significant improvements across all areas and the home was no longer in breach of the regulations and was no longer in special measures.

The provider, had after the last inspection, ensured that support had been made available to assist the home in meeting safe standards of care through improved quality monitoring and input from senior managers within the organisation. The new senior team, consisting of a newly appointed home manager, deputy manager, unit leader of the dementia unit and a new operations manager, had made significant improvements in the running of the home.

People living in the home and their relatives all told us they had seen a lot of improvements and everyone we spoke with said they felt safe and well cared for.

We found that people’s care needs were being better met. This was because people were being more thoroughly assessed when they came to the home and the care plans to meet their needs were much more detailed to accurately reflected their needs. These improvements were particularly evident in supporting people who were at risk of falling; those at risk of developing pressures sores; and people at the end stages of their life.

People in the home had better protection from abuse. The provider had ensured that all staff had been given training and now recognised the signs of abuse, knew their responsibilities and how to report, where appropriate, any issues for further investigation.

Risk assessments for the environment and the delivery of care were up to date with added levels of checking carried out to reduce any future risks. Accidents and incidents were managed correctly and reported to the appropriate authorities, including ourselves, CQC.

People received support in a timely way as the home was now staffed to safe levels. Since the last inspection, new staff had been recruited at all levels, including general nurses, mental health nurses, care staff and other support staff. Appropriate disciplinary action had been taken when staff were not fulfilling their job role.

Staff were being well-deployed in the home, helped by the addition of a senior care worker on each shift. Nurses and senior staff were taking more of a lead by giving staff better instructions and direction. This meant people’s needs were met in an orderly and timely manner.

All new staff had received induction training. This had been followed up by training in all the core subjects required to meet national standards, such as Skills for Care. There had been a focus on training for supporting people living with dementia and those people whose behaviour may challenge the service.

Staff now received good levels of training and of both formal and informal supervision which had helped them to develop. Staff said that communication at all levels had improved.

People looked well cared for with good attention to detail to ensure people were well-dressed and to their own taste. We saw staff being attentive and considerate to people’s needs and feelings. Call buzzers were answered promptly, and everyone we spoke to said that staff were kind and caring.

People’s health and more complex health needs were being well-monitored and managed. They received their medicines at the times they needed them and in a safe way.

Good nutritional planning and practice was in place so that people were supported to eat well and keep hydrated. People were happy with the food provided. Mealtimes were much more orderly and staff were spending time giving appropriate support and care to those people who needed more help.

The way the staff team communicated with external professionals had improved. Staff were much more pro-active in seeking advice from local GPs, community nurses, dieticians and mental health workers. This meant people’s care plans were up to date and their health and well-being had improved as a result.

People were protected from the risk of infection. Infection control measures in the home were good with the staff team suitably trained with access to personal protective equipment. The home was clean and orderly.

Healthcare and social services professionals told us that they had seen a marked improvement in the care and treatment of people in the home. They had been impressed by the new management team who they described as being open and receptive to advice.

The home was now meeting the requirements of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Assessments were being carried out of people’s capacity to make decisions. Staff had received training in this area.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Activities and entertainments within the home had improved, with activity coordinators engaging people in things they found interesting and stimulating.

Complaints and concerns were now being better managed by an effective system in place for identifying, receiving, handling and responding appropriately to complaint and concerns.

The service had developed a more robust quality assurance system. Measures had been put in place to improve the running of the service through the provider using a monitoring tool called the ‘Accelerated Improvement plan’. This involved much closer scrutiny of what was happening in the home, with more visits and face to face support from senior managers.

Overall, we found the home was being well-led with the strengthened, more effective management structure that was in place. There had been a significant change to an open culture that was learning from its mistakes. The staff team were proud of their achievements in such a short space of time being up beat, enthusiastic and keen to improve further.

While we acknowledged the improvements, we have rated the service as Requires Improvement as we need to be assured that these improvements are fully embedded and that they can be sustained.

The home provides accommodation for people with both nursing care and personal care. The home can accommodate up to 60 people. At the time of our inspection 53 people lived at the home.

This inspection took place on 3, 4 & 12 July 2018 and was unannounced.

There was no registered manager in post at the time of our 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. An interim manager had been in post since the departure of the previous registered manager in December 2017 and had made an application to CQC to become the registered manager.

Our last inspection in December 2017 was a focused inspection to check that breaches in legal requirements found on the last full comprehensive inspection of July 2017 had been met. We found that the breaches and the warning notice had not been met and we found further cause for concern with new breaches on the focused follow up inspection of December 2017.

The overall rating given in December 2017 for this service was ‘Inadequate’ and the service was placed in ‘special measures’. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, we will inspect again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

At this inspection July 2018 we identified continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to Regulation 12 (Safe care and treatment), Regulation 17 (Good governance) and Regulation 18 (Staffing). Three new breaches were found: Regulation 13 (Safeguarding service users from abuse and improper treatment); Regulation 16 (Handling complaints); and Regulation 11 (Need for consent).

