Archived: Holmfield Nursing Home

Holmfield Nursing Home is a care home, providing personal care, nursing and accommodation. There were 17 people with frailty due to older age living at the home at the time of the inspection.

What life is like for people using this service:

• People felt care staff were kind towards them and looked after them well. However, there were not enough staff. Planned for activities did not always take place because sufficient staff were not on shift to meet people’s needs.

• Most people had individual plans of care, so staff had the information they needed to care for them. However, this was inconsistent and one person had no individual plan of care.

• Risks were not always identified, and risk management plans were not always in place.

• People’s prescribed medicines were available, but medicines were not always managed safely which posed risks to people’s health and wellbeing.

• Staff did not always have the necessary skills to meet people’s needs.

• Staff employment files did not contain the information required to show the provider had undertaken required checks to ensure staff suitability.

• Care staff understood the need to gain people’s consent before personal care was provided. However, the provider had not ensured staff consistently understood, and worked within, the requirements of the Mental Capacity Act 2005.

• Most staff completed self-guided training, however some told us they had not received training.

• People were supported to eat and drink adequately.

• Care staff, the cook and the housekeeper interacted positively with people, showing kindness and compassion.

• People and relatives were, overall, complimentary about staff and had no current complaints. However, some complaints had not been recorded.

• There was no managerial oversight of the home in the provider’s, nominated individual’s and home manager’s absence. The lack of effective governance meant aspects of the quality and safety of the service were poor.

• The provider’s quality assurance system did not ensure quality and safety. General décor and maintenance required repair. Some maintenance issues posed potential risks of cross infection because effective cleaning could not take place.

Following our inspection, we notified relevant stakeholders including the Local Authority and Local Clinical Commissioning Group (CCG) about the areas of concern we identified.

We reported that the registered provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were:

Regulation 9 Regulated Activities Regulations 2014 - Person centred care

Regulation 11 Regulated Activities Regulations 2014 – Need for consent

Regulation 12 Regulated Activities Regulations 2014 - Safe care and treatment

Regulation 17 Regulated Activities Regulations 2014 - Good governance

Regulation 18 Regulated Activities Regulations 2014 - Staffing

Rating at last inspection: The last report for Holmfield Nursing Home was published on 29 May 2018 and we gave an overall rating of Good.

Why we inspected: We received information of concern including infection prevention and control, and the administration of medicines, from a joint quality monitoring visit undertaken by the local Clinical Commissioning Group (CCG) and Local Authority (LA). The CCG and LA commission (purchase) packages of care on behalf of people. A relative contacted us about their complaint about the services provided.

Enforcement: Action provider needs to take (refer to end of report). Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: On the day of our inspection visit, the provider, nominated individual and home manager were not available to be at the service. We gave detailed feedback to a senior person, by a telephone meeting, which took place with the nominated individual the day following our inspection visit. During our telephone meeting, we told the nominated individual about our immediate concerns. The nominated individual sent us evidence of some immediate actions they had taken to ensure the safety and wellbeing of people living at the home. We will continue to monitor any regulatory action as an outcome of this full inspection report.

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 act 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 act 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.

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

Holmfield Nursing Home provides accommodation, nursing and personal care and support for up to 22 older people living with physical frailty due to older age and complex health conditions. The home has two floors; with a communal lounge and dining area on the ground floor. At the time of our inspection, there were 20 people living in the home.

At the time of our inspection visit, the manager was awaiting confirmation of whether or not they had been successful in their application to register with us. Shortly after our inspection visit, it was confirmed their ‘registration’ had been accepted. We refer to the manager as ‘registered manager’ throughout the report. 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.

When we inspected Holmfield Nursing Home in August 2016, we gave a rating of ‘Requires Improvement.’ In November 2016, we returned to undertake a focused inspection which looked at whether the service was safe and well led. This was because we had received some information of concern regarding the management of risk to people’s safety and wellbeing. At that inspection, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and gave a rating of ‘inadequate.’ The service was placed in ‘Special Measures’. Services in special measures are kept under review and inspected again within six months.

At our inspection in May 2017, we found sufficient improvements had been made to remove the service from special measures, and the rating changed to ‘Requires Improvement’. However, we found continued breaches of the regulations related to people’s safe care and in the governance of the home. Risk of potential harm to people were identified, however, actions to minimise those risks were not always effective. Staff did not feel consistently supported by the registered manager, and planned improvements and actions had not always taken place. We also found staffing levels were not always sufficient to keep people safe.

