Cadogan Court

We found the following examples of good practice.

The layout of the home promoted effective infection prevention and control. There were 7 separate units around a circular atrium. Each unit was a 'bubble' with its own staff team, staff room and communal area. Activities took place within the ‘bubble’, and the spacious dining room had socially distanced dining tables for each one. This arrangement allowed people to maintain their friendships and contacts within the home, while minimising the spread of infection. It also supported effective ‘zoning’ in the event of a person showing symptoms of Covid 19 or testing positive.

The service ensured people could continue to receive visitors in line with government guidance. There was a clear process and testing regime in place for visitors, with personal protective equipment (PPE) provided. Two dedicated visiting suites had been created. There was also a visiting pod, accessed from both inside and outside with a dividing perspex screen. External visiting took place in the garden if required.

Visits were supported for people at the end of their lives. People had essential care givers, who followed the same testing regime as staff, People had been safely supported to celebrate significant occasions with their families, including a 101st birthday and 60th wedding anniversary. Risk assessments had been carried out, with measures in place to stop infection spread.

Staff received ongoing training in infection control. The infection prevention lead was also the homes trainer. They carried out spot checks and provided additional training ad hoc for staff if required.

Staff were seen to wear PPE throughout the inspection. They frequently used hand sanitiser, available throughout the home and on a lanyard around their neck. One person told us the measures in place to minimise the spread of infection helped them feel safe and spoke highly of the effectiveness and professionalism of the staff team.

There was an extensive cleaning schedule, with regular spot checks and audits. This ensured cleaning was completed to a high standard.

The registered manager reported good support from the local health professionals during COVID 19 outbreaks at the home. The service had engaged well and welcomed visits from community specialists in infection control. They had acted on the guidance given.

Cadogan Court is registered to provide accommodation for up to 70 people who require

nursing and personal care. 46 people were being supported at the time of the inspection.

People were living in six units over three floors. Holman, Barrington, Colenso-Jones and Eliot were providing care for older people who required residential care; Kneel was providing nursing care for older people; and Osborn was providing care for older people living with dementia.

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

Significant improvements had been made in all aspects of the management of the service since the last inspection. However, the providers systems to monitor the quality of the service were not fully effective because they had not identified the issues we found.

Care plans did not consistently record people’s involvement in their development or review, or that they had been consulted about their end of life wishes. Some failings in the management of risks had not been identified. The manager was taking action to address these concerns, but these changes had yet to be fully established and embedded.

There had been significant changes to the management team. The current manager had been in post for eight days at the time of the inspection and was in the process of registering with the Care Quality Commission. Two new deputy managers were being recruited. The manager was open about the previous failings at the service, the work they were doing to address them and where improvements were still required. They were committed to building on the progress made by the previous manager, promoting effective monitoring and accountability and an open and transparent culture. Written feedback from a relative stated, “We think it is important to add to our grateful thanks a recognition that whilst there were some issues with management back in 2016/17, we have seen evidence of improvements in this area and believe that Cadogan Court is returning towards being well managed again.”

Overall people felt safe living at Cadogan Court. Staff were recruited safely, and safeguarding processes were in place to help protect people from abuse. Risks associated with people's care had been assessed and guidance was in place for staff to follow. Care plans were detailed, person centred and reviewed regularly. There were systems in place to ensure information about any changes in people’s needs was shared promptly across the staff team.

People received their medicines safely, and in the way prescribed for them. The provider had good systems to manage safeguarding concerns, accidents, infection control and environmental safety.

People benefitted from suitably trained, competent and skilled staff. This meant their healthcare and nutritional needs were met. External professionals were complimentary about how the service worked in partnership with them.

Cadogan Court provided a person-centred service. The management team and staff used activity and mental stimulation to reduce people's anxiety and depression and maintain cognitive functioning.

Staff were caring and kind and had developed positive and meaningful relationships with people. People were respected, included in decisions and their privacy and independence promoted. The care provided was sensitive to people's diverse needs. All information was available in an accessible format, which meant people could make a meaningful contribution to their community.

