Archived: Charnwood

Charnwood is a residential care home providing personal and nursing care to up to 88 people. The service provides support to people over the age of 18. At the time of our inspection there were 35 people using the service. The home is split across two floors with a large garden to the rear.

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

People and their relatives told us they felt safe. People received their medicines in a timely and safe manner by competent staff who were trained who knew them well. Staff were recruited safely, and a comprehensive dependency tool ensured there was always the right amount of staff with the appropriate mix of skills to support people safely.

Staff were trained and knowledgeable about safeguarding issues and knew how to report concerns, this ensure people remained safe from harm and abuse. Staff confirmed they always received feedback and support from the manager with any concerns they raised.

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.

The new manager had reviewed and updated care plans. People’s needs were assessed, and care was delivered in line with people’s wishes. Staff were knowledgeable about the Mental Capacity Act (MCA) and supported people effectively and safely with the appropriate use of best interest decisions where they lacked capacity. Records showed and relatives told us they had been included in this process.

Care plans were person centred and reviewed on a monthly basis or as people’s needs changed. People and their relatives told us they were included in this process and staff were knowledgeable about their wishes and choices. People were supported to attend social events and groups that were important to them as well as daily group activities being offered.

People told us the service was well led, actively engaged with them, and sought their views. Relatives we spoke with supported this and told us management were open and transparent and responsive to feedback. Management and staff were clear about their roles, responsibilities and continuously looked for ways to develop and improve the service and the level of care provided.

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 4 November 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted by information received by the local authority who identified the service as making significant improvements. As a result, we undertook an unannounced focused inspection to review the key questions of safe, effective, responsive and well-led only.

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

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

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

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

Charnwood is a care home providing personal and nursing care to people. The service can support up to 88 people. At the time of the inspection, 29 people were using the service. The service is split across two buildings. The provider was not supporting anyone in one of the two buildings at the time of the inspection.

We found the following examples of good practice.

The service had implemented visiting arrangements which were in line with current best practice guidance. For example, a separate area of the lounge, with direct external door access and clear plastic screens in place, had been set aside for use by visitors.

The provider’s housekeeping and maintenance arrangements at the service were well organised and people’s living environments were clean and hygienic.

Charnwood is a care home providing personal and nursing care to people. The service can support up to 88 people. At the time of the inspection 39 people were using the service. The service is split into two buildings 'Charnwood House' and 'Charnwood Court'. Both were considered at the inspection.

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

People’s care needs were assessed appropriately. However, they did not always receive the care needed to protect them from developing pressure wounds or to reduce their risk of injuries caused by falling over. When incidents happened, the provider dealt with them appropriately, but did not always review them in enough detail to identify ways in which the incident might have been prevented. The provider’s quality monitoring systems were not always effective at ensuring people received the care support they required. That meant some people may have been at increased risk of harm. The provider recognised they needed to improve and had put in place additional support for the registered manager to continue the improvements in the service provided to people.

Discussions about people’s end of life preferences and plans had not always taken place with people or their relatives; and that meant care staff might not always know the person’s wishes at that important time. The care home did not always provide people with information in ways they could access and understand. For example, menu boards were not easy for people to see.

People were supported to eat and drink enough, and they had a varied menu to choose from. Arrangements were in place to monitor people’s weight, but there were not always suitable arrangements in place to ensure people drank enough to avoid potential dehydration.

People who smoked were able to do so outside the care home, but there was no suitable smoking shelter to protect people from the weather.

The care home environment was well maintained and safe, and people were supported by enough staff to meet their care needs. The service sometimes used agency care staff to help cover for staff vacancies and absences. The service aimed to only use regular agency staff, but not all agency staff had received a formal induction into the safety systems, and people’s support needs, at the service.

People lived in a care home which was clean and were supported by staff who understood about hygiene and the ways in which infections could be prevented and controlled. Care staff understood how to protect people from potential abuse and knew how to raise the alarm if they had any concerns about the support people received. People received their prescribed medicines from qualified nurses, and the provider’s arrangements for the management of medicines in the care home were well organised and safe.

People’s privacy and dignity was maintained, and they were supported by staff who treated them with kindness and compassion. People were encouraged to take part in planning their own care where they had the capacity to do so. People were offered a range of activities they could choose to take part in, and the provider employed an activity co-ordinator, and volunteers, to help people join in.