At this inspection, we found improvements had been made and the provider was no longer in breach of the regulations. The overall rating has changed to ‘Good’ overall. However, the rating for ‘well led’ remains ‘requires improvement because the provider needs to demonstrate stability and sustained improvement.

Action had been taken to ensure risks were properly assessed and plans were in place to manage those risks. There were enough staff on duty to ensure risks were well managed and people were kept safe. The provider had developed a new tool to ensure staffing levels remained sufficient. People’s medicines were now managed safely and were regularly checked to ensure good practice was followed.

Staff now felt well supported by the registered manager, and reported significant improvements had been made. The registered manager, with support from the provider, had developed a range of checks and audits to check the quality of service provided. However, further improvements were needed to ensure issues were identified and improvements were sustained.

Improvements had been made to ensure people were able to maintain activities and hobbies that interested them, and a range of activities were being developed to help engage and interest people.

People told us they felt safe with the staff who supported them, and we saw people were comfortable with staff. Staff received training in how to safeguard people and understood what action they should take in order to protect people from abuse. The provider ensured staff followed safeguarding policies and procedures. The provider conducted pre-employment checks prior to staff starting work, to ensure their suitability to support people. Staff told us they had not been able to work until these checks had been completed.

The risk of infection was minimised through effective infection control procedures and auditing.

People were asked for their consent before staff supported them. Where people lacked capacity to make particular decisions, this had been assessed to ensure people were protected. Where people lacked capacity and had been deprived of their liberty to keep them safe, the provider ensured they applied to the relevant authority to ensure this was done lawfully.

Effective induction of new staff was in place, and the registered manager had taken action to ensure nursing and care staff had the required skills and knowledge.

People and relatives told us staff were respectful and treated people with dignity. We saw this in interactions between people and staff.

People had access to health professionals when needed and care records showed support provided was in line with what had been recommended. People’s care records required updating to support staff to deliver personalised care and give staff information about people’s communication needs, their likes, dislikes and preferences. People were not always involved in how their care and support was delivered and reviewed, but the provider had plans in place to ensure this process was completed by summer 2018.

Complaints were logged and acted on in line with the provider’s policy and procedure, and actions were taken to ensure the service improved following complaints and concerns.

Holmfield nursing home provides accommodation, nursing and personal care and support for up to 22 older people living with physical frailty due to older age and complex health conditions. At the time of the inspection 13 people lived at the home. The home has two floors; with a communal lounge and dining area on the ground floor.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of this inspection the home had a registered manager in post, who had registered with us in March 2016.

When we inspected Holmfield Nursing Home in August 2016, we gave a rating of ‘requires improvement.’ In November 2016, we returned to undertake a focused inspection which looked at whether the service was safe and well led. This was because we had received some information of concern regarding the management of risks to people’s safety and wellbeing. At our focused inspection, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and gave a rating of ‘inadequate.’ The service was placed in ‘Special Measures’. Services in special measures are kept under review and inspected again within six months. In November 2016, the provider agreed to a voluntary placement stop which meant until improvements were made, no new people would be admitted to the service. Following the implementation of some improvements, the provider has maintained a restricted admissions policy. We requested that the provider send us fortnightly action plans on the implementation of their improvements, which they have.

At this inspection we found sufficient improvements had been made to remove the service from special measures. However, we found continued breaches of the regulations that related to people’s safe care and in the governance of the home. Some of the provider’s planned improvements had not always been made or sustained. Risks of harm to people were identified, however, actions to minimise those risks were not always effective. This was because the governance of the home had not always ensured actions were taken to ensure identified risks to people’s safety and wellbeing were managed effectively.

Staff did not consistently feel supported by the registered manager or that concerns raised were acted on. Audit systems and processes to monitor the quality and safety of the service were not always effective in identifying where improvement was needed. The governance of the home was not always effective in protecting people’s safety and wellbeing and staff did not consistency feel supported by management.

The provider’s improvement plan for the clinical support of the registered manager had been further delayed due to staffing changes. This also meant some planned improvements had not yet taken place. This included the support of nursing staff and undertaking their clinical competency assessments.

People had their prescribed medicines available to them and, overall, people were given their medicines by nurses following safe practices. However, we found records of some medicine applications were not kept by nurses to ensure manufacturer’s instructions were followed.

Staff knew how to deal with emergencies that might arise from time to time. The provider had a safe system of recruiting staff and checks were undertaken to make sure staff were of good character before they supported people who lived at the home. However, further checks to update records for long standing staff were not undertaken to ensure staff remained of good character.