The service has now been rated inadequate once again for the second time in 6 months. Where we take higher levels of enforcement action we will publish full details once all relevant representation timescales have elapsed.

While we did find that the provider and interim manager had made improvements in areas that had been prioritised by them, we found that the initial pace of improvement had not been sustained and other important areas were still giving cause for concern. These were that people did not always receive safe care and treatment that met their changing needs. There were not always sufficient numbers of staff on duty to meet people’s needs. People with needs that were complex and challenged the service were not being supported by staff with the appropriate skills and training.

Risks to people were still not being well managed. Risk assessments were not being carried out when a person's needs changed so that care plans were still relevant and people received person centred care and safe treatment from staff.

The management of falls within the service was poorly managed and not in line with current nationally recognised good practice. While some auditing of falls risks for the service as a whole was now undertaken, the individual risk assessment reviews were still not effective in managing falls prevention.

We found a similar lack of action and recording for people at risk of developing pressure sores. The nursing staff were not using, or using effectively, the assessment tools to monitor changes to people’s conditions and needs.

We found the service was operating a reactive model to addressing people’s health care needs; making a referral once the condition had worsened. Rather than being proactive in putting measures in place that prevent the likelihood of problems occurring or re-occurring.

We found the service was accepting people with complex health needs without sufficient numbers of skilled and trained staff to meet their needs. This was particularly the case on the top floor, Daffodil unit, which specialises in the care of people living with dementia. Staff had not received adequate training to meet the needs of people who may challenge the service and had more complex needs related to living with dementia.

Staff lacked leadership, support and guidance on how to support people living with dementia and the service lacked a cohesive dementia care strategy. This meant people living on that unit were not in receipt of safe care and support that met their needs. A lead nurse for this unit had just been appointed two days before our inspection who had plans to develop the unit.

All care plans had been reviewed and updated since the last inspection however, key information for safe and effective care was not available to all staff. Documentation was disorganised, incomplete and ineffective in communicating clear plans of how individuals should be supported.

The service did not always work effectively with key external health practitioners and advice given by external professionals was not always followed or updated into people's care plans.

This is a continued breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safe care and treatment.

At our last inspections, in July 2017 and December 2017, we had found the provider had failed to protect people against the risks associated with the unsafe use and management of medicines. At this inspection we found that medicines were being managed safely.

We made one recommendation about ensuring that medicine prescribed for calming people and reducing agitation had a care plan to instruct staff on how it should be used.

Staff did not always recognise the signs of potential abuse and therefore failed to take action. We found a number of incidents that had not identified by nursing and care staff that warranted independent assessment through a safeguarding alert to adult social care. We asked the service to make a number of safeguarding referrals during the inspection. This meant that people were not being adequately protected from potential abuse.

This is a breach of Regulation 13 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safeguarding service users from abuse and improper treatment.

The provider had put resources into a staff recruitment drive since the last inspection. However, there continued to be occasions when there were insufficient staff to consistently meet people’s needs. We found there was particularly a shortage of staff on weekend shifts. This was made worse by other key staff not being on duty at weekends, for example activity coordinators, housekeepers and hostess staff.

We found that nurses were given lead roles in important areas without having the training to support these roles, such as lead in nutrition, medicines, tissue viability and falls management.

This, and the lack of training to meet people’s needs, is a continued breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Staffing.

We found that how the Mental Capacity Act was being applied was inconsistent across the service. Assessments of people's capacity was done in a very general way and was not specific to decisions of varying types and complexity. This is a breach of Regulation 11: Need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the provider had not ensured that people's rights were being protected.

Some staff were not giving good care and did not demonstrate a caring attitude. On this inspection we received more mixed views and opinions from people living in the home and their relatives about the care given and the attitude of staff. Some people living in the home and their relatives continued to be happy with the staff. However, more people told us that there a number of staff who were described as “letting the side down" who were not giving good care and did not demonstrate a caring attitude. One person, who had experience of staying in other homes said, "They don't think much of you here."

The interim manager had used the providers disciplinary procedures to improve staff performance. However, there continued to be reports and concerns from people in the home, their relatives, staff working in the home and visiting professionals about staff attitude and work ethic of some staff.

People and their relatives did not feel their concerns and complaints were listen to and action taken. Some people did not feel comfortable about speaking up. One person told us, "It goes against you here if you complain."

The provider had failed to operate an accessible system for identifying, receiving, recording, handling and responding to complaints by people living in the home and other persons. This is a breach of Regulation 16: Receiving and acting on complaints.

The audit mechanisms in place were not being carried out effectively and staff were not held to account for tasks not completed to ensure practices were improved on. Staff reported that there was a blame culture with poor staff morale.