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

At the previous inspection this service was rated as inadequate (published 30 August 2019) and there were multiple breaches of regulations.

At that previous inspection, continuing breaches of legal requirements were found in respect of Regulation 12 (Safe care and treatment) and Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also identified the provider had not notified us of events that had occurred at the service, this is a legal requirement, so we can monitor the safety of a service. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Following the previous inspection, we issued the provider with two warning notices because of those breaches of Regulation 12 and Regulation 17. The warning notices told the provider the improvements that were required and the timescale by which the improvements should be achieved.

This service had been rated inadequate for the last three consecutive inspections and had been in Special Measures since 12 February 2019. During this inspection the provider demonstrated some improvements have been made, but the provider was still in breach of regulations.

However, the service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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

Since the inspection the provider has acted effectively to reduce some of the risks we identified. For example, in respect of protecting people from the risk of falls.

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

Enforcement

At this inspection, we identified breaches in relation to; how the provider acts to reduce people’s risk of developing pressure wounds or being injured by falling, and the leadership and governance processes the provider has in place to ensure those actions happen and are effective.

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

Follow up

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

Charnwood is a care home providing personal and nursing care to people. The service can support up to 88 people, at the time of the inspection 45 people were using the service. The service is split into two buildings ‘Charnwood House’ and ‘Charnwood Court’. Both were considered at the inspection.

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

Care records did not always provide sufficient detail to guide staff on how to look after people. Staff told us that they do not always have enough time to read care plan guidance. We found staff were not always aware of people’s needs. This put people at high risk of their care needs not being met safely.

People were not protected in a safe environment. The environment was unclean, and staff did not always follow hygienic uniform policies. The fire evacuation plan was unclear, which would put people at risk in the event of a fire emergency.

While people felt safe at the service, incidents were not always appropriately recorded and referred to the local authority to investigate. This put people at risk of incidents and potential abuse re-occurring.

People told us that staffing levels still impacted on the quality of care. They told us that this was variable according to the needs at the service. We did not observe unnecessary delays at our inspection visit.

Some improvements had been made to the management of medicines, medicines were now safely given as prescribed. Some improvements were needed to ensure that routine checks were completed as per the provider’s policy.

There had been some improvements since the last inspection, for example mattresses were now clean. However other concerns were raised on this inspection. The registered manager and provider had not ensured a consistently safe service.

Systems and processes designed to identify shortfalls, and to improve the quality of care were not always effective. While some improvements were noted since the last inspection, other concerns were raised on this inspection. This is the third time that this service will be rated inadequate, we are therefore concerned about the overall governance at the service.

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 Inadequate (published 16 July 2019) and there were multiple breaches of regulation. This service has been rated inadequate for the last two consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 30 April and 7 May 2019. Breaches of legal requirements were found in regulation 12 (safe care), regulation 17 (governance) and regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified that the provider had not notified us of events that had occurred at the service, this is a legal requirement so we can monitor the safety of a service. This is a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We undertook this focused inspection to check they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led. This is where we had the highest level of concerns at our previous inspection. The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains Inadequate. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Charnwood on our website at www.cqc.org.uk.

Enforcement

We have found the provider remains in breach of Regulation 12 (Safe Care and Treatment) and Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They have also failed to notify the CQC of events that have happened at the service. This is a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This service has been in Special Measures since 12 February 2019.

This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

People’s experience of using this service:

At this inspection we found the provider was no longer in breach of Regulation 9 of the Care Quality Commission (Registration) Regulations 2009. This was because some improvements had been made in this area. However, we found the provider had not made sufficient improvements in other areas since our last inspection and we found a continued breach of Regulation 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

People were not protected against the risk of infection. Urine stained mattresses had not been replaced and procedures to safely store used needles and razors that posed a risk of infection had not been followed. Staff did not follow hand washing guidance or wear gloves when administering eye drops.

Medicines management procedures did not always follow recognised good practice procedures. Some items in the medicines clinic rooms such as dressings for wounds, were out of date and not all equipment had been left on charge as expected.