Staff were given training and care staff felt this gave them the skills they needed for their role. However, nurses felt they were not offered sufficient opportunities to update and refresh their clinical skills. Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Overall, people enjoyed their food and were supported when needed with their meals and drinks. However, staff told us food choices were occasionally restricted because they ran out of basic items, such as white bread. People were supported to maintain their health and access healthcare professionals, although referrals were not always made as soon as they could have been.

Most people felt staff were kind and had a caring approach toward them. People told us staff did their best and overall, responded to them as quickly as they could. People were able to summon staff attention if they were in their bedrooms but improvement had not been made to ensure people had a call bell accessible to them in the communal lounge, that was not consistently staffed, and meant people could not gain staff attention if needed. Staff felt they were restricted in how far they were able to personalise care to individuals because of time constraints and felt care continued to be task led. Staffs were not consistently respectful to people when they focused on non-care tasks.

There were very limited opportunities for people to take part in any group activities or be supported with individual hobbies or interests so that risks of social isolation were minimised. People and their relatives felt activities had become less in the home and felt more were needed.

The provider’s complaints policy was displayed and relatives felt they could raise issues if they needed to.

We found continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is ‘Requires Improvement’

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

We informed the provider we would return, with the CCG, on 11 November 2016. We gave feedback about concerns we had identified to the registered manager, operations manager and provider on 10 November 2016. To reduce risks to people, the provider agreed to impose a voluntary placement stop on admissions to the home whilst improvements were made. Further feedback was given to the registered manager, operations manager and provider on 11 November 2016. Following our inspection visit, the provider sent us an action plan telling us what improvements they would make. Two inspectors returned, unannounced, on 24 November 2016 to check if immediate actions had been taken in response to concerns identified had been implemented by the registered manager and provider to address the issues we identified.

Holmfield nursing home provides accommodation, nursing and personal care and support for up to 22 older people living with physical frailty due to older age and complex health conditions. At the time of the inspection 15 people lived at the home. The home has two floors; with a communal lounge and dining area on the ground floor.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of our inspection there was a registered manager in post who had become registered with us in March 2016.

We inspected the home in August 2016, to check if improvements had been made following our inspection visit in January 2016. In January 2016, we found breaches of the regulations and rated the home ‘inadequate.’ We took enforcement action and served warning notices on the provider. In August 2016, we found some improvements had been made to people’s care and safety and in the governance of the home and the provider told us about further planned improvements. In August 2016, we rated the service as ‘requires improvement.’

At this inspection we followed up on the concerns we received from a member of the public and healthcare professional, as well as checking to make sure, planned improvements had been made. We identified improvements had not always been effective or sustained. The provider’s improvement plan for the clinical support of the registered manager had not been effective. We found breaches in the regulations relating to safe care and treatment, staffing and governance of the home.

The provider had quality assurance systems and processes in place to monitor the service, but these were not always effective.

People felt safe living at the home because staff were on shift to support them. However, people told us staff were ‘rushed.’ Staff told us there were not enough of them to do their job ‘properly.’

Sufficient numbers of staff were not always available to meet people’s needs in a way that promoted their safety and planned improvements to staffing levels had not been sustained.

People were assessed to reduce the risk of harm or injury, however, actions staff needed to take to reduce the risks were not always shared with them, so risks to people were not always minimised.

Staff felt they did not always have the equipment they needed to ensure people were comfortable and risks to people were minimised.

Some people felt cold in their bedroom and parts of the home were cold.

Staff had been trained to safeguard people and knew what to do if they had a concern. However, people were not always protected against abuse because senior management had not always followed their safeguarding policy in reporting a concern to the local authority.

People had their prescribed medicines available to them and were supported to take these by trained staff. Records of people’s medicines were not always kept as required.

We rated the home as ‘inadequate’ and placed the home in ‘special measures,’ which meant we will keep the service under review. We have written to the provider to tell them to update us on a fortnightly basis about what improvements are made.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

Holmfield nursing home provides accommodation, nursing and personal care and support for up to 22 older people living with physical frailty due to older age and complex health conditions. At the time of the inspection 21 people lived at the home. The home has two floors; with a communal lounge and dining area on the ground floor.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of our previous inspection in January 2016, there was a new manager who was not yet registered with us. This manager became registered with us in March 2016.

