Brimstage Manor Nursing Care Home

Brimstage Manor is a care home providing personal care to up to 46 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 38 people using the service.

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

Brimstage Manor Nursing Care Home had an open and transparent culture resulting in an organised, supportive and well-run service. The registered manager was clear about how the service should be provided and they led by example.

Staff were caring and treated people with kindness and respect. There was enough staff on duty to meet people's needs. Incidents and accidents were managed safely, the managers took necessary actions to keep people safe and minimise the risk of reoccurrence.

The provider had systems in place to protect people from the risk of abuse and people told us they felt safe. Risk assessments were completed to help identify and minimise risks people faced. Infection control measures were safe. Steps were taken to learn lessons if things went wrong.

The registered manager provided clear direction and good leadership. Feedback about the service was consistently positive. All the relatives we spoke with would recommend the home to others. Staff felt valued and supported, and were confident people received good care. Systems and processes for monitoring quality and safety were effective.

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 and update

The last rating for this service was requires improvement (1 June 2021).

At our last inspection we recommended that the provider reviews and updates its procedures to ensure guidance regarding testing is adhered to in order to minimise risks. At this inspection we found staff completed testing for COVID-19 in line with government guidance to prevent the risk of spreading the virus.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 based on the findings of this inspection.

We found no evidence during this inspection that people were at risk of harm. Please see the safe and well led sections of this full report.

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

Follow up

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

Brimstage Manor is a care home providing nursing care to up to 46 people living with dementia. At the time of the inspection, there were 31 people living in the home.

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

At the last inspection we identified a breach in regulation regarding the governance of the service. At this inspection we found that although improvements had been made and the provider was no longer in breach of regulation, further improvements were still required.

Systems were in place to help reduce the spread of COVID-19, however, staff testing procedures were not always completed by all staff as frequently as government guidance recommended. We made a recommendation about this in the main body of the report.

At the last inspection we identified a breach in regulation regarding the management of medications. At this inspection we found that improvements had been made and medications were stored and administered safely.

People told us they felt safe in the home and clear safeguarding procedures were in place. The home was clean and effective infection prevention and control procedures were in place. Staff told us they felt safe going to work and they had access to all required personal protective equipment.

Records showed that staff were recruited safely. There was mixed feedback regarding staffing levels within the home, but most people agreed that there were enough staff to meet people’s care needs. Feedback regarding the quality of service people received was positive and relatives told us they were kept updated regarding any changes within the home, or with their family members health and wellbeing.

Risks regarding the environment and facilities had been assessed and regular checks undertaken to ensure they remained safe. Care files showed that risks to people had also been assessed and measures were in place to reduce identified risks.

The registered manager was aware of events and incidents that needed to be notified to CQC and had submitted notifications appropriately. Staff worked with other health professionals to ensure people's needs were met and made relevant referrals when required to ensure people’s safety.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 15 January 2020).

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. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the safety of the building and the management of the service. A decision was made for us to inspect and examine those risks. 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 and well-led sections of this full report.

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.

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.

Brimstage Manor is a care home providing nursing care to up to 46 people living with dementia. At the time of the inspection, there were 41 people living in the home.

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

Medicines were not always managed safely as we found gaps in the recording of medicines administered, they were not always stored in line with guidance and they were not always administered as prescribed. There were sufficient numbers of safely recruited staff available to support people. The environment was safely maintained and risks to people had been assessed and mitigated. When necessary, referrals had been made to the local safeguarding team appropriately.

A new system of regular checks had been implemented to monitor the quality and safety of the service, however they were not always effective in identifying areas that may require improvement. Feedback regarding the management of the service was positive and the registered manager took responsive action to address concerns raised during the inspection.

