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Inspection Summary

Overall summary & rating


Updated 23 September 2017

The inspection took place on 21 February 2017 and 6 April 2017. The inspection visit on 21 February was unannounced but the second visit was announced.

The service provides residential care for up to 42 people, some of whom are living with dementia. At the time of our inspection 40 people were using the service.

A registered manager was 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.

At our previous inspection in October 2014 we found that people were receiving high quality care which responded to people’s individual needs. At this inspection we have found that these standards had been maintained and in some areas further improved. This meant that people received an outstanding level of care which responded to their individual needs and preferences. Skilled and caring staff supported people in the way that they chose.

People received safe care which met their individual needs and preferences. There was a strong commitment to enabling people who used the service to be as independent as possible through robust risk assessment to keep them safe. Risks were assessed and documented in care plans and environmental risks were very well managed. The manager and staff demonstrated a very good oversight of risk.

Staff were trained in safeguarding people from abuse and the manager referred incidents appropriately to the local authority safeguarding team for investigation. Internal investigations into safeguarding incidents were carried out in an honest and transparent way. The service worked well with other professionals to investigate any safeguarding matters.

There were enough staff to keep people safe and to enable them to live their lives in the way they chose. Staff were recruited safely as there was a robust recruitment procedure in operation. The service was overstaffed by 10% to further ensure care and support was delivered consistently by staff who knew people well. Staff had time to spend with people and people’s needs were met promptly.

Medicines were managed safely and people received their prescribed medicines when they needed them. Staff were trained and verified as competent to administer medicines.

The service was clean and infection control measures were in place. All staff had a good understanding of how to reduce the risk and spread of infection.

Staff received an excellent work based induction and a variety of relevant and person centred training to help them carry out their roles. Training was innovative, challenged staff and was designed to drive continual improvement. Staff were supported with regular meetings, supervision and values driven appraisal of their performance. Staff were very positive about the training they received and felt valued by the manager and the organisation.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Practice related to MCA and DoLS was very good and in line with legal requirements.

People who used the service praised the food highly. People were referred to appropriate healthcare professionals, such as dieticians, promptly if they required this support. There was sensitive support at mealtimes for people who needed help or encouragement to eat and to maintain their weight. Oversight of people’s nutritional needs was good. Mealtimes were very chatty and sociable occasions which people clearly enjoyed.

People were promptly supported to access the health and social care professionals they needed. There was evidence of good partnership working with the district nursing team and other healthcare professionals. Feedback from healthcare professionals working with the service was very positive.

Staff were exceptionally caring and compassionate. They treated people respectfully and demonstrated great patience and empathy. Staff sought to ensure people’s self-esteem and dignity was maintained. The caring role was not limited to care staff but administrative staff and volunteers played an important part in the caring life of the service.

The Christian values of the service were evident throughout and this was very important to all of the people who used the service. Many staff shared the Christian values which were fundamental to the service. This provided a common bond between staff and the people who used the service. The staff also actively supported people to explore other faiths if they chose to.

Care was person centred and people’s individual needs were well documented. Staff demonstrated a good knowledge of these. Care was delivered holistically and staff caring for those people living with dementia never lost sight of the person inside and had received training related to this in particular. People living with dementia played a full part in the life of the service and the atmosphere was inclusive and caring.

People were extremely well supported at the end of their life. They experienced care which reflected their very specific preferences and met their needs at this most important time. The manager, supported by the staff team, focussed on ensuring people’s end of life care was given in line with their expressed wishes. Staff were proud of the end of life care that people received.

People who used the service, and their relatives, were involved in planning and reviewing their care and had opportunities to feedback about the service. The provider was proactive in seeking people’s views and acted on information they received in order to improve the service.

People were supported to follow a range of hobbies and interests and to take an active and purposeful part in the daily life of the service. Those living with dementia and those unable to go out independently were provided with appropriate stimulation and occupation. People were encouraged to remain part of their local community.

