Archived: Berengrove Park Nursing Home

Berengrove Park Nursing Home is a residential care home providing personal and nursing care to 35 older people at the time of the inspection. The service can support up to 39 people in one large adapted building.

People’s experience of using this service and what we found

People told us they felt safe and staff were attentive to their needs. They told us staff responded to their requests quickly.

There was a new manager in post who had started their registration with the Care Quality Commission (CQC). The manager had started to make improvements within the service, addressing shortfalls identified at previous inspections. Though improvements had been made they had not been embedded or sustained to show continued improvement.

We were somewhat assured people were protected from infection. Staff wore masks but these often slipped down below their nose. Handwashing liquid was not always available, and some equipment and furniture were not always clean. The manager acted immediately to rectify the concerns.

Potential risks to people’s health and welfare had been assessed. Some improvements had been made in the guidance provided for staff to mitigate the risk, though further improvement was still required. There was now a system in place to record and analyse any accidents or incidents to identify any patterns and trends.

Staff were recruited safely. There was now a tool in place to calculate how many staff were required to support people. There were enough staff to meet people’s needs, though people did not always have access to meaningful activities. The manager was aware this was an area of improvement.

The manager had implemented a comprehensive quality assurance system covering all areas of the service. Audits had been started and the results were being used as a baseline to measure future improvements against. Quality assurance survey had been completed and the results were positive.

Medicines were managed safely, when shortfalls were identified these had been rectified. Staff attended regular meetings to discuss people’s needs and their practice.

The provider had been open and transparent with people, relatives and staff about the previous inspection. The new manager had been introduced to families and they had the opportunity to discuss how the service would be moving forward.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. There were systems in place to protect people from discrimination and abuse.

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

Rating at last inspection and update.

The last rating for this service was Inadequate (published 27 September 2021) and there were multiple breaches of regulation.

This service has been in Special Measures since June 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We received concerns in relation to management of medicines and assessing risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. There were breaches of regulation in the effective, caring and responsive domains but no new areas of concern were identified in these key questions. We therefore did not inspect them. However, we have followed up these breaches in the well led key question. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the safe and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Berengrove Park Nursing Home on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Berengrove Park Nursing Home is a residential care home providing personal and nursing care to 28 people aged 65 and over at the time of our inspection. The service can support up to 39 people in one adapted building.

People’s experience of using this service and what we found

It is a condition of the provider's registration to have a registered manager in place. There was no registered manager, and it was unclear who was monitoring the quality of the service. There continued to be widespread shortfalls in the way the service was led as the provider did not have full oversight of the service.

Risk to people’s health, safety and welfare were not consistently assessed, identified and monitored. Records were inconsistent and varied in the level of detail provided to guide staff to keep people safe.

The provider failed to ensure systems were in place to regularly assess and monitor the quality and safety of the service. Quality assurance audits were not undertaken regularly, and incidents and accidents were inconsistently recorded and monitored.

People did not always receive personal care as outlined in their care plans. Some people’s care plans stated two staff were required to support personal care, during the inspection this was not taking place as outlined, with only one staff member supporting people. This placed people at risk and impacted on their dignity.

People were at risk of isolation. Most people were being cared for in their rooms with limited meaningful engagement between staff and people to mitigate this. Some activities took place in the lounge with minimal participation.

The provider had failed to act on a previous recommendation to make dementia friendly improvements to the building.

The service had failed to protect people’s privacy and dignity.

Staff were not always deployed to provide support for people when they needed it. This posed risks to people and limited people’s ability to interact with staff and other people.

The service had made improvements to care planning, however, they contained inconsistences which could lead to people’s needs not being met and increased risk.

There were not enough skilled and competent staff deployed appropriately to meet people’s needs. Some staff had not received suitable training to carry out their role.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People living at the service and their relatives said the service was caring. One person told us, “They [staff] look after me. My room is set up well, I have my TV, a fridge and have my meals delivered.” A relative told us, “The nurses interact with my [relative] in a nice way and ask courteous questions”.

