Archived: Highermead Care Home

The service is on three floors with access to the upper floors via stairs or a passenger lift. At the time of our inspection only the ground floor of the building was in use. Shared living areas included two lounges, a dining room, an activities room and gardens with a patio seating area.

Highermead Care Home is owned and operated by Ark Care Service Limited. This company is based in London and also operates a second registered care home in Preston, Lancashire.

Prior to this inspection Highermead Care Home had been inspected five times since October 2016. At all of these inspections issues were identified in relation to the quality of care and support provided at the service. The service was rated Inadequate in October 2016 and Requires Improvement at each of the other inspections. The reports of all previous inspections are available on the Care Quality Commission website. These reports show that although the service had made some improvements in response to inspection findings these improvements had not been sustained. During our April 2018 inspection we identified concerns in relation the service’s staffing arrangements. As a result, we asked the provider to give us details each week of the service’s staffing arrangements. This information was provided.

On the day before this inspection the local authority informed people, their relatives and the service that they were no longer willing to commission care from Highermead. People were offered support to identify and move to alternate care placements during the week of our inspection. The provider chose to close the service on Friday, 15 June 2018 as at that time no one was living in the service. The provider has subsequently applied for this location to be removed from there registration.

At this inspection we again rated the service Requires Improvement. Risk assessments and care plans did not provided staff with appropriate guidance on how to support people whose behaviour could put them or others at risk. In addition, where incidents had occurred within the service they had not been documented or appropriately reported to senior staff for further investigation. Although accidents had been recorded there was limited evidence these had been investigated to identify any changes that could be made to improve safety in the service.

During our previous inspection we found that the service was understaffed but that all planned care shifts had been covered using staff overtime, management cover and agency staff. At this inspection we again found that the service did not employ sufficient staff to cover planned care shifts. There was a particular shortage of night staff and records showed that in the four weeks prior to this inspection only 56% of night shifts had been completed by staff employed by the service. The remaining night shifts had been completed by a staff member from the provider’s other service in Preston, Lancashire or by agency staff.

The service aimed to have three staff on duty during the day but we found the service had been short staffed on three occasions since our last inspection. In addition, we noted that the service’s domestic cleaner had been unavailable for a number of shifts. On the day of our inspection there was no domestic staff on duty and no domestic cleaning tasks were completed. Some areas of the home appeared unclean and malodours were found in areas throughout the service.

The service did not currently employ any dedicated activities staff and on the day of our inspection people were not supported to engage with meaningful activities. On two occasions people approached staff to enquire about activities but none were provided. There was a board listing activities planned for the week which included an exercise class. Staff told us the information was not accurate and one staff member commented, “There is not much going on at the moment”. We did not observe staff providing any individual or group activities during our inspection and there was limited evidence available to demonstrate the service’s activities room had been recently used. One person had been identified as being at risk of social isolation and their care records highlighted to staff the importance of spending time with this person on a one to one basis. However, there were no records to show this support had been provided.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was no registered manager in post at this inspection. The acting manager had resigned and withdrawn the application to register following our previous inspection in April 2018. This was the second occasion since 2016 when an acting manager at Highermead had withdrawn from the registration process.

The provider’s nominated individual was now managing the service directly and had been based in the service since the acting manager’s departure. Staff told us they had felt well supported by the nominated individual during this period and told us, “[The nominated individual] has been here the whole time, she is approachable.” However, there was a clear lack of leadership and oversight in the service on the day of our inspection. There were no domestic staff on duty and no arrangements had been made to allocate other staff to complete these tasks.

Records showed the nominated individual had not appropriately led by example while covering care shifts. No detailed records of the care provided to people in bed had been completed during a night shift covered by the nominated individual. This meant it was not possible for the service to demonstrate people’s care needs had been met.

In addition, the service’s quality assurance systems were ineffective as they had failed to ensure compliance with the legislation. Important information in relation to how staff should support individuals was missing from their care records and incidents had not been documented and recorded. Senior staff were unaware of significant incidents that had occurred within the service.