People’s consent to their care was sought and recorded in line with the principles of the Mental Capacity Act 2005. 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’s nutritional needs had been assessed and specialist diets and preferences were catered for. Staff were supported through regular training, supervision and appraisals, to ensure they had the necessary skills to meet people’s needs effectively. People’s needs had been assessed and they were supported to access relevant health and social care services when needed

Care plans had been rewritten since the last inspection and most were detailed and based on the needs and preferences of the individual. Two of the four care files reviewed required further updating to ensure they reflected people’s most up to date needs. There was a range of activities available, both in the home and in the community and relatives were encouraged to participate in these. A system was in place to manage complaints and people knew how to raise their concerns. Staff were trained to support people at the end of their lives.

Staff had developed meaningful relationships and knew the people they supported well, including their individual preferences regarding their care. People’s independence, dignity and privacy were promoted and protected by staff. One person told us, “The staff are great and look after me well” and a relative said, “The staff are extremely kind, the most caring place we found.”

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 20 November 2018) and there were breaches of regulation identified. 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 that some improvements had been made, but further improvements were required and the provider was still in breach of two regulations.

The last rating for this service was requires improvement. The service remains rated requires improvement. This service has now been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the safe management of medicines and the governance of the service at this inspection.

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

Since the last inspection we recognised that the provider had failed to comply with the conditions of their registration as they had not had a registered manager in post since March 2017. The provider accepted a fixed penalty and paid this in full.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Brimstage Manor 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. Brimstage Manor is owned by Century Healthcare Limited.

The care home provides nursing care to people who have dementia and can accommodate up to 46 residents. During the inspection, there were 37 people living in the home.

At the last inspection in May 2017, we found that the provider was in breach of Regulation 9 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because person-centred care plans were not in place for all people and systems in place to monitor the quality and safety of the service were not effective. We asked the provider to complete an action plan to show what they would do to ensure the necessary improvements were made and we received this. During this inspection we looked to see if these actions had been addressed. We found that although some steps had been taken to address the concerns, further improvements were required to ensure the service was meeting required standards. We identified breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as well as Regulation 18 of Care Quality Commission (Registration) Regulations 2009.

There was no registered manager in post. A manager had been appointed and been in post since May 2018. They were in the process of applying to the Commission to become registered. However, following the inspection we have been informed that the manager is no longer working for the service. 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 is currently being supported by a manager from one of the providers other registered services, along with support from the operations director, until a new manager is appointed.

At the last inspection in May 2017, we found that not all people had care plans in place. During this inspection, we saw that improvements had been made and care plans were in place.

However, we found that care plans were mainly pre-populated printed plans with gaps for people’s names. We saw that these were not always completed fully. Care plans did not all contain accurate information to ensure that staff had clear guidance on how to best meet people’s needs and they had not all been updated regularly.

In May 2017, we found that the registered provider was in breach of Regulation as quality monitoring systems were not effective. During this inspection we looked to see if improvements had been made and found that systems in place to monitor the quality of the service were still not robust and had not identified the issues we highlighted during the inspection.

The provider had some systems in place to help ensure they remained aware of how the home was running. However, we found that the registered provider had not ensured that CQC were notified of events and incidents that occurred in the home.

Not all safe medicine administration practices were followed in the home. For example, people’s allergies were not always recorded. When people were prescribed medicines as and when required, they did not always have protocols in place to inform staff when to administer them. Advice from a pharmacist had not always been sought for people who required their medicines to be administered covertly (hidden in food or drink).

We found that although some risk assessments were in place, risks to people were not always fully assessed and mitigated.

People’s relatives told us they felt their family members were safe living in Brimstage Manor. Staff we spoke with were knowledgeable about safeguarding and how to report concerns and we found safeguarding issues had been reported appropriately to the local authority. Accidents and incidents were reported and investigated appropriately.

Staff were recruited following checks to ensure they were safe to work with vulnerable people and we found that there were sufficient numbers of staff to meet people’s needs. Agency staff were utilised to ensure staffing levels were maintained when there was a vacancy or sickness.

Arrangements were in place for checking the environment and equipment to ensure it was safe. External checks took place on the gas, electricity, lifting equipment and fire safety systems. All areas of the home were clean and clutter and odour free.