Medicines were safely managed and administered. The provider had made improvements since our last inspection and medicines were stored correctly and dispensed at prescribed times. Medicine administration records were correct, and audits took place to highlight any errors.

Infection Prevention and Control policies and procedures were being followed. The premises looked clean and tidy and we were assured that the service had controls in place to minimise the risks posed by COVID-19.

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

Rating at last inspection and update

The last rating for this service was requires improvement [published 03 September 2019] and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made/sustained, and the provider was still in breach of regulations.

The service has deteriorated to inadequate. This service had been rated requires improvement for the last five consecutive inspections.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements in all areas. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our previous comprehensive inspection, by selecting the ‘all reports’ link for Berengrove Park Residential Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to assessing and monitoring risk, staffing, accident and incident recording and auditing, person centred care, dementia friendly adaptations, dignity and good governance at this inspection.

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.

Follow up

The overall rating for this service 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 the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Berengrove Park Nursing Home is a residential care home providing personal and nursing care to 31 people aged 65 and over at the time of the inspection. The service can support up to 36 people.

People’s experience of using this service and what we found

Some improvements had been made since the last inspection. However, the care and support provided to people was still not good.

People were not always protected from risks. Guidance for staff was inconsistent and contained contradictory information. When people were supported with their medicines, recording was not consistently in line with guidance and best practice. There were generally enough staff, however they were not always deployed efficiently to make sure people had the support they needed when they needed it. 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 and in their best interests; the policies and systems in the service did not support this practice. Staff were not up to date with their training and nurses still did not have access to clinical supervision to improve and enhance their professional development. Audits and checks on the quality of service people received were not robust and consistently effective.

People were supported by staff who had been recruited safely. Staff understood how to keep people safe from the risks of abuse and knew how to report any concerns. Accidents and incidents were monitored and reviewed.

People’s needs were assessed, monitored and regularly reviewed. People were offered choices of home-made meals and told us they enjoyed the food. People had access to health care professionals when needed. Staff worked with health care professionals, such as dieticians, and followed the advice given to support people to remain as healthy as possible.

People’s were not consistently treated or spoken about in a dignified way. People had built relationships with staff and told us the staff were kind and caring. People and their relatives were involved in the planning of their care and support.

People’s care plans had been developed since the last inspection and contained information about people’s life history and things that were important to them. However, some care plans and associated records were inconsistent and did not reflect the care and support people received. People were encouraged to stay active and activities were arranged to support this. People’s religious, spiritual and cultural needs were discussed to make sure these needs were met. People knew how to complain, and complaints had been resolved satisfactorily. People were supported to share their end of life wishes and these were recorded to make sure their choices and preferences were followed.

People spoke positively about the provider, registered manager and staff. Staff knew people well. The provider asked people, their relatives, staff and health professionals for feedback about the quality of service.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 07 August 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified five continued breaches in relation to people’s safety, inconsistent recording of medicines, people’s rights and how they consent to care, lack of staff training and development and lack of robust and effective checks and audits.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during the inspection of the care home. Berengrove Park Nursing Home is registered to provide accommodation for older people who require nursing or personal care. The home was registered to provide nursing care and support for up to 36 people. There were 31 people living at the home at the time of this inspection. People had complex health needs, including diabetes, stroke and Parkinson’s disease. Many people were living with dementia, some at an advanced stage requiring high levels of support from registered nurses and staff.

There was a registered manager in post at the service. 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.

Our last inspection report of this service was published on 21 October 2017 and related to an inspection that had taken place on 15 and 16 August 2017. At the inspection in August 2017, we found breaches of Regulations 9, 10, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Two breaches had continued since the previous inspection relating to the management, leadership and monitoring of the service provided and people’s safe care and treatment. Three further breaches were found in relation to, people receiving care and support that meets their individual needs; people receiving care and support that respects their privacy and dignity at all times and ensuring staff were deployed to adequately meet the needs of people throughout the day.

We asked the provider to take action to meet Regulations 9, 10, 12 and 18. We took enforcement action against the provider and the registered manager and told them to meet Regulation 17 by 03 November 2017.