The service had not been well-led or well managed over a number of years, as demonstr

At our previous comprehensive inspection of this service on 18 & 21 July 2017 breaches of legal requirements were found. One of these breaches Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Person centred care, had been made at a previous inspection in March 2016, and was a continued breach.

We issued a warning notice for the service to meet this regulation by 30 September 2017. This was because people who used this service did not have care or treatment that had been personalised specifically for them; important information was missing from the care plans; and people’s medicines were not being managed safely.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met the legal requirements as set out in the requirements of the warning notice. This report covers our findings in relation to those requirements, and other concerns found during this focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dalton Court Care Home on our website at www.cqc.org.uk.

The service had a registered manager in post and they had been in post since September 2016. 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.

On the first day of the focused inspection, 22 November 2017, we found that the warning notice had not been met and there was a continued breach of Regulation 9 Person centred care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that little progress had been made to meet the warning notice and there were new areas of concern identified. We immediately notified the provider who took swift action, and across the other subsequent visits we saw how the provider’s actions were leading to improvements in the service.

We found assessments of people’s needs were still not being carried out to cover all areas of the person’s support needs. There was little evidence of person centred care planning. This included end of life care planning and care plans. Some people living with dementia had not had a life story history undertaken. This is essential in the delivery of recognised national best practice for people living with dementia.

The registered manager had not been effectively managing new admissions of people to the home. Pre-admission assessments carried out lacked detail and were not always accurate. As a result we judged the service was accepting people with complex health needs without sufficient numbers of skilled and trained staff to meet people’s needs.

At our last inspection in July 2017, we had found the provider had failed to protect people against the risks associated with the unsafe use and management of medicines. At this inspection, while there had been some improvements we found that medicines were still not managed safely.

Risks to people were not being well managed. We identified that risk assessments were not being carried out when a person’s needs changed so that care plans were still relevant and people received person centred care and safe treatment.

The management of falls within the service was poorly managed and not in line with current nationally recognised good practice. We found a similar lack of action and recording for people at risk of developing pressure sores.

Staff also lacked the required skills and expertise to manage some of these more complex conditions and associated risks. For example there was inadequate guidance and training for staff to safely support people whose behaviour could challenge the service.

This is a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014: Safe care and treatment.

There were insufficient staff to consistently meet people’s needs. We found there was a shortage of trained nurses, senior staff and care staff on some shifts. There had been occasions when only one nurse had been on duty when a minimum of two was necessary to meet the needs of people in the service.

This is a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014 Staffing.

The registered manager and the provider had not ensured that the warning notice had been met. Some care plans highlighted in the warning notice had not been changed, updated or amended. The audit mechanisms in place were not carried out effectively and staff were not held to account for tasks not completed to ensure practices were improved on.

Key information for safe and effective care was not available to all staff. Documentation was disorganised, incomplete and ineffective in communicating clear plans of how individuals should be supported.

The service did not always work effectively with key external health and care practitioners, for example there are a number of people who are at high risk of falls who have not had recent assessments by either a physiotherapist or occupational therapist. This was compounded by a lack of falls management plan for individuals.

This is a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 Good governance.

The service was now reporting incidents and events as required by law into CQC. On the inspection of 18 & 21 July 2017 we found this was not the case and we prosecuted the service and issued a fixed penalty fine for this offence.

Staff and the service did not always recognise incidents that required making a safeguarding alert to adult social care. We asked the service to make a number of referrals on the first day of the inspection.

We observed that staff continued to be respectful, kind and considerate with people in the home. Relatives we spoke to and who contacted us continued to be happy with the care provided. One relative wrote to us tell us, “We are constantly relieved and heartened by the positive, affectionate atmosphere of Daffodil unit.”

The service had not been well-led but the provider took immediate action after our inspection visit, 22 November 2017, to strengthen the management of the home. We saw on our return visits, to check on progress, that the provider had put in place a recovery programme ‘Older people accelerated plan for quality improvement’ with tools and support made available to the service to this end.

Since the inspection in November 2017 the provider had worked collaboratively with stakeholders, such as NHS health teams and adult social care leads to jointly drive up standards in the home.

While we found this progress promising we also took the service's inspection history into account. The service had been rated as ‘Requires Improvement’ for the last two inspections and ‘Inadequate’ for two inspections prior to that.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can see what action we told the provider to take at the back of the full version of the report. Further information is in the detailed findings below.

We last inspected the service on 20 June 2016 when the service was found to be in breach of three regulations. Requirement notices were issued. This was because people’s medicines were not being managed safely and procedures for obtaining consent to care and treatment did not always follow current legislation and guidance. Also, people who used this service did not have care or treatment that had been personalised specifically for them and important information was missing from the care plans of some people.