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.

People were supported by suitably trained, competent and skilled staff. This meant their healthcare and nutritional needs were met. External professionals were complimentary about how the service worked in partnership with them.

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

Rating at last inspection (and update)

The last rating for this service was Requires Improvement (published 16 October 2018) and there was one breach of 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 was a planned inspection based on the previous rating.

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

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.

The service consists of seven units over three floors. However, at the time of the inspection people were living in five of the units because a refurbishment programme was in progress and Osborn and Elliot units were closed; Holman, Barrington and Colenso-Jones were providing care for older people who required residential care; Kneel was providing nursing care for older people; and Alford was providing care for older people living with dementia.

A comprehensive inspection of the service was carried out on 27 February 2017 and 02 and 07 March 2017. At that inspection we identified five breaches of regulations, related to staffing, quality monitoring, safe care and treatment, dignity and respect and person-centred care. We took enforcement action in relation to the staffing and quality monitoring breaches, by serving warning notices on the provider and registered manager. This required the provider to make urgent improvements in staffing by 14 April 2017 and to improve quality monitoring processes by 09 October 2017, due to the serious and major impact on the safety and quality of services people received. We issued requirements for the other three breaches of regulations, safe care and treatment, dignity and respect and person-centred care. The overall rating for the service at that inspection was ‘Inadequate’ and the service was therefore 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, 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.

We carried out an unannounced focused inspection on 12, 14 and 20 July 2017 to check that the required improvements had been made following the comprehensive inspection in February and March 2017. At this inspection we looked at the breaches of regulation related to safe care and treatment and person-centred care. Higher staffing levels put in place at the previous inspection were being maintained for 90 percent of the time. However, further work was needed to ensure people’s plans fully reflected their needs and risks. We identified a new breach of regulation because some risks were not always identified or managed well. Action was taken during the inspection regarding these concerns. Following the inspection, we wrote to the provider to formally request information about the actions they had taken to minimise the specific risks we had identified. They sent us the information we requested, detailing the actions they were taking.

A further comprehensive inspection was carried out on 16, 17, 22, 25 and 30 October 2017. At this inspection we identified breaches of regulations related to safe care and treatment, safeguarding people from abuse and improper treatment, staffing and quality monitoring. The service was in ‘special measures’ and the provider had not made the significant improvements required within the six-month time frame. This had a serious and major impact on the safety and quality of services people received. We proposed to remove this location from the providers registration, however the provider appealed this proposal through the care standards tribunal. CQC did not oppose this appeal due to improvements made at the service. The appeals process was therefore concluded with the provider agreeing to submit a monthly improvement plan to the CQC until February 2019, and to ensure the manager of Cadogan Court was supervised by key individuals within the organisation.

Cadogan Court was the subject of a whole home multiagency safeguarding investigation from 18 April 2017 until 18 April 2018. Whole service investigations are held where there are indications that care and safety failings may have caused or are likely to cause significant harm to people. During this period the local authority placed a suspension on any further local authority placements at Cadogan Court. The provider also voluntarily agreed not to admit privately funded people to the home. Since 18 April 2018 the local authority has continued to support Cadogan Court within their Provider Quality Support Policy Framework. This is a formal process used when the thresholds for a whole service safeguarding process are not met, but service improvement is still needed to minimise the risks to people. The provider has entered into this process voluntarily. The local authority suspension on new placements is still in place, as is the providers voluntary agreement not to admit privately funded people to the home.

At this inspection in June 2018 we found action had been taken to address all areas of concern, but improvements were still needed. Since the last inspection the provider had kept us informed about their progress, sending weekly updates of their continuous improvement plan (CIP). However more time was required to demonstrate the improvements had been embedded in practice and could be sustained.

Repeated changes in the management team had undermined continuity and consistency at the service. The manager in post at the time of the last inspection had not registered with the CQC. They had since resigned, along with the deputy manager. An interim manager, from another of the provider’s services, was now in post pending the appointment of a permanent manager. At the time of this inspection they were in the process of registering to manage the service. The provider and interim manager had been working to develop processes and systems which could be sustained when a new permanent manager was appointed. The interim manager was committed to supporting and mentoring a new permanent manager so that the improvements at the service would continue.

