Archived: Warwick Park Care Home

Warwick Park Care Home is a residential care home providing personal care to up to 50 people with care and support needs. The service provides support to younger people, older people, people with a physical disability and people living with dementia. At the time of our inspection there were 40 people living at the service.

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

Risks were assessed and recorded. However, when changes in people’s needs occurred, or when guidance was provided from healthcare professionals, this did not always trigger a review of the risks.

Care plans did not always contain accurate and current guidance and direction for staff on how to meet people’s needs and was sometimes contradictory.

Some people had been assessed as being at risk of pressure damage to their skin. Pressure relieving mattresses had been provided. Some mattresses were not correctly set. There was no process in place to ensure mattresses were always set correctly for the people using them.

People received their oral medicines as prescribed. The service had recently moved to an electronic medicines management system. However, there were no protocols for medicines that were prescribed ‘when required’, or when people required their medicines to be given covertly or when people were self-administering their own prescribed medicines.

People had been prescribed creams and lotions. There were many gaps in these records. We were not able to evidence that people were having these applied as prescribed.

Care plans provided some guidance for staff on how to meet people’s needs. However, we found gaps in the records where care had not been recorded as required. We judged this was a recording issue and we found no impact on people as a result of this recording concern.

There was an audit programme in place to help identify any areas of the service that may require improvement. However, some audits were not effective as they were not accurate.

There had been a serious event which had taken place at the service prior to the current registered manager taking up their post. This event had not been notified to CQC as required.

We had received concerns from visiting healthcare professionals regarding the service being cold. They told us, “It is often cold in Warwick Park.” A new boiler had been installed a few weeks prior to this inspection. During the first few hours of our inspection the service was not warm throughout. Inspectors found that most of the radiators had been turned off. This was addressed by the registered manager.

There were malodours throughout the service. The carpets throughout the service were worn and marked. The passenger lift was out of use and had been for several months. A stair lift had been installed to ensure people were not impacted by this.

Some staff training needed updating and not all staff had received supervision since the registered manager took up their post in January 2023. However, registered manager and the nominated individual were working through a service improvement plan which was addressing this issue.

The recruitment processes were satisfactory. The service had sufficient numbers of staff to meet people’s needs.

The registered manager was supported by two deputy managers, the provider and the nominated individual. Regular meetings took place to review the actions in the service improvement plan and there was evidence of improvements being made.

There were effective safeguarding systems in place and staff knew what actions to take to help ensure people were protected from harm or abuse.

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; however, the policies and systems in the service did not support this practice as the records held by the registered manager for people, who required restrictions to be placed upon them, were inaccurate.

Staff worked within the principles of the MCA and sought people's consent before providing personal care and assistance. Staff were observed providing kind and caring support.

People, staff and relatives had recently been asked for their views and experiences by the manager and the provider. Responses had not yet been received. A residents meeting and a staff meeting had been held since the registered manager took up their post.

The registered manager understood their responsibilities under the duty of candour.

Staff had been trained in the effective use of Personal Protective Equipment (PPE). We observed some staff wearing PPE to help protect people from the risk of infections.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (6 October 2022).

Why we inspected

The Care Quality Commission (CQC) had received concerns in relation to people’s care needs not always being met and poor governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

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

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 Warwick Park on our website at www.cqc.org.uk

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

Enforcement

We have found breaches in relation to safe care and treatment, good governance and failure to notify CQC as required at this inspection.

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.

Warwick Park Care Home is a residential care home providing personal care for up to 50 people.The service provides support to people requiring care and assistance. Some people were living with dementia. At the time of our inspection there were 42 people using the service.

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

At the inspection of the service in August 2019 we found breaches of regulation relating to the operation of the service. At this inspection we found the service had made improvement in all areas and were no longer in breach of regulations.

At the previous inspection not, enough improvement had been made to ensure people were protected from risks associated with their health needs, lifestyle choices, medicines and the environment. At this inspection we found improvements had been made to ensure peoples risk were being mitigated and the provider had met the outstanding breaches of regulation.

At the previous inspection we found the systems in place to monitor quality assurance and governance systems were not always robust and effective. At this inspection we found improvements had been made to governance and quality monitoring and the provider had met the outstanding breach of regulation.

The provider had used a recommendation at the previous inspection to improve the way it recorded medicines. All other aspects of medicine management were safe.

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.

Staff were recruited safely to ensure people were supported by staff who had undergone safety checks before they began working in the service. There were enough staff to meet people's needs and ensure their safety.