The registered provider gave us an action plan setting out how what they were going to do to improve and the timescales to carry out the improvements. During this inspection we reviewed the action taken by the provider to meet the requirement notices. We saw that some improvements had been made. Some breaches in the regulations identified in June 2016 had been addressed but some still remained.

We found that there was a continued breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A requirement notice had been issued at the last inspection on 20 June 2016. This was because some people who used this service still did not have care or treatment plans that had been personalised specifically for them. We found this was still the case for some people, including personalised advanced care planning for end of life care and to manage medication changes. This placed people at risk of receiving care or treatment that did not meeting their individual needs or expectations.

We found that improvements had been made to the management of medicines but this was not consistent across both Daffodil and Orchard units. Orchard unit demonstrated some good practice whereas Daffodil unit lacked effective oversight to sustain good practice. Similarly audit systems had been improved and were in place for medication and care plan reviews however Daffodil unit did not apply them with the clarity and effectiveness of other parts of the service.

During the first day of the inspection on 18 July 2017 we asked for further information and assurances from the registered manager of the safe handling of medicines on Daffodil unit. This was to mitigate the risks associated with the medicines management that we had found on that day. This information was provided and on the second day of our inspection 21 July 2017 we saw that appropriate action had been taken to mitigate the immediate risks to people in respect of medicines management and greater oversight in place. However improvement was required to continue and embed this.

We found a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the registered provider had not ensured that the systems in place were effective to make sure the nutritional and hydration needs of people were accurately recorded and monitored. A requirement notice was issued.

We found that the registered provider had met Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. This was because the service had improved procedures for obtaining consent to care and treatment and the practices were in line with current legislation and guidance.

We have made the following recommendations following the inspection 18 and 21 July 2017:

We have made a recommendation that the service seek advice and guidance from a reputable source on support and training for nursing staff on the use of audits and monitoring of practices to help ensure a consistent level of medicines monitoring within the home.

We have made a recommendation in relation to the development of head injury protocols within the home.

We have made a recommendation in relation to continuously reviewing staffing levels in line with changes in dependency.

We have made a recommendation regarding the recruitment procedures in use in regard obtaining references from previous employers.

We have made a recommendation that the service finds out more about training for staff, based on current best practice, in relation to the needs and management of people at the end of their life.

We have made a recommendation at the last inspection that advice and guidance be sought about the management of complaints in the service. We found that formal complaints were now being managed but that verbal complaints still needed greater attention and a prompt response.

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

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Dalton Court is a purpose built nursing home for up to 60 older people and for people living with complex nursing care needs. It is divided into two units. Daffodil unit for people who are living with dementia on the top floor and the Orchard unit on the ground floor for people with mobility and health issues. All bedrooms have en suite toilet and shower facilities. There are accessible gardens for people to use. A mini bus is available for trips out and for attending appointments. At the time of the inspection there were 58 people living in the home.

The service had a registered manager in post and they had been in post since September 2016. 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.

All of the staff we spoke with during our inspection told us of improvements to the staff morale in the home since the new registered manager had started. We were told by a visitor that since the new manager had been appointed “Things have improved”.

We observed staff supporting people who used this service in some of the communal areas and with meals and activities. People were treated with respect by staff who spoke with them in a friendly and supportive way. We saw that staff promoted people’s privacy and dignity. Staff knocked on doors and announced themselves before walking into people's private bedrooms and kept all doors closed during personal care. People who used the service told us that staff were “kind” and “nice”.

We noted that staffing levels could fluctuate and that were not always in line with the levels indicated by the dependency tool being used. Recruitment was underway to increase the permanent staff establishment to a level where staffing was consistent and continuously reviewed against identified levels of dependency.

We observed the service of the lunchtime meal and looked at a sample of the records relating to the support people received with eating and drinking. Staff helped people with their meals but the nutritional and hydration needs of people were not always accurately recorded and monitored.

We found that staff training and development had improved and that staff felt they were receiving training and support to carry out their roles and responsibilities. There remained some gaps in staff skills and knowledge but the manager was monitoring training and looking for opportunities to access additional training for staff to extend their skills and knowledge.

The service followed the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible.

We saw that there were systems in place to assess the quality of the services in the home. There was a programme in use to monitor or ‘audit’ the service provision, to try to identify areas of weakness and then address them. However, this was not being applied effectively across all areas of the service and there remained some inconsistencies in care plan reviewing to make sure all information was always up to date. During the inspection the registered manager increased auditing systems by doing a full check of medication systems. This additional monitoring needed to continue to sustain any improvements.

We had previously carried out an unannounced comprehensive inspection of this service between 14 December 2015 and 07 January 2016. Nine breaches of legal requirements were found. We judged that this service was “Inadequate” and Dalton Court was placed in special measures. We issued seven requirement actions and two Warning Notices.