People, relatives, staff and visiting health professionals spoke very highly of the interim manager and the improvements that they had made at the service. The interim manager engaged fully with the inspection process and was open and transparent throughout. They addressed all the issues we raised during the inspection immediately, and took any action necessary to improve the quality of the service and keep people safe.

There were now comprehensive systems in place for assessing and monitoring the quality of the service, however they had not identified the issues we found during the inspection, which meant they were not yet fully effective.

At the last inspection we found staff were not always available to meet people’s needs and keep them safe. At this inspection we found staffing levels across the service had been reviewed and increased. Staff on the dementia and nursing units were visible and safely supporting people throughout our inspection. However, people and staff on the residential units expressed concern about the availability of staff. They told us their support was often interrupted when a member of staff was called away. A member of staff said they frequently had to interrupt medicines administration to provide support, which was potentially unsafe because it distracted them from the task.

At the inspection in October 2017 we found the skills mix and deployment of new and agency staff undermined their ability to understand and minimise risks. At this inspection we found there were now more permanent staff in post and the number of agency staff had decreased since the last inspection. Consistent agency staff were used where possible and assigned to regular units to provide continuity. The service obtained a profile of their training and skills, so they could allocate them to the unit where they would be most effective. This meant there was a more stable and consistent staff team with a good understanding of people’s needs. However, a relative was concerned that a member of agency staff was unaware of the support their family member required to reduce their risk of choking.

Medicines were safely managed with the exception of prescribed topical creams which records did not demonstrate had always been applied as prescribed.

There was an effective call bell system at the home, however two people assessed as being at high risk of falls were not wearing their pendant alarms.

Staff made prompt referrals to relevant healthcare services when changes to health or wellbeing had been identified. The manager had worked with the local GP surgery to develop an effective referral process. However, visiting health professionals told us there had been a breakdown in the system for sharing information, which meant their advice and guidance was not consistently followed by staff.

At the inspection in October 2017 we found care plans did not always contain the information and guidance staff needed staff to support people. In addition, people and their relatives had not always been consulted when care plans were drawn up and reviewed. At this inspection we found improvements had been made. Care plans were comprehensive and reviewed monthly and quarterly. People, and their relatives where appropriate, were now consulted. However, some improvement was still needed to ensure the information in care plans consistently provided the information staff needed to support people.

The service promoted effective monitoring and accountability. The management

There was a manager employed at the home, although they had not yet registered with the Care Quality Commission to manage the service.

The last comprehensive inspection of the service was carried out on 27 February 2017 and 02 and 07 March 2017. At that inspection we identified five breaches of regulations, related to staffing, quality monitoring, safe care and treatment, dignity and respect and person centred care. We took enforcement action in relation to the staffing and quality monitoring breaches, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in staffing by 14 April 2017 and to improve quality monitoring processes by 09 October 2017, due to the serious and major impact on the safety and quality of services people received. They were failing to ensure there were sufficient numbers of, competent, skilled and experienced staff to meet people's needs. We issued requirements for the other three breaches of regulations, safe care and treatment, dignity and respect and person centred care. The overall rating for the service at that inspection was ‘Inadequate’ and the service was therefore 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, 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.

Staffing levels were increased during this inspection in response to the concerns raised. Following the inspection the provider sent us an action plan, outlining the improvements being made and a weekly ‘continuous improvement plan’ (CIP) to the local authority and the Care Quality Commission, identifying the areas of risk and the actions they were taking to address them.

The service continued to work in partnership with the local authority quality assurance and improvement team (QAIT) to help improve their systems and processes.

