Archived: HF Trust Rendle House

About the service

HF Trust – St Teath Site is a residential care home for up to 10 people with a learning disability and/or autistic people. The site consists of two separate houses, Rendle House and Valley View. Each can accommodate up to 5 people. At the time of the inspection 9 people were living at the service.

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

Right Support

Staff had identified goals for people and these had been included in care plans. However, there had been little progress in moving towards achieving these goals. Information on how to support people with appropriate skills was not available.

Daily logs were not consistently used to record what had worked well for people and what had not gone as well. There was limited information about people’s quality of life outcomes. This meant opportunities to learn from people’s experiences might be missed.

People’s individual interests were known and, when possible, staff supported them to do the things they enjoyed. However, opportunities were sometimes impacted by staffing arrangements.

People had a choice about their living environment and were able to personalise their rooms. Improvements were being made to the environment at Valley View and more were planned.

Staff enabled people to access specialist health care support in the community.

Staff supported people with their medicines in a way that promoted their independence. However, there had been a series of medicine errors.

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. The provider was investing in technology to enable restrictions in place to be reduced.

Right Care

Staff did not consistently respect people’s privacy and dignity.

There were not enough contracted staff to meet people’s needs and keep them safe. To mitigate this the provider had invested in regular use of agency staff. Although some agency staff were ‘block booked’ and worked at the service regularly, others were at St Teath less frequently. This did not ensure people received consistent care from staff who knew them well and who had built trusting relationships with them.

People’s communication preferences were known by staff. However, tools to support communication were not always in place.

People’s care, treatment and support plans had been updated to better reflect their range of needs.

The service worked with other agencies to protect people from potential abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture

There was a new manager at the service. They were receiving daily support from the local residential operations manager and further support from HF Trusts divisional Head of Care and Support - West.

Additional support from external agencies and professionals had been sought to try and drive improvements in the service.

Training in relation to the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have was being rolled out to contracted staff and regular agency staff.

The high dependence on agency staff had impacted on many aspects of the service. Challenges for the service meant managers had to prioritise where they focused their efforts, often having to spend their time on rota management. This impacted on their opportunities to monitor the service.

Feedback from professionals and relatives was that, although improvements had been made there were still areas where work needed to be done.

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 22 February 2023).

At our previous inspection we identified breaches in relation to person centred care, implementation of the Mental Capacity Act, safe care and treatment including in relation to the administration of medicines, risk management and safety checks at the service, oversight and management of the service, staffing levels, a failure to follow Duty of Candour policy and a failure to notify CQC of events as required by law.

We issued 2 warning notices in relation to the breaches of person centred care and management of the service. At this inspection we found the warning notices had been partly met although we still had concerns. We met with the provider who agreed to provide monthly action plans and reports to demonstrate how they were working to address the concerns.

We also made a recommendation about the environment. At this inspection we found improvements to the environment had been made and more were planned.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

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

Enforcement

We have identified breaches in relation to safe care and treatment, person-centred care, staffing and management of the service.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

About the service

HF Trust – St Teath Site is a residential care home for up to 10 people with a learning disability and/or autistic people. The site consists of two separate houses, Rendle House and Valley View. Each can accommodate up to 5 people. At the time of the inspection 9 people were living at the service.

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

Right Support:

The service did not support people to be independent and have control over their own lives.

People did not have fulfilling and meaningful everyday lives. They were not consistently supported to set goals. When goals had been identified there were no clear pathways to help people achieve their aims.

People’s opportunities to take part in activities and pursue their interests in their local area were limited. There was a lack of variety in the activities offered both in the service and in the community.

People’s individual needs and preferences were not always considered when administering medicines.

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.

The environment in one of the houses was in need of updating. There were plans in place to make improvements.

Right Care:

The service did not have enough appropriately skilled staff to meet people’s needs and keep them safe.

Staff had not completed training in communication techniques for people who did not use words to communicate. There were very few pictorial tools in use to support people’s understanding.

People’s care, treatment and support plans were out of date and contained repetitive and irrelevant information. Although a manager had started to review these, progress was slow as they were in the service infrequently.

