Archived: Woodlands

People's experience of using this service: The location has a history of none compliance with regulations and has been inspected six times since July 2015. At no inspection during this period has the provider achieved an overall rating of good.

At the last inspection we found three breaches of regulations. There was a failure to provide safe care and treatment, a failure to ensure staff had the required training and a failure to assess, monitor improve and mitigate the quality and safety of the services provided.

The service was not well led. The provider failed to have sufficient oversight of the home and ongoing breaches of regulations were identified. In total, nine breaches of regulations were identified during the inspection.

The action plan devised by the provider in response to the findings at our last inspection had not driven improvement.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Consent to care and treatment was not always sought in line with the principles of The Mental Capacity Act 2005 (MCA).

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

Appropriate action was not always taken to safeguard people from abuse. Incidents of a safeguarding nature were not always reported to CQC.

Training the provider deemed mandatory had not been delivered to staff.

Timely action had not been taken to address concerns regarding the environment. This placed people at risk of avoidable harm.

Support was not personalised and specific to the individuals needs and people were not always treated with dignity. Staff had not completed training in dignity and respect and had not recognised situations which were undignified for people.

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

Why we inspected: The inspection was brought forward as we received information of risk and concern.

Rating at the last inspection: The service was rated as requires improvement (the report was published in August 2018).

Enforcement: 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 concluded.

Follow up: Following the inspection we referred our concerns to the local authority responsible for safeguarding. In addition, we requested an action plan from the provider, and evidence of improvements made in the service. This was requested to help us decide what regulatory action we should take to ensure the safety of the service improves.

The overall rating for this registered provider 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 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.

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.

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.

During this inspection we found some improvements however there were some ongoing concerns identified in relation care records and risk assessments, fire safety, staff training and governance and quality assurance.

Woodlands 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.

Woodlands can accommodate 42 people in one adapted building across two floors. At the time of the inspection 19 people were living at the home, some of whom were living with a dementia.

The service did not have a registered manager. The current manager had been in post since February 2018 and had not yet made an application to register with the Commission. They had applied for their Disclosure and Barring Service (DBS) check to be completed. 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.

We found there were ongoing concerns in relation to medicine care plans and protocols for the administration of 'when required' medicines. Whilst the manager was working on developing these care plans this was an ongoing concern since the last inspection. Staff administered medicines safely and knew how people liked their medicines to be administered however this was not always recorded.

Some risk assessments were in place however, we found that if people were at risk of choking or presented with behaviour that staff found challenging, the risks had not always been assessed. Some care plans had not been kept up to date following a change in the person's needs and some lacked the level of detail needed to ensure care and support was personalised and met the person's individual preferences.

We discussed some concerns with the fire service, who were completing a visit during the inspection. The fire alarm panel did not meet the required standard which meant there may be a delay in identifying the location of the fire. Some staff did not fully understand the fire evacuation procedure, they had not been trained in the use of evacuation equipment and some fire doors did not fully close.

We have made a recommendation with regards to environmental improvements to ensure it meets the needs of the people living at Woodlands.

Governance procedures were in place and quality assurance audits had been completed however, there was no robust action plan in place for the accountability and monitoring of the required improvements. There were complexities in relation to level of authority the management agency had with regards to approving some improvements and this had led to a level of frustration for the manager and the regional manager.

Staff understood safeguarding and whistle-blowing procedures. Safeguarding concerns and complaints had been fully investigated and the appropriate authorities had been notified of any concerns and the actions taken to minimise the risk of reoccurrence.

Staff training had not been provided which meant staff, including the management team and the ancillary staff did not have in date training in relation to safeguarding, mental capacity, fire safety, dementia care or challenging behaviour.

Staff said they felt well supported and found the manager and deputy manager approachable. Plans were in place to ensure staff received appropriate supervision and an annual appraisal in order to discuss their personal development and support needs.

Staffing levels were sufficient to ensure people’s needs were met. The current manager had robust recruitment procedures in place and had identified some concerns in relation to some existing staff either not having a DBS check or the check had identified that they had a caution. The manager had responded by completing risk assessments with the staff and seeking approval for new DBS checks. This was yet to be authorised.

People told us the staff were kind, caring and compassionate. The staff respected people's privacy and dignity and we saw people were treated well and with respect.

Activities were provided which people had enjoyed, and we saw compliments had been received following specific activities that had been arranged for people.

