Heathland Court Care Home

Heathland Court Care Home is a residential ‘care home’ providing personal and/or nursing care to up to 58 older people. At the time of our inspection 55 people were living at the care home. They accommodate people across 4 separate floors, each of which has their own adapted facilities. The units located on the top and bottom floors support people with nursing needs and the first floor specialises in supporting people living with dementia.

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

The care home was able to demonstrate they had improved in the last 9 months since their last inspection and were no longer in breach of regulations, although further improvements are still required.

At our last inspection we found the provider had failed to ensure staff did not work excessive hours without sufficient time off between shifts; risks people might face were not always safely managed; and their governance systems were not effectively operated.

At this inspection we found enough improvements had been made to address these outstanding breaches. People now received personal care and support from staff who had been given sufficient time off between shifts to recuperate and therefore did not work excessive hours. Staff knew how to prevent and manage risks people might face and had access to newly reviewed, detailed, risk management plans. The providers established oversight and scrutiny systems were now operated effectively.

We received negative comments from a few community health and social care professionals about the standard of care provided at the service. However, most external professionals, people living at the care home, their relatives, and staff working there, told us the service was beginning to improve under the leadership of the new management team and was moving in the right direction.

However, we identified a number of new issues at this inspection which needed to be addressed. This included improving how the provider conducted checks and kept records of the daily room temperature of their clinical rooms where medicines were stored. The service was not meeting their legal requirement to have a registered manager in post to oversee the delivery of regulated activities at this location.

The service was adequately staffed by people whose suitability and fitness to work at the care home had been thoroughly assessed. People were kept safe and were confident any concerns they raised would be listened to and acted upon. Staff understood how to safeguard people. The premises were kept hygienically clean and staff followed current best practice guidelines regarding the prevention and control of infection including, those associated with COVID-19. Medicines systems were well-organised. 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 living at the care home, their relatives and staff working there were complimentary about how approachable and accessible the current management team were. The provider promoted an open and inclusive culture which sought the views of people living at the care home, their relatives, and staff working there. Complaints, concerns, accidents, incidents, and safeguarding issues were appropriately reported, investigated, and recorded. The provider worked in partnership with various community health and social care professionals and agencies to plan and deliver people's packages of care and support.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 October 2022) and there were breaches 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

We conducted an announced comprehensive inspection of this service on 22 September 2022. 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 how they ensured staff would not work excessive hours without sufficient time off between shifts; prevented and managed identified risks safely; and operated their oversight and scrutiny systems.

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 contained those requirements.

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

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good, although the well-led key question remains requires improvement.

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

Recommendations

We have made a recommendation about the management of some medicines.

Follow up

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

Heathland Court Care Home is a residential care home providing personal and nursing care to up to 58 people. The service provides support to older people. At the time of our inspection there were 55 people using the service.

Heathland Court Care Home accommodates 55 people across four separate wings, one of which specialises in providing care to people living with dementia.

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

People did not receive a safe service as accidents and incidents were not always monitored and investigated. People were at risk of poor tissue viability as the service failed to ensure staff repositioned people in accordance with guidance set by healthcare professionals. Staff worked long shifts without prior authorisation of senior management and there were delays for people who had requested pain relieving medicines.

People did not always receive a service that was well-led. The manager failed to implement effective oversight of the service and audits failed to identify issues found during this inspection. People were at risk of receiving care and support from a service that had a closed culture where staff were reluctant to highlight poor practice through fear of reprisal.

The provider ensured robust recruitment procedures were in place to ensure suitable staff were recruited. The regional director ensured notifications were submitted to CQC in line with legislation. The regional director was keen to ensure partnership working sought positive outcomes for people. People’s views were sought to drive improvement.

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.

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 02 March 2021).

Why we inspected

We received concerns in relation to staffing levels, record keeping, poor moving and handling techniques, poor tissue viability management and a closed culture within the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

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

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 Heathland Court Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

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

We have identified breaches in relation to the staffing levels, risk assessments and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

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

Heathland Court Care Home is a nursing home providing personal and nursing care to 38 people aged 65 and over at the time of the inspection. The service can support up to 58 people.

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

Identified risks were not always clearly documented in risk care plans. We have made a recommendation about the management of some risk assessments.