Prior to this inspection significant concerns were raised with CQC about recruitment practices within the service. As a result we reviewed the recruitment records available for 11 staff including all staff employed in 2018. We found the service had operated safe recruitment practices and that all necessary pre-employment checks had been completed. Staff records also showed appropriate training and supervision had been provided.

At this inspection we found people medicines were now managed safely. Creams had been dated on opening and accurate records maintained in relation to medicine that required stricter controls.

People were comfortable in their surroundings and told us, “The staff are great, lovely nice people.” While relatives said, “The staff are really good with [My relative] they can always calm him down” and professionals told us the staff knew people well. Staff responded quickly to people’s care needs and people told us, “Staff come when I ring the call bell.”

Following our inspection the provider made a decision to submit an application to cancel their registration of the service.

Highermead Care home is registered to provide care and support for up to 22 predominantly older people. Nine people were using the service at the time of this inspection some of whom were living with dementia. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

During our previous inspection we found mangers and staff did not have a good understanding of the Mental Capacity Act. People without the necessary authority had signed consent forms and individual capacity to make decisions had not been assessed. Best interest decisions had not been documented and we found there were unnecessary restrictions were in place and inappropriate applications had been made under the Deprivation of liberty Safeguards.

At this inspection we found significant improvements had been made in this area. The acting manager now had a good understanding of this legislation and inappropriately signed consent forms had been removed. People's capacity to make decisions had been assessed and the service now recognised that people's capacity to make decisions could vary. Two people had been recognised as having capacity and inappropriate DOLS applications had been withdrawn. Pressure alarm mats were no longer in use where people had the capacity to use the service call bell system. The acting manager had not yet introduced a system for recording best interest decisions and we have made a recommendation in relation to this.

Following our January inspection a warning notice was also issued in relation to environmental safety concerns. This was because a first floor and accessible window had not been fitted with restrictors, a nail sticking out of a wall at head height, Fire doors were propped open with furniture and damaged linoleum flooring represented a trip hazard.

At this inspection we found some issues had been resolved but also identified additional environmental safety concerns. The window was now appropriately restricted, the nail had been removed and furniture was no longer used to hold fire doors open. However. the damaged linoleum had not been repaired. In addition, at this inspection we found that the flooring in the dining room was uneven and could become slippery when wet. There were gaps between tiles that could represent a hazard to people using mobility aids. This meant that although the service had made some improvements it remained in breach of the regulations. We also found that the discoloured and unsightly carpets discussed in previous reports had not been replaced.

A significant incident had occurred prior to this inspection. A person subject to a DOLS application had left the service without support and fallen into an adjacent field where a boundary fence had collapsed. The person had subsequently been found by members of the public. Staff had only become aware that the person was missing following social media alerts. The acting manager had introduced additional door check following the incident to reduce the risk of similar incidents reoccurring. However, no records of an investigation into this incident were available in the service and the boundary fence had not been repaired.

In January issues in relation to the quality of medicines record keeping were identified and at this inspection we again identified failings in this area. Medicines that required stricter controls had not been recorded on receipt and creams had not been dated on opening. The service continued to use non-standard codes on printed Medicine Administration Records charts which unnecessarily introduced risks that these records could be misinterpreted.

At this inspection we found the service did not have sufficient numbers of staff employed to meet peoples’ needs. The provider had recognised this issue and a staff member from their service in Lancashire had been allocated to complete night shifts in this service in Cornwall on a two weeks on, one week off, basis. In addition, staff and the acting manager had worked additional hours to ensure all planned care shifts were covers until additional staff could be recruited. Staff told us, “There is enough staff to keep it going but we are just waiting for DBS’s for some new staff” and “I can’t see how it can’t improve as we have a lot of people applying.”

In relation to the current staff shortages one person’s relative commented, “The staff work long hours to cover for shortages sometimes and you can see it’s tiring work which I wouldn’t want the responsibility for. They are wonderful people.”

The service does not have a registered manager. The acting manager appointed shortly before our previous inspection was well respected by the staff team who told us, “The manager is fabulous, absolutely fabulous. She is single handedly holding this place together.”