People supported by the service told us staff were always polite, reliable and professional in their approach to their work. They said, “All the staff go above and beyond. Never disappointed” and “They [staff] have made such a difference to my dependence. Couldn’t have done it without them”.

The service had a complaints procedure which was made available to people they supported. People we spoke with told us they knew how to make a complaint if they had any concerns. One person said, “Yes, I know how to make a complaint. The registered managers are very good, and I am sure it would get sorted out”.

Staff were provided with personal protective equipment to protect people and themselves from the spread of infection.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found 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 01 November 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 we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

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 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.

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

Follow up

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

Warwick Park Care Home is registered to provide accommodation and personal care for up to 50 older people. At the time of our inspection, 39 people were living at the service.

People’s experience of using this service

People told us they felt safe, supported and were happy living at Warwick Park Care Home. Staff were kind, caring and treated people with dignity and respect.

At our last inspection we found the provider was failing to ensure they were doing all that is reasonably practicable to manage and mitigate risks. At this inspection we found improvements were still required as people were not always protected from risks associated with their health needs, life style choices, medicines and the environment.

Medicines managed by the service were stored and administered safely and appropriately by staff who had been trained and assessed as competent to do so. However, we found some aspects of medicines recording could be improved and have recommended the provider update their practice in some areas of medicines management to incorporate current best practice.

People were supported to have maximum choice and control of their lives; however, we have recommended that the registered manager reviews all documentation and guidance relating to how staff record best interests’ decisions.

Quality assurance and governance systems were in place to assess, monitor, and improve the quality and safety of the services provided. However, we found the systems in place had not been undertaken robustly, therefore had not identified that some records were not complete or up to date. We have recommended the provider undertakes a review of the effectiveness of the systems and processes in place.

People had confidence in the registered manager and told us the home was well managed. There was an open culture where people, relatives and staff were encouraged to provide feedback. Staff felt they received a good level of support and could contribute to the running of the home.

People's privacy and dignity was respected, their independence promoted, they had access to healthcare professionals when required and were supported to maintain a balanced healthy diet.

People were protected from potential abuse by staff who had received training and were confident in raising concerns. There was a thorough recruitment process in place that checked potential staff were safe to work with people who may be vulnerable by their circumstances.

Other risks were well managed. Risks had been identified, in relation to people’s care needs such as mobility and skin care, and action had been taken to minimise these.

Warwick Park Care Home was clean, and people were protected from the risk and/or spread of infection as staff had access to personal protective equipment (PPE).

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 on 21 August 2018). 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 not enough improvement had been made and the provider was still in breach of regulations.

The service remains rated requires improvement. This was the second consecutive inspection where the service has been rated as 'requires improvement'. Prior to this the service was rated inadequate.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach of regulation in relation to safe care and treatment. We have also made recommendations in relation to medicines and the recording of best interests decisions.

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

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 and continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme.

Following an unannounced comprehensive inspection on 24 and 25 May 2017 we told the provider to make improvements to how people's medicines were managed and to how people's care needs, and risks associated with their care were recorded and known to staff. We told them to ensure people's call bells were answered promptly, and to document people's mental capacity. In addition, we told the provider to improve their quality monitoring processes, to help identify when improvements were required. Following our inspection, we met with the provider to ask them how they would improve the service for people. They told us they would strengthen their governance processes.

The Commission considered its enforcement policy, and took enforcement action, which was to impose a condition on the provider's registration. This meant on a monthly basis, the provider was requested to carry out an audit of people's medicines and of care records; submit a summary of their findings to the Commission, and demonstrate what action was being taken to improve the service and to meet regulation. Since July 2017 the Commission had been receiving and reviewing the provider's monthly returns, which had demonstrated ongoing improvement at the service.

We carried out an unannounced comprehensive inspection on 14 and 15 November 2017. Our inspection was brought forward because we received information of concern about people's care. The findings of that inspection found that the information submitted by the provider to the commission about improvements they were making, had not always been fully accurate and did not always reflect the current regulatory position within the service. Following our inspection, the registered manager submitted a detailed action plan to the commission. The action plan set out how they intended to make urgent changes regarding the safe management of people's nutritional needs. As a result of the inspection the provider also decided not to provide nursing care in the future.

The Commission considered its enforcement policy, and took enforcement action, which was to impose further conditions on the provider's registration and place the service into special measures. This meant on a monthly basis, the provider was requested to carry out an audit of how they were monitoring the quality of the service and how they were keeping people safe; submit a summary of their findings to the Commission, and demonstrate what action was being taken to improve the service and to meet regulation. Since the inspection, the Commission had been receiving and reviewing the provider's monthly returns, which had demonstrated ongoing improvement at the service.