Staff safeguarding training was not always up to date, the manager had plans in place to address this. Sufficient numbers of staff were deployed to keep people safe. Medicines were managed in line with good practice and administered as intended. The provider ensured robust infection prevention control measures were in place to manage outbreaks of COVID-19. The provider was keen to ensure lessons were learned when things went wrong to minimise repeat incidents.

People their relatives and staff spoke positively about the changes to the management structure. People’s views were sought to drive improvements. The manager was aware of their responsibilities with regulatory requirements and under the Duty of Candour. The manager carried out regular audits of the service and issues identified were acted on. The provider worked in partnership with stakeholders and sought to ensure continuous improvement.

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 1 June 2018).

Why we inspected

We received concerns in relation to people's nursing care needs and management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them.

Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Heathland 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.

Heathland Court Care Home 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.

Heathland Court Care Home provides care and support for elderly people, some of whom have physical disabilities and dementia. The home can accommodate up to 78 people. On the day of the inspection there were 48 people using the service. The home is situated over five floors with one floor closed for renovations.

At the last inspection carried out on 6 September 2016 the service was rated Good, with Requires Improvement in well-led. At this inspection we found the service was rated Good in all areas.

At the time of inspection the service did not have a registered manager in post and was in the process to recruit a new 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.

There were safe systems and practices in place to protect people from potential abuse and harm. Care records reflected potential risks to people and staff used these records to support them safely. The service was in the process to recruit more permanent staff in order to reduce the number of the agency staff they used and to ensure consistent care for people. People had their medicines kept and administered safely. Staff were aware of the procedures and took the necessary actions to provide hygienic care for people and to report any incidents occurring at the service.

Manual handling equipment was provided for staff to deliver support and promote people’s independence where possible. Systems were in place to monitor the training courses attended by staff and those staff that were overdue for a refresher course had a date booked for it. Staff had the management teams’ support to discuss their developmental needs and they had dates planed for supervision and appraisal meetings. Staff assisted people to enjoy their meal times. People had access to healthcare professions if their health needs changed and they required a check-up. The service followed the Mental Capacity Act (2005) principals to support people to make important decisions for them.

Staff showed concern to people’s well-being and attended to their care with understanding. People made decisions about their daily routines and staff were respectful of their choices. Staff had time to have conversations with people and people felt they were listened to. Staff encouraged people to care for themselves if they were able to carry out tasks for themselves. People’s relatives felt welcomed at the care home.

People were involved in planning their care and had access to information about them. Care records had personal information about people and how they wanted to be supported. People took part in the activities provided for them and felt the activities were meeting their care and support needs. People knew who to talk to and felt comfortable to raise their concerns if they had any. Systems were in place to support people to stay comfortable at the end of their lives.

The management team had shared responsibilities to deliver what was required for the service. New systems were in place to support staff’s performance and team working practices. The management team had put strategies in place to ensure effective communication between the staff team. Quality assurance systems were used to monitor the services being delivered to people. Internal and external meetings were attended by the management team to gather information on changes taking place in the social care sector.

Heathland Court Care Centre provides accommodation for people who require personal care, nursing care and support with the tasks of daily living. The service specialises in caring for older people living with dementia. At the time of this inspection there were 58 people using the service.

The service is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager on our records left the service in September 2015. We were notified at the time by them and the provider. A new manager has since been appointed and has submitted the appropriate registered manager application to CQC.

At this inspection we found the provider had sustained the improvements made at the service in relation to the safe management of medicines. Arrangements for the safe management of medicines in the home were consistently followed and people were supported to take their medicines as prescribed. Staff had maintained appropriate records to reflect this. Medicines were stored safely in the home.

We also found staffing arrangements on the top floor dementia unit had been improved and sustained. The unit was now appropriately managed by a senior member of staff. We observed staff responding to people’s needs and requests for help and support promptly. Some people told us there did not seem to be enough staff to support people in other parts of the home. Staffing levels were planned based on the number of people at the home and their level of dependency. We saw staff were available to support people around the home when needed. Senior staff told us they had recruited new staff to work at the home. They also monitored the time staff took to respond to call bells to investigate those that took too long to answer. They took on board our feedback about the layout of the home and how this could affect people’s perceptions about the availability of staff in the home.

We received mixed feedback about the management of the service. People, on the whole, spoke positively about the home manager and their ‘open door policy’ and we saw the provider was committed to a culture of openness and candour within the home. People had been encouraged to provide feedback about their experiences and suggestions for how the service could be improved through various forums. But people said the home manager should improve their visibility and visit and speak with more people in the home.