Prior to this inspection we received information from whistle blowers indicating that staff and the manager had been unable to contact the provider’s director for a three week period. During the inspection this was confirmed to be accurate with staff reporting that during a flooding incident as a result of a burst pipe, staff had only been able to access support from the provider’s administrative officer but not contact the director. During the inspection the acting manager told us she did not feel appropriately supported by the provider. Following the inspection the acting manager withdrew their application for registration and gave notice of their intention to resign form their post.

At this inspection we have found that the provider has again failed to take all action necessary to fully comply with the legislation. Damaged, hazardous and unsightly flooring had not been replaced and the boundary fence had not been repaired following the incident where a person fell into an adjacent field. Staff recognised significant investment by the provider was necessary to address these issues and commented, "We need a lot of money invested in this place”.

The staff team were committed to the people they supported and people told us, “The staff are all very nice, caring people.” Records showed staff had routinely completed additional shifts to ensure peoples’ needs were met. For example one staff member had sat with a resident throughout the night following an equipment failure, to ensure the person safety.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Highermead is a care home which offers care and support for up to 22 predominantly older people. At the time of the inspection there were nine people living at the service. Some of these people were living with dementia.

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 the time of this, and the last inspection, there was no registered manager in post. A new manager had been in post since August 2017 and had already made a number of positive changes at the service. This manager was in the process of applying to CQC to become the registered manager.

There were systems in place for the management and administration of medicines. People were receiving their medicines as prescribed. Regular medicines audits were being carried out by the manager and these were effectively identifying if any errors had occurred. Missed signatures on Medicine Administration Records had reduced since such audits had been in place. A recent audit had identified an error in the records held of medicines that required stricter controls. This was in the process of being investigated with the district nursing team. Some medicines had not been dated upon opening and this had led to them being used after they should have been disposed of.

At the last inspection we were concerned that applications to the supervisory body for authorisation under the deprivation of liberty safeguards (DoLS) had been made in the absence of a best interest process. This meant we could not be assured that the restrictions set out in these documents were the least restrictive available. At this inspection such concerns remained. We continued to see examples where relatives had signed documents to consent to elements of people's care and treatment without the legal authority to do so. The records held at the service relating to appointed powers of attorney were not correct. The registered provider was not ensuring that people’s rights were always protected. Capacity assessments should be carried out for specific questions each time. The registered provider had recently carried out assessments for people to address multiple questions at the same time. Where people were considered to lack capacity, we saw no evidence of best interest processes to ensure that decisions taken on their behalf were the least restrictive available, or in the person's best interests. This is a repeated breach of the regulations.

The premises were in need of some refurbishment. We had raised concerns about the badly stained carpeting in the ground floor at previous inspections. We had received assurances from the registered provider that this would be addressed. At this inspection the carpet remained badly stained. At the last inspection we found some COSHH (care of substances hazardous to health) items such as disinfectant were left in an unlocked bathroom and an unlocked sluice. We again found such substances were left in a bathroom and although there was a lock on the sluice it remained unlocked throughout this inspection.

Most staff had received appropriate training and updates. However, two staff, who carried out medicines administration, had competency checks on their files but had not had any formal training updates for some years. We were advised by the manager this would be addressed immediately. At our last inspection we identified that new staff, who had not worked in the role before, were not undertaking the Care Certificate, or a suitable alternative. At this inspection we found that whilst new staff were provided with an induction, the Care Certificate was not being used to support staff new to the role. The Care Certificate is a national set of standards for people who work in the care sector.

The service was now displaying the most recent inspection rating.

People’s end of life care plans now contained details of the person’s wishes if the person had been happy to express and discuss such matters. Where some people had declined to discuss their wishes this was clearly recorded.

The new manager was carrying out regular audits in a number of areas, addressing concerns and making improvements to the service. A recent survey of the views and experiences of people living at the service and their relatives had received positive responses with 100% of people stating they would recommend other people to live at Highermead.

The service was registered for dementia care and there was pictorial signage to support some people, who may require additional support with recognising their surroundings. Bedroom doors were decorated to help people recognise their own room. Toilets and bathrooms were clearly marked. This helped people to be as independent as possible.