The provider sent us an action plan on 18 October 2017 telling us the action they were taking to comply with regulations 9, 10, 12 and 18. They told us they would be fully compliant by 01 January 2018.

At this inspection, on 2 and 3 May 2018, we found that some improvements had been made in all the areas highlighted as requiring improvement. However, further improvements needed to be made and we found other areas of concern not found at the last inspection.

Risk assessments around people’s personal and nursing care needs were in place. However, these continued to primarily focus on the areas of risk common to most people living in the service and did not reflect individual or changing needs. Health and safety hazards were observed around the premises. The control of infection within the service was not clearly managed or understood by staff.

Some elements of medicines management needed improvement in order to provide a safe and effective service when administering people’s prescribed medicines.

Mental capacity assessments had been undertaken to ensure people’s rights were protected under the basic principles of the Mental Capacity Act 2005. Documents used were of poor quality and therefore illegible at times. Decisions were not always made in people’s best interests and consent to care and treatment was not appropriately sought.

New staff received a good induction to the service and training was available for staff to complete to ensure they had the skills and training to support the people living in the service, however not all staff had kept their training up to date. Evidence was not provided that registered nurses had completed suitable professional development to make sure their nursing and clinical skills were kept up to date.

Feedback from people’s relatives and staff was positive about the management of the service. The management and monitoring of the quality and safety of the service needed further improvement to evidence the clear oversight of the management team.

Improvements had been made to people’s care plans, they contained information that was person centred and individual. Care plans did not cover all the areas of people’s care and treatment so further improvement was needed. We have made a recommendation about this.

Accidents and incidents were recorded well and monitored by the registered manager to prevent further incidents. Plans were still in place to assist people to evacuate the building or keep them safe in an emergency.

Referrals to health care professionals was evidenced however, a consistent approach was not always taken as some people were not referred for some treatments when a need had been identified. We have made a recommendation about this.

People and their relatives told us the food served was good and they had a choice. The registered manager told us people were now given a choice if they wanted to sit at a dining table to eat their meal, evidence was not provided that this was the case. We have made a recommendation about this.

People had the opportunity to discuss their wishes at the end stages of their life if they wished, however, this was not always appropriately transferred into a care plan to ensure staff understood what people wanted to happen. We have made a recommendation about this.

People and their relatives gave positive feedback about the kind and caring nature of the staff team. Staff knew people well and a friendly and more relaxed atmosphere was evident.

A greater emphasis was now placed on meaningful activity. People’s interests were taken into account and catered for on a more individual basis. During this inspection, people were not left unattended for long periods of time.

Staff had a good understanding of their responsibilities in raising concerns of a safeguarding nature. Staff felt the management team would listen to and act on any concerns they had and they knew how to tell organisations outside of the service if this was necessary.

Maintenance of the premises and servicing of equipment was undertaken when necessary by the appropriate professional bodies.

The provider had continued to display the ratings from the last inspection, in August 2017 in a prominent place so that people and their visitors were able to see them.

During this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. You can see what action we told the provider to take at the back of the full version of this report.

Berengrove Park Nursing Home is registered to provide accommodation for older people who require nursing or personal care. The home could provide care and support for up to 36 people. There were 32 people living at the home at the time of this inspection. People had complex health needs, including diabetes, stroke and Parkinson’s disease. Many people were living with dementia, some at an advanced stage requiring high levels of support from registered nurses and staff.

There was a registered manager in post at the service. 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.

Our last inspection report of this service was published on 06 July 2016 and related to an inspection that had taken place on 12 and 13 April 2016. At the inspection in April 2016 we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 12, hazards had not been fully identified and managed, meaning people, staff and visitors were at risk of potential harm; Regulation 15, people who use services and others were not protected from the risks associated with unsafe or unsuitable premises because of inadequate cleaning and maintenance; Regulation 17, the provider had failed to ensure adequate auditing and monitoring were in place to check the safety and quality of the service provided. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, CQC had not been notified of important events that had taken place in the service. We asked the provider to take action to meet the regulations.

