Archived: Four Seasons

We found the following examples of good practice.

People’s relatives were provided with supplies of lateral flow test kits by the provider which helped to ensure they followed safe visiting practices and increased the amount of face-to-face time spent on-site with their family members.

Staff and visitors had access to PPE and there was a plentiful supply throughout all areas of the home. We saw staff and visitors wearing PPE in line with current guidance. Staff had completed training in infection control, COVID-19 and putting on and taking off PPE.

Four Seasons is a purpose-built care home, registered to provide care for up to a maximum of 121 people. The home provides residential, nursing, residential dementia and nursing dementia care and is split into five wings. On the day of the inspection there were 99 people using the service. One area specialised in providing nursing care for people living with dementia, other areas specialised in providing residential care and dementia care.

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

People's needs were assessed before starting with the service. People and their relatives, where appropriate, had been involved in the care planning process.

Risks to people's health and wellbeing were assessed and mitigated, however, people's medicines were not always managed safely.

The provider followed safe recruitment processes to ensure the right people were employed. There were enough staff to keep people safe.

People were protected from abuse. Staff understood how to recognise and report any concerns they had about people's safety and well-being.

The home was clean, and staff followed procedures to prevent the spread of infections.

The provider and registered manager followed governance systems which provided oversight and monitoring of the service. More robust quality assurance systems were now in place to ensure any shortfalls were identified and to drive continuous improvement within the service.

When required, people were supported to access healthcare professionals and receive ongoing healthcare support. People were supported to share their views and shape the future of the care they received.

Care plans provided staff with the information they needed to meet people's needs. People could choose how they wanted to spend their time. Staff worked with other agencies to provide consistent, effective and timely care. We saw evidence that the staff and management worked with other organisations to meet people's assessed needs.

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 15 October 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 17 and 18 July 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person-centred care, staffing and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain some of those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

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

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Four Seasons is a purpose-built care home, registered to provide care for up to a maximum of 121 people. The home provides residential, nursing, residential dementia and nursing dementia care and is split into five units. On the day of the inspection there were 103 people using the service. There were 20 people in Spring Unit, 24 people in Summer Unit, 25 people in Winter Unit, 17 people in Autumn Unit and 17 people Autumn Berry Unit. There are six sitting rooms and five dining areas, as well as a café, a hairdressing salon, an activities room, a library, two conservatories and enclosed landscaped garden areas.

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

The systems to monitor falls were not always used effectively at the home and there was a lack of oversight of managing the associated risk; we raised a safeguarding alert with the local authority in respect of this.

Medicines were not consistently managed safely and advice and guidance was not always being followed.

Although we found most people appeared well cared for, it was not always clearly documented in the care records we saw, how people were involved in making decisions about their care.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. Staff did not always receive the necessary supervision and appraisal to support them in their roles.

Nutritional records were sometimes incomplete, and nutritional intake was not always being monitored. Assessments were not always completed in a timely way or updated when a change in need was identified.

Some people living at the home and visiting relatives made positive comments about the care provided, whilst others were less positive. Whilst we observed many good interactions between staff and people, we saw occasions when staff did not always ensure people were supported to express their views. People told us staff respected their privacy and dignity.

The registered manager had moved to another home which was operated by the same provider and a turnaround manager was overseeing the home during this inspection.

Audit and governance systems were not consistently effective as the provider had not identified and resolved the concerns we found during this inspection. Quality assurance systems needed to be improved to ensure any concerns were identified and acted upon in a timely manner.

Day-to-day clinical and operational leadership of staff was not effective, and the provider had failed to provide sufficient oversight to recognise and respond to emerging issues identified at the inspection. However, during the inspection we were reassured that the provider and manager took these issues seriously, and immediately put measures in place to respond to and rectify the issues we found.

We received mixed feedback from people we spoke with about management and leadership within the home.

People told us they felt safe living at the home. We found the building and the premises were monitored, and equipment certificates were in place. Staff were recruited safely. The premises were adapted to meet people’s mobility needs and the needs of people living with dementia.