Requirement actions were issued as people who used this service did not receive respectful and dignified care or appropriate treatment that met their needs and reflected their preferences. People were at risk from the risks of infections and contamination, of having unlawful restrictions placed on their liberty and at risk as their nutritional and hydration needs were not met. People who used this service did not receive their care and support from people who had the skills, competence and experience to do so safely. The management of the service was not open and transparent, with no clear lines of accountability in place. The registered provider sent us an action plan to show how they would ensure compliance with these parts of the regulation.

We issued two Warning Notices because the registered provider was not complying with Regulation 17 – Good Governance and Regulation 18 – Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A Warning Notice tells a registered provider or a registered manager that they are not complying with a regulation.

We undertook an unannounced focused inspection on 4 May 2016 to check that the requirements of the two Warning Notices had been met. We found that the registered provider had complied with the requirements of the Warning Notices.

Our unannounced inspection on 20 June 2016 was a full comprehensive inspection. We found improvements had been made. Some breaches in the regulations identified in December 2015 had been addressed but some still remained.

We have made the following recommendations:

We have made a recommendation in relation to risk assessing whether staff were safe to work with vulnerable people.

We have made a recommendation about the management of complaints.

We found breaches of the following Regulations:

Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used this service did not have care or treatment that had been personalised specifically for them. This placed people at risk of receiving care or treatment that did not meeting their individual needs or expectations.

Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. Procedures for obtaining consent to care and treatment did not always follow current legislation and guidance. This meant that people who used this service were placed at risk of receiving care or treatment that they had not agreed or consented to.

Regulation 12 of the Health and Social Care act 2008 (Regulated Activities) Regulations 2014 because people were not protected from the risks of receiving unsafe care, treatment and avoidable harm. Additionally, medicines were not managed safely and people were placed at risk of receiving their medicines not as their doctor intended.

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

Dalton Court Care Home (the home) is operated by Amore Elderly Care Limited, a unit of the Priory Group. Dalton Court is registered to provide accommodation for people who require personal and/or nursing care. The home can accommodate up to 60 older people and people with complex health care needs. Accommodation is provided in single, en-suite rooms over two floors, with the upper floor accessible via stairs or passenger lift. There is a separate unit at the home that provides accommodation for people living with dementia.

The home does not currently have a registered manager. 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 manager in post has made an application to register with CQC.

The provider had made improvements to ensure the home had sufficient numbers of suitably qualified staff on duty at all times. Everyone that we spoke to commented on the improvements made in this area. People who used this service confirmed that staff attended quickly when they “pushed the buzzer” and felt that there was enough staff around to meet their needs in a timely manner.

We found that staff training and development had improved and that staff felt “better supported” with their roles and responsibilities. However, there remained some gaps in staff skills and knowledge but the manager was aware of most of these and had started to address them. The manager had identified that the standard induction period was not always sufficient for some staff and arrangements had been put in place to help monitor and support new staff with their work. We have made a recommendation about induction training for new staff.

The accuracy, quality and detail recorded in people’s risk assessments was inconsistent. Gaps in information meant that people who used this service were placed at risk of receiving unsafe care and treatment that did not meet their needs.

Most people received their medicines at the times they needed them. However, people were not always fully protected against the risks associated with the use and management of medicines because there was not enough personalised information available to enable staff to support people to take their medicines correctly and consistently.

We found that staff had received some training with regards to the Mental Capacity Act 2005. However, we found that staff did not have a working knowledge of this legislation. We found examples where decisions had been made about the care and support people would receive without mental capacity or best interest assessments being carried out .

Where people had needed to be deprived of their liberty. We found that the manager had acted appropriately and obtained lawful authorisations.

We observed the service of the lunchtime meal and looked at a sample of the records relating to the support people received with eating and drinking. We found that when necessary people were referred to the dietician and/or speech and language therapist. The kitchen staff were aware of any special dietary needs of people who used this service.

We observed staff supporting people who used this service in some of the communal areas. People were treated with care, respect and dignity. Staff knocked on doors and announced themselves before walking into people’s private bedrooms. People who used the service told us that staff were “very nice”, “marvellous” and “look after me beautifully.”

Seven of the people who used this service, who we spoke with told us that there were plenty of social and leisure activities available if they wished to join in or attend them . During our inspection of the service we observed that there were plenty of interesting and appropriate activities available if people wanted to join in. We noted that people all had polling cards so that they could participate in the EU referendum if they wished.

We found that some improvements and additions had been made to people’s care and support plans. One really useful addition were “pen pictures” on the front of each care file. This provided information at a glance of the things that were important to people. However, the main body of the care plans had important information missing such as individual management strategies to help ensure people were supported safely and with dignity during periods of anxiety or distress.

