The Old Vicarage Nursing and Residential Care Centre

The Old Vicarage Nursing and Residential Care Centre (The Old Vicarage) is a residential care home with nursing registered to accommodate up 60 people in need of nursing and personal care. Accommodation is provided over two floors with single rooms and one double room. Most rooms have en-suite facilities. On the days of the inspection there were 55 people living at the home.

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

People received safe care from kind and caring staff. People were protected from the risk of harm and staff supported them to maintain their safety and wellbeing. People received their medicines as prescribed from staff who had been trained in medicines and had their competencies checked by managers.

Relatives told us they felt confident their relations were safe living in the home and praised the friendly and caring attitudes of staff and managers. People's rights were protected and their equality and diversity needs were respected. People's bedrooms were personalised to reflect their tastes and preferences.

People were confident in the management team at the home and praised how approachable they were. Relatives were similarly pleased with the way the home was managed. Some relatives and staff members said that, on occasions, the home was short-staffed. We did not see evidence of this at inspection and staffing rotas supported the home was properly staffed.

Quality assurance systems, audits and checks were robust and embedded within the service. The home, the environment and the equipment in use was clean and tidy. We did not find any shortfalls around care planning and record keeping. This assisted in ensuring people received proper and safe care.

Staff felt valued and enjoyed working at the home. They also said the new registered manager had provided a good degree of stability to the home. People's views and opinions of the service were sought and acted on.

The service made appropriate notifications to us and other authorities of safety incidents to ensure these incidents received appropriate oversight. Infection prevention control measures were robust and safe visiting processes were in place to ensure people could see their visitors safely.

People received high-quality person-centred care because the provider and managers had maintained effective oversight of the quality of care practice and records. Staff were committed to providing high-quality care and felt they were supported in their role by managers. 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

The last rating for this service was requires improvement (published 25 April 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We identified the service may have improved since the last inspection. We carried out a focused inspection to review the key questions of safe 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 The Old Vicarage Nursing and Residential Care Centre on our website at www.cqc.org.uk

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.

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care. The Willows unit is specifically for people living with dementia. On the day of the inspection 31 people were living at the service.

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

Following our last inspection, the provider implemented changes to the running of the service that resulted in a number of identified improvements to the standard of care people received. However, further improvements are still needed to address issues found during this inspection.

The environment was now noticeably clean and hygienic however, some equipment used by people for mobility, such as wheelchairs, and some chairs in communal areas were found to be unclean. Maintenance records and staff meeting notes had identified that these items required cleaning. However, action had not been taken to address these issues. In addition, cleaning schedules lacked information regarding some cleaning tasks; such as communal areas and high-touch services.

Staff were provided with the appropriate PPE and had received training and guidance around its use. However, we observed some staff who were not following correct guidance in the use of masks. The provider was aware this was an ongoing issue and had previously followed their disciplinary processes to address it. However, this process did not appear robust enough.

We have made a recommendation regarding these issues.

Systems to review and improve the overall quality of the service were now more effective at identifying issues. However, further improvements were needed to ensure staff took the necessary action required.

Changes to the management structure within the service had been instrumental in the improvements found during this inspection. Staff spoke positively about the managers and were confident continued improvements would be made. Family members told us they had seen many improvements to the standard of care their relative received. However, they felt communication from managers about the overall service was lacking. The provider agreed to review their communication processes to address this.

Risks to people's health and well-being were appropriately assessed and detailed plans were in place to manage these and keep people safe from harm. Staff responded quickly to changes in people's needs and relevant referrals to external professionals were made in a timely manner. People told us they felt safe and family members were confident their relatives were well-looked after.

Medicines were managed safely by staff who received regular reviews of their practice. People received their prescribed medication on time and relevant administration records were completed accurately. Accidents, incidents and safeguarding concerns were regularly reviewed and analysed by managers. Appropriate action was taken to prevent incidents from occurring in the future.