The service was meeting the requirements of the accessible information standard and people told us they were encouraged to maintain relationships that mattered to them.

There were a large range of activities available for people to participate in, which people valued highly. People told us they knew how to make a complaint and felt confident in doing so.

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 good (published 28 August 2018)

Why we inspected

The inspection was prompted in part by notification of two specific incidents, following which two people using the service died. These incidents are subject to on-going enquiries. As a result, this inspection did not examine the circumstances of these incidents.

The information CQC received about the incidents indicated concerns about the management of falls from moving and handling equipment and the unsafe management of medicines. This inspection examined those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

During this inspection we found the provider had taken action to mitigate the risks, but this has not always been effective. The provider responded immediately during and after the inspection. Shortly after the date of the inspection the provider sent us an updated action plan which identified these issues were now being immediately dealt with.

You can see what action we have asked the provider to take at the end of this full report.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Four Seasons is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Four Seasons is registered to provide care for 121 people who require nursing, residential and care for people living with dementia. The home also provides an intermediate care service. This supports people who have been discharged from hospital and need rehabilitation to support them in preparation of returning to their own home or to alternative care setting.

The home is split into five houses. On the day of the inspection there were 97 people using the service. There were 12 people in Spring house, 21 people in Summer house, 28 people in Winter house, 17 people in Autumn house and 19 people Autumn Berry house.

The home had a manager in post who was in the process on registering with the Care Quality Commission (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 and associated Regulations about how the service is run. The manager has been registered with the CQC before and has several years’ experience of managing care homes.

At our inspection on 18 October 2017 we found two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to the safe administration of medicines and governance and a new breach in relation to staffing levels.

At this inspection we found that good progress had been made in addressing the breaches and an improvement had been made within the service.

You can read the reports from previous inspections on our website at www.cqc.org.uk.

On arrival at the home the front doors were secured. Visitors had to ring the bell to gain access into the home. This helped to keep people safe and to prevent unauthorised people from entering the home. We saw visitors were welcomed into the home and people could see their visitors in private if they wished.

There was a large comfortable reception area. The reception area had a café area for people to sit in with their guests. The home had accessible gardens with tables and chairs. There were a number of pet rabbits which were cared for by people living at the home.

Information about the home and the facilities offered were available in the reception area.

The service used the local authority safeguarding procedures to report any safeguarding concerns. Staff had been trained in safeguarding topics and were aware of their responsibilities to report any possible abuse.

Recruitment procedures were robust and ensured new staff should be suitable to work with vulnerable adults. We noted in one staff file that this person had no contract of employment and no job description. We discussed this with the manager who sent us a copies of the missing documents following our inspection.

in the main,the administration of medicines was safe and had improved in most of the houses with the exception of Winter house.

Most of the houses were clean, tidy and fresh and the environment was maintained to a good standard. Winter house was malodourous and the décor required attention.

There were systems in place to prevent the spread of infection. Staff were trained in infection control and provided with the necessary equipment and hand washing facilities.

Electrical and gas appliances were serviced regularly. Each person had a personal emergency evacuation plan (PEEP). A PEEP informs the fire service what room people live in and what assistance they require to evacuate them safely.

People were offered a well balanced and nutritional diet and were encouraged to eat and drink to ensure they were hydrated and well fed.

Staff had been trained in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The registered manager was aware of her responsibilities of how to apply for any best interest decisions under the Mental Capacity Act (2005) and followed the correct procedures using independent professionals.

New staff received induction training to provide them with the skills to care for people. Staff training was on-going. The home’s manager and the management team were completing supervision sessions. These meetings gave staff the opportunity to discuss their work and ask for any training they felt necessary.

We observed there were good interactions between staff and people who used the service. People told us staff were kind and caring.

We saw that the quality of care plans gave staff sufficient information to look after people accommodated at the care home and they were regularly reviewed. Care plans contained people’s personal preferences so they could be treated as individuals.