Some people’s care plans did not reflect their current needs or health conditions. Some staff did not use safe and appropriate moving and handling techniques with people or offer reassurance and communication when people were moved with such equipment as hoists.

Staffing had not been planned to ensure people received timely care. For example, over lunchtimes when we observed some people waited for up to 20 minutes before staff were able to assist them with their meals.

Systems and processes had not always been operated effectively to assess, monitor and mitigate risks and ensure improvements. Actions had not always been taken to improve the quality and safety of the service when shortfalls had been identified. Not all personal confidential information was kept securely. Statutory notifications had not always been sent in a timely manner as required.

People were happy with their meal choices, however not all people had positive outcomes from their dining experiences as they sometimes had to wait for up to 20 minutes for staff to assist them with their meals.

People’s health and care needs were assessed with nationally recognised assessment tools, however photographs had not been effectively used to monitor wounds.

Some actions had been taken to adapt the premises to people’s needs, however sometimes the noise levels from televisions and radios all on at the same time did not always create a calm atmosphere for people.

We observed some staff were caring and took time with people, however this was not consistent. For example, we saw some staff did not engage with people when they had the chance too.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People and relatives had been involved in their care plan and decisions about their care. People’s privacy and dignity was respected and staff promoted people’s independence.

People were able to complain and any concerns raised were investigated. People’s views and those of their relatives had been gathered. Care plans were in place for when people required care at the end of their lives.

Staff were knowledgeable in areas relevant to people’s needs, including understanding dementia. The provider followed recruitment processes to help them recruit staff that were suitable to work at the service.

Rating at last inspection:

At our previous inspection, the service was rated as ‘Inadequate.' (Published 19 February 2019).

At the previous inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed the service in ‘special measures.’ We expect services placed in special measures to have made significant improvements at their next inspection.

The overall rating for this service remains 'Inadequate' therefore the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Why we inspected:

This is a scheduled inspection to check on the improvements made since the service was placed in ‘special measures’ at the previous inspection. The inspection also considered concerns received about a serious injury. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of mealtimes and wound care. This inspection examined those risks.

Following the previous inspection the provider submitted an action plan to tell us what actions they would take to become compliant with the other regulations.

Follow up:

We will continue to review information we receive about the service until the next scheduled inspection. If we receive any information of concern, we may inspect sooner than scheduled.

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

Charnwood is situated in Carlton, Nottinghamshire and is operated by Four Seasons (Evedale) Limited. The service accommodates up to 88 people. At the time of our inspection there were 55 people living at the home. The home is split across two units, both of which have two floors. Charnwood House is staff by registered nurses and care staff and primarily support people living with dementia. Charnwood Court is also staffed by nurses and care staff, however people’s needs are mainly related to their physical health needs.

At our last inspection in April 2017 the service was rated good. At this inspection we found the quality of some aspects of the service had deteriorated. Consequently, we found concerns across a range of areas including safety, medicines management, staffing and leadership and governance. This resulted in several 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.

There was no registered manager in place at the time of our inspection. The previous registered manager had left the home in early 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a new manager in post who started in October 2018, they had applied to register with us and this was being processed at the time of our inspection.

During our inspection we found the service was not safe. Risks such as falls, choking and behaviours were not always managed safely. This placed people at risk of harm. Opportunities to learn from accidents and incidents had been missed. We found multiple concerns about the management and administration of medicines, this placed people at risk of not receiving their medicines as prescribed. There were not always enough staff to meet people’s needs, people told us this had a negative impact on the care they received. Action had not always been taken to protect people from the risk of abuse and improper treatment. People were exposed to verbal abuse. In addition, there was a risk safeguarding incidents may not be appropriately investigated in a timely manner resulting in people being left at risk of abuse. Improvements were required to ensure the home was clean in all areas. Safe recruitment practices were followed.

Staff lacked training in some key areas. This meant there was a risk people may be supported by staff who did not have sufficient training or competency to provide safe and effective support. Staff did not always receive formal supervision or support. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice. Mealtimes were not always positive experiences for people and there was a risk this may have a negative impact upon how much people ate. People had access to a range of health care professionals, but care plans required more information about people’s health to ensure consistent support. Overall, the home was adapted to meet people’s needs.

