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Inspection Summary

Overall summary & rating


Updated 8 June 2017

The inspection was carried out on 9 May 2017 and was unannounced. The service is a residential care home that can accommodate up to 29 older people; some people may also have mild dementia type illnesses that they have developed whilst resident. At the time of inspection there were 22 people in residence. People have their own bedrooms; some have ensuites; bedrooms are located over the ground and first floors. A shaft lift provides access to the first floor.

There was a registered manager in post. A registered manager is a person who is 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 previous inspection in May 2016, we found that the provider was not meeting all the regulations inspected at that time because the quality monitoring system in place were not effective. Medicines administration and recording needed improvement as did the recording of fire drills, and tests of fire equipment. The service at that time had also not ensured that The Care Quality Commission was informed of notifiable events.

Staff spoke kindly to people and treated them with respect. People were able to make decisions and choices for themselves about what they did, and where they ate their meals and with whom, people were encouraged where possible to maintain their independence seeking support when needed.

At this inspection we looked at the improvements made in these areas and was satisfied these had been addressed appropriately. The provider, who was a visible presence in the service, had taken steps to ensure greater involvement in the day to day operation of the service. This helped to relieve the registered manager of some responsibilities in regard to the completion of paperwork meaning they could increase their focus on care delivery. Investment in an electronic records system provided the facility for the registered manager and the registered provider to have greater oversight and scrutiny of day to day care delivery, even remotely when not on site. This enabled the registered manager and provider to check at any time of day or night, the support provided to people, the administration of their medicines, food and fluid intake, personal care routines supported and activities participated in. This provided them with greater assurance that all aspects of the service were meeting requirements consistently and systems in place were being carried out as per their own policies and procedures.

More robust recruitment practice meant that staff suitability for the role was assessed through a full range of checks in line with legislation requirements. Medicines were managed well and observed staff practice showed improvements in the way administration was undertaken and recorded. Staff understood how to keep people safe from abuse and harm. In the event of a fire or event requiring evacuation staff had had practiced for this and the registered manager ensured all staff attended a minimum of two practice drills per year. Staff understood where to take people to keep them safe. The premises were well maintained. All areas viewed were visibly clean and cleaning staff told us about their cleaning schedules each day. All necessary equipment servicing, checks and tests were carried out. The Provider also carried out an annual health and safety check to ensure that the environment was safe and that equipment was in good working order.

The majority of individual and environmental risks to people’s safety were assessed and managed appropriately. There was a low level of incidents and accidents and staff took appropriate action when these occurred, the registered provider and registered manager understood what events they needed to notify the Care Quality Commission about.

The registered manager underto

Inspection areas



Updated 8 June 2017

The service was safe

Improvements had been made to the management of medicines. Risks to people from health conditions had been risk assessed but would benefit from additional information.

The premises were clean and well maintained, important servicing and checks of equipment were undertaken and improvements had been made to fire procedures.

There were enough staff to support people, and recruitment procedures ensured important checks were made of their suitability. Staff knew how to protect people in the event of emergencies and understood how to recognise and respond to abuse to keep people safe.


Requires improvement

Updated 8 June 2017

The service was effective but minor improvements were needed

A programme of training was in place for all staff to help them provide people with the right support; not all staff had yet completed this. All staff received appropriate induction into their role. There were opportunities for them to discuss their development and they felt listened to and supported.

The manager and staff supported people in line with the principles of the Mental Capacity Act, and sought peoples consent when they received support.

People enjoyed the food they received and could make choices around this. People’s health and wellbeing was monitored by staff and where necessary they were referred to health professionals.



Updated 8 June 2017

The service was caring

The atmosphere in the home was welcoming, visiting times were flexible and visitors were made welcome.

People were treated with dignity, respect and kindness; they were able to bring personal possessions to make their rooms more homelike.

People were consulted about their care and end of life wishes and were provided with opportunities to comment about the service



Updated 8 June 2017

The service was responsive

People were given information on how to make a complaint in a format that

met their communication needs.

People and their relatives were involved in their care planning. Changes in care and treatment was discussed with people.

People were supported to utilise their time how they wished and to maintain their own interests and hobbies. A range of activities for people to choose from was available.



Updated 8 June 2017

The service was well led

Investment in new technology had helped improve the provider and registered manager oversight and scrutiny of service quality.

People and staff found the manager approachable, they felt listened to and supported. Staff had opportunities to express their views through handovers, supervision and staff meetings. People and relatives were asked to comment on service quality and this informed service development.

The service analysed accidents and acted upon any emerging trends or patterns to reduce occurrences. The Registered manager ensured the Care Quality Commission was kept informed of notifiable events.