We found that the registered provider had taken the situation of Dalton Court being in special measures very seriously. A new manager had been appointed and frequent quality audits continued to take place to help measure improvements and the successful implementation of the recovery action plan.

Even though we found areas where further work was still needed, everyone we spoke to about Dalton Court was very positive about the improvements to the service and the current situation at the home.

We have judged that the overall rating for the service is Requires Improvement. Although some breaches in the regulations have been addressed some still remain. We need to be confident that the registered provider can demonstrate consistent good practice over time. We will check this again during our next planned comprehensive inspection .

We issued two Warning Notices because the registered provider was not complying with Regulation 17 – Good Governance and Regulation 18 – Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focused inspection to check that the registered provider had complied with the requirements of these Warning Notices.

This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Dalton Court Care Home) on our website at www.cqc.org.uk

We could not improve the ratings for Safe and Well Led from inadequate because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

This focused inspection took place on 4 May 2016 and was unannounced.

Dalton Court Care Home is a purpose built nursing home for up to 60 older people and people with complex healthcare needs. It is divided into two units: one for people with dementia on the top floor and the ground floor accommodation for people with mobility and health issues.

All bedrooms have ensuite toilet and shower facilities. There are a variety of communal lounge and dining areas and pleasant gardens for people to access if they wish.

At the time of this inspection the service did not have a registered manager.

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 provider had appointed a new manager for the home. During this inspection of the service the new manager told us that they had made an application to become a “registered manager”.

We found that the registered provider had met the requirements of the warning notice in relation to the concerns about the staffing levels at the home.

One of the people who used this service told us; “The staffing is much better now. There are lots of them about and they (staff) are lovely. There is new management and they are very nice and friendly too.”

Another person said; “Staff seem to have more time now. They are all very nice although there has been a lot of people come and go.”

The staff we spoke to also commented on the improved staffing levels and support they were receiving. One person told us; “We have more time to give people the time and care they need. It’s much more relaxed here now.”

We found that the service had recruited more staff and that there was less reliance on staff coming to work at Dalton Court from other homes within the organisation. We checked a sample of the recruitment records of recently employed staff. We found that proper checks had been carried out by the registered provider to help ensure only suitable people had been employed.

We found that the registered provider had met the requirements of the warning notice in relation to the concerns about the way in which quality and safety were managed at the home. However, there remained some areas where further improvements still needed to be made.

For example, we reviewed a sample of care records that belonged to some of the people who used this service. Whilst we could see that some work had been carried out to help improve the accuracy and detail of these records, there was still a significant amount of work to be done on them to ensure people received the standard of support and care they needed.

The new manager and senior staff at the home were able to provide assurances as to when this work would be fully completed.

Everyone we spoke to during this inspection, commented on the improved communication between management, staff, people who lived at Dalton Court and their relatives. Meetings had been held with these groups of people by senior managers from the organisation. Meeting minutes showed that the registered provider had been open and transparent about the poor outcomes from previous inspections and about how they were going to make improvements.

Staff told us that they were involved and aware of the improvement programme. One member of staff told us about the “long” and “short term goals for improvement” that had been set by the registered provider.

Internal quality and safety audits had been undertaken by the registered provider and where shortfalls had been identified, action plans were in place to help ensure progress and improvement. The action plans had been shared with people who used this service and their relatives so that they could see what the registered provider was doing to make improvements to the service.

This provider is in special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

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

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Dalton Court Care Home is registered to provide accommodation for people who require personal and/or nursing care. The home can accommodate up to 60 older people and people with complex healthcare needs.

Dalton Court Care Home is operated by Amore Elderly Care Limited, a unit of the Priory Group.

Accommodation is provided in single, en-suite rooms, over two floors, with the upper floor accessible via stairs or passenger lift. There is a separate unit at the home that provides accommodation for people living with dementia.

There is a registered manager in post at the home.

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.

We found that staff worked very hard, sometimes working extremely long shifts, to try and meet the needs of the people who used this service. Their role was very task orientated with little time for staff to interact on a personal level with people who lived at Dalton Court.

We found that staff had not completed or updated essential aspects of their training, for example moving and handling training, basic life support and first aid.

We observed and people told us, that their experience of care, treatment and support was task orientated rather than in response to their needs as individuals. Staff were aware of some of the individual needs and choices of the people they supported but they were unable to effectively and consistently respond to them due to the lack of staff at the home.

Care plans relating to people’s wishes when they came to the end of their life contained little information about preferences and choice.

We saw that staff were very busy responding to call bells throughout the day. There were times when people who used this service were calling out for assistance and we had to go and find a member of staff to help them.

People who lived at Dalton Court told us that the staff were, “mostly very good” but they also said that the staff were, “always in a rush”; they thought the home was short of staff. Although we noted some good interactions between staff and people who used the service, we saw that some people had not received support to meet their personal preferences and choices.