The provider sent us a report of the actions they had taken to comply with Regulations 12, 15 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on 08 July 2016 and they told us they were already meeting the Regulations. They also said they had taken action to meet Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

At this inspection we found the provider and registered manager had made some improvements to the service and standard of care. However, we found improvements were still required and found a continuing breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found new breaches of Regulation 9, care and support was not always provided to meet all the needs and preferences of people; Regulation 10, people’s privacy and dignity were not always respected; Regulation 12, risks were not always assessed, reviewed and monitored; Regulation 18, staff were not suitably deployed to ensure people’s needs were sufficiently met.

Risk assessments around people’s personal and nursing care needs were in place. However, risks were not always reviewed to take into account people’s changing needs or incidents that had happened.

Staff were not deployed sufficiently around the service to ensure people’s care and support needs, including social and welfare needs, were met. People were often left sitting on their own in the lounge or in their bedroom with little stimulation. People were not engaged in meaningful activities that were based on their interests and to create a motivating environment.

People’s care plans were suitable for their personal care and nursing needs. However, care plans were not person centred or focussed on people’s well-being and social and cultural needs or based on their preferences and interests. People and their relatives were not always involved in reviewing their care plans.

Plans in place to provide meaningful activity were not adequate to meet the needs of people, to provide social stimulation and to maintain the emotional well-being of people. People were left alone with little interaction for long periods of time.

Mental capacity assessments had been undertaken within the principles of the Mental Capacity Act 2005 and best interests decisions had been made around people’s nursing and personal care needs. However, some important decisions had not been considered which constituted a contravention of people’s basic rights. We have made a recommendation about this.

Daily records, including food and fluid charts, bowel recording charts and activity records were not recorded consistently so not showing a complete and accurate record. Although an audit and monitoring system was in place it was not used effectively to identify concerns and act on them to drive improvements within the home.

The provider had asked for feedback of the service from relatives and professionals involved in the service. There was no evidence that some comments made had been listened to and actioned.

The registered manager had not received regular one to one supervision to provide them with the support required to provide good management and leadership. We have made a recommendation about this.

Staff were complimentary about the registered manager, the provider and the nurses and said they would take any concerns they had to any of them.

The provider had robust recruitment processes in place to make sure only suitable staff were employed to work in the service.

Staff had regular one to one supervision meetings with their manager to support their development. Suitable training was provided and staff received the appropriate refreshers and updates. New staff received a good induction into the service and experienced senior care staff supported the first weeks in their new role. Staff were kind and caring in their approach.

Staff meetings had not taken place for over one year. We have made a recommendation about this.

Complaints were dealt with by the provider. Records were kept showing the action taken and the outcome to the complaint.

People received their prescribed medicines by registered nurses. The medicines administration process was managed well, including the ordering, storage and return of medicines in the home.

The provider had a safeguarding procedure in place so staff could access the information they needed to protect people and raise concerns.

People and their relatives said they were happy with the food provided. The food looked attractive and menus were nutritious and varied. No people sat at the two available dining room tables and people were not given the choice whether they wanted to. We have made a recommendation about this.

People’s health needs were generally taken care of by the registered nurses working in the home and GP practices. Health referrals had been made as appropriate to other health care professionals.

The trip hazards that meant people, staff and visitors had been placed at potential risk of harm had been removed and electric lights were now working correctly. Maintenance of the premises and servicing of equipment had been carried out as required.

Cleaning schedules were in place, hoist slings were now used for one person only and the nurses clinical area had been cleaned and refurbished.

The provider now made sure they notified CQC of any important events that happened in the service as they are required to do.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

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.

At the last inspection, on 5 and 6 August 2014, we identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The breaches were in relation to the safety and suitability of premises, cleanliness and infection control and assessing and monitoring the quality of service providers. The provider sent us an action plan telling us how they were going to make changes to improve the service.