Services in special measures are kept under review and, if we have not taken immediate action to

propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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 inspection was to check whether sufficient improvements had been made.

Warwick Park Care Home is registered to provide accommodation and personal care for up to 50 older people. 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.

Accommodation and facilities are spread over two floors, with access to the lower and upper floors via stairs or a passenger lift. There are shared bathrooms, shower facilities and toilets. As well as two lounges, a dining area, a conservatory, a garden and decked seating area. On the days of our inspection there were 20 people living at the service.

A manager had been employed to manage the service. They had been in post for four months and were in the process of registering with the commission. 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.

At the last inspection we found people’s care was not provided in a safe way. We found concerns with the way people’s medicines and risks relating to their health needs were managed. We found people were not always moved in a safe way and that staff were not always trained to meet people’s specific needs. We found that changes to people’s needs were not always identified and acted upon; and that the care they received was not always based on best practice. We also found that staff did not attend people promptly when called.

At the last inspection we also found that the Mental Capacity Act 2005 (MCA) was not always followed and staff did not always know how to support people to communicate. We found that people’s care plans were not all complete and did not always reflect individual preferences. We found that people were not always treated with dignity and respect, their confidential information was not always protected and they were not supported effectively at the end of their life.

We found people were not always protected by the provider's infection control procedures and that people were exposed to the risk of consuming hazardous substances such as cleaning fluids.

At the last inspection we found the service was not well led. We found that the provider and registered manager had not embedded learning from investigations and had not implemented systems and processes that enabled them to effectively assess and improve the quality of the service. We found that the service did not reflect up to date practice or promote a person-centred culture.

At this inspection, we found improvements had been made; however, we found some improvements were still required.

We found improved checks were in place which helped ensure medicines were managed safely. However, these had not identified that people’s confidential medicines records were regularly left unattended in communal areas. People told us they received their medicines on time and in their preferred way.

At this inspection we found people’s health needs were well known to staff who ensured people received the help and support they required. Staff monitored people’s health and where necessary, changes to people’s needs were identified quickly, shared with the staff team and appropriate action taken. Risks relating to people’s needs were known and understood by the staff team, however the level of risk to people had not always been assessed to ensure it was an acceptable level.

People told us they felt safe using the service. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected. However, the provider’s safeguarding policy did not reflect the procedures of the local safeguarding authority. Staff ensured people were not put at risk by items, such as cleaning fluids.

At this inspection we found the staff workload had been reduced so they were able to respond to people more promptly when they called. The time it took for staff to respond to call bells was monitored regularly to ensure improvements were sustained. There were sufficient numbers of suitably qualified staff to meet the needs of people who used the service. Checks were carried out on new staff members, however, staff members who had recently started working at the service had started work at the service before DBS checks applied for by the service had been returned. This was not in line with the provider’s policy.

At this inspection we found information from all monitoring activities including complaints and incidents, were used as learning to improve the service. Audits and governance arrangements had been developed and improved, however they had not identified some of the concerns we found during the inspection. The manager had made changes, in consultation with people, to ensure the service reflected up to date practice and legislation. The manager had worked hard to develop a positive, person centred culture in the service and was consulting people and staff about what the service values should be.

Staff training was up to date. Staff had completed training relevant to people’s specific needs and people reported feeling safe when they were supported to move by staff. The manager and staff had recently updated their training and regularly attended local care forums and training opportunities in order to ensure people benefitted form care based on best practice.

At this inspection we found people were treated with dignity and respect. People were supported with care and understanding if they became anxious, however details of how to best support people at these times was not always included in people’s care plans. People’s communication needs were known and respected by staff members. People had mental capacity assessments in place, when appropriate

We found care plans had been re written in consultation with people and where appropriate their friends or family. However, where people could no longer communicate their routines and preferences to staff, these had not been recorded in people’s care plans. People had care plans in place that contained detail about how they would like to be cared for at the

The overall rating for this service is ‘Inadequate’ and the service is therefore been placed into ‘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.

We carried out an unannounced comprehensive inspection on 24 and 25 May 2017. The overall rating improved from inadequate to requires improvement, therefore the service came out of ‘special measures’.

We told the provider to make improvements to how people’s medicines were managed and to how people’s care needs, and risks associated with their care were recorded and known to staff. To ensure people’s call bells were answered promptly, and to document people’s mental capacity. In addition, we told the provider to improve their quality monitoring processes, to help identify when improvements were required.