People did not receive care that supported their needs and aspirations, was focused on their quality of life, and followed best practice.

The service did not give people opportunities to try new activities that enhanced and enriched their lives.

Staff had training on how to recognise and report abuse and they knew how to apply it.

Right Culture:

There had been a lack of consistent leadership and oversight at the service. Staff practice was not monitored, and staff were unclear where to go for guidance and support on a daily basis.

Staff meetings and supervisions had not been in place for all staff which limited their opportunity to raise concerns and ask questions.

Staff had not received training or information in relation to best practice and the wide range of strengths, impairments or sensitivities people with a learning disability and/or autistic people may have. There was a culture of doing ‘for’ rather than ‘with’ people.

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

Rating at last inspection

The last rating for this service was good (published 13 October 2018).

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At our last inspection we recommended that the provider ensured staff were able to administer medicines in a calm environment in order to mitigate the risk of human error. At this inspection we found improvements to the way in which medicines were administered were still required.

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk. This inspection examined those risks.

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.

You can see what action we have asked the provider to take at the end of this full report.

The provider had taken steps to mitigate the specific risks which led to the incident. We found no evidence during this inspection that people were at risk of harm from this particular concern.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for HF Trust – St Teath Site on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, risk management, safeguarding people from potential abuse, person centered care, consent, staffing, notifying the commission of significant events, duty of candour and governance.

We have made a recommendation about ensuring the environment meets people’s sensory needs and supports their emotional well-being.

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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

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.

People in care homes receive accommodation and nursing or 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 this inspection.

The service is required to have a registered manager and there was one 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.

The service was operating in line with the values that underpin 'Registering the Right Support' and other current best practice guidance. This guidance includes the promotion of the values of; choice, independence and inclusion. The service was working with people with learning disabilities that used the service, to support them to live as ordinary a life as any citizen. People had access to private spaces and were able to choose where they spent their time. Staff supported people to access the community regularly. People’s independence was respected and they were encouraged to develop and maintain skills.

The service requires a registered manager and there was one 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 were protected from identified risk. Staff were aware of the support people needed to help keep them safe. Any changes in people’s behaviour or health was monitored to try and identify causes and triggers. Action was taken to learn from any untoward events.

The premises were clean and largely well maintained. People had access to safe outdoor spaces. Any maintenance was carried out quickly and there was a programme of redecoration in place. People’s bedrooms were personalised and reflected their tastes and interests.

There had been a high level of vacancies at the service with a large number of agency staff being used to ensure people were supported according to their care plans. A recent recruitment drive had been successful and, at the time of the inspection, there was only one staff vacancy. Planned rotas showed people were to be supported by a consistent staff team. Each site had their own distinct staff team which was overseen by a senior support worker. Key workers had responsibility for monitoring individual delivery of care. Relatives told us key workers were very familiar with people’s needs.

There had been a high level of medicine errors at the service, over a prolonged period of time. We looked at systems for the management and administration of medicines and found there were suitable arrangements in place, including when people went for days out or weekends away. Training was regularly refreshed and there was a system of competency checks in place. We concluded the mistakes were due to human error. We have made a recommendation about ensuring the environment is calm when staff are administering medicines.

Staff were supported by a system of induction, regular training and supervision. They told us they felt well supported by the registered manager and higher organisation. HF Trust had a clear set of values in place which were well known by staff.

People were supported in line with the legislation laid down in the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments were in place for specific decisions to show when people were unable to make decisions for themselves. DoLS applications had been made appropriately and the any decisions made on people’s behalf was made following the best interest process.

People were comfortable and at ease with staff. Some people needed additional support to move around. Staff were patient and kind when providing this support and people were relaxed and confident with them. Relatives told us they believed their family members were safe and well supported by staff who knew them well and understood their needs.

There were quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by the registered manager, and staff and managers from other HF Trust services.

HF Trust – St. Teath Site is owned and operated by Home Farm Trust (HFT). There are two properties on one site: Rendle House and Valley View. Each property provides care and support to adults who have a learning disability and/or autistic spectrum disorder. Each property can accommodate up to a maximum of five people. At the time of our inspection nine people lived at the service.