The system in place to monitor Deprivation of Liberty Safeguards (DoLS) was not always clear. We discussed this with the manager and they updated the system during the inspection.

Staff had a good understanding of the MCA told us they always asked for people’s consent before providing care. Records showed that people’s consent was sought in relation to living in Brimstage Manor and receiving care and treatment. When people were unable to provide their consent due to memory difficulties, we saw that mental capacity assessments were usually completed.

Records showed that staff received regular training to help ensure they could meet people’s needs. The registered provider has supported three senior staff to undertake an accredited course in becoming a Care Home Advanced Practitioner (CHAP). CHAP’s had the skills and knowledge to undertake some of the tasks traditionally undertaken by nurses. Comprehensive induction and appraisals were also provided to staff. Not all staff had received regular supervision, but staff told us they felt well supported in their role.

We saw during the inspection that drinks and snacks were available throughout the day and a choice of alternative meals were available if people did not want the main meal on offer that day. If there was a concern about the amount a person ate or drank, staff recorded their intake so it could be monitored.

Adaptations had been made to the environment to support people living with mobility difficulties to get around easily and people living with dementia to find their way around and locate where they were more easily.

We saw that staff interacted with people in a caring and compassionate way and relatives told us that their family members were treated with respect and dignity by all staff. We saw positive interactions between people who lived in Brimstage Manor and staff. Staff spent a lot of time with people, if anyone became unsure or upset staff were present to distract them and reassure them.

We observed relatives visiting throughout both days of the inspection and they told us they were always made welcome. The manager told us they would make referrals to local advocacy services if required, for people that did not have friends or family to support them.

Some care plans contained information about people’s preferences and choices. Most care files contained end of life care plans. This showed that discussions had been held with people or their relatives to establish people’s wishes and preferences at this time.

Regular activities were available to people in the home. We saw that there was a lot of activities during the day to support people to remain occupied.

People had access to a complaints procedure and this was displayed within the home. Relatives we spoke with were aware of the process and told us they would not hesitate to raise a concern if they needed to.

Systems were in place to gather feedback regarding the service. This included annual quality assurance surveys and meetings.

Ratings from the last inspection were displayed within the home as required. The provider’s website also reflected the current rating of the service.

You can see what action we told the provider to take at the back of the full version of this report.

Staff and people’s relatives were positive about the new manager and their approach. Family members told us they were approachable and the manager had organised a family meeting for the week following our initial visit.

At the last inspection in April 2016, the service was rated overall Good. At this inspection we found the service was rated as Requires Improvement.

During this inspection we found that there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were of Regulation 9; Person-centred Care and Regulation 17; Good Governance.

We completed this inspection after concerns had been raised with us relating to the quality of care planning for people nearing the end of their life. We found that the end of life care planning in place was in the form of a ‘pre-palliative /holistic’ plan, which was generalised and did not offer staff enough guidance that was individualised to the person. At the point of being coded as amber on the end of life register this plan replaced more individualised and person centred care planning. We saw that some people had been on a ‘pre-palliative / holistic’ care plan for 19 and 22 months, without it being reviewed as appropriate after a period of time had elapsed.

At the time of our inspection the clinical director along with the newly appointed manager had already been reviewing the care files of each person. We saw some people’s care files where comprehensive care plans had been reinstated and updated for each aspect of a person’s care and the ‘pre-palliative / holistic’ generic care plan approach had stopped being used.

In other areas of care planning we saw that there was not sufficient information in people’s care files relating to pressure relieving mattresses and actions that had been taken to reduce the risk of falls. We also saw that in people’s care files there was a ‘getting to know you’ document containing information about a person, their background and preferences. A one page profile was kept in each person’s room which ensured that staff had to hand prompts and reminders to help them support people well. One family member we spoke with praised their relative’s recent experience of care planning at the home.

After our previous inspection we gave written feedback to the registered manager highlighting that at times care plans had not contained appropriate details to inform care staff. In these areas there had not been significant improvements. The systems that had been in place until recently had not been effective in gathering and assessing information about the quality of services provided to people and ensuring improvements were made.

