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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 need

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