The service is required to have a registered manager and there was one 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.

Due to the complexities of people's care needs we were unable to speak with anyone who lived at the service to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

There were quality assurance systems in place to make sure that any areas for improvement were identified and addressed. Some areas, such as medication audits, maintenance and checks on appropriate supervision arrangements were not thorough.

Maintenance required by the service was not appropriately prioritised or recorded to demonstrate when action had taken place.

On the day of our inspection there was a relaxed and friendly atmosphere at the service. We saw that people were comfortable and at ease approaching staff at HFT – St. Teath and staff interacted with people in a caring and respectful manner. Relatives of people who used the service were mainly positive about the level and quality of care provided to people. Comments included, “In my experience the care provided at St. Teath is good. There is a genuine concern to provide the best for people.” And, “On the whole communication is good between myself and management and staff.” One relative commented that they recently raised a concern about the welfare of a person who lived at the service. The registered manager was open about this and we saw the incident had been appropriately investigated and an action plan put in place to prevent a repeat of the incident.

People took part in a range of group and individual activities of their choice including work and social activities. Relatives spoke of the ‘busy’ and ‘active’ lives people lived. This helped to prevent people from becoming socially isolated and promoted their emotional well-being.

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Some relatives expressed concern about the turn-over of staff at one of the houses and the use of agency staff commenting, “It is just a pity the staff turnover is frequent.”. We saw evidence that the rate of use of agency staff had reduced significantly over the last 12 months.

Staff completed a thorough recruitment and induction process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

People had access to healthcare services such as occupational therapists, GPs, chiropodists and dieticians. Relatives told us they were confident that the service could meet people’s health needs and they were always kept informed if their relative was unwell or a doctor was called. The service demonstrated good management of people’s health conditions. Relatives told us how management had worked effectively to bring together a group of health professionals; this ensured treatments were provided with the least amount of stress to the person involved.

Staff supported people to maintain a balanced diet appropriate to their dietary needs and preferences. Weekly people made choices of the meals they wanted for the forthcoming week and the service had a picture notice board showing what had been chosen for the week. People were free to choose an alternative if they wanted to. Relatives said the quality of meals provided was, “good.”

Care records accurately reflected people’s care and support needs. Details of how people wished to be supported were individualised and provided clear information to enable staff to provide appropriate and effective support. Any risks in relation to people’s care and support were identified and appropriately managed.

Management and staff had an understanding of the Mental Capacity Act 2005 (MCA). Where people did not have the capacity to make certain decisions the management and staff acted in accordance with legal requirements under the MCA. Staff applied the principles of the MCA in the way they cared for people and told us they always assumed people had mental capacity. Management met regulatory requirements to notify CQC when approved DoLS authorisation were made.

People and their families were given information about how to complain. People told us they knew how to raise a concern and would be comfortable doing so. We were provided with examples of incidents when concern had been raised and evidence of how the service had handled issues.

There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example. Staff said, “Communication is good” and “it’s a good place to work.” Management were visible in the service and regularly observed and talked to people to check if they were happy and safe living at HF Trust – St. Teath.

At this inspection because we only looked at care records and quality monitoring records we were unable to answer all of our five questions. Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found from a records perspective the service was safe.

At our inspection on 12 June 2014 we found people's care records were held electronically and in paper form, which resulted in information being inconsistent and fragmented between the two systems. This meant people's care records were not always kept up to date and were not always reflective of people's care needs.

At this inspection we found the service had carried out a review of the whole care records process. This had resulted in the service reducing the number of different paper records and using the electronic system as the main source of information. We found a review of each person's care needs had taken place and information from all previous documents had been amalgamated into the electronic records.

We found paper care plans were kept in folders in each of the two houses where people lived. We looked at the paper and electronic care plans for four people who used the service. We found care plans, kept in paper form, had been printed from the information held electronically and therefore information was consistent. All care plans had been updated and accurately reflected people's needs.

This meant that people were protected from the risk of unsafe or inappropriate care because care plans contained accurate information about how people's care and support needs.