There were enough staff to meet people's needs and keep them safe from harm. Staff were now deployed effectively around the home to make sure people received support in a timely manner. Safe recruitment processes were followed and relevant checks were completed on new applicants to make sure they were appropriate for the role. Robust systems were now in place to make sure that agency staff had the relevant training and experience and had followed current guidance in relation to reducing risks associated with COVID-19; such as COVID-19 testing.

The environment was clean and hygienic. Staff received training in infection, prevention and control and were provided with regular updates and changes to guidance; particularly in response to COVID-19. Staff and people using the service accessed regular COVID-19 testing. The service supported family members to regularly visit their relatives safely and had processes in place to prevent visitors from catching and spreading infections.

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 6 September 2021) 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.

This service has been in Special Measures since 6 September 2021. During this inspection the provider demonstrated that improvements have been made. 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

We carried out an unannounced focused inspection of this service on 22 July 2021. Breaches of legal requirements were found in relation to safe care and treatment and governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 inadequate to requires improvement. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Old Vicarage Nursing and Residential Care Centre on our website at www.cqc.org.uk.

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

The Old Vicarage Nursing and Residential Care Centre is a care home providing nursing and personal care to 47 people aged 65 and over at the time of the inspection. The service is registered to support up to 60 people over two double storey units. The Willows unit is specifically for people living with dementia. There is also a conservatory and a large garden at the back.

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

People were at risk of receiving inadequate care that did not meet their needs because assessments and care plans were poorly completed and not person-centred. Records were either incomplete, inaccurate or lacked detail to provide staff with guidance on how to support people in line with their needs and preferences.

Risks to people’s health and wellbeing were not assessed, recorded or manged effectively. This placed people at risk of avoidable harm.

Medicines were not always administered or managed safely. Not all staff with responsibility for administering medicines had received training or had their competency assessed. There were not always person-centred care plans in place for people’s specific medicines such as insulin.

There were shortfalls in relation to the management of infection and prevention control. Staff had access to appropriate personal protective equipment, but they did not always wear it properly. Communal areas, including the main lounges and dining areas, were not always clean and well maintained. Some equipment used to support people was dirty.

There was lack of evidence to show that people were involved in decisions about their care, support and treatment. Some relatives told us there was lack of communication and involvement in care planning.

The management and leadership of the service was inadequate. Systems to monitor, assess and improve the safety and quality of service being provided were ineffective. Relatives told us they felt communication with the home could be improved.

Governance arrangements did not promote the provision of high-quality, person-centred care which fully protected people's human rights.

There was no registered manager at the time of the inspection. However, a manger had been appointed a few weeks prior to the inspection. Staff told us communication and morale were starting to improve with the new manager. Staff felt confident the new management team would make much needed improvements.

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

Rating at last inspection

The last rating for this service was requires improvement (published 9th January 2021).

Why we inspected

We received concerns in relation to the management of people’s health related risks, staffing concerns and lack of leadership. As a result, 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. The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. 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.

The registered provider has been responsive to concerns noted during the inspection and has started to take action to make improvements and promote safety within the home.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment and good governance.

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

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

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care, the Willows unit is specifically, for people living with dementia. On the day of the inspection 54 people were living at the service.

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

People told us they liked living at the service and relatives were positive about the staff, especially of the activities programme although they raised concerns about the use of agency staff.

The manager had developed a staffing rota to help provide better stability and standards of care within the service. Due to the management of change, a higher use of agency had been employed to ensure they had the right numbers of staff in place. Plans were in place to continue recruiting to vacancies to eventually have the stability of their own core team.

The provider had detailed governance systems to help mitigate risk to the health and welfare of people living at the service. The provider set out a clear plan to drive improvements. They had employed an experienced manager and deputy to help provide stability and training for staff in delivering person centred care.

Staff were knowledgeable in how to safeguard and protect people at the service. However, induction training records for new staff lacked recorded updates for this training.

The manager had expertise to swiftly identify people’s individual risks and took immediate actions to improve aspects of care, particularly for pressure care and nutritional needs. Plans were in place to provide further stability and improvements. Electronic care records were being introduced to help improve oversight and record keeping.