People had access to external health care professionals, including doctors, district nurses, dieticians and chiropody.

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

After the last inspection, the provider sent us regular action plans to show how they would rectify our concerns and we returned to check all regulations were now being met. We found the provider had made improvements and was no longer inadequate, but there remained some areas for further improvement to be made or further time to be given for us to be assured the improvements made could be maintained.

At the previous inspection, the service was put in special measures due to the rating they received. We found that, although further improvements were required, the service was no longer in a position to continue to be in special measures and these have been removed.

Woodlands is situated in Wideopen on the outskirts of Newcastle. It provides residential care for up to 42 people, some of whom are living with dementia. At the time of our inspection there were 18 people living at the service. The lower occupancy figure was due to a voluntary suspension having been put in place by the provider until they were able to confirm they were meeting all of the regulations and had made satisfactory improvements. After consultation we agreed with the request to lift their voluntary suspension and this is no longer in place.

The service had 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 2008 and associated Regulations about how the service is run.

People we spoke with told us they felt safe living at the service. Family members also confirmed that they felt their relatives were safe and that the service had improved.

Staff we spoke with had a good understanding of safeguarding procedures. They also knew how to report any concerns they had. The provider had a system in place to log and investigate safeguarding allegations. People were moved and handled in line with guidance and best practice.

Risk assessments were in place and had improved, although guidance for staff was in the process of being put in place. Checks on the premises and equipment were undertaken to ensure the safety of people who lived at the service. Accidents were recorded and monitored by the provider to ensure that no trends were forming.

We found some further improvements with medicines needed to be taken but found no evidence this had impacted on people’s health. Medicines were largely managed well, but we have made a recommendation in this area.

There were enough staff in place. The provider had recruitment procedures and checks to ensure staff were suitable and had the right skills to support people at the service. Staff received suitable training which they put into practice and felt supported by their line manager.

The Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the registered persons were complying with their legal requirements. Thirteen people were subject to a DoLS authorisation.

Communication had improved between the staff team and also with healthcare professionals. Care and support was planned and provided in accordance with their needs. People’s health and wellbeing was monitored, with access to general practitioners, hospital appointments and other health professionals as needed.

Updates had been made to the environment with more improvements underway.

People told us they liked the food made available to them on the whole and were given opportunities to choose a variety of meals. Anyone who required special diets were supported by staff and referred to their GP for advice when required. Food and fluid recording needed to be further improved and we have made a recommendation.

People and their family members told us they were well cared for and were treated with dignity and respect. We completed a number of observations during the inspection and saw positive and appropriate interactions taking place and had no concerns with the way that people were being treated.

There was a new activity coordinator now employed at the service. They had a range of activities organised which people could be part of if they so wished. Some people preferred to remain quiet in the comfort of their own room and this was respected as their choice.

There were some further areas to improve with record keeping but we acknowledged the registered manager and staff had spent considerable time bringing records up to date and organising them better.

A complaints procedure was available. Four complaints had been received in 2017. Feedback systems were in place to obtain people and their representatives’ views.

The registered manager undertook regular checks on people’s care and the environment of the home. Staff felt the registered manager was approachable and supportive. There were regular meetings with staff and interactions with people and their relatives, to allow them to comment on the running of the service.

We have made two recommendations overall with details in the above summary and in the body of the report.

Our last inspection of this service was carried out in June 2016 to check that improvements had been made, in respect of breaches of regulations, identified at a comprehensive inspection in May 2015. At our last inspection we found that some of the previous breaches had been addressed and compliance achieved, but that serious failings still existed in respect of the safety of the premises and good governance. We issued a requirement notice in respect of the breach in safe care and treatment and issued a warning notice, in respect of the continuing breach in good governance. The service was also placed in special measures at that time.

At this inspection we found that some improvements had been made, but shortfalls still existed in respect of both of the above regulations. We identified further concerns about the way people were treated with a lack of dignity and respect, and established that staff did not always protect people from improper treatment. This inspection found that there was not enough improvement to take the provider out of special measures and the Commission is continuing to work with the provider to improve the quality of the service delivered.

A registered manager was in post who had been registered with the Commission to manage the carrying on of the regulated activity since August 2013. 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.

We found failings in the standards of care delivered which compromised people's safety. Medical attention was not consistently sought in a timely manner for all people, when they presented with changes in their physical or mental wellbeing. Some staff adopted moving and handling procedures that were not safe or in line with best practice guidelines. In addition, we could not be sure that the management of pressure area care was safe, as documented instructions for staff to refer to, were not in place.