Some staff also spoke positively about senior staff and those that did felt well supported by them. They told us, and records confirmed, they received training and supervision to support them in their roles. However some staff felt senior staff did not investigate their concerns or issues when they raised these. We were able to see that senior staff did take appropriate action to address concerns when these were raised. But staff were not always aware of the outcomes. Senior staff said they would take action to improve communication with staff and reassure them their concerns or issues were taken seriously.

The home, on the whole, was well maintained and pleasant. However attention to care and detail lacked consistency in some parts of the home. Some areas were not well presented and welcoming. However in other parts of the home, it was clear thought and care had been taken in how areas were decorated and presented, particularly for people living with dementia. The premises and equipment were regularly serviced, checked and maintained to ensure these did not pose unnecessary risks to people. We observed the environment was free of hazards that could pose a risk to people’s safety.

At this inspection we found improvements had been made to people’s care records. Staff now had access to up to date information about how to support people. People’s care plans reflected their choices and preferences for how support should be provided. Where people lacked capacity to make specific decisions there was involvement of their representatives and relevant care professionals to make these decisions in their best interests. People’s care and support was reviewed monthly to check this continued to meet their needs. People said staff were able to meet their needs. Staff were knowledgeable about people's needs, knew their likes and dislikes and how they wished for their support to be provided. They ensured people’s right to privacy and to be treated with dignity were respected.

People were, on the whole, satisfied with the care and support provided. People told us and we observed staff were, in the main, kind, caring and respectful. People knew how to make a complaint if they had any issues or concerns about the service. The provider had arrangements to deal with any concerns or complaints that people had, in an appropriate way.

People said they were safe in the home. Staff knew what action to take to ensure people were protected if they suspected they were at risk of abuse. They were encouraged to raise and report any concerns they had about people through safeguarding and whistleblowing procedures. Risks to people’s health, safety and wellbeing had been assessed. Appropriate plans were in place to guide staff in how to minimise these risks to keep people safe. The provider followed good practice in relation to staff recruitment. Appropriate employment and criminal records checks were made on all staff to ensure they were suitable to work for the service.

People were encouraged to eat and drink sufficient amounts to support them to stay healthy and well. Senior staff monitored people’s general health and wellbeing. Where they had any issues or concerns about this they took appropriate action so that medical care and attention could be sought promptly from the relevant healthcare professionals.

People were encouraged to participate in a range of activities at the home. Staff were prompted to ensure people could be as independent as they could and wanted to be and only stepped in when people could not manage tasks safely and without their support. People were also supported to maintain relationships with the people that were important to them. Staff were welcoming to visitors to the home and relatives and friends were free to visit when they wished.

There was a quality assurance programme in place through which audits and checks of the service were undertaken by senior staff. This enabled them to check that expected standards were being maintained by all involved in the provision of care and support at the home. The home manager took full responsibility for making improvements to the service when these were needed. They ensured records maintained by the service were accurate and up to date.

The service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and conditions on authorisations to deprive a person of their liberty were being met. DoLS provides a process to make sure that people are only deprived of their liberty in a safe and correct way, when it is in their best interests and there is no other way to look after them.

After the inspection the provider wrote to us to say what action they would take to meet their legal requirement in relation to the breach. We undertook this focused inspection to check the provider had followed their action plan and had addressed the areas where improvements were required.

This report only covers our findings in relation to that requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heathland Court Care Centre on our website at www.cqc.org.uk

Heathland Court Care Centre provides accommodation for up to 82 people who require personal and nursing care and support. The service specialises in caring for older people living with dementia. At the time of this inspection there were 49 people using the service.

The service is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager left the service in September 2015. We were notified at the time. A new manager has since been appointed and is in the process of submitting the appropriate registered manager application to the CQC.

At this inspection we found the provider had taken all the necessary action to improve the management of medicines which meant they were no longer in breach of the regulation.

People received their medicines as prescribed. Our checks of stocks and balances confirmed this. People’s records had been properly maintained by staff which gave additional assurance that people received all their medicines when they needed them.

Staff responsible for supporting people with their medicines received appropriate support from senior managers. They were aware and understood their responsibilities in relation to the safe management of medicines.