Some staff had been trained in end of life care which should enable them to provide support to people who used the service and their family at the end of their life.

We saw activities were provided. The home had two activities coordinators that worked across the houses. People spoken with told us there was a lack of suitable activities for people living in Winter house.

Audits, quality assurance surveys and meetings helped the service analyse performance to help improve the service.

There was a suitable complaints procedure for people to raise any concerns. There were a number of compliments and cards on each of the houses from relatives.

Four Seasons is registered to provide care for 121 people who require nursing, residential and care for people living with dementia. The home also provides an intermediate care service. This supports people who have been discharged from hospital and need rehabilitation to support them in preparation of returning to their own home or to alternative care setting.

The home is split into five houses. On the day of the inspection there were 109 people using the service. There were 22 people in Spring house, 24 people in Summer house, 25 people in Winter house, 18 people in Autumn house and 20 people Autumn Berry house.

The home had a registered manager in post. 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 our inspection 23 January 2017 we found continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to safe care and treatment. This was because the service had failed to ensure medicines were being managed safely. We also found a continued breach in governance with regard to recording of personal care charts. You can read the report from our last inspections on our website at www.cqc.org.uk.

At this inspection we found two continued breaches of the of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to the safe administration of medicines and governance and a new breach in relation to staffing.

On the 18 October 2017 we found that medicines were not were not always being given safely and as prescribed. We found this was a continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 in relation to safe care and treatment. This was as the service had failed to ensure medicines were being managed safety

We found that suitable arrangements were in place to help safeguard people from abuse. Staff knew what to do if an allegation of abuse was made to them or if they suspected that abuse had occurred.

Staff were able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions.

We found staff had been safely recruited, received ongoing training relevant to their role and had regular supervision meetings.

Staffing levels were not sufficient in some areas of the home to meet the needs of people who used the service.

We found during our inspection and observing interactions that there was a friendly and respectful rapport between staff and people who used the service.

People's care records contained enough information to guide staff on the care and support required. The records showed that risks to people's health and well-being had been identified and plans were in place to help reduce or eliminate the risk.

We looked around the building and found it had been maintained, was clean and hygienic and a safe place for people to live. We found equipment had been serviced and maintained as required.

There were personal emergency evacuation plans (PEEPs) in place for each individual at the home. These were updated when changes occurred and outlined the level of assistance each person would require in the event of having to be evacuated.

We looked at health and safety records and saw an up to date fire risk assessment, liability insurance certificate, gas and electrical safety certificates. A number of health and safety checks were undertaken regularly, such as alarm and emergency lighting tests, means of escape checks, extinguisher checks, equipment maintenance and servicing and regular water temperature tests. Staff wore protective clothing such as disposable gloves and aprons when needed. This reduced the risk of cross infection. We found supplies were available around the home for staff to use when required.

People were happy with the choices, quality and quantity of the meals and snacks available.

We noted that there were omissions of recording on six of the food and fluids charts we looked at. This meant we could not determine whether people had sufficient food and drink. Failing to complete records accurately could have a detrimental effect on people’s health and well-being.

There were activities coordinators that helped plan a range of activities for people to join in with if they wished.

Systems were in place for receiving and responding to complaints. A number of compliments had been received from relatives.

Systems were in place to monitor and audit the quality of the service provided. Feedback from relatives meeting and satisfaction questionnaires had been reviewed and appropriate action taken.

Notifications of deaths, incidents and accidents had been sent to the CQC as required.

The inspection took place on 06 April2017 and was unannounced. This was a focused inspection which means we were only looking at two domains, safe in relation to medicines and well-led in relation to governance.

This focused inspection took place in Spring House following a previous focused inspection on 20 January 2017 to follow up concerns in relation to the safe administration of medication and governance.

There was a home manager in place whose was in the process of applying to become 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.

We found Spring House was safe, clean and clutter fee and appropriate health and safety measures were in place. Risk assessments had been completed.