We carried out an unannounced focused inspection on 12, 14 and 20 July 2017 to check that the required improvements had been made following the comprehensive inspection in February and March 2017. At this inspection we looked at the breaches of regulation related to safe care and treatment and person centred care. The higher staffing levels put in place at the previous inspection were being maintained for 90 percent of the time. However, further work was needed to ensure people’s plans fully reflected their needs and risks. We identified a new breach of regulation because some risks were not always identified or managed well. Action was taken during the inspection regarding these concerns. Following the inspection we wrote to the provider to formally request information about the actions they had taken to minimise the specific risks we had identified. They sent us the information we requested, detailing the actions they were taking.

Cadogan Court has been the subject of a whole home multiagency safeguarding investigation since 18 April 2017. Whole service investigations are held where there are indications that care and safety failings may have caused or are likely to cause significant harm to people. The issues identified at this time related to concerns about medicine management, staffing levels, staff training, care plans/risk assessment, skin integrity management and people’s nutritional needs. These concerns had meant the local authority placed a suspension on any further local authority placements at Cadogan Court. The provider had also voluntarily agreed not to admit privately funded people to the home during this period.

A local authority safeguarding meeting was held with the provider on 14 November 2017 and it was decided that although some improvements had been made, the home should remain in the whole service safeguarding process. This was because the changes made were not fully embedded and the provider was still working through their CIP.

At this inspection in October 2017 we found people continued to be at risk because the service continued to be poorly led. While the provider had identified where improvements were needed, people were not protected by the provider’s systems and processes to monitor the safety and quality of their service.

Staff were not always available to meet people’s needs and keep them safe. There were five occasions during the inspection when no staff were present in the communal area of Alford unit to support people who had been assessed as being at risk due to falls, choking or behaviour that challenges. Two staff had not arrived for work on the two nursing wings when we visited at the weekend, which meant there were five staff working there instead of seven. The skills mix and deployment of staff undermined their ability to take the actions required to understand and minimise risks. New staff were moved around the different units during their induction, which they told us made it difficult for them to become familiar with people and their needs, or to support them in line with their individual preferences. An agency member of staff was left to cover Alford unit on their own on their first shift there, so other staff could have a break. People told us staff were too busy to spend time with them. Staff confirmed that although they were able to meet people’s basic needs, they were rushed. One person had to remain in their room until there were enough staff available to provide the one to one support they needed in the communal area.

The provider confirmed that staffing was a concern at the service, with 50 per cent of the workforce being agency staff. Recruitment was their ‘biggest priority’. They responded immediately to our concerns by increasing staffing levels on the dementia units and booking an agency registered mental nurse (RMN) to work there for a minimum of two months for consistency. A new two week rolling rota was being introduced the week after the inspection, which would ensure better coverage of all units by permanent staff who knew people’s needs. The manager was working with agencies to develop a consistent core team of staff to work at the service. Three weeks after the inspection the provider informed us the number of agency staff had reduced to 44 per cent.

People and relatives spoke very positively about the quality of the support they received from some permanent members of staff. However, there was a risk they would not receive effective care because staff did not always have the competence, skills and experience to provide it. Although there was a comprehensive induction and training programme in place, this did not always enable new staff to safely meet people’s individual needs because they did not have the time and support they needed to complete it. One new member of staff told us, “There is no support for the people who have just started.” In addition staff did not consistently receive supervision and support in line with the provider’s policy. There was an induction for agency staff, but feedback received during the inspection suggested this was not always effective in enabling them to support people safely. Information about the training, skills and knowledge of agency staff had not consistently been requested from the agencies, which meant the provider did not know whether they had the skills and knowledge to support people safely.

Staff did not consistently follow safeguarding policies and procedures, which meant people were not always protected from the risk of abuse and avoidable harm. Following the inspection the provider advised us that the safeguarding policy had been re-issued to staff and was under review.