Management checks of medicines had been strengthened. Senior staff checked stocks to ensure there were sufficient quantities of medicines to meet people’s needs. They also checked medicines had been ordered and received in time for people to be given these as required. Audits of medicines were carried out daily, weekly and monthly by senior staff to check staff followed the provider’s policy and procedures in place for the safe management of medicines. Issues identified through these checks were dealt with promptly by senior staff.

We undertook an unannounced focused inspection on the 22 December 2015 to check that they now met legal requirements. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Heathland Court Care Centre on our website at www.cqc.org.uk

Heathland Court Care Centre provides accommodation for up to 82 people who require personal and nursing care and support. The service specialises in caring for older people living with dementia. At the time of this inspection there were 45 people using the service.

The service is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager on our records left the service in September 2015. We were notified at the time by them and the provider. A new manager has since been appointed and is the process of submitting the appropriate registered manager application to the CQC.

At this inspection we found the provider remained in breach of their legal requirement for safe care and treatment of people through the safe management of medicines. The provider had failed to ensure there were sufficient quantities of prescribed medicines in stock in respect of one of the people using the service. As a result this person did not receive medicines at times they needed them which put them at unnecessary risk of harm to their health and wellbeing.

We also found records of medicines administered had not been properly maintained by staff and we could not be assured that people had received all their medicines when they needed them.

We are taking action against the provider and will report on this when our action is completed.

We found the provider had taken some action to improve the way they managed medicines at the home. People’s records now contained guidance for staff on how and when to administer ‘as required' medicines, topical creams and ointments. Meetings had been held with the supplying pharmacy to improve the collection and delivery of medicines to the home. Arrangements to check medicines were properly and safely managed had been improved. Audits were carried out monthly by senior staff. In addition senior staff carried out spot checks on records to identify any issues or concerns about people’s medicines. However given the issues we identified these checks may not have been as effective as they should have been.

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with nine people using the service and visiting friends and family members. We also spoke with two senior home managers who were in charge of the home on the day of our inspection, the deputy manager and three registered nurses.

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

Is the service safe?

We asked people using the service, and their friends and family, if people were safe at the home. People told us that they were. One person using the service said, 'I think I feel safe. You never know how people will react in an emergency but on the whole I feel confident they would deal with an emergency quickly.' Another person told us, 'Yes, I feel safe here.'

As part of their annual customer satisfaction survey the provider asked people using the service if they felt safe. We looked at people's responses from the last survey in Autumn 2013. The majority of people agreed they felt safe and secure in the home.

However it was apparent from feedback we received, people using the service, and their friends and family, had concerns about staffing levels in the home and the continuity and consistency of care they received. Although people said most staff were 'nice' and 'caring', people were less satisfied with the temporary staff that cared for them. We spoke at length with senior staff on the day of our inspection who explained the actions taken by the provider and service to address people's concerns. It was clear that action had been taken to recruit new, suitably qualified staff to work within the home. On the day of our inspection nine new members of staff were attending induction training. However it was too early to assess whether this would sufficiently address people's concerns. We will continue to monitor the provider's progress to maintain a consistent and stable staffing complement within the home.

Any potential risks to people's health, safety and welfare within the home were assessed by senior staff. There was appropriate guidance for staff on how to take action to minimise these risks to keep people safe from harm or injury in the home. However the service acknowledged these checks were not carried out as regularly as they should be, in line with the provider's own standards. The service was taking action to ensure this information was up to date by the end of June 2014.

People were cared for in an environment that was kept clean and hygienic. Staff knew how to maintain good standards of cleanliness and hygiene to reduce the risk of cross infection, as they had received training to do so.

The provider carried out appropriate checks on staff before they started work to assure themselves they were suitable to work at the home. This included carrying out security checks to ensure people were not barred from working with vulnerable adults.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The service had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made and in how to submit one. This means that people will be safeguarded as required.

Is the service effective?

People using the service and their relatives were involved in planning and developing their care and support. Their views and experiences were used to develop their individual care and support plan. People's specific needs had been taken into account and staff demonstrated a good understanding and awareness of these.

People using the service were asked for their consent before care and support was provided. Where people were unable to make complex decisions about their care and support their representatives and other healthcare professionals had been involved in making decisions on their behalf which were in their best interests.

Where people needed extra care for specific conditions, we saw short term care plans were put in place to support people to become well again. People's progress and wellbeing was monitored and evaluated by senior staff to ensure the care and support planned for them was meeting their needs.

Is the service caring?