Staffing levels in Spring House on the day of the inspection were sufficient to meet the needs of the current occupants of the house.

The home had an up to date medicines policy; the section on self- medication was awaiting ‘sign off’. Medicines were given as prescribed and were safely stored.

There was evidence within the care plans of good partnership working with other agencies. Referrals were made appropriately and advice followed by staff to ensure the best outcome for people who used the service.

People we spoke with told us the staff were kind and caring. We saw respectful interactions between staff and people who used the service throughout the day.

We saw that people were treated with dignity and respect and their opinions and views were listened to. Independence and autonomy was encouraged

Appropriate information was given out to patients and their families.

Care records included a range of health and personal information. They evidenced patients likes, dislikes, preferences and choices were taken into consideration.

There was an appropriate complaints procedure and this was included in the information given to people. There had been no recent complaints and the service had received a number of compliments.

Feedback from patients during their stay in Spring House were positive about accessibility and support from staff at the home.

Staff told us the management and other team members were approachable and supportive.

A number of audits and checks were carried out at the service. The results were analysed to ensure continual improvement to the service.

The home had a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated regulations about how the service is run.

At our previous inspection in October 2016, we had found a continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment. This was as the service had failed to ensure medicines were being managed safely. You can read the report from our last inspections on our website at www.cqc.org.uk.

This focused inspection was carried out on 23 January 2017 to follow up previous concerns in relation to the safe administration of medication. Good progress was found within three units of the home; and in these areas medicines were found to be managed safely.

Since the previous inspection in October 2016, the purpose of Spring Unit had been changed to provide intermediate care. This type of care is used to provide additional short term support to people when they no longer require hospital care. People using this support may then return home, or receive an assessment for long term care and support. Additional multi-disciplinary staff were employed to provide additional onsite support such as physiotherapy and pharmacy services. On the first day of the inspection 23 people were resident on the Spring Unit.

Within this part of the home we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment; and good governance. This was as the service had failed to ensure medicines were being managed safely, which placed people at risk of harm. In addition, the governance system in place to monitor the safety and efficiency of the new scheme had been ineffective, which meant the issues we found at the time of the inspection had not been identified by the service and addressed. Appropriate records were not being adequately maintained.

Due to our concerns, we liaised with the provider, the local authority and the local clinical commissioning group (CCG). At this point, the Spring Unit closed to all new admissions to enable a full review to be undertaken and for actions to be taken to improve. We carried out a further day of inspection on 20 February 2017, at this time there were 11 people resident on the Spring Unit. We found improvements had been made to reduce the level of risk to people receiving care. Due to the lower level of risk, admissions to the unit recommenced with additional monitoring arrangements in place from the CCG. A further inspection was planned to check the effectiveness of the actions that were put in place.

The home had a registered manager who was registered in April 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 and associated Regulations about how the service is run.

At our inspection of 15 August 2016 we found that the service has made significant improvements. However we found a number of failings in relation to the safe administration of medicines .

On the 22 August 2016 the service sent an action plan relating to the medication issues noted at the inspection of Four Seasons Care Home on 15 August 2016. This action plan had been formulated from the verbal feedback provided at the inspection. The service had taken immediate action to review systems in the home to minimise further medication issues, most notable of which is the agreement to move over to blister packed medication from Boots with their Monitored Dosage Systems (MDS).

We carried out a focused inspection on 27 October 2016 to check that medicines were now being handled safely. This report only covers our findings with regard to the management of medicines. You can read the report from our last comprehensive inspection on our website at www.cqc.org.uk.

During this inspection we found there were still areas of poor practice that were a cause for concern.

The home is registered to provide care and support for 121 people. The home is split into four areas known as houses. At the time of this inspection there were 77 people living at the home. On the day of the inspection there were 13 people living in Spring house, 24 people in Winter house, 20 in Autumn house and 20 people in Summer house. We were informed by the registered manager that four people were currently in hospital. This gave an overall total of 81 people on the home’s register.