The management of medicines was not safe. Some people's medicines had gone out of stock and were not available to them. The recording of the administration of medicines was poor and it was not always possible to reconcile if people had received their medicines or not. In addition, people did not always receive their medicines in a timely manner.

Safeguarding policies and procedures were in place to help protect people from harm and abuse. However, we found evidence of staff not alerting the manager to inappropriate treatment of people by their colleagues, until sometime after the event. Staff had received training in the safeguarding of vulnerable adults but they had not always safeguarded people in practice.

Improvements to the premises had been made since our last visit. Accidents and incidents were appropriately recorded and monitored for any patterns or trends. Health and safety checks and checks on equipment were carried out regularly to ensure they remained safe for use. The environment within the home did not reflect best practice guidance about steps that could be taken to support those people living with a cognitive impairment or dementia. We have issued a recommendation about this.

Staffing levels were appropriate to people's needs, but we found that people's needs were not always met in a timely manner due to the way staff carried out their duties and how they were deployed. Some people had to wait for their care to be delivered, but this was linked to how staff organised themselves, how they completed their tasks and a lack of awareness. By the last day that we visited, an extra staff member was rostered on duty to observe people during busy times of the day such as when people were being assisted to rise from bed.

Recruitment procedures adopted within the service were thorough and robust. Staff had been trained in key areas relevant to their roles and a programme of repeat training was on-going at the time of this inspection. However, we found staff did not always apply what they had learned. There was an outstanding breach in Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 entitled Staffing, which the provider was still working to address at this inspection, in line with the action plan they sent us after their last inspection in June 2016. We will review the provider's compliance with this regulation at our next visit to the service. Supervisions and appraisals were in place.

Overall, people's general healthcare needs were met. People and their relatives reflected varying levels of satisfaction with the quality of care delivered and some people said that their needs were not met. Some people had not been supported to bathe regularly and their personal care had not always been attended to. We identified concerns about how some people were treated and spoken to by some members of the staff team. People's dignity was compromised during care delivery.

People were supported to eat and drink in sufficient amounts to remain healthy.

CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty safeguards. The Mental Capacity Act (MCA) was appropriately applied and applications to deprive people of their liberty lawfully had been made to prevent them from coming to any harm where they lacked capacity. The service understood their legal responsibility under this act and that they assessed people’s capacity when their care commenced and on an on-going basis when necessary. Decisions that needed to be made in people’s best interests had been undertaken and records about such decision making were maintained.

Care records were individualised and reflected the care and support people needed. Not all care records were well maintained and recording processes within the service were not robust. At times, records could not be located when we asked to see them and there was an impact on people's health and wellbeing where entries made on handover records about people's needs had not been properly followed up.

Choices and activities within the home were limited. People's social needs were not always met. We have made a recommendation about this.

Governance and quality assurance systems within the home required improvement. Although a range of audits were carried out, these were not effective in identifying the shortfalls that we found at this inspection. Action plans were not consistently used to drive through improvements within the service and there was a lack of oversight by the provider and registered manager on the quality of service delivered.

We identified five breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely; Regulation 9, Person-centred care; Regulation 10, Dignity and Respect; Regulation 12, Safe care and treatment; Regulation 13, Safeguarding service users from harm and abuse; and Regulation 17, Good governance. The provider has entered into a voluntary agreement with the Commission to suspend admissions to the home until the point at which they achieve compliance with all of the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We will continue to work with the provider to monitor and improve service. We have written to the provider and asked them to submit some specific information to us for review. You can see further action we have asked the provider to take at the back of the full version of this report.

We carried out a comprehension inspection in May 2015 where we found four breaches of the regulations. These included meeting nutritional and hydration needs; staffing; premises and equipment and good governance.

After the comprehensive inspection, the provider wrote to us on 11 September 2015 to say what action they were taking to meet legal requirements.

We inspected the service again on 28 and 29 June 2016 to check that action had been taken. We found that improvements had been made with regards to staffing and meeting nutritional and hydration needs. However, we identified serious shortfalls with the safety of the premises.

Woodlands provides care to a maximum of 42 older people, some of whom have a dementia related condition. There were 27 people living at the home at the time of the inspection.