Staff were fully supportive of the provider and the new management team. They acknowledged the improvements to the service and an increase in morale.

The service was clean and staff used appropriate techniques to prevent the spread of infection. Health and safety checks were robust but needed some improvements to their record keeping.

The manager had identified plans to further develop the service to enhance the environment for people living with dementia..

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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk by selecting the ‘all reports’ link for The Old Vicarage Nursing and Residential Care Centre .

Rating at last inspection

The last rating for this service was good ( published 13 December 2018 )

Why we inspected

We had received continued updates from the provider over the last three months in relation to the management arrangements at the service. As a result, we undertook a focused inspection to review the key questions of Safe 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 coronavirus and other infection outbreaks effectively.

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.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider continues to make improvement. 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 The Old Vicarage Nursing and Residential Care Centre on our website at www.cqc.org.uk.

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care, the Willows unit is specifically, for people living with dementia. On the day of the inspection 57 people were living at the service. Accommodation is provided on two floors, with lounges available on both floors. The dining areas are on the ground floor. There is also a conservatory and a large garden at the back and a small car park at the front.

The service has a registered manager in post who had worked at the home for three and a half Years. 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. Prior to this inspection we received feedback from the local authority contract monitoring team, who said that the home had been subject to an improvement plan that they were in the process of reviewing.

Everyone we spoke with told us that the service was good. Some areas needed oversight and improvements with the management of paperwork.

People were protected from potential harm and abuse by trained staff who were knowledgeable of local safeguarding procedures. Risks to people’s safety were identified and where necessary, appropriate action taken to keep people safe. There were systems in place to help make sure staff employed at the home were suitable to work with vulnerable people.

Staff supported people to take their medicines safely and as prescribed.

People were supported by a team of staff that had had training and support to maintain their skills and knowledge to meet the needs of the people they supported.

People were treated with respect, consideration and kindness. Their privacy and dignity was upheld and they were supported to maintain their independence whenever possible. People receiving support and their relatives offered lots of positive comments about the care provided.

Care was provided in a personalised way from staff who knew people’s needs and preferences. People were involved in the planning and review of their care and support.

The home employed an activity organiser who engaged people in activities in small groups and individually during the day.

Information and arrangements were in place for the staff team to respond to concerns or complaints from people using the service and their representatives.

People who used the service who we spoke with and their relatives all had a positive attitude about the service being delivered and about the standard of care and support provided by the staff team. People were referred to appropriate health and social care professionals when necessary to ensure they received treatment and support for their specific needs.

Stakeholders and members of multidisciplinary teams shared positive feedback about the care provided to people living at the service.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrict way possible. Staff had followed the Code of Practice in relation to the Mental Capacity Act 2005 (MCA).

The Old Vicarage Nursing and Residential Care Centre provides nursing and personal care for up to 60 people. The home has two units, each providing nursing and personal care, but the Willows unit is specifically for people living with dementia. On the day of the inspection 59 people were living at the service.

Accommodation is provided on two floors, with lounges available on both floors. A passenger lift and stairs provide access to the first floor. The dining areas are on the ground floor. There is also a conservatory and a large garden at the back and a small car park at the front. Assisted bathing facilities are provided.

The service had a registered manager in post who had worked at the home for about a year and a half. 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.

Prior to this inspection we received feedback from the local authority contract monitoring team, who said that the home had been subject to an improvement plan but the actions required were almost completed.

We found that the service provided good care and support to people enabling them to live fulfilling and meaningful lives. People that were able to talk to us said they were happy in the home and with the people they lived with. The interactions we observed between people and staff were positive.

People told us they felt safe living at the home, staff were kind and compassionate and the care they received was good. Comments included: “The staff are quite good, you can have a laugh with them”; “They look after us with care in their hearts”; “They’re fantastic”.

The staff ensured people’s privacy and dignity were respected. We saw that bedroom doors were always kept closed when people were being supported with personal care.

