Stilecroft Residential Home

Stilecroft Residential Home is a residential care home providing personal care to up to 44 people. The service provides support to older people and people living with dementia and mental health needs. At the time of our inspection there were 38 people using the service.

Stilecroft Residential Home accommodates people in one adapted building across three floors.

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

This was a targeted inspection that covered safeguarding people from abuse, assessing and managing risks and eating and drinking. Based on our inspection we identified checks of people and health and safety were not always recorded to show they had taken place. This included checks of equipment people used, such as sensor mats. People were aware of people who may be at risk, including at risk of weight loss. We identified improvements were needed to risk assessment records and made a recommendation about this.

Recording systems did not always show when people had been referred for additional support with weight loss and what advice had been given. The registered manager was responsive to our feedback and made changes following this. These changes had yet to be embedded.

People received appropriate support from staff to encourage them to have regular drinks and assist them with meals. People responded positively to staff.

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

Rating at last inspection

The last rating for this service was requires improvement (published 16 June 2022).

Why we inspected

The inspection was prompted in part due to concerns received about people’s eating, drinking and weight loss. A decision was made for us to inspect and examine those risks. 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 of eating, drinking and weight loss. This inspection examined those risks.

We use targeted inspections to follow up on Warning Notices or as in this instance, to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. We found no evidence during this inspection that people were at risk of further harm from these current concerns.

Follow up

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

Stilecroft Residential Home is a residential care home providing personal care to up to 44 people. The service provides support to older people and people living with dementia and mental health needs. At the time of our inspection there were 29 people using the service.

Stilecroft Residential Home accommodates people in one adapted building across three floors.

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

People were at risk of harm because of failures to adequate identify and address concerns about the quality and safety of the service. The registered manager and manager were working to make improvements, however quality assurance systems were not always effective in guaranteeing the quality and safety of the service.

Whilst noticeable improvements had been made in response to concerns identified at our last inspection, further improvements were needed. We identified new concerns, which placed people at risk of harm.

People were at risk as medicines were not managed safely. People did not always receive their medicines as prescribed. Staff did not monitor or escalate concerns where people refused their medicines repeatedly.

Environmental safety issues had not always been identified or addressed by the provider to keep people safe. This included issues we identified at the last inspection.

People were not always supported to have maximum choice and control of their lives and did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

People and their relatives had confidence staff had the necessary skills and knowledge to provide effective support. We made a recommendation about first aid training.

People received personalised care from staff who knew about their preferences. The manager was working to improve and develop the variety of activities on offer to stimulate and engage people.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was inadequate (published 30 September 2021) and there were breaches of regulation. The provider met with us and completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, we found the provider had made some improvements but remained in breach of some regulations.

At our last inspection we recommended that the provider improve the support given to people living with dementia. At this inspection we found the provider had not met this recommendation.

This service has been in Special Measures since 30 September 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 undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions safe, effective, responsive and well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

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.

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 monitor the service and will take further action if needed.

We have found breaches in relation to consent to care, safe care and treatment and 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

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

Stilecroft Residential Home (Stilecroft) is an older property that has been extended and adapted to provide personal care for up to 44 older adults and people living with dementia. There were 25 people the living at the home at the time of our inspection.

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

We found shortfalls in the way the service was led. The provider’s governance systems had failed to identify the issues we found on inspection. This included management of risk, maintaining a safe living environment, staffing levels not meeting people’s needs, incomplete assessments, deficits in care planning, and not abiding to the requirements of the Mental Capacity Act. Auditing systems were not effective in monitoring and improving the service.

Risk was not always appropriately identified, assessed and managed in a timely manner. During the visit we identified several concerns regarding risk which were escalated to the registered provider who then took action. Safeguarding procedures aimed to keep people safe were not consistently implemented and when people had been exposed to risk of harm, incidents were not always reported to the local authority safeguarding team for review. Infection prevention control (IPC) measures were not robust with lapses in practice observed. People were receiving their medicines safely however the provider agreed to review how medicines were stored.