Since the focussed inspection in July 2017 all care plans and risk assessments had been reviewed and risk assessments had been completed in relation to people’s skin, diet and mobility. When risks had been identified, we saw plans were in place to manage and reduce these risks where possible. Care plans had been updated since the last inspection and many now contained good person centred information for staff to follow, but this was not consistent. Care plans did not document people’s end of life wishes or provide the information staff needed to support them according to their wishes and preferences. Some care plans were not reflective of people’s current care needs. They did not always provide the guidance staff needed to support people safely and effectively in line with their preferences. People and their relatives had not always been involved in drawing care plans up and their review. The provider’s representative acted immediately to address our concerns about the care plans. They told us they were introducing a ‘resident of the day’ initiative. This which would help to ensure care plans were reviewed regularly with people and their representat

This focused inspection was to follow up if the required improvements had been made following our last inspection on 27 February 2017 and 2 and 7 March 2017. We had identified five breaches of regulations, related to staffing, quality monitoring, safe care and treatment, dignity and respect and person centred care. We took enforcement action in relation to the staffing and quality monitoring breaches, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in staffing by 14 April 2017 due to the serious and major impact on the safety and quality of services people received. They were failing in ensuring there were sufficient numbers of, competent, skilled and experienced staff to meet people's needs. We did not look at quality monitoring at this inspection because we had given the provider until October 2017 to have become compliant.

We issued requirements for the other three breaches of regulations, safe care and treatment, dignity and respect and person centred care. At this inspection we looked at the safe care and treatment and person centred care breaches. We found there had been some improvements but further work was needed to ensure people’s plans fully reflected their needs and risks. We identified a new breach of regulation because some risks were not always identified or managed well. The provider took action about this during the inspection.

Since the inspection in February 2017 we have received an action plan from the provider which outlined the improvements being made. The provider is also sending a ‘continuous improvement plan’ (CIP) each week to the local authority and the Care Quality Commission (CQC) identifying the areas of risk and the actions they are taking to address them. The service had continued to also work in partnership with the local authority quality assurance and improvement team (QAIT) to help improve their systems and processes.

The provider had attended a local authority whole service safeguarding meeting in November 2016 because of concerns which had highlighted issues in relation to the risk management of falls, medicine management, poor practice around moving and handling, insufficient staffing levels, lack of supervision for staff and care plans not being up to date. The local authority were assured at the time by the high levels of assurances given by the provider around how they were going to address the concerns. The meeting had decided these were more an issue of quality and so the safeguarding process was closed. This was with a view that the provider would work with the local authority QAIT and continue to improve the areas of concern.

However Cadogan Court has been the subject of a whole home multiagency safeguarding investigation since 18 April 2017. Whole service investigations are held where there are indications that care and safety failings may have caused or are likely to cause significant harm to people. The issues identified at this time related to medicine management, staffing, staff training, care plans/risk assessment, skin integrity management and people’s nutritional needs being met. This has meant a suspension on further local authority placements being placed at Cadogan Court. The provider has also taken the step not to admit privately funded people to the home during this period. Following this inspection on the 25 July 2017 a local safeguarding meeting was held with the provider and it was decided that although some improvements made the home should remain in the whole service safeguarding process. This was because changes made were not embedded and therefore unable to see if effective and the provider was still working through their CIP.

We found staff levels had been maintained at the higher level put in place at the previous inspection for 90 percent of the time. The management team were actively recruiting new staff but ensuring they employed staff with the right skills to work at the home. Staff levels were above the level assessed by the dependency tool used by the provider. This meant on the whole people were getting their needs met in a timely way. However there were concerns to take in consideration the size and layout of the service and the deployment of staff to the right areas.

The skills mix and deployment of staff were not always allocated appropriately to ensure people remained safe. Poor communication within the home meant that the management team were not always aware of the day to day issues being experienced within the home.

The provider was using a high number of agency staff at the home. The manager told us at this inspection they were using approximately 40 percent of agency staff to cover gaps in the rota. Systems were put into place during our inspection to check agency staff identification when they arrived at the home. An induction for agency staff was also introduced so they knew how to support people and what to do in an emergency. Improvements had been made in relation to call bell response times. The manager was working to improve these further.