At our inspection on 12 June 2014 we found records did not show if the provider had considered the impact of any restrictions put in place for people that might need to be authorised under Deprivation of Liberty Safeguards (DoLS). At this inspection we found the provider had carried out a DoLS assessment for everyone who used the service. This had resulted in the provider submitting several applications to the local authority because restrictions were in place for people.

We therefore found the service understood the legal requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (MCA & DOLS) provide a legal framework that protects people who lack the mental capacity to make decisions about their life and welfare.

Is the service well-led?

We found from a quality monitoring perspective the service was well-led.

At our inspection on 12 June 2014 we found the provider had systems in place to monitor the quality of the service being provided. However, these systems were not always effective in identifying areas which required improvement. This included not identifying inconsistencies in care plan documentation. We also had concerns that senior managers in the organisation were validating the quality monitoring audits without visiting the site to check the content of the audits.

At this inspection we found improvements had been made to the consistency of care plan documentation. We also found that a senior manager had visited the site to check if actions from the quality monitoring audits had been completed.

This is a summary of what we found-

St Teath had been subject to local authority safeguarding authority procedures. At the time of our inspection the systemic safeguarding alert had been closed. However, feedback from relatives expressed that although they had seen some improvement, work was still required to improve staffing stability, care documentation, communication and confidence in the management of the service.

Is the service safe?

At the time of the inspection the service was safe.

Due to the complexities of people's care needs we were unable to speak with them to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

During our inspection we observed staff supported people in a dignified, respectful and adult to adult manner. We spoke with some relatives/representatives of those living at Rendle House and Valley View to obtain feedback about the service. Overall, people felt that their relatives were safe. However, one relative told us, in response to being asked whether they felt there relative was safe, with 'I think so' and one relative explained to us that they had lost confidence in the management of the home and told us that there had been too many 'negatives' surrounding the care of their relative.

We found Rendle House and Valley House to be clean and there were no unpleasant odours.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DOLs) which applies to care homes. The recent judgement made by the Supreme Court on 19th March 2014 places a responsibility on providers when a person is deemed to lack mental capacity to ask two key questions; is a person subject to continuous supervision/control? and is the person free to leave? If a person is subject to both continuous supervision/control and not free to leave, then a person is being deprived of their liberty. We found there was a key code to the entrance, which meant people who lived at Rendle House and Valley View where unable to come and go as they pleased. However, it was not clear from people's care plans how the provider had considered this having regard to the DOLs legislation. People who lived in both houses were also supported on a one to one basis, some of whom were supported for 24 hours a day.

People were kept safe from the associate risks regarding the administration of medication.

There was a safe and robust recruitment process in place for new staff which ensured people who lived at the care home were not placed at risk.

We found people were not always protected from the risks of unsafe and inappropriate care and treatment because accurate and appropriate records were not maintained. Care plans and associated documentation was excessive, making it difficult to find relevant and accurate information. We found that due to the fragmentation of information, care plans were not always kept up to date and were not always reflective of people's care needs.

Is the service effective?

At the time of the inspection the service was effective.

People's health and care needs were assessed and individual care plans were in place to guide and direct staff to meet a person's health and social care needs. However, improvement was required as care plans were not always reflective of a person's care needs.

We spoke with a relative who was concerned about the use of agency staff, particular male agency staff at night time as their relative preferred female support. They told us that the agency staff did not always know what people's care needs were and on one occasion had had to explain to the member of staff about the support their relative required. One relative told us 'I have faith in some of the staff'.

Is the service caring?

At the time of the inspection we found the service to be caring.

Due to the complexities of people's care needs we were unable to speak with them to obtain feedback about the care and support they received. We used observation to ascertain whether people were happy with the care and support they received and whether their care needs were met.

We observed staff provided care and support to people in a caring and respectful manner. Staff showed compassion in the way in which they spoke with people and supported them.

Relatives we spoke with were complementary of the staff. However, one relative told us, 'You just trust that staff are caring and patient'. During our inspection we found staff to be attentive to people's care needs. We saw staff engaged in friendly conversation with people.

Is the service responsive?

At the time of the inspection we found the service to be responsive.