People remarked that the food was good and there was plenty of it. One person said, “The food and the catering here is really good, they are very generous”.

People could choose how to spend their day and they took part in activities in the home and the community. The home employed activity organisers who engaged people in activities in small groups and individually during the day. They also took people out in the local community and a minibus was available to take people out on day trips.

People’s needs were assessed and care plans were developed to identify what care and support people required.

People's health and well-being needs were well monitored. There were regular reviews of people’s health and staff responded promptly to any concerns. People were referred to appropriate health and social care professionals when necessary to ensure they received treatment and support for their specific needs.

Staff received specific training to meet the needs of people using the service and received support from the management team to develop their skills. Staff had also received training in how to recognise and report abuse. All were clear about how to report any concerns. Staff spoken with were confident that any allegations made would be fully investigated to ensure people were protected.

People knew who to speak to if they wanted to raise a concern and there were processes in place for responding to complaints.

Some people who used the service did not have the ability to make decisions about some aspects of their care and support. Staff had an understanding of the systems in place to protect people who could not make decisions and followed the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

There were processes to monitor the quality of the service and seek feedback from people who used the service, their representatives and the staff. We saw evidence that the provider had acted upon feedback received, which demonstrated a learning organisation.

We inspected the Old Vicarage Nursing and Residential Care Centre on 29 September 2014 in response to information of concerns from the local infection control team and Warrington Borough council.

This was an unannounced inspection. The inspection set out to answer two of the five questions we always ask:

' Is the service safe?

' Is the service well led?

Below is a summary of what we found. The summary is based on speaking to the manager and by walking around the home and looking at areas of cleanliness. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

During the visit we walked round the building and looked at all bathrooms, the majority of bedrooms, main lounges and dining rooms. All areas looked clean and tidy and there were no unpleasant odours.

We saw that the home had domestic staff on duty and that the home smelt fresh and clean.

Is the service well led?

We looked at the audits that had taken place for the end of August and September for cleanliness of the home and medication management.

We saw that areas of concern had been identified with regard to cleaning schedules and the manager was taking action to rectify this.

Whilst we were at the home we checked to see how the manager was responding to concerns raised by the local authority about how medicines were managed. The manager told us they were intending to change their pharmacy supplier in October 2014. A pharmacist inspector from the Care Quality Commission will carry out a focussed inspection to assess how medicines are managed when the new system is in place.

Following our inspection in January 2014 the provider sent to us an action plan. This showed us that the provider was aware as to what needed to be done and was committed to ensuring that the people who lived at the home received safe and appropriate care that met their needs and protected their rights.

The home had been subject to monitoring visits by Warrington Borough Council following safeguarding issues reported by the home and whistle blowing concerns reported to Care Quality Commission.

The home had provided an action plan to Warrington Borough Council to address issues raised.

Visits had been made by the Infection Control team to ensure that the home was clean and free from infection. At the last visit on 6 August the score for the cleanliness at the home had deteriorated.

Notwithstanding the above we considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations, including SOFI during the inspection, speaking with people using the service, their relatives; the staff supporting them and from looking at records.

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

' Is the service safe?

The manager advised us that appropriate procedures, including review were in place should anyone need to be subject to a Deprivation of Liberty Safeguard (DoLS). DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. Some of the staff we spoke with were not fully aware of Mental Capacity Act and DoLS.

We spoke with the registered manager who told us they were aware of the shortfalls in training and had booked training sessions. They told us they were currently reviewing all training at the home and were planning the training for the coming year. This training included the Mental Capacity Act and DoLS.

Is the service effective?

We saw that care plans had been written based on the information provided in the assessment documents. Care plans were comprehensive and provided a good picture of the person, their needs and how these were to be met. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

During our inspection we found that the people living at The Old Vicarage looked well cared for and were dressed appropriately for the weather on the day. People were clean and tidy and their hair had been brushed or combed.

Is the service caring?