Equipment and services used at Highermead were regularly checked by competent people to ensure they were safe to use.

We walked around the service which was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. People were treated with kindness, compassion and respect.

Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible.

Staff were supported by a system of induction training, supervision and appraisals.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to all staff with regular updates provided. The manager had a record which provided them with an overview of staff training needs.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had one staff vacancy at the time of this inspection and was using agency staff to cover this. Staffing numbers had been reduced recently to two care staff supported by a senior on each shift. There were four people living at the service who required very regular care and support from two staff, along with another person who needed close monitoring by staff due to their behaviour which sometimes challenged staff. This meant that it often left only one member of staff available for other people and to administer medicines. Staff told us they found this stressful and pressured at times.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff.

New staff were recruited safely with the service taking appropriate steps to ensure they were staff to work with vulnerable people.

People had access to some activities. However, these activities were not person centred and did not happen every day. An activity co-ordinator was not in post and staff told us they did not have time to provide activities as often as they would like to. A nail bar had been created but was not used. A hair salon had been planned but not completed.

On the day of this inspection we saw many caring and kind interactions from staff. People and their relatives were positive about the care and support provided at Highermead. Healthcare professionals were positive about the care provided by staff at the service and commented that they followed any guidance given.

The manager was supported a team of motivated staff. There were shift leaders who supported care staff on each shift. The manager was also accessing support from other registered managers in the local area. The provider visited the service regularly.

We found repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. This is the third time this service has been rated overall Requires Improvement.

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.

Highermead Care Home is a care home which provides accommodation for up to 22 older people who require personal care. At the time of the inspection 13 people were using the service. Some of the people who lived at the service needed care and support due to dementia, sensory and /or physical disabilities.

At the time of the inspection, there was no registered manager in post. A new manager had been appointed who was about to undertake their induction. The owner told us this manager would seek to become the registered manager of 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.

We previously inspected the service on 7 February 2017. Prior to that inspection, this service had been placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During the inspection on 7 February 2017 the service demonstrated to us that improvements had been made and it was no longer rated as inadequate overall or in any of the key questions. Therefore, this service was no longer in special measures. At that time, the overall rating of the service was requires improvement. The service was also meeting the requirements of the previous regulatory breaches. At this inspection, we found that improvements in some areas had been sustained however, a number of issues previously identified had not been resolved.

People’s rights were not always protected as the principles of the Mental Capacity Act were not always followed. Some people’s records contained out of date or irrelevant capacity assessments and some capacity assessments had been left blank. Where people were considered to lack capacity, we saw no evidence of best interest processes to ensure that decisions taken on their behalf were the least restrictive available, or in the person’s best interests. The previous registered manager had submitted applications to the supervisory body for authorisation under the deprivation of liberty safeguards (DoLS) however, in the absence of a best interest process, we could not be assured that the restrictions set out in these documents were the least restrictive available. We saw examples where friends and relatives had signed documents to consent to elements of people’s care and treatment without the legal authority to do so.

We found people’s end of life care plans were not detailed. Many of them directed staff to speak to the person’s next of kin. This placed people at risk of not receiving care in the way they had chosen at the end of their life.

We found the home was visibly clean and free from adverse odours. There was an on-going programme of refurbishment. We saw that murals and paintings had been added to the walls in several areas of the home and the outdoor courtyard was now in use. We noted that the carpet in the downstairs corridors remained heavily stained. We found some concerns with the environment, for example some COSHH (care of substances hazardous to health) items such as disinfectant were left in an unlocked bathroom throughout the day. People had personal emergency evacuation plans (PEEPS) in place, but these did not contain a photograph of the person. This might mean emergency staff could not identify the person in the event of an emergency if they were not in their bedroom. We noted that the sluice room was not lockable. We also found that the CQC rating was not displayed at the service as required.

People’s medicines were not always safely managed. Practices and recording around the use of covert medication (medicine which is disguised in food or drink) were not robust. We saw some discrepancies on people’s medication administration charts (MAR). We found that the storage and disposal of people’s medicines was generally safe.