Following our inspection, we met with the provider to ask them how they would improve the service for people. They told us they would strengthen their governance processes.

The Commission considered its enforcement policy, and took enforcement action, which was to impose a condition on the provider’s registration. This meant on a monthly basis, the provider was requested to carry out an audit of people’s medicines and of care records. Submit a summary of their findings to the Commission, and demonstrate what action was being taken to improve the service and to meet regulation. Since July 2017 the Commission had been receiving and reviewing the provider’s monthly returns, which had demonstrated ongoing improvement at the service. However, the findings of this inspection determined the information which had been provided had not always been fully accurate and did not always reflect of the current regulatory position within the service.

We carried out an unannounced comprehensive inspection on 14 and 15 November 2017. Our inspection was brought forward because we received information of concern about how people’s medicines were managed, how people were being supported with their mobility and that there was a delay in staff responding to people’s call bells. We were also told, people were not always effectively supported with their nutrition and continence needs, and staff did not always know how to support people, or have access to their care records. In addition, repairs were not always carried out promptly and the environment was not always clean and tidy. During this inspection we looked at the concerns which had been raised, and found some improvements were required.

Warwick Park Care Home is registered to provide accommodation for nursing and personal care for up to 50 older people. The service also provides assessment and rehabilitation when people are discharged from hospital, usually for a period of up to four weeks. This is known as 'Discharge to Assess' (DTA). The assessment and rehabilitation of people staying in a DTA bed is overseen by a DTA team, which includes external community physiotherapists and occupational therapists. At the time of the inspection the service had four DTA beds, and two were occupied.

Accommodation and facilities are spread over two floors, with access to the lower and upper floors via stairs or a passenger lift. There are shared bathrooms, shower facilities and toilets. As well as two lounges, a dining area, a conservatory, a garden and decked seating area. On the days of our inspection there were 35 people living at the service.

There was 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 2008 and associated Regulations about how the service is run.

People’s medicines were not always safely managed. People did not always get their medicines on time or as prescribed. People living with long term healthcare conditions did not always get the help and support they needed.

People, who had risks associated with their nutrition, did not always receive the correct diet and professional advice was not always followed. People who were at risk of losing weight were not effectively monitored to ensure prompt action was taken to recognise weight loss and to seek advice. People told us the quality of food was variable, however the registered manager had already started to obtain people’s views in order to make improvements.

Overall, the environment was assessed to ensure it was safe. Equipment used by people, such as hoists were serviced in line with manufacturing guidelines. However, a cleaning trolley had been left unattended which contained cleaning products, and we found nutritional supplements in people’s bedrooms. Both, posed risks to people if consumed. People who required assistance to move were not always supported safely, when being assisted with moving and handling equipment.

People were not always protected by the provider’s infection control procedures. The service was clean and odour free.

Overall, people were cared for by suitable numbers of staff. Staff told us the registered manager was responsive to making staffing alterations when necessary. However, the weekly use of agency nurses meant people’s clinical needs were not always met with consistency. The registered manager told us, that the recent appointment of three new clinical leads would shortly be making a great difference.

People told us they felt safe living at the service. People were protected from abuse because the staff knew what action to take if they suspected someone was being abused, mistreated or neglected.

People’s care and support was not always based on best practice guidelines, helping to ensure the best outcomes for people. This demonstrated nursing staff required updating on current best practice.

People had access to external healthcare professionals to ensure their ongoing health and wellbeing, but did not always receive an organised and prompt response to their changing health and social care needs.

Overall, people were cared for by staff who had received training. However, staff had not all completed courses specific to people’s individual needs. Nursing recruitment was ongoing, which had resulted in clinical competence not being effectively monitored within the service.

Staff received an induction prior to commencing their role, to introduce them to the provider's ethos and policy and procedures.

The Mental Capacity Act 2005 (MCA) was not always followed in respect of the management of people’s medicines, which meant people’s human rights were not always upheld. Staff, were heard to verbally ask people for their consent prior to supporting them and had a good understanding of the Mental Capacity Act 2005 (MCA). Deprivation of liberty safeguards (DoLS) applications to the supervisory body had been made when necessary. However, people’s mental capacity and best interests decisions had not always been recorded that showed how their human rights had been upheld.

People lived in a service which had been designed and adapted to meet their needs. People were consulted and encouraged to get involved in the ongoing changes to the environment.

Overall, people were cared for by staff who showed kindness. However, some staff, displayed more compassion than others. People were not always treated with dignity and respect and given emotional support. People’s individual preferences were not always recorded which meant staff may not know how people wanted to be supported.