At our previous inspection on 20 and 21 January 2016, we found multiple breaches of the Health and Social Care 2008 (Regulated Activities) 2014. We identified two breaches in relation to person-centred care, three breaches in relation to safe care and treatment, one breach in relation to safeguarding, one breach in relation to meeting nutrition and hydration needs, one breach in relation to premises and equipment, two breaches in relation to good governance and two breaches in relation to staffing. As a result of this the home was placed into special measures meaning significant improvements were required, or further enforcement action could be taken. Following this inspection, the home sent us an action plan of the improvement they intended to make.

Following the inspection in January 2016 the home had been closely monitored by the local authority contract and monitoring team and the local clinical commissioning group (CCG). Both agencies told us they had noted improvements throughout the home.

At this inspection we found that the service has made significant improvements. However we found a number of failings in relation to the medication. On the 22 August 2016 the service sent an action plan relating to the medication issues noted at the inspection of Four Seasons Care Home on 15 August 2016. This action plan had been formulated from the verbal feedback provided at the inspection. The service had taken immediate action to review systems in the home to minimise further medication issues, most notable of which is the agreement to move over to blister packed medication from Boots with their Monitored Dosage Systems (MDS). We are considering our enforcements actions in relation to this.

The registered manager was registered in April 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 and associated Regulations about how the service is run.

We arrived at the home at 06.30. This gave us the opportunity to speak with the night staff and to observe the early morning routine. The night manager confirmed most people were still asleep; the people who were up and dressed were sat in the lounges.

We found that people were able to move freely around the houses, the only restrictions being if floors were in the process of being cleaned and were wet, the doors were locked to prevent accidents.

We looked around the home and found it to be clean and tidy. The atmosphere was calm and relaxed.

We saw that improvements to the environment had been made especially for people living with dementia in Spring and Winter houses.

We found that staffing levels in each of the houses were sufficient to meet the needs of the people living in them. Staffing spoken with confirmed that staffing levels had improved and the use of agency staff had greatly reduced.

We looked at the training records and these indicated what training staff had completed and when refresher dates were due.

The service was working within the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Staff spoken with had a good understanding of safeguarding and whistleblowing procedures and knew how to report any concerns.

People who used the service told us they felt safe living at the home. The relatives spoken with told us that things had improved since the arrival of the new registered manager and that they felt the home was now a safe and better place.

Infection control and prevention systems were in place and staff had completed training in this topic.

We found that appropriate recruitment systems were in place and checks had been carried out to ensure the suitability of people applying to work with vulnerable adults.

Staff was now receiving regular supervisions and appraisals.

People had care plans in place that contained sufficient information to guide staff on the care, treatment and support required.

We found that the activities within the home had improved and people were offered a varied range of stimulating activities.

People who used the service, relatives and staff spoke favourably about the management of the home.

We saw that equipment and services had been maintained in line with the manufacturers’ instructions and valid certificates were available for inspection.

We saw the ratings from the previous inspection were clearly displayed in the reception area. There was also wide range of information about the home and other services available.

The home is registered to provide care and support for 121 people. The home is split into four areas known as houses. On the first day of our inspection there were 26 people living in Winter House, 15 living in Spring House, 27 living in Autumn House and 27 living in Summer House.

The home has a large reception area with appropriate information to inform people about the home and the services provided, including safeguarding and whistleblowing procedures. There is also a café (not staffed) with vending machines for drinks and snacks. There is access to the garden from the reception area.

The home had a registered manager at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At our inspection in May 2015 we found three breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, good governance and person centred care. At this inspection, we noted breaches of Regulations 9, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we found that medication was not being administered in a safe and timely manner and that on occasions people had run out of their prescribed medicine. The provider had not taken reasonable steps to ensure people’s care and support needs were being met. The provider had failed to ensure that people who used the service were protected from abuse and improper treatment. The nutritional and hydration needs of people were not being met. Systems or processes were not established and operated effectively to ensure compliance with the regulations and sufficient numbers of suitably qualified, competent, skilled persons were not deployed.