Staff and visitors gave us mixed feedback about the number of staff available at the home and we saw one person waiting for care. We recommended that the manager review the numbers and deployment of staff members to ensure times of pressure on staffing levels are minimised.

People’s medication was administered safely. However improvements were required in the documenting of as and when required (PRN) medication and prescribed topical creams. We recommend that the manager review these procedures.

People told us they liked living at the home. One person said, “I’m very happy here, it’s quite good here.” During our visit there was a friendly and relaxed atmosphere at the home. We saw that the staff made visitors feel welcome. We saw that staff were respectful towards people, stopped to talk to them and were positive in their communication. People’s relatives were positive in their feedback about the staff at the home. One person’s relative said about the staff, “They are lovely, experienced and really care.” Staff and people’s relatives told us that at certain times there was not enough staff at the home.

People told us that the food was very good and people’s relatives were very positive in their feedback with regard to the dining experience at the home. We saw that people were frequently offered choices in daily living. However people’s care plans did not always show that they were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible. The home’s policies supported this practice but the documentation systems in place needed improving. We recommended that the registered manager review the documents used for recording a decision made in a person’s best interests.

Staff members told us that they felt well supported in their role. We saw that they received annual appraisals, regular supervision meetings; appropriate training and some staff told us they had opportunities for professional development. We saw that staff had received training in safeguarding vulnerable adults and new staff had been recruited safely ensuring that they were suitable to work with vulnerable adults.

The home was clean and free of unpleasant odours. The building had a series of checks to ensure that the environment, services and any equipment used was safe. Parts of the environment were mono-tone with no distinguishing features, visual stimulation or aids for orientation for people living with dementia. The owner of the home had plans in place to make improvements as they had already done in their other homes.

We saw that people had been supported to attend health appointments and have access to their GP. We looked at documents that showed how the nurses prioritised people’s health needs as part of their daily planning.

A range of activities were organised and facilitated by the activities co-ordinator, visitors from outside the home and occasional trips out into people’s local community. We saw that people who were receiving care from their bed were supported to participate in relaxation sessions.

Most people’s relatives we spoke with told us they had been happy with the communication they received from the managers and staff at the home. People living at the home, their relatives and staff members spoke positively about the new manager. Many people commented that they had found them approachable, positive and very visible at the home. We spoke with the new manager and saw that they already had plans in place to make improvements to the service people received.

There was a registered manager working at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The manager had a warm and kind approach to people and helped them with patience. We noted that she was familiar with people and knew them by name. During our visit we observed her taking time to stop and talk to people living at the home and their relatives. Staff we spoke with told us she was approachable and was visible at the home. People’s relatives also told us she was approachable and that communication from the manager and staff at the home was good. The manager had used questionnaires and conversations to gain feedback from family members about the care of their relative.

People’s care files we looked at were recent and they had the dates noted of regular reviews. They contained brief information about a person, their care plan and risk assessments. We found the information in people’s care documents wasn’t always up to date, complete, detailed enough or at times didn’t follow a logical pattern. We have made a recommendation that the manager review how care plans and other care documents are reviewed and updated at the home.

People living at the home and their relatives who we spoke with told us they felt the home was a safe place. There were security measures in place within the building. The home was clean. There were adequate staff available to support people. The staff were trained in and were aware of, safeguarding vulnerable adults. The home’s environment was safe and health and safety checks had taken place on the safety systems of the building, equipment used by people and the maintenance of the environment. Accidents and incidents were recorded and we observed some incidents had led to a quick response from the manager and staff when necessary. People’s medication was stored and administered safely by nursing staff.

People who lived at the home and their relatives told us they liked their rooms. People had been supported to put up their own pictures and ornaments in their rooms to personalise them. One in three of the rooms were ensuite. The Hesketh wing was described as an area of the home specialising in caring for people with dementia. However the corridors and dining room walls of the wing were all painted in one light mono-tone colour with no distinguishing features and they felt clinical. There were no dementia friendly signs or evidence of any adaptions or points of interest in the environment for people experiencing dementia. We have made a recommendation that the manager review current best practice on how the environments of a home can affect a person living with dementia.