We looked at the way in which people were supported with eating and drinking. People we spoke to were not very complimentary about the standard of food provided at Dalton Court. We observed that the presentation of meals was of different standards. Great care had been taken with the soft diet options to make them look appetising and tempting. People told us that getting enough to drink was a bit, “hit and miss”. When we checked people’s care records, we found that people’s nutritional needs were not adequately monitored.

At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the management of medicines and this action has been completed. There were no significant concerns with regards to the management and administration of medicines but there were some areas that could be improved upon.

The home is well appointed and was generally clean and tidy. There were no unpleasant odours. However, we noted that there were areas of the home, and items of equipment that were not clean. Some food items were not appropriately stored because adequate provisions for refrigeration had not been made. This raised the risks of the spread of infection and contamination.

Despite high level management oversight, the service is not well led. We found gaps in record keeping and evidence of issues that had been identified during internal audits but had not been addressed. The ways in which people were able to express their views and opinions on the quality of the service they received were limited.

We have made a recommendation about the staff recruitment and selection processes.

We have made a recommendation about the management of medicines.

We have made a recommendation about involving people in decisions about their care.

We have made a recommendation about best practice for end of life care.

We found breaches of the following Regulations:

Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used this service did not receive appropriate treatment that met their needs and reflected their preferences. At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the way in which people were supported with their needs and this action has not been sustained.

Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people did not always receive respectful and dignified care.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people did not receive their care and support from people who had the skills, competence and experience to do so safely.

Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used this service were not protected from the risks of infections and contamination.

Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People who used this service were placed at risk of having unlawful restrictions placed on their liberty. At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the way in which Deprivation of Liberty safeguards were managed at the home and this action has not been sustained.

Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were placed at risk of malnutrition and dehydration. At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the way in which people were supported with their nutritional needs and this action has not been sustained.

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because there were no effective systems and processes in place to ensure compliance with the Regulations. At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the way in which quality and safety were assessed and monitored and this action has not been sustained.

Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were not enough staff to meet the needs of people who used this service and people were placed at risk of receiving unsafe care and support because staff did not have up to date skills and knowledge. At the last inspection in May/June 2015 we asked the provider to take action to make improvements to the staffing levels and this action has not been sustained.

Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The management of the service is not open and transparent, with no clear lines of accountability in place.

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

We used the information to answer the five questions we always ask;

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

This is a summary of what we found:

Is the service caring?

We carried out a short observational framework inspection (SOFI) in the dementia unit during this inspection. SOFI is a "tool" designed to help inspectors record their observations during an inspection of a service, particularly where people have cognitive or communication impairments and cannot verbally give their opinions of the service they receive.

Our observations saw warm and positive interactions between people who used this service and staff. The scenario we observed involved people who used the service participating in a singing and musical activity. Some people were more able than others but staff ensured inclusion for everyone. People with limited communication and cognitive skills were seen to respond with warm smiles.

We saw staff helping people to eat their lunch too. Staff were kind and attentive, explaining the content of the meal to people and encouraging them to eat and drink. We did not observe staff rushing or trying to deal with too many people at once.

One of the people who used this service told us, 'The care staff are kind and very nice to me. I prefer to stay in my own room most of the time but they (staff) do take me outside in my wheelchair for walks.'

A relative we spoke to told us that they had previously experienced poor care in a different home. They said about Dalton Court, 'I am very happy with the care and support here. My relative has settled very well. The staff are very good and often have a laugh and a joke, all the things my relative loved to do when they were well.'

We did receive one comment from a relative who was concerned about the numbers of staff on duty at 'peak times' such as first thing in the morning. They told us that, 'Staff seem to rush and things are overlooked sometimes.'

Is the service responsive?

Most of the samples of records that we looked at during our visit were up to date and accurate. For example, where people's care needs had changed due to hospitalisation or an adverse event in their life, we saw that risk assessments and care plans had been reviewed, updated and amended to reflect the current care and support needed.

At previous inspections we had noted that pureed meals had not been presented appropriately. At this recent inspection we saw that food moulds were used to help make the meal look more attractive on the plate. However, not everyone we spoke to thought the moulds were the most appropriate. For example, mashed potato was served in the shape of a flower. One person thought that although it looked nice, it could cause confusion for someone with dementia.

The provider's internal compliance manager had recently visited the home and produced a report of their findings. The report identified where improvements had been made since the last assessment and also areas where further improvements were needed. The manager of Dalton Court had used the findings of the report as an action plan to help ensure the required improvements were addressed.

Is the service safe?

There were procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. The Deprivation of Liberty Safeguards are a legal framework, designed to ensure that people lacking capacity who are being cared for or treated by others should be deprived of their liberty only in accordance with the law and where there are no other less restrictive ways of keeping them safe.

Three applications had been made by the home. We spoke to the manager and the deputy manager about the Deprivation of Liberty Safeguards. They understood when an application should be made, and how to submit one.