People who used the service were not cared for safely. Appropriate care was not provided and staff had failed to access timely professional advice. This placed the health and welfare of people at risk of harm.

We found there was conflicting and confusing information in the care records. Without clear and accurate records to monitor and manage potential health care risks to people it was not possible to know if people were receiving the care and support they required. Information was not always followed in accordance with the care plans and this potentially posed a risk of harm and poor care to some people who used the service. We found that charts that were important to people’s health and wellbeing were incomplete.

Systems were not in place to prevent and control the risk of cross infection. People who used the service were potentially at risk from poor practice.

We found that staffing levels and skill mix at the home were insufficient. We observed people were left unobserved in the lounges for long periods of time. The home relied heavily on the use of agency nurses and care staff.

We looked at the staff training records. Staff training was on going, however due to some of the concerns raised it was evident that training was not embedded into the home to ensure good, safe quality care was being delivered. Staff confirmed that staff supervisions were ad-hoc and we found staff appraisals were inconsistent.

We found areas were locked and this restricted people’s freedom of movement around their home.

The environment in places required cleaning and some en-suite bathrooms were cluttered and were being used to store equipment.

The service was working within the legal requirements of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS).

Following our inspection in May 2015, the home had been supported by the local authority and the clinical commissioning group (CCG). There was a restriction on placing any new people at the home. The local authority lifted their suspension in November 2015, the CCG suspension on nursing patients remained in place.

On the 21 January 2016, the inspection team had significant concerns for the safety of people who used the service and halted the inspection. We contacted the local authority and the CCG who attended the home and actions were put in place to ensure that people living at the home were protected.

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.

This inspection was carried out due to further serious concerns around the safety and well-being of people who used the service being raised following a previous inspection.

During the inspection we looked at respect and involvement, care and welfare, nutrition, safeguarding, medication, staffing, and quality assurance.

This is a summary of what we found, using evidence obtained via observations, speaking with staff, speaking with people who used the service and their families, and looking at records:

Is the service caring?

We saw staff administering interventions in a considerate and respectful way offering appropriate reassurance and explanation. However, it seemed the only opportunity staff had for interacting was when they were engaged in a task.

We felt on the whole that staff were committed and dedicated to their caring roles. They were positive and hopeful that changes were being made and would lead to a better standard of care at the home.

We witnessed some instances where staff ensured people's dignity was respected and some examples of people's dignity being compromised. People were not given stimulation or having meaningful interactions with staff.

We asked a person who used the service if they felt they staff understood their needs and they responded, 'Yes, I do'.

Is the service responsive?

We saw that people's preferences for a male or female carer were not always adhered to, which meant they were not having choice around their care. One person who used the service said they preferred a female carer and told us she did not like to have personal care carried out by men.

Another relative, when asked about male or female carers said, 'Yes, he gets embarrassed with young girls".

We saw references to a person's cultural and spiritual needs within a care plan. However, it was unclear if or how these needs were being met in a practical way.

We saw little evidence of any meaningful activities or interaction with people who used the service. The environment was bland and provided little stimulation for people living with dementia.

A relatives' meeting had been held recently and this was very positive. We were told relatives were very interested in being involved in some of the dementia training and in interviews for the recruitment of new staff.

We asked if staff responded well to people being unwell and were told they did. One relative said, 'Yes, they have had to call the GP out and I have asked that he doesn't go into hospital unless absolutely necessary, and they do seem to be able to look after him properly".

There was an emergency on one of the units on the day of the visit. A person who used the service was extremely poorly and staff responded to the situation efficiently and in a caring and compassionate manner.

Is the service safe?

One person who used the service was observed to be in a kirton recliner chair. The care plan reflected the fact that this person had suffered a number of falls and was at considerable risk. An urgent Deprivation of Liberty Safeguards (DoLS) application had been made for this person, to ensure they were not unlawfully deprived of her liberty due to being strapped into this chair.