Risks to people’s safety on Alford Unit both for people living there and the staff working on the unit were not well managed or documented. Two people had regular altercations which was seen as part of their normal pattern of behaviour. One had the habit of going into other people’s rooms. There was a lack of guidance as to how staff should prevent this happening.

Care plans contained personalised information including people’s social history and morning, afternoon and evening summaries of care. However, some of the information was not up to date and did not provide clear advice to staff how to manage people’s care needs. The management team were revising everybody’s care plans as part of their continuous improvement plan (CIP) and had completed nearly half at the time of the inspection. The provider said this was taking time because staff were being trained to complete the care plans as part of the process and they were being completed thoroughly. They said they planned to have them all completed by the end of October 2017 and were prioritising them dependent on the level of risk.

People had ‘wardrobe care plans’ in their rooms. Handover sheets were available to staff but did not always contain people’s relevant information to guide agency and staff new to the home. Improvements were made to the information on the handover sheet during the inspection. Improvements were made during the inspection regarding people’s individual risks in relation to fluids, nutrition and continence. This meant staff would have the right information to provide effective care and support.

The service had a registered manager who we were informed by the provider was on extended leave for three months from the 20 June 2017 and was not working at the home. An interim manager was in place at the time of our inspection. Following the inspection the provider informed us that the registered manager had resigned their position as the registered manager and the interim manager had been appointed. They would be submitting their application to CQC to register as the 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.

Since the last inspection a clinical lead had been appointed into a new position. The provider had also sought the input of a consultant who is referred to at the service as the support manager. The role of deputy manager was vacant and the provider was actively looking to recruit to this position. The manager was also supported by the provider’s regional operations manager who visited the service every week along with senior management staff who specialise in medicines, pharmacy and compliance and audits. The manager put in place a temporary staff organisation structure guide during our visit so staff were clear about the roles and responsibilities of the management team and who they should approach. The clinical lead and support manager work at the service seven days a week and are visible on the wings. They were working with the care staff to raise their awareness of issues found. The manager said they would like to be out and about more but were prioritising the areas which needed to be addressed but planned to increase their presence once things settled down.

There was a positive culture at the home staff fed back that they were seeing improvements and were aware of what was being done. They all said they “weren’t there yet but were making progress” and felt people were being cared for safely. Staff were positive about being able to approac

There was a registered manager employed 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 and associated Regulations about how the service is run.

At the last inspection in July 2016 we found the domains of ‘safe’, ‘effective’ and ‘responsive’ required improvement. At the time, people, relatives and staff expressed concern that agency staff (staff used from an agency to support permanent staff on a temporary basis) did not always have the knowledge and skills to meet people's needs safely. In addition some care plans had not always provided the guidance staff needed to meet people's care needs safely and effectively. At this inspection we found this had been addressed and systems were in place to ensure agency staff could easily access important information they needed to meet people’s needs. Care plans were now comprehensive and ensured staff had good information to ensure they knew how to meet people’s care needs. At the last inspection we found that people's legal rights had not always been fully protected because some people had restrictions in place, such as bed rails or pressure mats, but there had been no consideration of whether these restrictions were in their best interests. At this inspection we found this had been addressed and the home was meeting these legal obligations. People had access to healthcare services for on-going healthcare support, however at the July 2016 inspection health and social care professionals had not always known if their recommendations had been shared with staff or acted on due to a breakdown in communication.

At the last inspection in July 2016 we also rated ‘well led’ as requiring improvement. This was because the home had been without a registered manager for five months, and at the time of the inspection was managed by the current registered manager who at that time was newly registered with the Care Quality Commission. At that inspection staff told us the previous manager had "not been there very much", and there had been little improvement in the service over an 18 month period. The provider and new registered manager had identified where improvements were needed and developed a comprehensive service improvement plan. However, whilst we were confident that the provider had recognised the failings and put in place actions to address them, previous systems had not been successful in maintaining the quality of service provision. At that time it was therefore not yet possible to determine whether these actions would be effective in keeping people safe and improving the quality of support provided. Therefore, at that time some aspects of the service were not well led as there had been no leadership at the home for some time which had impacted on the quality of the service.