When we inspected the home in January 2016 we identified breaches in the regulations relating to safe care and treatment and good governance of the home. We rated the home as ‘inadequate’ and placed the home in ‘special measures,’ which meant we kept the service under review. We served a warning notice on the provider because the quality of the care the provider has responsibility for, fell below what is legally required. We told them improvement must be made by 10 June 2016. At this inspection visit, we looked to see if the requirements of the warning notices had been met and found they had. Improvements had been made, however some further improvement was still required. Following our inspection feedback to the provider and registered manager, the provider informed us how further improvements would be implemented and gave us timescales for some of these.

People told us they felt safe living at the home. Staff knew how to protect people from the risk of abuse because they had been trained to safeguard people and knew what to do if they had a concern.

People felt there were not enough staff on shift and we found sufficient numbers of staff were not always available to meet people’s needs in a timely way that promoted their safety. Risks to people were assessed to reduce the risk of harm or injury, however, actions staff should take were not always shared with them which meant risks to people were not always minimised.

People had their prescribed medicines available to them and were supported to take these by trained staff. Some information about medicines was not kept by staff as needed and checks on the safe temperature storage of medicines in the medicine fridge were not effective.

Staff had received training to give them the knowledge and skills to care for and support people. People felt staff had the skills they needed to care for them. Staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People were offered choices of what they wanted to eat and drink. People were referred to healthcare professionals when needed and staff followed their guidance to maintain people’s health and wellbeing.

People told us staff were kind and had a caring approach toward them and involved them in day to day decisions about their care, although at times staff told us they felt rushed. People had limited opportunities to be involved in their care planning

Some planned social activities were offered to people, however there were periods of time when activities were not offered and staff were not always available to respond to people because they were busy with other tasks. People were not always able to gain staff attention because call bell cords were not accessible in communal areas of the home. Staff felt care was often task led at the home.

Improvements had been made in the governance of the home, although some further improvement was required. Systems and processes were in place to monitor the quality of the service, although where actions were identified as needed to make improvement, these had not always been implemented. The clinical lead nurse role had not yet been fully developed as effective support to the registered manager or in undertaking the competency assessments for nurses.

Holmfield Nursing Home provides accommodation, personal care support and nursing care to up to 22 older people living with health care conditions and / or physical frailty due to older age. At the time of the inspection 21 people lived at the home.

The home is required to have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. At the time of this inspection the home did not had a registered manager in post. The provider had appointed numerous managers at the home but there had been no registered manager since February 2013. A new manager had commenced employment in November 2015 and, in January 2016, had submitted their application to become registered with us.

At our previous inspection in July 2014 we found concerns with the maintenance of records. During this inspection we found no progress had been made to address the issues. We found further concerns with records, such as people’s food and drink charts did not reflect their identified needs had been met.

We found people had their prescribed medicines available to them, however, we saw medicines were not safely managed by staff. For example, ‘homely remedies’ available for people’s use were out of date and we found out of date prescribed food supplements. We could not be sure people always had creams applied as prescribed because records were incomplete. We also found medicines were not always stored securely.

Some risks associated with people’s care had not been assessed and no action had been taken to ensure people were protected from harm or injury. Staff told us there were not sufficient staff on shift. We found care staff were allocated non-care tasks to complete such as kitchen and laundry tasks that took them away from keeping people safe and meeting their needs.

We found the storage arrangements of some items, such as prescribed dressings, were not suitable and presented a risk of contamination or infection. Some areas of the home were in need of maintenance. For example, we found some wooden window frames were rotten which allowed cold drafts into people’s bedrooms and prevented effective cleaning.

Staff had completed some training to deliver care and support but they felt it was not always effective in giving them the skills or knowledge they needed to undertake their roles. Staff had a limited knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. This meant some staff were not aware of their responsibilities under this Act. Staff did not consistently offer people choices about their food. People identified at risk of malnutrition, did not always have the extra calories added to their food as required because items were not always available to staff. People were not consistently supported to maintain their health and were not always referred to health professionals when needed.

Staff had a caring approach to people and were kind and compassionate, but staff spoken with felt care was ‘task-led’ at times because of time constraints. People were treated with dignity and respect, but were not routinely supported to express their views or involved in making choices or decisions about their care.

Overall, staff knew people’s needs, however, people’s care plans did not always contain the information for staff to refer to if needed. There were limited social activities offered which did not meet people’s needs.

Some systems were in place to assess the quality of the service provided but these were not effective. We found there was insufficient oversight, from the provider, to check delegated duties had been carried out effectively.