A stairgate had been fitted to the main stairwell. This was neither secure nor fit for purpose. The fitting of some window restrictors in the home did not conform to the Health and Safety Executive (HSE) guidelines to prevent any serious accidents or incidents. Some of the flooring was uneven and concerns had been raised about a number of fire doors. The kitchen freezer had a crack in the bottom and was an electrical safety risk and a gas safety check had highlighted that the secondary boiler was not safe to use. One person with a dementia related condition had left the home unobserved on several occasions, placing them at risk of harm. Although some measures had been implemented such as bolts on the front door and key pads; the manager said that they were still waiting for anti-tamper locks to be fitted to the fire exits, since this person could override the key pads by pressing the emergency exit buttons. Some of the décor and furnishings were worn and damaged. Five of the lounge chairs had damaged cushion covers. The lounge/dining area carpet was stained and was covered with ingrained food and debris and the first floor carpet was threadbare in places. The chairs and carpets not only looked unsightly, but were an infection control risk because they could not be cleaned easily. Further work was required to ensure that the environment met the needs of people who had a dementia related condition.

There were deficits in the governance of the service since action to address the premises shortfalls was not taken in a timely manner.

Following our inspection, the regional manager emailed us to state that immediate action had been taken to ensure the safety of the premises. Whilst we acknowledged the work which had been carried out; we considered that action should have been taken in a timely manner and not, as it appeared, in response to our intervention.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

Staff told us that the service had been through a period of uncertainty. They told us that there had been changes in the provider’s management structure. Although the provider’s legal entity remained the same - ‘North East Care Homes Limited,’ a new management company was now overseeing the service; this had been the second management company within 12 months. Staff told us that these changes had affected morale.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. They were fully aware of the whistle blowing procedure.

Safe recruitment procedures were followed. No concerns about staffing levels were raised by people or relatives. We observed that staff carried out their duties in a calm unhurried manner.

The manager provided us with information which showed that staff had completed training in safe working practices. However, with the exception of dementia care, most staff had not carried out training to meet the specific needs of people including; falls awareness, continence awareness, Parkinson’s disease and pressure area care. The manager informed us that she was in the process of organising specific training.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. MCA is a law that protects and supports people who do not have ability to make their own decisions and to ensure decisions are made in their ‘best interests’ it also ensures unlawful restrictions are not placed on people in care homes and hospitals. The manager had submitted DoLS applications to the local authority to authorise in line with legal requirements. Although staff were following the principles of the MCA, improvements were required to ensure that evidence was available to demonstrate this. We have made a recommendation that the provider ensures that there is documented evidence that care is always sought in line with the Mental Capacity Act 2005.

At our last inspection, the provider had used an external catering company to provide meals at the service. At this inspection, the provider no longer used the catering company and employed their own kitchen staff. People and staff explained that this had improved the meals at the service.

Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff. People were supported with kindness and care. We noted however that some people with a dementia related condition were not wearing footwear. We considered that this not only affected people’s dignity, but also their safety. The manager told us that this had been addressed immediately.

Person-centred care plans were in place which gave staff information about how people’s needs were to be met.

There was an activities coordinator employed to help meet the social needs of people. The activities coordinator had been off for a period of time and had only recently returned to the service. We saw that she sat with people and talked with them in the morning and organised group activities in the afternoon.

There was a complaints procedure in place. Three complaints had been received and we noted that these had been responded to in line with the provider’s complaints procedure. Meetings and surveys were carried out.

The overall rating for this service is ‘Requires improvement.’ However, we are placing the service in 'special measures.' We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment, staffing and good governance. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We spoke with eight people to find out their opinions of the service. We also talked with the provider's representative, registered manager, deputy manager, laundry assistant and the activities coordinator. We contacted a local authority contracts and commissioning officer and had spoken previously to an environmental health officer.

An infection control practitioner from the local NHS trust was present at the home at the time of our inspection. She had carried out infection control training for staff and supported the manager to address the concerns we raised during our last inspection in July 2014. She told us, 'It's much improved. There are just a few minor issues to sort out.'

We considered our inspection findings to answer 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:

Is the service safe?

We found that improvements had been made to the environment and premises. All areas of the home were clean and maintenance and servicing had been carried out in a timely manner.

Records were now fit for purpose. Care plans documented people's likes and dislikes and aimed to meet people's physical, emotional and social needs. Risk assessments were in place for identified risks. Accident and incident records were correctly completed.