Not all staff we spoke with had received appropriate training. One person who was new to care had been in post several months and had not undertaken the Care Certificate, or a suitable alternative. The care certificate is a national set of standards for people who work in the care sector. We found some gaps in staff member’s mandatory training. Some staff had not received recent supervision, however all staff we spoke with told us the owner was approachable and supportive should they require help or assistance. Recruitment practices were generally safe; however we found one staff file where references were not sought appropriately and where there was no record of the person’s DBS check (disclosure and barring service). We were provided with this information following the inspection. The person had a DBS in place which had been undertaken at another place of employment, but the check had been made too long ago to ensure it was robust.

People had access to activities on a daily basis, provided by housekeeping staff. However these were basic and not person centred. We have made a recommendation about this. There were visitors to the service such as singers and petting animals, however these were infrequent.

People had access to a range of health and social care professionals and this was reflected in their care records. Where people’s needs changed staff promptly sought the assistance and advice of external agencies. During the inspection, we saw health professionals visiting the service. Care plans had been reviewed and updated and contained guidance for staff on meeting people’s needs. However, some of the assessment tools were not reflective of people’s changes in need.

Mealtimes were sociable and relaxed with staff on hand to provide assistance as required. The food on offer looked plentiful and appetising and people were offered second helpings. The cook was aware of people’s dietary requirements. People were encouraged and assisted to have enough to drink during the day. There was a snack station which people could obtain items such as fruit, chocolate and yoghurt from.

People who used the service were protected from the risks of abuse. Staff knew how to recognise and report signs of abuse, including which external agencies they should alert. Alerts had been made to the local authority and care Quality Commission when required.

On the day of the inspection, we observed sufficient staff on duty to meet people's needs in an unhurried way. Staff had time to sit and chat with people and engage them in activities. We were told that periods of short staffing were managed through the use of agency staff and that new staff had now been recruited to fill some of the vacancies. Staff were caring and we observed positive interactions between people and staff in which they were treated with kindness and respect.

You can see what action we told the provider to take at the back of the full version of the report.

Highermead Care Home is a care home which provides accommodation for up to 22 older people who require personal care. At the time of the inspection thirteen people were using the service. Some of the people who lived at the service needed care and support due to dementia, sensory and /or physical disabilities.

At the time of the inspection there was a new manager in post who was seeking 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the comprehensive inspection on 3 and 4 October 2016 we found multiple breaches in regulations. We found that people who used the service were not always protected from the risks of abuse. There were some instances, where people who were at risk of harm, were not reported to safeguarding authorities, or satisfactory plans were not put in place to minimise the risk of harm to others. Staff were not always trained so they knew what to do if people were at risk of abuse.

There were not always enough staff on duty, and employed to meet people's needs. Staff were seen to work hard, but unsatisfactory numbers of staff meant they struggled to meet people's basic needs. Although people thought staff were caring, we had concerns about some incidents we witnessed and were told about, which were not considered to be professional and respectful.

There was a lack of activities for people who lived in the home. This meant many people had little to do apart from watch television or sleep. People could not use the garden without staff, and staff had little time to socialise with people. Care plans did not contain accurate and up to date information, and were not regularly reviewed. Care plans did not provide suitable guidance to help staff where people had complex needs which may have put them and others at risk.

The registered persons had not ensured the service worked effectively to meet the needs of people who lived at the home. Suitable quality assurance systems were not in place to check the service was operating effectively and bring about improvement where this was required.

The Care Quality Commission was not always informed of incidents which according to regulation we need to be informed about as they may have put people at risk. The building was not maintained to a good standard. For example there was a need to improve furnishings

and some fixtures and fittings.

Staff did not always receive a suitable induction, for example working for a reasonable period of time with experienced staff before working on their own. Staff training was not satisfactory to provide people with the skills and knowledge to do their jobs. For example most staff had not received training about the needs of people with dementia.

Medicines were not always given to people as prescribed by their doctor. Medicines were not always stored securely. Staff were not always trained to give medicines.

Arrangements for people to receive suitable help to eat and drink, for example at meal times were not satisfactory. People did not receive the right support when they needed it. Routines to keep the home clean were not always satisfactory. For example commodes were not always emptied and cleaned in a timely and appropriate way.