Records showed that decisions had been made about the end of life care for some of the people who used this service. Records did not include how or why these decisions had been made. It was impossible to tell whether these arrangements had been made with the person's consent and in their best interests.

We found that some areas of the home were not as clean as they should have been. For example tables were stained and sticky. Some of the furniture needed replacing because it was badly stained. The laundry room and the downstairs sluice also required attention to help minimise the risks associated with the control and prevention of infection.

Is the service effective?

People's health and care needs were assessed with them and with their relatives where appropriate.

Specialists dietary, mobility and equipment needs had been identified in care plans where required. We observed that staff carried out the instructions recorded in people's care plans.

A relative and a member of staff commented about staffing levels, particularly at busy times such as early morning. We noted that there were a significant number of highly dependent people. We have suggested that the provider reviews people's needs assessments as well as the planning and delivery of care. This will help to ensure the welfare and safety of people who use this service are supported by sufficient numbers of staff.

Is the service well led?

The service worked very well with other agencies and services to help make sure people received safe and appropriate care. Monthly meetings took place with the managers at the home and external health and social care professionals. We spent some time at one of these meetings during our visit to the home. This facility helped the manager ensure people who used this service received co-ordinated care and were able to access other health and social care services as they needed them.

A member of staff that we spoke with told us of the improvements that had been made at the home since the appointment of the new manager. She noted that staff training and support had improved and that 'staffing issues' were getting 'sorted out'.

One relative told us that the new manager 'is very visible in the home' and that she was also 'very approachable.'

Another person said 'I would not be afraid to approach the managers or staff at the home in order to raise any concerns I had.'

We looked at a wide selection of records including those relating to care delivery and planning, risk assessments, staff supervision, recruitment and quality monitoring.

The staff told us about the increase in staff supervision and that managers now carried out 'spot checks on paperwork to make sure it was up to date.'

We saw that care records had been reviewed, updated and generally reflected people's needs accurately. However, there were concerning shortfalls in the records and support people received with their nutritional requirements.

We found that the people who lived at Dalton Court were generally 'happy' with the service and that the staff were 'very good, caring and helpful.'

One person told us 'I sometimes have to wait for staff to assist me, but they are very good and helpful. They always come as soon as they can.'

Another person said 'The staff are very good, they come to help me when I need them. They make sure I always have my call bell to hand so that I can alert them.'

People told us that they knew who to speak to if they were worried or had concerns about something. One of them said 'The staff treat me well. They are never unkind, I would say if they were and I would tell the manager.'

Another person said, 'I have never had cause to complain about anyone. The staff are lovely and I would tell someone about it if they weren't.'

The staff we spoke to told us of the 'changes and improvements' they had noticed since our last inspection, including staff training, support and supervision from more senior staff. They felt there was 'generally' enough staff on duty but there were times that caused them concern. For example, early mornings 'when everyone wants to get up and have breakfast'. Staff found this time of day very busy and challenging.

The relatives we spoke to during our visit told us that they were 'very happy' with the service their relatives received. One person told us that there was, 'Good communication' and another said, 'The staff phone me if there is a problem with my relative. I don't mind this I would rather know and if there is something I can do to help, I will do.'

We looked around all areas of the home during our inspection visit and saw that the home was clean, tidy and generally well maintained and there were no unpleasant odours.

The relatives we spoke to all said that they were satisfied with the care their relative received. They told us that the 'staff are excellent' and that relatives received 'good care'. One person in particular said, 'Our relative is looked after very well and we are kept up to date with what is going on. It is a five star establishment.' However, another person told us, 'They never seem to have the same nurses on, there seem to have been lots of changes in staff. This is not good for people with dementia.'

We found that care plans did not provide accurate information about people's care and support needs. Risk assessments, particularly around the management of continence, mobility and behaviours meant that some of the people who used this service did not experience care and support that was safe, appropriate and promoted their dignity. We also found examples where people had not had access to appropriate health care professionals to help them balance the risks and benefits involved in the course of their care or treatment.

We found that the auditing systems in place were not effective and failed to identify the issues found during our inspection of the service.

We observed that people's privacy and dignity were upheld and staff sought their views to influence the care, treatment and support offered. People we spoke with understood the care and treatment choices available to them and said they were involved in making decisions about their care and support.

People experienced care, treatment and support that met their needs and protected their rights. One person told us, “If I had any gripes I would tell them but we have been very pleased with the home. We knew straight away, the atmosphere was lovely and the staff are very friendly.”

We found the home to be appropriately staffed for the needs of the people living in the home. Staff had received training and support that helped them to carry out their roles.

We saw that the provider had an effective system in place to identify, assess and manage the quality of the care and the environment. This meant, for example, that the home was clean, tidy and well maintained.