We looked at Deprivation of Liberty Safeguards (DoLS) and saw that the manager, in collaboration with the local authority DoLS lead, had begun to put through the most urgent applications for authorisation. These appeared to be appropriate and thorough and we felt this issue was well on the way to being addressed.

Staff still had little awareness of the Mental Capacity Act (2005) (MCA), and DoLS. However, this lack of knowledge was being addressed by the management team, in conjunction with the local authority MCA and DoLS lead.

We spoke with three visitors on one of the dementia units. All of them felt the unit was safe.

On one of the units the nurse in charge had to be sent home as they smelled strongly of alcohol. We referred this matter to the local safeguarding team. The management team immediately made arrangements for the person's shift to be covered by another nurse in the building and to cover subsequent shifts for the immediate future.

Another nurse commenced giving out medication it was observed that Medication Administration Sheets, (MARS) had already been signed by the nurse who had been sent home, prior to the medication being actually given to people. This took some time to put in order as there was the potential for people to be given too much medication.

Staffing levels were still an issue at the home on the day of the visit. A number of new employees had been recruited but were awaiting the return of Disclosure and Barring Service (DBS) checks or references. This had resulted in agency staff still being utilised regularly by the home. The management team told us they tried to ensure they used agency staff who had been at the home before, but this was not always possible.

On the day of the visit there were a number of agency staff who had been on the night shift. There were also some agency staff working the day shift.

Is the service effective?

On one of the dementia units the staff the previous night had consisted of two agency staff and one permanent staff member from another unit. They told us they found it difficult to deliver care as effectively as they would like to because they did not know the people on the unit well.

We saw that most files contained up to date information about the personal and health requirements of the people who used the service. Partnership working was on-going and there were appropriate referrals within the files to other services, such as nutrition and dietetic service.

New systems had been implemented by the new unit manager on the residential unit. Staff told us these systems were working very well and they were all positive about the new routines. We saw the atmosphere on this unit was calm and tasks appeared to be being carried out efficiently and well.

We asked staff about nutrition and hydration. One told us that dieticians and GPs are involved. Others understood the need for certain types of diet and they were able to explain how many drinks were offered during the day and told us people could have a drink any time if they requested one.

A visitor told us their relative was often awake in the night and was given drinks and sandwiches or a biscuit by the night staff.

Is the service well led?

The home had a manager registered with the Care Quality Commission. However, on the day of the visit there was a management team overseeing the home and they facilitated our visit.

In house medication audits had been carried out by the Quality Assurance Manager on all of the units and all had failed. There was an action plan in place and the management team were in the process of addressing the shortfalls.

Spot checks were now being regularly carried out by the management team. Any shortfalls identified were addressed.

A number of audits had recently been implemented which highlighted issues. Action plans were put in place and actions completed.

Appropriate notifications were being sent in to Care Quality Commission as required.

During the inspection we looked at respect and dignity, consent, care and welfare, nutrition and hydration, management of medicines, staffing and quality assurance. We also gathered evidence to help answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of what we found, using evidence obtained via observations, speaking with staff, people who used the service and their families, and looking at records.

The home had two dementia care units, a residential unit and a nursing unit.

Is the service safe?

We spent time on the dementia units; the majority of the people living on those units were not able to tell us about their care and support and relied on relatives acting on their behalf. One relative told us, 'The staff are very good, there's just not enough of them'. We spoke with people who used the service, all of the people spoken with told us that they felt safe from abuse and that their privacy was respected.

The service had systems in place to help protect people living at the home from harm. Staff had access to policies and procedures to guide them in areas such as safeguarding from abuse, Mental Capacity Act 2005 (MCA), Deprivation of Liberty Safeguards (DoLS), confidentiality and recruitment. We found that not all staff had adhered to these policies.