A complaints procedure was in place. No formal complaints had been made but informal issues were well managed and resolved quickly to people’s satisfaction. The manager gave people many opportunities to raise informal issues and was always looking to improve the service. People had the confidence to raise concerns and felt listened to.

A comprehensive system of audits and spot checks was in place to monitor the safety and quality of the service. Staff took pride in carrying these audits out regularly where they had been given the delegated authority to do so. The manager took overall responsibility for ensuring that any identified actions were put in place.

The exceptional manager acted as role model and was respected by people who used the service, relatives and staff. They led by example and clearly set out the standards they expected from staff. They had excellent oversight of the issues that affected this service, which has a history of positive inspections by CQC, and were able to motivate their team exceptionally well. The manager demonstrated a commitment to the ongoing improvement of the service. They aimed to ensure that people’s individual needs and preferences were met through the delivery of innovative and person centred care. The manager and staff took a pride in their work and clearly cared deeply about the people who used the service and their families.

Inspection areas



Updated 23 September 2017

The service was safe.

Staff understood their responsibilities with regard to safeguarding people from abuse and had received appropriate training.

Risks to people were very well managed and staff demonstrated skills in reducing risks to people.

There were enough skilled and experienced staff to meet people�s individual needs and spend quality time with them.

Medicines were managed safely.



Updated 23 September 2017

The service was effective.

Staff received a comprehensive induction and training was provided to help staff meet people�s individual needs. Training was challenging and encouraged staff to think deeply about their practice.

Staff had received training in MCA and DoLS. The service had ensured decisions had been taken lawfully and in people�s best interests. People were supported to be as independent as possible and restrictions were always sensitive to people�s need to be independent.

People were positive about the food. Those at risk of not eating enough were supported with their diet and were well monitored.

People were promptly supported to access healthcare professionals when they needed to.



Updated 23 September 2017

The service was extremely caring.

Feedback from people who used the service and relatives was very positive about the kindness and patience of the staff.

People�s privacy and dignity was maintained and their distress and anxiety alleviated. Staff, including office staff, were skilled in managing people�s anxious and distressed behaviour.

People were encouraged to remain independent which raised their self-esteem. Those living with dementia were enabled to have a role in the day to day life of the service.

People received outstanding end of life care which respected their very individual wishes and provided comfort. Staff went the extra mile to ensure people received the person centred end of life care and support they needed.



Updated 23 September 2017

The service was extremely responsive.

People�s care needs were assessed before they were admitted to the service. People who used the service, and their relatives, were involved in assessing, planning and reviewing care which responded to their individual needs. Care plans took into account people's specific needs and gave staff detailed guidance on how to provide individualised care. Care was provided in a holistic manner and care plans showed how people's needs were interlinked.

Care for people living with dementia focused on the person and not on their condition. People were provided with occupation, group and one-to-one activities and sensory stimulation. People were encouraged to feel that they had a role and were needed.

People were supported to follow their own interests and hobbies and to access leisure opportunities outside the service. People were supported to follow their Christian faith in their daily lives. The Christian values of this organisation were demonstrated throughout the service.People were also actively supported to explore other religious faiths if they chose to.

A complaints procedure was in place. Although no issues had been raised formally, informal issues were very well managed. The manager was proactive in ensuring that people were satisfied with the service they received and responded promptly to any minor issues that were raised.



Updated 23 September 2017

The service was extremely well led.

Staff were well supported and motivated by the exceptional manager. The manager was a very effective role model for excellent practice. The provider supported and encouraged the manager and recognised and celebrated their achievements.

There was a comprehensive system of audits in place to monitor the quality and safety of the service. Action followed promptly when any issue was identified.

The manager had good oversight of the service and was focussed on continuous improvement. They managed the service in an open and transparent way for the benefit of all.

The caring and Christian ethos and values were evident throughout the service. The feeling was of an inclusive and caring service focussed on excellence and always looking to improve