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Inspection Summary

Overall summary & rating


Updated 8 March 2017

The unannounced inspection took place on 5 and 6 January 2017. A previous inspection on September 2014 found the standards we looked at were met.

Innisfree Residential Home is registered to provide accommodation and personal care for up to a maximum of 28 people. The service specialises in the care of older people living with dementia. There were 23 people using the service at the time of the inspection.

Innisfree Residential Home has a registered manager. 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.

The registered manager ran the service with passion and commitment, in close partnership with the registered provider. There were many examples of how their understanding of the needs of people living with dementia had improved those individual’s lives. People lived in a homely, friendly and caring environment, which had adaptations which helped maintain their independence. The quality of the service was closely monitored, with the registered manager fully informed of how staff provided people’s care and support.

People benefitted from a staff team which were well trained. However, they were not adequately trained in the complications of one health care condition, which had the potential to put people at risk. The registered manager arranged the training immediately.

Staff felt supported in their work and said they could take any question or concern to the registered manager. The service was actively recruiting new staff. People had no concerns around staffing numbers. Staff felt they could meet the needs of people using the service in a timely manner and we found people’s needs were being met.

Staff had a good understanding of how to protect people from abuse and protect their legal rights. People received their medicines as prescribed.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. The service had sought appropriate advice and was meeting people's legal rights in relation to MCA and DoLS.

People received a balanced, nutritious diet and commented about the food positively. People said they had a choice of meals and there was food and drinks available at all times. Staff ensured people who were on specialist diets had their needs met. Where they had concerns about people’s dietary intake they took action and involved health professionals.

The service worked in partnership with health care professionals to meet people’s health care needs. Health care professionals said they were contacted appropriately.

People’s views were sought through day to day conversation with staff and observation, resident meetings, care plan reviews and a yearly survey of opinion. Where a need for improvement was identified an action plan was produced, with timescales for the improvement.

People had a wide variety of activities available to them. These included entertainment, outings, arts and crafts, helping with domestic and gardening chores and quizzes and puzzles. Staff had developed good relationships with people. The layout of the home offered different options for people, such as a cosy sitting room or the conservatory for arts and crafts. There were examples of how staff knowledge and empathy had enriched and improved people’s lives, such as removing well established fears and providing support following bereavement.

The registered manager’s commitment to the care of people living with dementia had exte

Inspection areas



Updated 8 March 2017

The service was safe.

People were protected through robust staff recruitment.

Staff understood how to protect people from abuse.

The provider had systems in place to ensure that medicines were handled in a safe way.

There were sufficient numbers of staff deployed to meet people’s care and

support needs.

Safety within the premises was under regular review with plans in place for upgrading.


Requires improvement

Updated 8 March 2017

The service was effective but this could be improved.

Staff lacked knowledge in the complications of one health care condition, which had the potential to put people with that condition at risk.

Staff received regular training and updates in all aspects of health and safety and were well supported through supervision of their work.

People’s legal rights were very well understood and upheld.

People’s health care needs were met through contact with external health care professionals.

People liked the food and they received a healthy, balanced diet according to their preferences and assessed needs.



Updated 8 March 2017

The service was caring.

People lived in a homely and friendly environment.

People were treated with respect and dignity. Their privacy was upheld.

People had made caring relationships with staff and other residents.

People’s views were sought about every aspect of their lives.



Updated 8 March 2017

The service was very responsive.

People’s needs and behaviours were fully understood, which had enhanced their lives.

People had a wide variety of activities available to them and their independence was promoted. Staff responded with understanding and empathy to people’s emotional, physical and social needs.

People’s needs were comprehensively assessed and their care was planned in detail with them. They received person centred care of a high standard.

People felt confident to raise any concerns or complaints and these would be followed up effectively.



Updated 8 March 2017

The service was well-led.

The registered manager displayed a passion, competence and commitment in the way the service was managed. They worked in close partnership with the provider.

There were systems in place to monitor the quality of the service provided, including seeking people’s views and audits and checks, which were under regular review. Links with health and social care organisations kept the management informed of current good practice.

There was a strong culture of putting people first and this was led from the top.

Statutory responsibilities were being met.