' Is the service effective?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the premises, cleanliness and infection control, assessing and monitoring the quality of the service and records. Therefore this question will be answered at a later date.

' Is the service caring?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the premises, cleanliness and infection control, assessing and monitoring the quality of the service and records. Therefore this question will be answered at a later date.

' Is the service responsive?

This question was not reviewed. Our inspection was carried out to check whether the provider had taken action to improve the premises, cleanliness and infection control, assessing and monitoring the quality of the service and records. Therefore this question will be answered at a later date.

' Is the service well-led?

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

We found that issues raised in health and safety audits and maintenance checks and servicing were now carried out in a timely manner. Any issues or actions highlighted during these checks had been addressed.

' 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:

Is the service safe?

Some people were unable to communicate with us verbally because of their dementia. We therefore spoke with their relatives and observed staff practices to determine how care and treatment was provided.

We consulted with a local authority care manager; a local authority contracts officer and a safeguarding officer to find out their views.

Prior to this inspection, we received information about a concern that the necessary health and safety checks on the premises had not been carried out. We spent time looking around the home and found that areas of paintwork in the corridors and communal areas were damaged. In addition, repairs and maintenance had not always been carried out in a timely manner.

We found that the home had not been cleaned properly. Flooring and certain continence equipment was dirty, stained or covered with debris. The manager explained that they had been without cleaning staff for some time. However, new domestic staff had now been appointed.

We noticed that effective infection control systems were not fully in place. There were no hand washing facilities in two of the shower rooms and laundry room. Clinical waste bins were not pedal operated which meant that staff had to manually lift up the bin lid which was an infection control risk. Cleaning schedules had not been completed since May 2014.

We looked at people's care plans and records relating to staff and the management of the home. We found that these were not always accurate nor fit for purpose.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS are part of the Mental Capacity Act 2005. These safeguards aim to ensure that people are looked after in a way that does not inappropriately restrict their freedom. The manager informed us that she was aware of the recent Supreme Court ruling which redefined the deprivation of liberty in care settings. She informed us and records confirmed that she had submitted seven deprivation of liberty applications to the local authority. These had been authorised by the local authority and the necessary paper work was in place. The manager told us that she was in the process of submitting further applications and was following advice issued by the local authority.

Is the service effective?

Most people and relatives with whom we spoke said that they were happy with the care provided by staff. We spoke with a local authority care manager who told us that feedback from people and relatives was generally positive when she carried out reviews of care at the home. She stated that one relative had commented at a recent review, 'Staff are receptive to her needs' and 'Staff helpful and down to earth.'

Is the service caring?

We saw that most interactions between people were positive. One person told us that staff made her feel special. We saw that people looked well cared for and presentable. Their glasses had been cleaned and nails manicured.

Is the service responsive?

There was a complaints procedure in place. People and relatives informed us that they were aware of this procedure and said that any concerns or issues that they had raised previously had been addressed promptly.

A new activities coordinator had been employed to help meet people's social and emotional needs. She told us and records confirmed that she assisted people out into the local community. One to one and group activities were carried out within the home.

Is the service well led?

There was a registered manager in place. A registered manager is a person who is registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

A number of audits were carried out to monitor health and safety. However, we found that maintenance issues were not always completed in a timely manner.

We raised concerns about infection control and the cleanliness of the environment. The manager explained that an infection control audit was completed annually to monitor infection control systems and processes in the home. We considered that undertaking an infection control audit only annually meant that any issues or concerns were not highlighted in a timely manner.

We found that people who used the service were able to express their views and were involved in making decisions about their care and treatment. People were given the opportunity to join in activities both inside and outside the service. People told us they were felt they were well cared for and the staff were attentive to their needs. Comments included, "This is my home now, I like it here" and "Nowhere is the same as home but we are well looked after here, there are plenty of nice staff around". We concluded people's care needs were assessed and care and treatment was planned and delivered in line with their individual care plans.

We found people were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We found there were effective recruitment and selection processes in place so appropriate staff were employed to care for people who used the service.

People told us they knew how to make a complaint and felt their comments would be taken seriously and investigated. Comments included, "I have never needed to complain but I would tell them if I wasn't happy about something" and "I can speak my mind and they listen to what I say". We concluded people had their comments and complaints listened to, and acted upon, without the fear they would be discriminated against for making a complaint.