People's care records showed that staff involved external health care professionals such as GP's, psychologists, and social workers to support people with their changing care needs.

We spoke with a relative who told us that actions from an annual care review had failed to be carried out. As a result of this, the staff had failed to support the person to access a local youth club.

During our inspection we observed staff to respond to people's need when requested.

Is the service well-led?

At the time of the inspection we found the service to be well-led.

We spoke with some relatives/representatives of those living at Rendle House and Valley View to obtain feedback about the service. Overall people felt that communication had improved and were complementary of the role of their relative's keyworker. Key workers are used to provide a person and family with a key contact. One person told us that due to a change in management of the service communication had been a problem. They told us it was difficult know 'who my point of contact is'.

The service had a manager who was registered with the Care Quality Commission. The manager had recently returned to the service following time off, in her absence the service was being run by two managers. We met with all three managers on the day of our inspection and found them to be knowledgeable and passionate.

It was clear from our observations that the managers were actively involved in the care and support of people who lived at Rendle House and Valley View. Staff we spoke with told us they enjoyed working at St Teath. The staff were complementary of the managers and used words such as 'approachable' and 'supportive' to describe them.

We found the provider had systems in place to monitor the quality of the service being provided, however, these systems were not always effective in identifying areas which required improvement.

Throughout our visit we saw that staff were observant to people's changing moods and responded appropriately. We observed that staff communicated appropriately with people, and we saw the relationships between staff and people in the home were positive.

Medicines were not kept safely. We saw that the medicines cupboard keys were kept in a key cupboard in Valley View which we saw was unlocked. This meant that any member of staff could access the keys at any point. The medicines keys were also bunched with other keys, for example money tins. Medicines keys should be held separately to others and allocated to a designated member of staff to avoid multiple uses by various staff members which would allow for a clear audit trail.

Auditing at a local level was not happening which would allow for issues to be flagged up in a timely manner and for a more proactive approach to attending to arising issues to be adopted.

Staff ensured that people had access to things that reassured them, for example having access to a favourite object.This information was reflected in people's care files, which were detailed and helped staff support people in a person centred way.

We spent time with people living at the home, staff members and observing how people's safety was maintained. We observed a relaxed atmosphere, where people appeared happy in their surroundings and with the staff supporting them.

Staff confirmed that people's needs were met in a timely manner and felt that there were sufficient staffing numbers.

We saw evidence throughout our visits that the wider organisation and staff at St Teath site had worked hard to resolve the issues identified earlier in 2013. This could be demonstrated by better ways of working with other health and social care professionals, reviews of support plans and risk assessments and appropriate measures put in place to safeguard people from abuse.

One health care professional commented on the improvement of a person she was reviewing, commenting, "I can't believe the change in Xxx; she looks much better." A second health care professional commented how relaxed one person (who could become very anxious) was in the company of a support worker they were with.

People's care files contained current, easily accessed information and people were also better protected through staff communication. This meant that support workers were fully informed at all times.

Support workers were very supportive of changes at the home, which included training, a key working scheme and continual review of how people's lives could be made safer and improved. Support workers had good knowledge of the people they were supporting and the risks to their welfare. Where risk had previously been poorly managed it was now much improved and people were safer. One example was a "walk through" at each staff changeover to look for objects which could cause choking.

External health care advice was regularly sought and followed. People were supported by enthusiastic staff with more knowledge and better care arrangements.

People's care and welfare were not being promoted; some care was inappropriate and some unsafe. Examples included a lack of understanding of people's anxiety and inadequate arrangements to protect two people known at risk of choking.

People were not being safeguarded from abuse or their legal rights upheld.

Staffing levels had been improved but people's safety and welfare were still not always promoted. Additional staffing was provided between our inspection visits for this reason.

The provider organisation had not identified through their own quality monitoring that there were risks to people at the home and that the newly registered manager had struggled to implement her improvement plan. Adverse events related to people using the service escalated and more support and resource was then provided. Support workers said that they had confidence in the new manager and we saw that their views were being taken into account.

Poor record management was adding to the risks from unsafe or inappropriate care.