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Inspection Summary

Overall summary & rating


Updated 19 December 2018

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 inspection took place on 21 and 22 November 2018 and was unannounced. At our last inspection on 25, 27, 29 September and 9 October 2017, the service was found not to be meeting the required standards in the areas we looked at. There were breaches against regulations of the Health and Social Care Act (Regulated Activities) 2014.

The breaches included regulation 9. Care and treatment of service users did not always meet their nutritional needs.

Regulation 12. The provider had not ensured people’s changing needs were reviewed and actions put in place to mitigate risks.

Regulation 13. The provider had not ensured all incidents had been reviewed and investigated to ensure people were safe.

Regulation 17. The provider had not ensured effective systems to monitor and improve the service.

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 in safe, effective, caring, responsive and well-led to at least good. At this inspection we found that the provider had made the improvements required.

There was a manager in post who had registered with the Care Quality Commission (CQC). 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 and associated Regulations about how the service is run.

The service was safe. Staff received training in safeguarding and understood how to report concerns. Recruitment practices ensured that suitable staff were employed. Accidents and incidents were monitored to identify any trends or patterns to ensure appropriate actions could be taken. Identified risks to people were reviewed regularly to ensure people’s changing needs and risks were managed. Medicines were managed safely by staff that received appropriate training. People were protected from the risk of infections by staff who followed correct infection control procedures.

The service was effective. People’s nutritional needs were managed appropriately. Staff received training to meet people’s needs effectively. Staff had inductions and supervisions and were supported to do their job. Staff worked in line with the principles of the mental capacity act. People’s care was reviewed regularly.

The service was caring. Staff knew people well and staff cared for them in a compassionate way. Staff respected people’s privacy and dignity and supported people to maintain relationships. Staff delivered care that was supportive, kind and caring. People were involved in deciding how their care was provided and staff promoted their choice.

The service was responsive. People received person-centred care. People`s needs were assessed to ensure they received the support they required. People were involved with their care plan reviews. People were given the opportunity to think about what was important to them regarding end of life care. People had a voice and the opportunity to discuss and raise concerns.

The service was well-led. The registered manager was very clear about their vision regarding the purpose of the home. Staff understood their roles and responsibilities and worked well as a team. There was an open culture and staff felt they could approach the management team at any time. There were effective systems to monitor the quality of the service, identified issues were actioned and lessons learned. People, relatives and staff were positive about how the home was run.

Further information is in the detailed findings below.

Inspection areas



Updated 19 December 2018

The service was safe.

People were kept safe by staff trained to recognise and respond effectively to the risks of harm.

Safe and effective recruitment practices were followed to help ensure that all staff were fit, able and qualified to do their jobs.

People were supported to take their medicines safely by trained staff.

Infection control systems were in place and staff received the appropriate training.



Updated 19 December 2018

The service was effective.

People had their mental capacity assessed and best interest decisions were completed to promote people�s choice.

People were supported by staff that were trained to meet people�s needs effectively.

People�s nutritional needs were met. People were provided with a healthy balanced diet.



Updated 19 December 2018

The service was caring.

People were cared for in a kind and compassionate way by staff that knew them well and were familiar with their needs.

People and their relatives were involved in the planning, delivery and reviews of the care and support provided.

Care was provided in a way that promoted people�s dignity and respected their privacy.

People's confidentiality of personal information had been maintained.



Updated 19 December 2018

The service was responsive.

People were supported to take part in meaningful activities.

People received care that met their needs and took account of their preferences and personal circumstances.

Detailed guidance made available to staff enabled them to provide person centred care and support.

People and their relatives were confident to raise concerns which were dealt with promptly.



Updated 19 December 2018

The service was well led.

Systems were in place to quality assure the services provided, manage risks and drive improvement.

People and staff were very positive about the registered manager and how the home was operated.

Staff understood their roles and responsibilities and were supported by the registered manager.