Most people we spoke with had mixed experiences of staff that worked in the home. From the feedback we received people were less satisfied with temporary staff. People said; 'The quality of care is good. Staff vary in that some are very good and considerate but the older ones have less time for most things.'; ' Most staff are nice. The ones that are nice are very caring.'; 'One or two of the staff are more helpful than others. Some are caring but some are just doing a job.'; 'Nine out of ten staff are caring. The agency staff not so much as they don't know people so well.' And, 'The staff are caring and the ones who have been here a long time know (relative) quite well. But I'm not so sure about agency staff.'

During our inspection we observed friendly and kind interaction between staff and people using the service. Staff spoke with people respectfully and took time to listen and chat with them. People that needed extra help and support moving around the home or with eating and drinking were not rush or hurried by staff and could do so at their own pace.

Is the service responsive?

There were appropriate mechanisms in place to monitor people's general health and wellbeing. Checks of people's weights were undertaken by staff. These were documented and reviewed by senior staff to identify any potential underlying issues or concerns.

On the whole staff were responsive to changes and deterioration in people's general health and well-being and took appropriate action in most cases so that people got medical care and attention they needed.

When people made formal complaints about the service we saw senior staff took appropriate action to investigate and resolve these to people's satisfaction.

Is the service well-led?

The views and experiences of people using the service and their relatives were sought by the service. Changes and improvements to the service were made when people wanted or needed these.

The provider understood the importance of robust quality assurance and carried out regular checks to assess and monitor the quality of service provided.

At our previous inspection in May 2013 we found that staff had not received adequate training and support from the provider for their roles. We asked the provider to send us an action plan on this and to report what they had done. We reviewed evidence that demonstrated the provider's compliance in this area.

During this review we received confirmation that all staff had completed their mandatory training and that the supervision and appraisal system had improved. Staff had also undertaken further learning and development to be able to meet people's specific needs.

This meant that further arrangements were in place to ensure that staff received the training and support they needed for their role and to care for people appropriately.

At the time of our visit, there were 42 people using the service and we spoke with fifteen of them. We also spoke with two visitors, six members of staff, the registered manager, a visiting area manager and a quality consultant.

Due to their needs, some people were unable to communicate their views and experiences. We used observations to gain an understanding of their experience of care. The majority of people we spoke to said they were pleased with the service. Individual comments included, 'I have no complaints. They look after me pretty well' and 'the staff are very nice, very pleasant and helpful.'

We saw staff interacting with people in a relaxed, friendly and respectful manner. Comments from staff included, 'things are a lot better'; 'The manager gets things done' and 'everybody helps each other, there's good teamwork.'

Arrangements had been made to provide people with more opportunities to engage in social and leisure activities. Quality monitoring systems had been strengthened. We saw evidence that when improvements had been identified, they were acted upon. At this inspection there were sufficient numbers of staff to meet people's needs. However we found that the arrangements for staff supervision, training and development were in need of improvement.

At the time of our visit, there were fifty people using the service and we spoke with ten of them. We also spoke with two visitors, ten staff, the operations manager and deputy manager.

People told us there had been improvements with staffing and they did not have to wait for attention. Comments included, 'Staff are good, we never have to wait too long for help. It's much better than it was. Sometimes we go upstairs to join in an activity, that's good. There's a new lady in charge, you can already see the changes and she really listens to you.' One person described the staff as 'absolutely wonderful' and another said, 'We're looked after very well, staff are really professional, very kind'. A visitor told us, 'people seem to be quite happy here, it's been different lately, more staff around.'

Since our last inspection, one of the accommodation floors was no longer in use and the staffing establishment had been reviewed. This meant that staff were being deployed more effectively and able to meet people's needs. All the staff we spoke to said there had been improvements.

We found staffing levels did not meet the individual needs of the people living at the home. People said they often had to wait for attention. On some floors, we saw that people were not always supervised. There were not always sufficient staff to safeguard the health, safety and welfare of people. Structured activities within the home did not provide interest and stimulation for people. On some floors people were not getting enough support to eat their meals.

People told us that the ongoing management changes have had an impact on the service. There had been three different managers in eighteen months. Comments from people included, 'there's no one at the helm,' and 'We don't have any proper management. The staff have to run the place.'

At our last two inspections in September 2011 and March 2012 we identified areas where the provider was not meeting the essential standards of quality and safety. We were concerned that several actions remained outstanding from the provider's service improvement plan.