We made a recommendation the provider reviews IPC practices in the home.

Staffing levels, and the way staff were deployed did not always ensure people were safe and their needs were met. The oversight of people who required additional support to remain safe was inconsistent. We raised these issues with the provider who reviewed their staffing levels and very quickly arranged for additional extra staff hours.

People were not always supported by staff who had the training and skills to meet their needs. This was particularly the case when supporting people whose behaviours challenge the service, and those people living with dementia. Plans of care were not always reflective of people’s needs and one person did not have a care plan or risk assessments in place for a high-risk need.

We made a recommendation about improving the support given to people living with dementia.

People’s rights were not always protected by the actions of the service. 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. We saw people had been moved to different areas of the home without the appropriate best interests reviews and consultations.

We observed some positive interactions between staff and people who lived at the home. However, people did not always receive care in a timely way and that was personalised to meet their preferences and choices. Staff shortages, and the lack of an activity co-ordinator, had meant that people had limited support with their interests or to be engaged in meaningful activities. People told us they enjoyed the food and their dietary needs were monitored.

People told us staff were kind and caring. Relatives also praised the caring attitude of the staff team. They gave us positive feedback about how they were supported to maintain relationships across the pandemic and lockdown.

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

Rating at last inspection

The last rating for this service was good (published 24 April 2019).

Why we inspected

The inspection was prompted in part due to concerns received about infection control and leadership of the service. A decision was made for us to inspect and examine those risks.

We inspected and found there were further concerns, so we widened the scope of the inspection to become a comprehensive inspection which included all five key questions.

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

The registered provider has been responsive to concerns noted during the inspection and has started to take action to make improvements and promote safety within the home. We were sent an action plan shortly after the inspection.

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 safe care and treatment, safeguarding service users from abuse and improper treatment, staffing, need for consent, person-centred care 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

We will request an action plan for the registered provider to understand what they will do to improve the standards of quality and safety. We will work alongside the registered 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.

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’s experience of using this service:

At the last inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service did not always meet people’s needs as there were insufficient staff; hazards in the environment were not sufficiently identified; and the service did not have effective quality assurance systems in place. We found this was because the service was not being well-led or properly managed. We rated well-led as inadequate and the other key questions as requires improvement.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, caring, responsive and well-led to at least good.

At this inspection, March 2019, we found the breaches had been met and shortfalls had mostly been rectified. We found improvements had been made to the quality of the service and running of the home. A new manager had been in post for three months and along with the provider had driven up the quality of the service. Staff in the home had worked hard to bring about these improvements.

There was a strengthened senior leadership team in place and this along with improved quality assurance systems meant people now received good quality care. People were happier with how the home was being run. One person told us, "The new manager is lovely, really lovely, she comes in and sits down and talks to you sometimes, not just about the home but about everything and that’s really nice.”

People’s needs were now being better managed. This was due to more thorough assessments of people’s needs; care plans that were up to date; and more staff on duty who were deployed and managed to respond to people’s needs.

Care was person-centred, based around each individual’s personal care and health needs and met people’s social needs and interests. Care planning had improved with particular attention paid to including instructions from healthcare professionals.

We had made a recommendation at the last two inspections that the service seeks expert advice from a reputable source in developing a dementia care strategy for the home, that would encompass staff training, approach, the environment and activities. This had not been done. The new manager and provider made a commitment to doing this and sent us evidence of what action had been completed shortly after the inspection.

Staff knew how to keep people safe and this included having a good knowledge of safeguarding people from abuse. Risks to people were now well managed, with a particular focus on reducing people’s risk of falls and ensuring the environment was safe, especially for people living with dementia.

People's rights were respected and protected because the service had a good understanding of the Mental Capacity Act (MCA). People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People’s consent and capacity to make decisions was understood and managed in line with the MCA.

People were treated with dignity and compassion. They told us the staff team knew them well, took a genuine interest and were kind and caring. People looked well-groomed and well cared for and staff displayed warm and positive relationships with people in the home.