We saw that staff were recruited and introduced to the home safely with the relevant checks in place. New staff received induction training when new to the role. All staff received training relevant to their role with longer standing staff receiving refresher training. We looked at the manager’s training plan which organised this. Staff told us and we looked at records that showed staff received regular supervision and annual appraisal. There was staff meetings held in which staff were updated with new information.

We observed lunchtime in the ‘House’. The dining room was well laid out and people were supported with kindness and respect. People’s preferences were sought and staff did not assume to know but rather asked people. There was a main meal and a choice of alternatives. People we spoke with told us they enjoyed the food at the home. The kitchen facilities had been awarded the highest rating of five stars by the local authority.

The home was operating in line with the principles of the Mental Capacity Act (2005). Some people had a Deprivation of Liberty Safeguard (DoLS) in place, for some other people the manager had submitted an application to the local authority. When a person didn’t have the capacity to make a decision and a decision needed to be made the staff at the home had made arrangements for a best interest meeting to take place, and invited the relevant people. People were provided with information and supported to make their own decisions as much as possible. This included being involved in making future decisions for end of life care.

The staff at the home had a caring approach to people. We observed staff to be warm and kind, using people’s names and treating people with dignity. Visitors came and went from the home. They told us they were made to feel welcome at the home and felt comfortable making phone calls to the home at other times. There was a range of activities available to people, some of these involved going outside of the home.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

At our last inspection of the home in May 2014 we identified concerns with the support people were given with their care and welfare. At this inspection we found the provider had taken action to address those concerns. We found that a review of the use of safety gates within the home had been carried out. As a result the use of these had lessened. Where they remained in use this was as a result of an assessment to ensure it was of benefit to the person.

At our last inspection of the home in May 2014 we found major concerns with the way the home safeguarded the people living there. At this inspection we found the provider had taken action to address those concerns. Training for staff in safeguarding adults was on-going and staff had an understanding of their role in identifying and reporting potential abuse. Information on how to report any safeguarding adults concerns had been displayed within the home so that visitors and staff could access it easily.

We saw evidence that potential abuse had been reported to the correct authorities for investigation under safeguarding adult's procedures.

Is the service effective?

At our last inspection of the home in May 2014 we found concerns with the support provided to people to make decisions or have them made on their behalf. At this inspection we found that some work had been undertaken to update assessments. However others lacked detail regarding the way in which the decision had been reached, the options considered and how it should be carried out. This could lead to decisions being made on the person's behalf that may not be in their best interests.

Is the service caring?

People living at the home and their visitors told us that they were satisfied with the support they received with their care and welfare. A visitor described staff as, 'lovely and kind' and we observed staff spending time interacting with people throughout the day as well as meeting their care needs.

Is the service responsive?

This was a responsive inspection to look at previous non-compliance against the regulations and we did not look specifically at this area. For information regarding this please refer to the report of our inspection carried out at the home in May 2014.

Is the service well-led?

A registered manager was in post at the home.

At our last inspection of the home in May 2014 we identified concerns with the systems in place to monitor the quality of the service provided by the home. At this inspection we found that action had been taken on the points raised at our last inspection. Audit files were readily available and audits had been undertaken in a number of key areas including, fire equipment, care plans and medication.

We used a number of different methods to help us understand the experiences of people using the service. This was because the people using the service had complex needs which meant they were not all able to tell us their experiences. Due to this we have used a formal way to observe people in this review to help us understand how their needs were supported. We call this the 'Short Observational Framework for Inspection' (SOFI). We spoke with four people living at Brimstage Manor and met with several others. We also spoke with seven relatives and with nine members of staff who held different roles within the home.

Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

At our last inspection of the home in November 2013 we found minor concerns with how the home safeguarded vulnerable adults. At this inspection we found major concerns. This was because incidents of abuse towards the people living at the home had not been reported to the relevant authorities for investigation and action as required. This meant that the home had not taken the appropriate action to safeguarding vulnerable people.

We found that some records relating to the running of the home could not be readily located by the person in charge of the shift. This meant that information they may need to carry out their role effectively was not available to them in a timely manner. We also found that the use of safety gates had not been risk assessed. It was therefore not possible to establish whether they were of benefit or a risk to people living at the home.

People had been cared for in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly.

We observed that there were enough staff on duty to meet the needs of the people living at the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Assessments had been carried out and applications had been submitted to the appropriate authorities where they were identified as needed.

Is the service effective?

Overall assessments of people's capacity to make decisions had been carried out. We found that these did not refer to a particular decision. An overall assessment stating that a person lacks capacity could lead to decisions being made on their behalf that are against their wishes and that they may have been able to make.

People living at the home and their relatives told us that they were happy with the care provided. Relatives told us that staff had been quick to note any health issues the person had and records we saw confirmed this. We observed that people had received support with their personal care and that staff knew people well and spent time interacting with them as well as meeting their care and welfare needs.

Staff told us that they had felt supported by senior staff and had received the training they needed. Training records showed that staff had undertaken a variety of training in relevant areas. However some of this training including supporting people with dementia and safeguarding adults' had taken place some time ago.

Is the service caring?

The people living at the home and their relatives told us they had found staff kind and caring. One person told us, 'The attitude is far more caring than I imagined.' Another person commented, 'They have got time for you.'

During most of our inspection we observed staff spent time interacting with people and engaging them in activities However during the lunchtime meal staff had limited interaction with people.

Is the service responsive?

People's needs had been assessed before they moved into the home. We found that care plans and risk assessments had been put into place to guide staff on how to support people with their care and welfare needs. These had been updated regularly and as people's needs changed.

Is the service well-led?

A registered manager was in post at the home. Systems were in place for monitoring the quality of the service. These included seeking the opinions of relatives and professionals. However we found that decisions made in relation to safeguarding vulnerable adults were not in line with current guidance and legislation and may place vulnerable people at further risk. We also found that quality assurance audits failed to note a lack of detailed capacity assessments and a lack of assessments relating to the use of safety gates.

The care plans we reviewed were all individualised and person centred. All care plans reviewed had a comprehensive social history. They were all well organised up to date. All had relevant risk assessments, such as:-falls, mobility, nutrition and bed rails which were reviewed monthly. Where appropriate the provider also had records of best interest assessments which were detailed, signed by the respective family and GP. All families we spoke to were aware of the care plans and most had been involved in there development. The care provider undertook audits of all care plans which we saw had been completed this year.

We saw the kitchen was clean and clutter free. We saw kitchen staff had food hygiene certificates. We spoke to the chef who told us how he catered for a variety of diets, for example, diabetic and vegetarian. Four out of the six relatives we spoke to all agreed the food was 'very good' this was also supported by the one service user we spoke to.

The provider produced a training matrix which showed that most of the staff had training in challenging behaviour, dementia awareness and safeguarding. The provider might like to note that most of this was done in 2009 and needed updating.

Due to the nature of the home staff told us challenging behaviour was very common. The provider might like to note that it would be beneficial for all staff to attend a training update on how to manage challenging behaviour. When asked staff were able to tell us what they would do in such events but this was not necessarily the correct and safest way.

'It's excellent',

'Very nice home, the best she has been in',

'It's a lovely place, they are warm, caring and she is well looked after'.

People told us and we saw evidence that they were involved in care and treatment decisions, especially around end of life care. We observed that people were well cared for and treated with dignity and respect. People's needs were assessed, planned and reviewed. We found that the provider monitored the quality of the service and gained views on the service from staff and people who used the service.

There were suitable numbers of experienced and qualified staff to look after people and their varying needs. They demonstrated an awareness and understanding of how to protect people from abuse.