People’s equality and diversity was respected by staff. Staff told us people were not discriminated against, on grounds of their culture or sexuality. People’s privacy was respected. Staff, knocked on people’s doors prior to entering their rooms.

People’s families and friends were welcome to visit at any time. People and/or their families were involved in decisions relating to their care. When people did not have a family, or anyone to act on their behalf, advocacy services were considered.

Overall, people had care plans in place which provided staff with information about how they wanted, and needed their health and social care needs to be met. However, some care plans had not been fully completed and some clinical care plans lacked detail. This meant people could be at risk of receiving inconsistent support.

Overall, people’s communication needs were assessed. People had care plans in place to help guide staf

On the first two days of the inspection 39 people were living at the service, two people were in hospital. The service also provides assessment and rehabilitation to some people when they are discharged from hospital. This would normally be for a period of up to four weeks and is known as ‘Discharge to Assess’ (DTA). At the time of the inspection the service had four DTA beds, and three were occupied. The assessment and rehabilitation of people staying in a DTA bed is overseen by a DTA team, which includes external community physiotherapists and occupational therapists.

Accommodation and facilities at Warwick Park Care Home Care Home are over two floors, with access to the lower and upper floors via stairs or a passenger lift. There are some shared bathrooms, shower facilities and toilets. Communal areas include two lounges, a dining area, a conservatory, a patio seating area and a garden.

The service had a new 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 2008 and associated Regulations about how the service is run.

The service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make sure that significant improvements have been made within this timeframe.

The overall rating for this service is ‘Requires improvement’.

At the previous three inspections (December 2014, March 2016 and September 2016) we asked the provider to take action and make improvements. This was because care was not always safe, personalised and consistent; and the systems in place to monitor the quality of the service were ineffective. People were not protected from risks associated with their care. People were also at risk of not receiving their medicines as prescribed. People’s records were not completed accurately to reflect care given and people’s mental capacity was not always assessed.

At the unannounced comprehensive inspection of this service on 1, 6 and 28 September 2016, continued breaches of legal requirements were found. We rated the service as inadequate overall. In line with our enforcement policy we made the decision to place conditions on the provider’s registration. We told the provider they must send us monthly reports to tell us about their progress to address the concerns raised. This condition would remain in place until we are satisfied sufficient improvements have been made. At this inspection we found many improvements had been made but we had on-going concerns related to medicine management, risk management and the governance systems in place.

Medicine management was not always safe. We found the systems in place to check medicines were administered as prescribed had improved but there were still multiple issues. We found one person had not received their prescribed antibiotics and another had not received their medicine due to poor stock control. There were ongoing issues with gaps on medicine charts and we found medicine equipment which had expired. However, recording of creams on body maps had improved, fridge temperatures were being recorded, there were policies relating to medicine management in place and thorough audits identifying issues which were being followed up and action taken. Following the inspection the registered manager sent us information detailing the improvements which had been made to ensure medicine management would be safer.

Risk assessments were in place, completed and reviewed regularly. However, we found changes to risk did not always lead to care plans being updated and staff being aware of changes for example changes to the frequency of weighing when weight loss had been identified. Following the inspection you advised process had been changed to reduce the likelihood of this occurring again. Changes to weight would now be recorded straight into care plans.

People told us they sometimes waited a long time when they called staff for help. We reviewed the call bell audit the service used and found some people had waited significant periods of time for assistance. Dependency tools were used on a daily basis to guide staffing levels. This information was being used by the service to inform staffing levels at peak times of day and recruitment was in progress.

People were cared for by staff who had undergone further training and education regarding safeguarding, what constitutes abuse and they knew how to report their concerns. Staff underwent thorough recruitment checks, an induction and further training to meet people’s needs. Staff were supported by the management team and had one to one meetings with their manager. Individual issues were addressed in staff supervision. Staff meetings were held and staff were encouraged to share good ideas. Staff were rewarded and nominated by others within the service for good practice.

People’s human rights were protected because staff had a better understanding of the Mental Capacity Act (MCA) 2005. People were asked for their consent prior to care being given and when people were unable to consent the service involved health and social care professionals and others in making decisions about their care.

People were supported to access relevant healthcare professionals where there were concerns relating to their physical or emotional well-being.

Communication systems within the service had improved. Handover processes were more robust and staff were reading people’s care plans.

People were enjoying the food at the service. The new chef was developing menus following discussion with people about their likes and dislikes. The kitchen staff had a list of people who required a special diet.