We saw that staff interacted well with the people who lived at the home. The atmosphere in the home felt relaxed and sociable. We saw that staff spoke to people who used the service when they were passing them in corridors or in the lounges. Relationships were warm and respectful.

Staff spoken with were knowledgeable about the people they cared for.

People we spoke with said "I like it here. Staff are really nice," " I can't fault the staff, the whole place is great" and "yes it's ok the food is good."

Relatives told us " the home is improving all the time. They look after my relative well." and " the staff and managers are always pleasant. I know my relative is looked after."

Is the service responsive?

At our last visit in January we issued compliance actions in two outcomes we looked at . The provider had produced an action plan and at this visit we found that these actions had been met.

We looked at the care plans and found that referrals were made and recorded when people had needed professional support such as GPs district nurses, tissue viability, dieticians and mental health teams.

We saw that the service had been visited by the infection control team and Warrington Borough Council's monitoring team. The registered manager had completed action plans and liaised with these external teams to improve the care people received at the home.

Is the service well led?

The Old Vicarage had systems in place to gather information about the safety and quality of the service provided. This included audits of areas such as care plans, medication, accidents, falls, the environment and the kitchen. If there were any issues identified following an audit these would then be dealt with. We saw examples of action plans completed and signed by the manager.

A survey had been sent out to relatives in July and comments such as 'found the registered manager to be pleasant and professional and feel she would listen to my concerns,' 'staff are pleasant and treat my relative very nicely' and ' happy atmosphere' were made.

At the time of the inspection the provider had recently introduced new documentation to the service, however we found that this was not always fully completed or contained conflicting information.

We gathered information from a number of sources which included speaking with people who used the service, their relatives and health professionals. We also spoke with the manager, the deputy manager of the service and members of the staff team. Comment cards were also made available to people who use the service, visitors and staff for them to tell us their experiences.

During the inspection we observed staff speaking and interacting with people with dementias and with each other.

We also made general observations of the environment that we have referred to in the report. Additionally we found that there was room for improvement in the area of the dementia lounge as we found staff coats and belongings stored there, a filing cupboard that was open and contained care files and a bottle of a cleaning product. This meant that personal information was not always secured to ensure confidentiality and that people living at the home could be at risk if they mistook the cleaning product for a drink.

We found that the home had a policy statement relating to dementia that referred to the National Institute for Clinical Excellence (N.I.C.E) guidelines and the manager told us that they had undertaken specialist training in dementia. However the service had not signed up to the National Dementia Pledge and staff that we spoke with were not aware of the N.I.C.E. guidelines. This meant that staff may not always be aware of current recommended best practice and innovations to support people who have a dementia type illness and their families. Being signed up to the dementia pledge also demonstrates that the provider and staff are committed to the care and support of people with dementia.

We observed two mealtimes and discussed with the manager that improvements in this area will make for a more positive experience for the people living at the home.

We received six returned feedback cards and comments included: ''The attitude of the nursing and auxiliary staff has vastly improved '' and ''Things are mixed, ok overall but still a way to go.'' and we were told '' I never cease to be amazed at the patience and care given to my relative and all of the other residents''.

We saw that some improvements had been made in the service. However, further improvements were required and these are referred to in the body of the report.

During this visit we saw that improvements had been made in the identified areas and that work was still ongoing. There was a relaxed atmosphere within the home that was clean and there were no offensive odours.

Since the previous inspection the manager and the activities co ordinator have left employment and the provider is currently recruiting to these positions.

We saw that people were being supported by staff at mealtimes in an appropriate way and that the food appeared appetising and was plentiful. However, although we saw a planned menu rota for several weeks people living at the service were unable to say what food was available on the menu as their choice was only provided verbally.

One person living at the service told us that ''everyone goes out of their way to help '' and ''all of the staff are very good and caring and towards the people who are most vulnerable.''

A relative told us that they were always made welcome and there were no problems with the care provided. However there was a problem with personal possessions being lost or misused and with the cups that were used being too big or difficult for some people to manage.