At this inspection we found that the provider had taken action to address the breaches from the previous inspection and improved the environment in some areas. However, there remained a number of areas of concern where the provider had not effectively carried the learning from the previous inspection into other areas of the home. The premises were not adequately maintained to minimise risk to people using the service. There were areas that were not cleaned to a satisfactory level, such as the kitchen and corridors. Equipment such as mobile hoists had not been cleaned to an acceptable standard. Slings used with the mobile hoists were not stored in people’s rooms, causing a cross infection hazard. The clinical room area had parts that were not maintained causing a potential infection control risk. Lighting was poor in an area that was a busy thoroughfare and had mobile hoisting equipment stored, causing a trip hazard. Auditing and monitoring mechanisms had not picked up any of these concerns, rendering them not fit for purpose.

Although care plans were in place and up to date, these were not person centred. There was no information recorded about the person as an individual or describing the person’s life before they moved to Berengrove Park Nursing Home, who was important to them or their likes and dislikes. However, staff clearly knew people well and had good relationships with them.

We have made a recommendation about this.

There was little information around the home to tell people what was happening in the service. For example, what activities were taking place and when, so people had to rely on staff to let them know.

We have made a recommendation about this.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The manager had taken steps to comply with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. People were not being restricted and their rights were being protected. However, the registered person had not notified CQC they had made DoLS applications that had been authorised by the local authority. They are obliged to do this by law.

The manager at Berengrove Park had applied to become the 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and their relatives told us they felt safe living at the home. Staff had a good understanding of their responsibilities in keeping people safe. They could tell us their role in safeguarding vulnerable adults from abuse and were all clear they would always report any suspicions they had. Individual risk assessments were in place to keep people safe when receiving care and support.

There were adequate staffing levels in all areas of the home to ensure people received the care and support they were assessed as needing. Registered nurses were employed to make sure people’s nursing needs were attended to by trained professionals. Suitable training was available to ensure people were supported well by staff who had the training and experience to fulfil their role. Staff were supported with their own professional development whatever their role through training as well as one to one supervision. The registered nurses were supported to maintain their professional qualifications.

People’s health needs were met by registered nurses on every shift as well as referrals to specialist health care professionals. Initial assessments were carried out by the registered nurses to enable the manager to be sure the service was in a position to adequately support people. Care plans were developed with the involvement of people and their relatives where appropriate.

There was a caring atmosphere in the home and people and their relatives told us the staff were friendly, kind and considerate. Staff were happy and were singing and smiling while going about their work. There were good examples of people being treated with dignity and respect.

Complaints were investigated and responded to well. The provider personally addressed most complaints, responding quickly and feeding back to the complainant.

Surveys were carried out each year to gain the views of people, their relatives, staff and health care professionals. There was no formal mechanism for feeding back to people and their relatives about these and we have made a recommendation about this.

People, their relatives and the staff thought the service was well run and the provider and manager were approachable and supportive. There was an open and positive culture which focussed on people who used the service. The manager and provider were available, and people who lived in the

home, staff and visitors could speak with them at any time.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

People’s diverse and complex needs were understood and managed by the staff working at the service. People felt their care needs were met by caring and friendly staff. One person commented “There are some very good girls here”.

People were supported to receive adequate nutrition and hydration. One person told us “The food is pretty good, there is always a choice”.

People were not fully protected from the risk of harm because some of the door closing devices were not working properly and the provider had not completed personal emergency evacuation plans for all the people living at the service.

The recruitment policy and procedures used by the service ensured that all possible relevant checks were made on staff so that people’s welfare was protected.

The service had an effective complaints procedure in place and people living at the service felt confident that should they have made a complaint it would be dealt with.

Staff were confident in reporting abuse and understood that they could blow the whistle if they were concerned about how people were treated.

The service had policies and procedures in place to minimise any risks of cross infection, and we found all areas of the home clean.

We found that the service had provided staff with training updates in core areas such as moving and handling, first aid, food hygiene and The Mental Capacity Act 2005. Staff we spoke with were able to demonstrate how they had benefited from the training and apply it to their work.

The service had a robust quality assurance system in place which enabled the manager and proprietor to identify areas for improvement and assess the quality of the service.