At the last inspection we found the care people received was variable. At this inspection people were more positive about their care and the kindness they were shown by staff. Care plans had more detail to guide staff delivering care and were improving. Staff were continuing to gather information about people’s backgrounds and histories so care could be more person-centred. As the staff team became more stable plans were in progress for keyworkers to be allocated to people. Families felt more involved in discussions and changes occurring within the service.

People told us staff were kind, respected their privacy and dignity and listened to them. People’s special occasions were celebrated.

The service had plans to improve activities for people and ensure people were sufficiently engaged and stimulated if they wished. Whilst some people enjoyed their own company and privacy in their rooms, others told us they enjoyed the musical activities. We saw people enjoying the garden and the events that were being planned, which included a summer fete.

A new registered manager had been appointed since the previous inspection in September 2016. They and the staff team at Warwick Park were committed to addressing the detailed action plan in place. Many changes had been made to the systems in place for monitoring the quality of care. These were still being tried, changed when necessary and embedded into new ways of working. For example, audits were completed frequently and areas identified for improvement were being actioned through further staff training, supervision and new processes.

All people, relatives and staff told us they had confidence in the leadership team and their ability to make the required changes whilst keeping staff motivated and engaged. Families were more involved in suggested changes and staff were encouraged to raise their ideas for improvement.

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.

On the first two days of the inspection 45 people were living at the service. At the time of the inspection the provider was involved in a pilot project with the NHS and local hospital, to help facilitate faster hospital discharges. Thirteen of the 50 beds at the time of the inspection were contracted by commissioners for this purpose. During the inspection, due to our concerns, admission to these beds was stopped by the provider.

Accommodation and facilities at Warwick Park Care Home Care Home are over two floors, with access to the lower and upper floors via stairs or a passenger lift. There are some shared bathrooms, shower facilities and toilets. Communal areas include two lounges, a dining area, a conservatory, a patio seating area and a garden.

The service 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 2008 and associated Regulations about how the service is run. The manager was also the registered provider.

At the previous two inspections (December 2014 and March 2015) we asked the provider to take action and make improvements. This was because care was not always safe, personalised and consistent; there were not sufficient staff to meet people’s needs in a timely way and, the systems in place to monitor the quality of the service were ineffective. People were not protected from risks associated with their care. People were also at risk of not receiving their medicines as prescribed. People’s records were not completed accurately to reflect care given.

At the unannounced comprehensive inspection of this service on 22 and 23 March 2016, breaches of legal requirements were found. We served Warning Notices on the registered provider. Warning notices are part of our enforcement policy and tell the provider where they were not meeting their legal requirements. They had to have put this right by 18 June 2016. An action plan was submitted by the provider on May 2016.

This inspection was to confirm that the service now met legal requirements. Following the first two days of our inspection, we found although there had been some improvement, we had continued concerns about people’s safety and medicine management, a lack of consistent and personalised care and the systems in place to monitor the quality of the service remained ineffective. We shared our concerns with the registered manager and the local authority. The registered manager took an immediate decision to stop admissions to the short term discharge beds. A further action plan was submitted on 14 September 2014 to address concerns raised on the 1 and 6 September 2016. On the third day of the inspection, 28 September we found systems and processes had been developed which would support people living at the service to be kept safe. However, these systems were very new and would require considerable time to be implemented and improve practice. Following the inspection on 11 October 2016 an updated action plan was submitted to CQC detailing the actions the provider planned to take following inspection feedback.

There were problems with medicine management. We were unable to tell whether people had received all their medicines. Antibiotics did not always match what was recorded on the medicine administration records (MARs) and one person had a medicine available for chest pain that was not written on the MAR. Staff told us they would not know when to give that medicine. Additionally, we found, body maps did not give staff clear direction about where and how skin creams should be applied, and MARs did not record these being administered.

Care plans and a new care planning system were in the process of being implemented. The care plans we reviewed on the first day of the inspection lacked sufficient detail and guidance for staff. Important information about how to meet people’s needs in relation to their health was lacking, for example how to care for people who had epilepsy or were vulnerable to skin damage. End of life care plans were insufficient and lacked information about how people may wish to receive care at this stage of their life. On the second day of the inspection the new “business manager” showed us an example of a care plan they had developed. They intended to implement these new, more detailed and personalised care plans for all people. These would to help guide staff to deliver effective and responsive care.

