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Inspection Summary

Overall summary & rating


Updated 24 December 2015

This inspection took place on 12 and 13 November 2015 and was unannounced. The home provides accommodation, nursing and personal care for up to 25 older people, some of whom are living with dementia. There were 15 people living at the home when we visited.

There was a manager but they were not registered with the Care Quality Commission. The manager was new and told us they were in the process of registering with us. 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 and relatives were positive about the service they received. They praised the staff and care provided. People were also positive about meals and the support they received to ensure they had a nutritious diet.

People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people’s legal rights was followed correctly. People’s ability to make decisions had been recorded, in a way that showed the principles of the Mental Capacity Act 2005 (MCA) had been complied with. Staff were offering people choices and respecting their decisions. The Deprivation of Liberty Safeguards (DoLS) were applied correctly. DoLS provides a process by which a person can be deprived of their liberty when they do not have the capacity to make certain decisions and there is no other way to look after the person safely.

Plans were in place to deal with foreseeable emergencies and staff had received training to manage such situations safely. There was an environment maintenance and improvement program that gave consideration to ensure the environment supported people living with dementia or those with visual perception difficulties. The program had an action plan where improvements were required.

Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people’s individual care needs. People had access to healthcare services and were referred to doctors and specialists when needed. Reviews of care involving people and/or relatives were conducted regularly. Activities were offered with people able to choose to attend or not.

There were enough staff to meet people’s needs. Contingency arrangements were in place to ensure staffing levels remained safe. The recruitment process was safe and helped ensure staff were suitable for their role. Staff received training to meet the needs of people and were supported.

People and relatives were able to complain or raise issues on a formal and informal basis with the manager or staff and were confident these would be resolved. This contributed to an open culture within the home.

Visitors were welcomed and there were good working relationships with external professionals. Staff worked well together which created a relaxed and happy atmosphere, which was reflected in people’s care.

The manager and provider were aware of key strengths and areas for development of the service and there were continuing plans for the improvement of the environment. Quality assurance systems were in place using audits and regular contact by the provider and manager with people, relatives, staff and other professionals.

Inspection areas



Updated 24 December 2015

The service was safe.

People told us they felt safe. Staff knew how to identify and report abuse and were aware of how to respond in an emergency situation.

Systems were in place to ensure people received their medicines as prescribed.

Risks to people and environmental risks were identified and managed.

There were enough staff to meet people’s needs and the process used to recruit staff was robust and helped ensure staff were suitable for their role.



Updated 24 December 2015

The service was effective.

Staff received training that equipped them to meet the needs of people living at the home.

People’s rights were protected.

People’s health was supported by access to primary health services.

People were supported to ensure their nutritional needs were met.



Updated 24 December 2015

The service was caring.

People who lived at the home told us they felt staff really cared about them and we observed positive interactions between people who lived at the home and staff.

Staff were motivated and inspired to offer care which was compassionate and person centred.

People told us that they were treated with dignity and respect.

People were included in making decisions about their care whenever this was possible and they were consulted about their day to day needs.



Updated 24 December 2015

The service was responsive.

People were supported to take part in a range of recreational activities both in the service and the community. These were organised in line with peoples’ preferences.

Comments and compliments from people and relatives were monitored and complaints acted upon in a timely manner.

People and their relatives were asked for their views about the service through questionnaires and surveys.

Care plans were in place to ensure people received care which was personalised to meet their needs, wishes and aspirations.



Updated 24 December 2015

The service was well led.

People were supported by staff who felt they had a good team.

Staff said the manager and provider were approachable and communication within the home was good.

There was good management and leadership at the home. Regular audits and checks were carried out, records were kept and good data management systems were in place.