Although the above issues had now been addressed and the service improvement plan was on-going, we found that systems in place did not ensure the following concerns found at this inspection had been identified and actioned effectively.

People were not always safe at Cadogan Court because there were not enough staff, particularly on the residential units. A recruitment drive had been in place for some time and continued to fill staff vacancies and the registered manager was keen to recruit good quality staff over time. The current use of agency staff in relation to permanent staff was around 17%. However, although the registered manager had listened to staff concerns about low staffing levels, identified a need for more care staff and submitted a business plan to the provider, which was in progress, we found the staffing levels for the home were lacking at the time of our inspection. This meant that although staff were caring and worked hard to meet people’s basic needs, they were physically unable to ensure person centred care in a timely way and people living at Cadogan Court with more complex needs were put at risk. For example, people’s basic needs were mostly in the morning when staff assisted people to get up but during the inspection staff did not have time or enough staff to maintain people’s continence effectively, assist people with their meals in a timely way, meet people’s social needs consistently or supervise those people identified as at risk of falling despite the use of preventative equipment.

Although people were supported by very kind, caring and compassionate staff who tried to promote people's independence and treated them with dignity and respect, they were unable to ensure that people’s dignity was maintained at all times. For example, we had to ask staff to assist a person who was not completely covered, with their door open.

We contacted the provider following our first day of inspection to inform them of the need to increase staffing levels especially on the residential units. The provider immediately increased staffing on the residential units the next morning. There was a positive outcome when we rang the home to monitor the situation and when we visited on the second day of our inspection. For example, emergency call bells were not ringing constantly, people’s needs were ,met and staff told us they were much happier working effectively. Care staff were more visible and felt able to meet people’s needs effectively as they could work together and did not have to use the call bells to summon assistance of a second care worker, often from another unit.

Although there were quality assurance systems in place to monitor all aspects of the home to identify areas for improvement, including a new dependency assessment tool, they had not clearly identified the urgency for a safe level of staffing in practice. We also found that due to lack of staffing, medication rounds were taking too long, resulting in some people not receiving medication when it was due, such as ‘before food’. Some records relating to medication were not clear about medication described as ‘as required’ to enable staff to know when and why to offer this medication.

Although there were two activity co-ordinators and opportunity for people to attend external entertainment opportunities we found that some people were not facilitated to maintain regular social stimulation in a person centred way to maintain wellbeing. During our inspection some individuals were left for long periods alone and staff did not have time spend with people or to have input into activities and social stimulation. The activity co-ordinators were employed for 52 hours per week to meet the needs of 70 people. This meant that people had little contact with staff other than for tasks and some people with more complex needs such as living with dementia or other mental health needs were not consistently supported. Staff were unable to be pro-active in ensuring care was based on people's preferences and interests, join in and seek out activities in the wider community and consistently help people live a fulfilled life, individually and in groups.

The registered manager had been employed at the service for just over a year and provided good leadership and had responded to the issues raised at the last inspection, resolving issues to ensure a more stable, competent staff team and working with the local social services quality assurance and improvement team. There were clear job roles, support and boundaries and discipline for staff with clear lines of accountability and responsibility. They were proactive in building a culture of transparency and openness at the home. Staff support and training had been improved as well as information sharing as a team and within the wider healthcare professional community where positive relationships had been built for the benefit of the people living at Cadogan Court. People, relatives, staff and external professionals had confidence in the registered manager and spoke highly of them, however they all expressed concerns about the low level of staffing.

Staff were clear about their individual roles and responsibilities and although they felt valued by the registered manager, deputy manager and senior management team they felt let down by the lack of effective staffing levels. However, people and the staff knew each other well and these relationships were valued, the staff did the best they could with the resources available and tasks such as personal care, managing health needs and maintaining nutrition were completed well. People were well kempt and assisted to make choices such as when they got up, what they ate and when they ate. People had call bells and drinks accessible and were generally comfortable.

All staff had received appropriate training, since the last inspection, in