Risk assessments were in place but were not always correctly completed and risks were not carried through to people’s care plans and the care they received. For example, not all people who had skin damage and who required regular moving to maintain their skin integrity received the care they required. During the inspection process action was taken to address people’s risks and risk management in a more robust way.

Care provided did not always match the identified needs in people’s care records, for example exercises to help with people’s mobility or being moved to maintain their skin condition at the intervals their care records advised. Food and fluid charts were completed but we found the amounts recorded did not always match what people had consumed and the recording was not always an accurate reflection of what they may have had.

People’s health needs were not always met because of inadequate care planning. Poor record keeping also made it difficult to establish if people had received the care they needed. Health and social care professionals we spoke with gave us mixed feedback about people’s care and their confidence in the registered manager’s ability to action and embed learning from safeguarding feedback. However, they told us they were more confident in the new business manager’s ability to improve the quality of care at the service.

The systems and process introduced to monitor quality since the previous inspection were not well understood by staff. Staff did not always understand what they were auditing. Some completed audits had identified what we found during the inspection, but these areas had not been followed up. Other audits undertaken for example, on care plans had not identified the concerns we found.

Most people we spoke with told us they were happy, the food was good and they felt cared for. We observed kind interactions between people and staff throughout the inspection.

The registered manager attended forums where best practice was discussed and had completed a locally run leadership course. Leadership and governance of the service had been considered following the last inspection and new key roles had been appointed, for example, a head of care and a new business manager. The new business manager intended to go through the registered manager process and the current registered manager intended to take on a training and overview role. The provider had made these decisions in order to drive future improvements and the implementation of the service’s action plan.

Following the inspection feedback from the first two days of the inspection, the registered manager made a decision to stop some of the admissions to the service to enable the service to reflect and consider the action they needed to take immediately to ensure people were safe. The service considered how they were going to improve care planning, risk assessment, medicine management and quality monitoring of the service. An action plan was submitted to CQC on 14 September 2016 which had been developed in collaboration with the local authority improvement team. This action plan updated at the end of the inspection and a new one covering all areas of concern submitted to CQC on 11 October 2016.

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

The home is on two floors, with access to the upper floors via stairs or a passenger lift. Some bedrooms have en-suite facilities, whilst other bedrooms have shared toilets, bathroom or shower facilities. There are two lounge/dining rooms, two conservatories, a patio seating area and garden.

There was a registered manager in place. 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.

At the last inspection on 4 December 2014 we asked the provider to take action to make improvements to how they respected and involved people, social activities, and how records relating to people’s care were documented. Improvements were also required to help ensure the management of medicines was safe, and there were enough staff to meet people’s needs.

The provider sent us an action plan on 7 April 2015 confirming how improvements were going to be made and advising us these improvements would be completed by June 2015. During this inspection we looked to see if these improvements had been made. We found they had not all been completed.

People told us they felt safe living at the service, with one person telling us, “They check on me about every hour, so I know I’m safe enough”. People were protected from abuse and harm because staff and the registered manager understood their safeguarding responsibilities. People were not always protected from risks associated with their care because staff did not always have guidance and direction about how to minimise risks relating to people’s care.

People lived in an environment which had not always been assessed for risks which could cause people harm. For example, doors which should have been locked to prevent injury, for example a cleaning store was not. Overall, the environment was clean and free from odour; however there were some bedrooms which had a smell of urine.

There was not always enough staff deployed to meet people’s needs. Some people did not receive the care they required because their call bells were not answered promptly. People who were unable to use their call bell had to wait for staff to hear them calling out, which meant they may not always receive support quickly. Staff told us staffing levels could vary at times, impacting on the quality of care people received. However, people did not complain to us about staffing levels with one person telling us, “There is always plenty of staff around if I need anything”.

People were complimentary of the food and of the recently employed chef, telling us, “Today it is meatballs, since that chef came we’ve had marvellous meals, everything is lovely and tasty. I look forward to everything he brings up. In fact if you want extra things he gets them”. A member of staff explained, “We went through a few different chefs but the new one he’s fantastic. Now he’s here the kitchen is finally sorted. He’s very approachable, nothing is too much trouble and he gives a lot of variety as well. He will go and chat with people and ask them what they would like if. He’s jolly and boosts morale as well”.

People’s care plans did not always provide detail about how to meet their individual nutritional needs, so staff may not always know how to correctly support people. Documentation which was being completed to monitor how much a person was eating and drinking was inconsistently completed, meaning it was not clear if the person was eating and drinking enough.