As a result of the findings of this inspection, the service was rated as inadequate and was placed into special measures. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, are inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the inspection, the service was required to submit to the Care Quality Commission, detailing the provider’s immediate response to the concerns raised. The service was then required to submit regular ongoing action plans of their progress. The service also received support from the quality assurance team and commissioners.

At this inspection, we found that improvements had been made. One relative said; “Since the last inspection report, they have made big strides in every respect”. We found that people who used the service were protected from the risks of abuse. Staff knew how to recognise and report signs of abuse, including which external agencies they should alert. Although alerts had been made to the local authority and care Quality Commission, these had occasionally not been made in a timely manner.

There were sufficient staff on duty to meet people's needs in an unhurried way. Staff had time to sit and chat with people and engage them in activities. Staff were caring and we observed positive interactions between people and staff in which they were treated with kindness and respect.

There was a programme of activities for people to participate in and the service employed an activities coordinator. There outside area was being renovated so that people would soon be able to enjoy the enclosed garden area. Care plans were detailed and contained accurate and up to date information about people’s needs. Care plans had been reviewed and updated.

Suitable quality assurance systems were not yet in place to check the service was operating effectively and to bring about improvement where this was required, however the provider explained that processes were first being put in place and that audits and quality assurance would flow from that, as processes became established.

There was a programme of refurbishment at the service. Some areas had been redecorated, including new wall paper, freshly painted areas, a new sluice machine which was due to arrive imminently and new flooring to parts of the service. The service was visibly clean and free from adverse odours throughout.

Staff received a suitable induction which including shadowing more experienced staff members. Staff training was satisfactory to provide people with the skills and knowledge to do their jobs and an e-learning package had been introduced.

People had their medicines as prescribed and on time and there was a suitable system in place to store, administer and dispose of medicines safely. Arrangements for people to receive suitable help to eat and drink, for example at meal times were satisfactory. People received the right support when they needed it. A new snack station had been introduced in the lounge which people could access independently which contained items such as fruit, crisps and yoghurts.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Although there was significant change at this inspection, we have rated the service as requires improvement because it is too early to be certain that the service will maintain full compliance in the future.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

We inspected Highermead Care Home on 3 and 4 October 2016. The inspection was unannounced. The service was last inspected in May 2014 when it was found to be meeting the requirements of the regulations.

People who used the service were not always protected from the risks of abuse. There were some instances, where people who were at risk of harm, were not reported to safeguarding authorities, or satisfactory plans were not put in place to minimise the risk of harm to others. Staff were not always trained so they knew what to do if people were at risk of abuse.

There were not always enough staff on duty, and employed to meet people’s needs. Staff were seen to work hard, but unsatisfactory numbers of staff meant they struggled to meet people’s basic needs.

Although people thought staff were caring, we had concerns about some incidents we witnessed and were told about, which we did not regard as professional and respectful.

There was a lack of activities for people who lived in the home. This meant many people had little to do apart from watch television or sleep. People could not use the garden without staff, and staff had little time to socialise with people.

Care plans did not contain accurate and up to date information, and were not regularly reviewed. Care plans did not provide suitable guidance to help staff where people had complex needs which may have put them and others at risk.

The registered persons had not ensured the service worked effectively to meet the needs of people who lived at the home. Suitable quality assurance systems were not in place to check the service was operating effectively and bring about improvement where this was required.

The Care Quality Commission was not always informed of incidents which according to regulation we need to be informed about as they may have put people at risk.

The building was not maintained to a good standard. For example there was a need to improve furnishings and some fixtures and fittings.

Staff did not always receive a suitable induction, for example working for a reasonable period of time with experienced staff before working on their own. Staff training was not satisfactory to provide people with the skills and knowledge to do their jobs. For example most staff had not received training about the needs of people with dementia.

Medicines were not always given to people as prescribed by their doctor. Medicines were not always stored securely. Staff were not always trained to give medicines.

Arrangements for people to receive suitable help to eat and drink, for example at meal times was not satisfactory. People did not receive the right support when they needed it.