There was an improved choice of meals and people said the food was very good and they liked that they had homemade cakes and puddings. Mealtimes had been restructured so that support was provided with food and drink when this was needed. People’s nutritional support needs were managed with support sought from external health specialist.

Good working relationships had been developed with health and social care professionals that meant people were supported to stay well and any health issues were quickly addressed.

People’s medicines were being better managed with a focus on staff training and competency.

The home was comfortable, clean and odour free. Since the last inspection a number of improvements had taken place. These included the improved use of technology which had benefited people in the home and the staff team.

Rating at last inspection: Requires improvement (9 August 2018).

Why we inspected: We inspected the service as part of our inspection schedule methodology for services rated requires improvement and to check the provider had made the improvements they told us they would, following our last inspection.

Follow up: We will monitor the service as part of the re-inspection programme for a Good service. If any concerning information is received we may inspect sooner.

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

At the last inspection in July 2017 the service was rated overall as Requiring Improvement as we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to infection control, trip hazards and issues around evacuation in the event of a fire. We judged that the systems to monitor quality in the home had failed to identify these matters in a timely manner.

We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe and Well-led to at least Good.

At this inspection we found the actions required to address these particular issues of the July 2107 inspection had been completed with the exception of on-going issues in Regulation 17 set out below.

During this latest inspection of 21 & 23 May 2018 we found two further breaches. Regulation 18: Staffing as we found there were insufficient staff to meet people’s needs; Regulation 9: Person centred care as people were not receiving care that met all their needs and preferences. We also found that the service continued to be in breach of Regulation 17: Good governance because the provider and the service did not have effective quality assurance systems in place and Regulation 12: Safe care and treatment as hazards in the environment were not sufficiently identified.

The home continues to have the rating of Requires Improvement.

Stilecroft Residential Home (Stilecroft) is a care home. 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. The home provides personal care and accommodation for up to a total of 44 people. On the day of the inspection there were 38 people residing at Stilecroft. Accommodation is provided over three floors and the Victorian building has been extended and adapted for the purpose. The ground floor unit specialise in supporting people living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with the (CQC) 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 found that there were insufficient staff available to meet people’s needs. We found that the registered person had not ensured sufficient numbers of suitably qualified, skilled and experienced persons were deployed in order to meet people’s needs. This was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us that at times there were not enough staff available to answer their call bell and provide support when they needed it. We observed that staff were very busy and were working under pressure. Care and support was mainly based around completing tasks and did not always take account of people’s preferences or to meet their social and recreational needs. We found this to be the case in particular within the main house with staff also reporting being “over stretched” on this floor. At times some people had to wait to be given personal care, such as support to go to the toilet. The downstairs unit for people living with dementia we judged as having sufficient staff to meet people’s needs.

We found insufficient staff levels had a detrimental impact on other areas such as record keeping. While people’s health and support needs were documented in their care plans we found some records had not been fully updated or reviewed after changes to a person’s condition had occurred, such as after a fall. We also found this to be the case with records for supporting people with behaviours that were challenging to the service.

We observed that some people were left for long periods of time without staff supervision or stimulation. Those people who used wheelchairs spent significant periods without being transferred to other chairs or given a change in position.

Staff were trained in end of life care and we saw evidence to show that this was being done with sensitivity. The home had links with the Hospice at Home team and had specifically developed plans to put in use when people were approaching the end of their life. However, some of the care plans to support people at the end of their life were incomplete and required more detail to inform staff.

The provider told us that the activity coordinator organised on average two trips out per month during the summer season and could use the mini bus shared with the providers sister home for this. However, on a day to day basis we found the majority of people did not leave the home unless friends or relatives took them out

The home had a part time activity person and people told us they enjoyed the sessions she put on. This person also offered additional support to people at mealtimes and with drinks.

We made a recommendation at the last inspection that the service seeks expert advice from a reputable source in developing a dementia care strategy for the home, that would encompass staff training, approach, the environment and activities. This had not been put in place.