People were not protected by the Mental Capacity Act (MCA) 2005 and associated Deprivation of Liberty Safeguards (DoLS). Staff and the registered manager had a limited understanding of the legislative frameworks and of their responsibilities, which meant people’s freedom or choices may not always be supported or respected.

People received care from staff who had undertaken training to meet their needs. Staff told us they received enough training commenting, “There’s always training courses going on”. Nursing staff kept their training up to date to ensure their professional registration with the Nursing and Midwifery Council (NMC) was maintained. There was a management structure in place and staff told us they felt supported.

People told us staff were kind, telling us, “The care and attention is out of this world”, “Everybody cares, from the maintenance man to the manager” and “The staff are a good crowd and a good laugh”. We found interactions between staff and people varied. On our first day of our inspection there was little positive interaction. For example, staff were focused on carrying out their tasks and did not take time to engage with people. On the second day staff took time to speak with people, showed a tactile approach, and laughed and joked with people. We asked the registered manager about this who said the staff had been upset by the last inspection report which had contributed to their behaviour on the first day.

People’s confidentiality, privacy and dignity were not always respected and staff did not always speak with and treat people in a respectful manner. For example, people’s bedroom doors were open, so at times people were observed to be exposed lying in their beds. Staff used phrases in front of others to describe people such as, “She is very confused”.

People’s choices and wishes for the end of their life had not always been documented. This meant staff may not know how to meet people’s individual needs. People did not always receive their medicine safely.

People were not involved in the creation and implementation of their care plan, so people’s care may not be delivered in line with their wishes and preferences. People’s care plans did not always give staff guidance and direction about how to meet people’s needs.

People’s changing care needs were referred to health services in a timely manner to help ensure they received responsive care and treatment. One person told us, “When I first came out of hospital I couldn’t eat anything, and now I can walk out into the garden for a smoke on my own, so I’m progressing”. The registered manager and nursing staff worked in partnership with external professionals to help ensure people’s health care needs were met.

People told us there was not always enough to occupy their time, commenting “It’s ok in here but there’s not much to do” and “I am bored silly”. There were no activities for people on the first day of our inspection, but on the second day a spontaneous game of catch was organised by staff which people enjoyed.

People were asked their views and opinions by completing questionnaires, one person told us “They used to do tea at 4pm or 4.30pm, but they listen to what we say to them and now it’s a bit later”. People told us if they had any complaints to make they would feel confident to do this. One person told us, “I have no complaints about the staff; they look after me in the way I would like”. The registered manager had a complaints policy which was followed when a complaint was raised. Complaints were used as a learning opportunity, and the registered manager apologised and was honest when something had gone wrong. This reflected the provider’s responsibilities under the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

The provider did not have effective processes in place to monitor, assess and improve the service provided to people. Required improvements were not identified quickly to help ensure action was taken promptly.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We found that people at the home felt safe. Staff had a good knowledge and understanding of safeguarding and they knew how to raise any concerns they may have about a vulnerable person. The staff we met felt supported by the registered manager and able to discuss and share concerns they may have with her.

We found the home had a complaints policy and followed this to manage complaints which people had made. The registered manager was keen to learn from complaints that had been made and we saw that this had occurred with a complaint the provider had recently received.

We met ten of the people who used services, talked with the staff on duty and checked the provider's records. We also met and spoke to seven relatives, two visiting professionals and the registered manager also provided information. We also observed staff interaction with people as they went about their daily routines.

We saw people's privacy and dignity being respected and we saw and heard staff speak to people in a way that demonstrated a good understanding by staff of people's choices and preferences. People said, 'I am looked after well'.

We saw that four people's care records described their needs and how those needs were met. We saw that best interest meeting were held to determine the best way to support someone who was unable to make that decision.

Some people were able to say that if they had any concerns that they would speak to staff or the management and felt confident that appropriate action would be taken.

We saw that the staff had a good understanding of people's individual needs and that they were kind and respectful. They took time to work at people's own pace.

We saw that staff treated people with consideration and respect. For example, we saw that staff responded to people's care needs to ensure that they were kept comfortable and informed about what was happening, such as discreetly assisting someone to the toilet and informing them about when lunch would be.

Care plans that we saw reflected people's health and social care needs and demonstrated that other health and social care professionals were involved.

We spoke with staff about their understanding of what constituted abuse and how to raise concerns. They demonstrated a good understanding of what kinds of things might constitute abuse, and knew where they should go to report any suspicions they may have.

We had received concerning information about people's needs not being met in a timely way possibly due to low staffing levels. During our visit we saw that the registered manager was aware of and dealing with this issue, by restructuring the staff team and recruiting additional staff.