Routines to keep the home clean were not always satisfactory. For example commodes were not always emptied and cleaned in a timely and appropriate way.

People’s monies were stored securely, and suitable records were kept of expenditure made on their behalf. Satisfactory checks were carried out before staff members started working at the service. This included references and a check to ensure people did not have any criminal convictions, or there was any other information which meant they should not work with vulnerable people.

Processes to assess people to check they had mental capacity were satisfactory, although most staff had not received training in this area. People had access to GP’s and other medical professionals.

Health and safety records were kept appropriately. Checks on fire precaution, electrical and gas appliances were suitably completed.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

Yes we judged the service was safe.

People told us they felt safe and secure. The people we spoke with were positive about the staff who worked with them. People told us staff were caring and supportive. For example one person said 'I am very happy, all the staff are very kind. They are very good.'

The staff that we spoke with said they had confidence in colleagues' practice. Staff told us if they had any concerns about how people who used the service were cared for the registered persons would take their concerns seriously.

We saw that the home was well designed and maintained. Decorations and furnishings were homely, clean and comfortable. Equipment was well maintained and regularly serviced.

On the day of the inspection the home was clean and there were no unpleasant odours. The people who used the service all said they were happy with the standard of cleanliness.

We inspected the staff rotas which showed that there were sufficient staff on duty to meet people's needs throughout the day and night. People said they received a consistent and safe level of support. For example we were told if people rang the call bell staff would come to assist them promptly.

Is the service effective?

Yes we judged the service was effective.

People all had an individual care plan which set out their care needs. Care plans contained satisfactory information and were accessible to staff. People said staff met their needs and responded promptly when they needed assistance. People had access to doctors, district nurses, chiropodists and opticians and suitable records were maintained regarding this support.

Is the service caring?

Yes we judged the service was caring.

People who used the service said they were supported by kind and professional staff. We were positive about the care practice we observed. Comments included 'I like it here. The care staff are very good,' and 'It is very, very good here.'

Our observations of the care provided, discussions with people and records we looked at enabled us to conclude that individual wishes regarding people's care and support were taken into account and respected.

Is the service responsive?

Yes we judged the service was responsive.

The people we spoke with all said the staff treated them with respect and dignity. The care practice we observed was professional and supportive.

People who used the service told us there was a choice of activities available. If people did not want to get involved with organised activities this was respected.

People were positive about the care they received. People we spoke with said their care was unrushed. From reviewing records we judged care plans included suitable information to assist the staff who worked at the home.

Is the service well-led?

Yes we judged the service was well led.

The home had a system to check people were happy with the service. People's personal care records, and other records kept in the home, were accurate and complete.

People who used the service, and the staff were positive about the registered manager and senior staff. People told us if they had any concerns or complaints management were approachable and would take suitable action. There was clear evidence the registered persons do what they can to ensure the home is well run and is continually improving.

We saw people's privacy and dignity was respected and staff were helpful. We saw people chatted with each other and with staff.

We observed staff had positive interactions with people. People told us staff answered their call bells promptly. One person told us the staff were 'polite and friendly', another person said,'I am very happy here, no complaints'. People told us the food was good and they were offered choices. We were told visitors were welcome. One person said 'I can go to bed when I want, if I wanted to go out someone would take me'. Another person told us they were involved in the planning of their care.

We heard care staff ask people what they would like to do and they shared ideas if people could not make a choice.

Although care and support were good some of the communal rooms for example the lounges were beginning to look in need of redecoration, and the outside of the house looked in need of painting. All the bedrooms were decorated and furnished to a good standard. There were some gaps in documentation regarding health and safety checks completed, although the registered persons took action to rectify any health and safety shortfalls shortly after the inspection visit.

When we inspected the home was clean and odour free. At the time of the inspection staffing levels were to a good standard. There was evidence that suitable recruitment checks were completed. Staff training provision was not satisfactory. Some staff had received limited training, and there was not evidence that training had occurred for many of the staff since 2009. Staff however were observed working professionally with the people living in the home. Although outcomes for people living in the home were good, there was no systematic quality assurance system in place.