Staff were provided with training in areas such as safeguarding, MCA and DoLS. Staff spoken with had a good understanding of safeguarding; however their understanding of MCA and DoLS was limited, therefore people's rights were not protected where important issues needed to be addressed and decisions made.

We saw risk assessment forms had been completed where potential hazards had been identified with regard to pressure care and falls and use of bed rails; however we found that these were not always being followed.

On the day of our inspection we found that staffing levels needed to be increased to meet the needs of the people living at the home.

The home was clean and spacious allowing people with mobility difficulties to move freely around the home.

Is the service effective?

We spoke with the staff on night duty and with the day staff. Staff spoken with were dedicated and committed to people they were caring for.

Prior to the inspection some staff told us they did not feel comfortable in reporting any concerns or issues to the home's senior management team as these were not dealt with appropriately and in confidence.

People's needs had been assessed before they moved into the home to ensure their needs could be met by staff. Where possible people who lived at the home were involved in writing their care plan. Any special dietary needs, mobility and equipment needs had been assessed and identified.

We saw that people's orientation needs were taken in to account with the help of appropriate signage around the home to help people identify where bedrooms, bathrooms and toilets, lounges and dining rooms were located.

Is the service caring?

Individual care records were in place for people living the home. These records provided staff information about how to care for and support people. Plans were reviewed regularly but not all information was up to date.

We spent time observing how care was provided. We saw that privacy and dignity was respected when staff supported people with their personal care needs. Staff addressed people by their preferred name and were heard asking people's permission to provide care and explaining to people what they were about to do before carrying out any intervention.

For people who had difficulty in communicating we observed people's body language and facial gestures were positive when staff approached them.

Is the service responsive to people's needs?

Information was available about the service and what people could expect should they choose to live at Four Seasons. Assessments were carried out prior to people being admitted to the home to help ensure that people's needs could be met by the staff.

People were offered a range of activities both in and away from the home. We saw that one of the activities coordinators spent time sitting and speaking with people on the dementia units giving them individual attention.

We were told that visits were made to the home by local clergy so that people's cultural and religious needs were met.

Staffing levels could be improved especially on night duty to enable staff to meet the needs of people they were supporting more effectively.

Is the service well-led?

The home had a manager who was registered with the CQC. However, on the day of our visit there was another manager overseeing the home with a team of senior management offering support.

We had been made aware by a number of staff that issues or concerns that had been brought to the registered manager's attention and to other senior staff had not been dealt with appropriately in line with company policies nor had they been dealt with in confidence. This was being addressed by the management team.

The CQC had not been notified as required of all accidents, incidents and deaths which had occurred at the home in line with current regulations.

The management team currently working at the home were in the process of checking and addressing any shortfalls found in the audit checks and will continue to monitor ensuring effective systems are in place to improve the service.

On arrival at the home we found most people were still in bed. Some people were up, dressed and sat in the lounges. Some had been offered a hot drink.

We found the home to be warm, clean and tidy. We looked on all four units and found the home to be sufficiently staffed by waking night staff, apart from one unit where we were told one member of staff had to go home due to unforeseen circumstances.

We saw people who used the service were well presented and we observed staff interacting with them in a friendly, polite manner and respecting their dignity and privacy.

At this inspection we focused on the two dementia care units. We looked at four care records and other information that was kept providing evidence that the home was properly managed.

We spoke with people who used the service and relatives. One person told us, 'Everything is fine, I am well looked after'. Another said, 'The staff are very good'. A relative told us, 'The care, dignity and respect shown to my X is fantastic. All the staff are brilliant'. Another said, 'X has settled really well and is well looked after'.

We saw staff had access to relevant policies and procedures including safeguarding procedures and contact details.

We saw a number of compliment cards from relatives displayed on the units.

One person spoken with said, 'The staff are very good, they look after us really well'.

Another said, 'I have no complaints about the home or the care I receive'.

One person told us, 'My relative is really well looked after and I feel that they are safe in their care'.