People were not provided with care that met their individual support needs and preferences. This included being offered appropriate opportunities or meaningful activities based on person-centred care that met their needs and reflects their personal preferences. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The majority of people told us that the quality and choice of the meals on offer had deteriorated over recent weeks. We were told that the food supplier had recently been changed and the provider was addressing quality issues with the new supplier. We found the meals did not look appetising, fresh fruit was not freely available and snacks offered to people were of a poor nutritional value.

We found that the nutritional assessments on admission were basic and needed to be in more detail and following on from this people’s preferences and nutritional support needs needed to be recorded in more detail.

We found this to be a breach of Regulation 9: person centred care as people were not being offered a choice of food and drink that meets each persons preference and assessed nutritional and hydration needs to support their well-being and quality of life.

At the last inspection we pointed out hazards in the environment and on this inspection we continued to find that people were exposed to potential hazards. A near miss had occurred in February 2018 whereby a person had managed to drink a small amount of a potentially hazardous substance.

This is a breach of Regulation 12: Safe care and treatment as the provider had not done all that was practically possible to mitigate risk.

Local health care practitioners were called on to see people and to give advice. People also saw other health care professionals like chiropodists and opticians, and referrals to other healthcare professionals had been made. We did receive feedback from a number of professionals about the not always receiving referrals in a timely manner and communication not always being effective.

People who lived at Stilecroft and their relatives told us staff were caring and their privacy was respected by staff. We saw and heard positive interactions between people and staff throughout our inspection. However, people’s dignity was at times compromised due to having to wait for personal care and by some of the responses from staff.

We made a recommendation about ensuring the home has measures in place to protect people’s dignity.

People told us that their family could visit whenever they liked and were made to feel welcome.

The processes used for identifying how best interest decisions were made for people who lacked the capacity to make complex decisions for themselves had not always been recorded. We found the records on people’s capacity to make decisions could be improved.

We have made a recommendation about assessing people’s capacity to make decision and recording of this to ensure the guidance outlined in the Mental Capacity Act 2005 is followed. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.

Where safeguarding concerns or incidents had occurred these had been reported by the registered manager to the appropriate authorities and we could see records of the actions that had been taken by the home to protect people. Staff understood how to recognise and report abuse which helped make sure people were protected.

Staff had completed a variety of in-house training that enabled them to improve their knowledge and were supported to take national care qualifications. We found that some of the in-house training was at a basic level. For example, dementia training was at a basic level. Staff worked between both areas of the home and some staff needed more training on dementia care.

Suitable arrangements were in place to ensure that new members of staff had been suitably vetted and were the right kind of people to work with vulnerable adults. Staff received regular supervision to support them in their job.

Systems were in place for the safe administration and disposal of medicines. The majority of records showed people received their medicines as prescribed and in their preferred manner.

We made a recommendation about the safe use of prescribed drink thickeners and recording of some medicines.

The provider had a suitable complaints policy and procedure in place. However, we made a recommendation about recording informal and verbal complaints, as

At our last inspection in October 2014 we judged the service to be good.

Stilecroft Residential Home provides accommodation and personal care for up to forty four older people. The main accommodation is provided in the original Victorian building which has been adapted for the purpose. There is an extension to the main property that has been appropriately and purposely adapted to accommodate people who have dementia. The home is in a residential area on the outskirts of Workington.

The home had a suitably qualified and experienced 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. The previous manager remained registered at this location. We asked the area manager to deal with this matter.

We noted a number of issues in the home that potentially had a negative impact on the safety of people in the home. There were some matters in relation to infection control, trip hazards and potential legionella infection which needed attention. There were issues around evacuation in the event of a fire. Immediate action was taken on the day of the inspection to ensure people would be safe.

This is a breach of Regulation12, Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because these hazards posed a risk to vulnerable people and to visitors and staff in the home.

We judged that the systems to monitor quality in the home had failed to identify these matters in a timely manner.

This is a breach of Regulation17 of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the systems were not working effectively to identify the issues we identified during the inspection.