People did not receive consistently kind and caring support. There was an inconsistent approach to involving people about decisions about their care and support. Staff did not always treat people in a dignified manner. People told us they were supported to be as independent as possible. People told us staff respected their right to privacy. People had access to advocacy services if they required this.

People did not always receive consistent support that met their needs. Support plans were not always up to date and did not reflect people’s needs. The risk of inconsistent support was increased by the use of temporary agency staff. People were not always provided with opportunity for meaningful activity. There were systems in place to respond to complaints. However, concerns were not always resolved. People’s diverse needs were accommodated.

There was a lack of leadership, coordination and oversight at Charnwood, this had a negative impact on the quality and safety of the service. Although there were auditing systems in place there had been a failure to identify and address some serious issues. Where issues had been identified timely action was not taken to make improvements. Systems to analyse, investigate and learn from incidents were not effective. Records of care and support were not accurate or up to date. Following our inspection, the provider developed a comprehensive action plan detailing actions taken and planned to make improvements and reduce risk.

This was the first time the service had been rated as Inadequate. During this inspection, we found five breaches of the Health and Social Care Act 2008 regulations. You can see what action we told the provider to take at the back of the full version of the 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 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.

The service had a registered manager in place at the time of our inspection. 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 were supported by staff who understood the risks they could face and knew how to keep them safe. Risks to people’s health and safety were identified and assessed and action taken to reduce risks were known by staff and recorded in people’s care plans. People received their medicines as prescribed and although improvements were required to documentation, these were administered and stored safely.

People were supported by sufficient numbers of staff who received appropriate training, supervision and had an understanding of people’s care needs. People were supported to maintain their health and appropriate hydration and nutrition. Some improvements were required to ensure people’s choices and rights were respected and the principles of the Mental Capacity Act 2005 were adhered to.

People were cared for and supported by staff who respected them as individuals and staff had developed friendly and positive relationships with people. People and their relatives were involved in planning their own care and the service sought to ensure people’s privacy and dignity was respected.

People received person centred care and were provided with meaningful interaction and activities. Improvements to people’s care plans had been identified by the provider and a plan was in place to address this. People felt confident to make a complaint and were confident these would be responded to.

People were supported by staff who worked well as a team and were supported by effective management to drive improvements in the service. Quality monitoring systems were in place which sought, identified and acted upon areas for improvement.

The inspection took place on 3 and 4 February 2016 and was unannounced. Charnwood is registered with the Care Quality Commission to provide personal care, nursing care and accommodation for up to seventy four people. There were forty six people living at the service at the time of our inspection.

Charnwood consists of two separate units on the same site. One provides personal care and is known at Charnwood House. The other provides nursing care and is known as Charnwood Court.

Charnwood is required by the CQC to have a registered manager, which they did have at the time of our inspection. 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 time of our last inspection of the service on 14 and 15 January 2015 we identified the provider was in breach of one Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was not an effective system in place to regularly assess and monitor the quality of the service provided. We asked the provider to take action to make improvements in the area of good governance. We received an action plan dated 15 June 2015, in which the provider told us about the actions they would take to meet the relevant legal requirements. During this inspection we found that the provider was meeting these legal requirements.

People told us they felt safe. The provider had policies and procedures in place to protect people at risk of abuse. Staff could identify the different types of abuse and knew how to raise any concerns. The registered manager had made relevant referrals if people were suspected of being at risk of abuse. The service had responded to accidents and incidents, but had not always taken action to keep people safe and reduce the risk. The building and environment were not well maintained in places, and we found four radiators that could pose a burn risk to people due to their excessive heat and lack of protective covers. We also found an unsafe bath panel.

The provider had not always followed up on any risks that the recruitment process identified to make sure staff were suitable to work at the service.

People received their medicines on time. The medicines were stored of and disposed of safely by staff that were trained to administer medicines. However, we noted that when the service administered controlled drugs, the second person checking the medicine had not always had training to be able to safely support this task.

Staff approached people in a caring way which encouraged people to say when they needed support. When supporting people with behaviours that may challenge, we noticed staff used techniques such as distraction, and a calm approach. Staff had developed positive relationships with people and their families.

The CQC monitors the use of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager had followed the correct process to submit applications to the supervisory body for a DoLS, where it was identified this was required for people who lack capacity. However some of the care plans showed inconsistent of understanding of the Mental Capacity Act and its uses.