We found numerous breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

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

We looked at five outcomes to answer the following five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our findings during the inspection, speaking with people using the service, the staff supporting them and from looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

People we spoke with told us staff treated them with dignity and respect and they felt "safe".

People's needs were assessed before people lived at Holmfield to make sure their needs could be met.

We saw risk assessments and audit processes were in place to make sure risks associated with people's care were appropriately managed.

We saw there was a Mental Capacity Act (MCA) 2005 policy in place. The manager understood her responsibilities under the MCA and Deprivation of Liberty Safeguards (DoLS). We were told there were some DoLS applications in progress. Training records showed some staff had completed training in relation to the MCA and DoLS.

We found records across the service were not always sufficiently detailed or clear to demonstrate the service was operating effectively. This included records linked to care, medication and training.

Is the service effective?

People's health and care needs were assessed with them and people were involved in making decisions about how their care and treatment was delivered. People had an individual care plan which explained what their needs were.

We saw arrangements were in place to enable people to access a range of health professionals to meet their health and welfare needs.

We saw staff asked people before delivering care make sure they agreed to this.

Staff were able to access training on an ongoing basis to make sure they updated their skills and provided effective care to people.

Is the service caring?

During the inspection we observed staff providing support to people in the lounge. We saw they were caring and treated people in a respectful manner.

We spoke with three staff members who were knowledgeable of people's care needs and how they wished to be supported to enable their needs to be met.

People and a relative spoken with were satisfied with the quality of care provided and made positive comments about the staff. They told us, 'The carers make X very happy.' 'I feel safe with them. They will come and speak to me kindly and ask if I want to get up and they get me up.' 'The nurses come in to check me and do that all of the while.'

Is the service responsive?

We saw regular reviews of people's care plans were carried out. This enabled changes in people's needs to be identified and acted upon.

We saw when staff identified health concerns, these were followed up with a health professional. This meant people received any medical treatment required to maintain their health.

People told us they felt confident in raising any concerns with staff or the manager and felt they would be addressed. All the people we spoke with were satisfied with the service they received.

Is the service well-led?

We saw there were systems in place to monitor the quality of care and services provided. This included a quality monitoring questionnaire which nine people had responded to. We saw people were satisfied overall with the service and all those that took part in the questionnaire responded they would recommend the home to others.

We saw the provider had used information gathered through quality monitoring processes to assess and improve the quality of service for people.

During our visit the provider was present. When we identified areas where improvements could be made, the provider took prompt action to begin to address these areas.

Staff understood their roles and received support and training on a regular basis to ensure they were competent to provide care and support to the required standard.

We received an action plan from the provider telling us what they were going to do to ensure the necessary improvements were made.

We carried out this visit to check that improvements had been made and to confirm the service was now compliant. The visit was unannounced so that no one living or working in the home knew we were coming.

We found that changes to the environment and new equipment provided had improved the standards of hygiene in the home. Systems had been implemented by management to monitor and assess infection prevention and control systems.

This meant that people and their visitors were supported by staff who understood the need for good hygiene measures and how this was important in order to reduce the risk of infections.

We therefore, judged that the compliance action set at the last inspection had been complied with.

All the people we spoke with said they felt well cared for. One person said staff were 'very kind', another person told us that staff were 'first class.'

People told us they could make choices and if they had any complaints they would talk to the manager. One person told us, 'I ask for my meals on a tray in my room and that's what I get.'

We spoke with two visiting family members who were happy with the way the service cared for their relatives. They spoke highly of the staff and described them as kind and caring. One visitor told us, 'The staff are all very friendly, I feel my mother is in the best possible place.'

We had some concerns about infection prevention and control practices in the kitchen, which were discussed with the provider and management on the day of our visit.

The people who used the service had complex needs which meant they were not able to tell us in detail about their experiences. When we met with them they smiled when we asked them how they were and gave very brief answers when we asked about the meals served to them at the home.

When we spoke with staff they could tell us how they ensured people had sufficient food and drink to maintain their well being. We saw that people were relaxed and at ease with staff at mealtimes and when receiving support with their meal.

Staff told us they had recently, or were, undertaking training in nutritional care. They told us this was 'good' training and helped them to be 'aware' of the risks to elderly and frail people if their food and fluid intake was poor.

We found all records about people's dietary needs were completed and up to date. This showed that the provider was supporting people with their dietary needs as recommended by healthcare professionals such as dieticians and speech therapists.