Staff understood how to protect vulnerable adults from harm and abuse. Staff had received suitable training in safeguarding. The management team understood how to report any potential or actual abuse. Staff told us that there were 'whistleblowing' arrangements in place to support any concerns or complaints they had.

We checked on staffing levels and found these to have improved since our last inspection and were suitable to meet the needs of the people in the home, on the day of our inspection. The registered manager was developing deployment strategies to ensure staff were giving people good levels of support.

Suitable arrangements were in place to ensure that new members of staff had been suitably vetted and were the right kind of people to work with vulnerable adults. The registered provider had policies and procedures in place to ensure that any disciplinary matters could be dealt with in an appropriate manner.

Medicines were ordered, stored, administered and disposed of appropriately because the service had a very efficient system for supporting people who needed help with medicines.

Staff received suitable levels of training in subjects the provider judged to be appropriate. We noted that supervision and appraisal was in place in the home but that some of these meetings were out of date. We recommended that the systems for supervision and appraisal were reviewed and formal records kept in more detail.

The registered manager was aware of her responsibilities under the Mental Capacity Act 2005 when people were deprived of their liberty for their own safety. We judged that this had been done appropriately and that consent was sought for any interaction, where possible.

People told us they were happy with the food provided. Simple nutritional plans were in place.

Local health care practitioners were called on to see people and to give advice. People also saw other health care professionals like chiropodists and opticians.

We observed kind, patient and suitable care being provided. Staff made sure that confidentiality, privacy and dignity were adhered to. People were encouraged to be independent where possible.

Staff were trained in end of life care and we saw evidence to show that this was being done with sensitivity.

We looked at care files and saw that everyone had an assessment of needs and preferences and that care plans were then put in place. Some of these needed more detail when people had complex needs.

We recommended that care planning was reviewed and more detail put into some of the plans, especially when people are living with dementia.

We judged that people received good levels of personal care support.

People were happy with the activities and entertainments on offer. Everyone was given the opportunity to follow their own interests, where possible. There were plans to widen the options for people with dementia.

The provider had a suitable complaints policy and procedure in place. We had received some concerns that we judged needed more in-depth investigation and the area manager readily agreed to do this.

The actions taken by the provider included reassessing dependency levels of all persons living in the home in order to calculate the number of staff required to meet their needs.

On the day of our visit there were 13 people on the dementia unit and the staffing had been increased by one during the day and by one at night. Staff we spoke with told us they could now meet people's needs in a timely manner and supervise people in the communal lounge.

The care plans we looked at were person centred with information about life histories and personal preferences recorded. One relative we spoke with told us, ' We are kept informed on a regular basis if changes occur, the staff are approachable and the atmosphere is relaxed.'

People who lived in the home and their relatives we spoke with all thought both the building and the gardens were fit for purpose. One person told us, 'The house is always nice and clean.'

We spoke with staff about their recruitment and when asked about their experience one person told us, ' I felt they were very thorough. I had to do training first and then I was shadowed.'

Staff told us that due to the recent reduction in staff levels the morning routine was more difficult and meant some people were not getting their needs met in a timely manner and that some of their choices and preferences could not be met.

People and their relatives had been asked for their views about the care they received. 60% of people asked commented that the standard of care was excellent, 40% said it was good and 20% said it was satisfactory.

We visited the home at 6.30 am to check on these matters of concern. We did not find any concerns in these areas. On the contrary we found people being supported to get up when they wanted to and the care they received was in line with what was recorded in their individual care plans.

When we arrived there were two people up and dressed sat in the lounge, another person was dressed and making their way into the lounge. We spoke with them and they said they were early risers and always had been. One person told us, "I'm always up at this time, me and the other lady are the first up. I usually start to dress myself and then staff come along and help out, they know my routine so they know I'll be awake. The staff do me a cup of tea and then I have breakfast about 8 o'clock." We found the majority of people were still in bed when we arrived and across our visit they started to get up at different times. When we left at just before 10 o'clock some people were still in bed as a matter of choice.

The atmosphere was calm and relaxed and we observed staff offering support to people that was both respectful and considerate.