Staff enabled people to make their own choices and decisions about the care they received, where possible. Staff involved relatives and other professionals when important decisions had to be made about people’s care.

Staff involved other professionals in a timely manner when required, and ensured people were supported with their healthcare needs. People were encouraged to participate in activities, and the home had a full and varied activities programme.

People’s nutritional needs were met, and they had a choice of food and drink, including specialist diets where required. People’s preferences, routines and what was important to them had been assessed and recorded.

Staff did not always feel supported, and were not always confident they could raise any concerns with the registered manager, or that they would be listened to.

People and their families were aware of the complaints process, but some issues they raised were not dealt with promptly. There were systems in place to monitor and improve the quality of the service provided, but these needed time to embed.

People and their relatives were given some opportunities to give feedback their views and opinions on the service.

When we visited the service in October 2013 we had some concerns about the service. We asked the registered provider to send us an action plan telling us what they would do to improve this. The provider sent us an action plan as requested and we visited this time to see if the required improvements had been made in line with the action plan. We found improvements had been made to the service, however we still found some concerns.

We spoke with six people using the service, four of their relatives and eight staff working in the home. We looked at the records for eight people using the service.

Consent to care and support was now being sought from people. People we spoke with told us they were given choices and were involved in their care and support and our observations supported this.

People's care was assessed, planned and delivered in line with their care plan. People we spoke with were happy with the care they were receiving. One person we spoke with told us, 'I get good care. My family are happy knowing I am looked after.'

Improvements had been made in relation to people being supported to maintain their nutrition. However people at risk of choking on food or fluids were not being protected from risk.

We found there were unpleasant odours in the home and when we looked at how infection control was managed we found there were concerns which needed to be addressed.

Although staff numbers had been increased during the day people still felt they had to wait a long time for assistance from staff and said they thought there should be more staff. We saw that people were sometimes kept waiting for long periods of time.

We found staff were now being given supervision and had been given more training. One person said, 'The staff are very good.' One relative thought that staff were adequately trained and instructed to deliver the right care.

We found there were better processes in place for the provider to monitor the quality of the service. People told us they went to meetings and had a say in the quality of the service.

We spoke with nine people using the service during our inspection. We also spoke with five relatives. However, people did not comment on every standard that we inspected.

We were joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service. They also spoke with a small number of people using the service and relatives.

People using the service told us they were treated with dignity and respect. One person said, 'I've always found [staff] very good.' Another person said, 'The staff are lovely.'

A relative told us their family member was treated with dignity and respect and said staff were, 'Pleasant' and 'Very caring.' They told us they had been involved in decisions about their family member's care and in reviewing the care.

People using the service told us that staff members offered them choices and respected their choices. However, we found that some Mental Capacity Act assessments had not been completed about specific decisions, when appropriate.

People who provided feedback about the care told us they received good care. One person said, 'It's good. They look after you well.' However, we found that people did not always experience care, treatment and support that met their needs.

People who provided feedback about meals were positive about the food. However, we found that people were not always protected against the risks of inadequate nutrition.

People told us they received their medication on time. We found that medicines were handled appropriately and were safely administered.

We found that people who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

However, we found that there were not sufficient staff to meet people's needs.

We found that staff were not fully supported to deliver care and treatment safely and to an appropriate standard.

We also found that the provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

We found that records were kept securely.

People told us they were offered choices. However, we found it was not always clear if people had given their consent to decisions about their care.

One person said the care was, 'Pretty good'. However, we found that care records had not always been fully completed. This meant updated information was not always available in care plans and people could not be assured of receiving care appropriate to their specific care needs.

One person said the food was, 'Marvellous'.

We found that medication was not always stored within acceptable temperature ranges. We also found gaps on the medication administration record (MAR) charts.

A relative said, 'The home has recently had some new furniture but it does look a bit dated.' We found that people were not fully protected against the risks of unsafe or unsuitable surroundings.

We found there were not always sufficient numbers of appropriate staff. We found gaps in staff inductions, supervision, appraisal and training.

We found that the provider did not always identify, assess and manage risks appropriately to maintain the health, safety and welfare of people using the service and others. We also found records were not always kept secure and fit for purpose.