Archived: Marlyn House

Marlyn House is a care home providing personal care to 18 people at the time of the inspection. The home is registered for up to 18 people. People have access to their own bedroom along with communal spaces including lounges and gardens.

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

People did not always receive safe care, as care plans and risk assessments were not always in place. When events or incidents had occurred, these were not always documented, and it was unclear what action had been taken. There was no evidence lessons were learnt when things went wrong. Infection control procedures were not always followed to ensure the spread of infection was reduced. There were safeguarding procedures in place however these were not always followed to ensure people were protected from potential harm.

The systems in place were not effective in identifying areas of improvement and often there were no audits in place or inconsistently completed. Documentation was not always available or stored where the manager or provider thought it was. Key information had also not always been documented. For example, when the someone had fallen. We were not always notified of events that had happened at the service.

We received mixed views on staffing, there was a dependency tool in place that worked out the staff levels for the home.

Improvements had been made to how medicines were managed.

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. Where needed capacity assessments and best interest decisions were in place.

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 2 March 2020) and there were breaches of regulations.

The provider 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 remained in breach of regulations.

Why we inspected

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

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 Requires Improvement to Inadequate based on the findings of this inspection.

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

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

During this inspection we carried out a separate thematic probe, which asked questions of the provider, people and their relatives, about the quality of oral health care support and access to dentists, for people living in the care home. This was to follow up on the findings and recommendations from our national report on oral healthcare in care homes that was published in 2019 called ‘Smiling Matters’. We will publish a follow up report to the 2019 'Smiling Matters' report, with up to date findings and recommendations about oral health, in due course.

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 regulation 12, Safe care and treatment, regulation 13, safeguarding service users from abuse and improper treatment and regulation 17, Good governance.

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 continue to monitor information we receive about the service until we return to visit as per our reinspection 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 of 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.

Marlyn House is a care home providing personal care for up to 18 older people. People have access to their own bedroom along with communal spaces including lounges and gardens. At the time of our inspection there were 10 people living at the home, some of whom were living with dementia.

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

People were not receiving safe care as their needs were not always understood and risks were not managed in a safe way. Care plans and risk assessments that had been introduced did not have the detailed information in to keep people safe. Plans were not reviewed and updated following incidents. People were not always protected from harm as incidents were not always reported to ensure appropriate action was taken. There was a lack of understanding from staff as to why incidents needed to be reported and the importance of safeguarding people. Improvements were needed to ensure all medicines were administered as prescribed. There were limited activities taking place which meant people were sometimes sleeping.

People were not always supported in a dignified way. The language used in the home was not always dignified. People's communication needs were not fully understood and therefore people did not always receive the support they needed.

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 provider continued to fail to ensure lessons were learned when things went wrong. The provider was unable to sustain improvements made and demonstrate they were able to support people safely. The systems in place were not effective in identifying areas of improvement.

Peoples needs were assessed but evidence was needed to show people and families were involved with this. Staff had received an induction and training. There was a complaints policy in place, and this was followed when needed. People had plans in place that considered their end of life care.

People enjoyed the food, and their dietary needs were assessed and considered. Referrals were made to health professionals for support when needed.

There were enough suitably recruited staff available to support people and people were happy with the staff team that supported them. People felt their independence and privacy was promoted.

Improvements had been made to the home environment and infection control procedures were in place and followed.

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

Rating at last inspection and update

The last rating for this service was requires improvement (Published 27 October 2022). The provider 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 remained in breach of regulations.

Why we inspected

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

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

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

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

Enforcement

We have identified breaches in relation to the dignity and respect, how people are safeguarded, the care and support they received in relation to risk management, capacity and consent and the systems in place to ensure the home is effectively governed.

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 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 of 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.

Marlyn House is a care home providing personal care for up to 18 older people. People have access to their own bedroom along with communal spaces including lounges and gardens. At the time of our inspection there were 15 people at the home, some who are living with dementia.

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

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. This was because mental capacity assessments and best interest decisions were not always in place when needed and conditions in place were not being met.

When incidents and accidents had occurred, the action the provider had told us they had taken to keep people safe was not always followed. Care plans and risk assessments were not always reflective of incidents that had occurred or did not always hold up to date information. People did not always receive person centred care as there were not always assessments in place for people. There was no evidence to show how people had been involved with their care or in making decisions.

There were some areas of the home that were in need of repair, the provider had identified this as an area of improvement.

The systems in place were not always effective in identifying areas of improvements. There were some evidence lessons were learnt however this needed to be embedded across all areas.

People were supported in a kind and caring way by staff they liked. Staff promoted people’s privacy and dignity and independence. Improvements had been made and staff had the relevant training to support people. There were enough staff to meet people’s needs, and they did not have to wait for support. The provider had ensured staffs suitability before they could start working in the home.

People enjoyed the food and were offered a choice; people’s dietary needs were considered. There were activities taking place within the home that people told us they enjoyed. Safeguarding procedures were in place and understood. People had access to health professionals when needed.

Medicines were managed in a safe way and infection control procedures were followed. Complaints were also responded to when needed.

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 17 June 2022) and there were breaches of regulations. At this inspection we found the provider remained in breach of regulations.

This service has been in Special Measures since 17 June 2022. 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

This inspection was a planned inspection, prompted by a review of the information we held about this service.

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

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to regulation 12; safe care and treatment, regulation 11; need for consent and regulation17; good governance.

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 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.

Marlyn House is a residential ‘care home’ that provides accommodation with personal care for up to 18 people. People who use the service had physical health and / or mental health needs, such as dementia. At the time of the inspection, 17 people used the service.

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

Quality assurance processes in place were not effective. Quality audits had been completed, however, they failed to highlight issues that were found during the inspection. Care records were not accurate or up to date. The registered person did not have an accurate understanding of risks associated with people. The service has a history of noncompliance relating to quality assurance processes which dates back to our inspection in May 2016. The subsequent four inspections since have highlighted that governance systems in place have not been robust enough. Quality assurances processes have consistently failed to identify issues within the service to ensure the safety of people or drive sustainable improvements.

People’s care files did not appropriately identify risk prevention measures to allow staff to ensure people’s risk of pressure ulceration was managed in a safe way. The registered manager did not have clear processes in place to manage risks appropriately.

Care files did not always contain information on what to do to keep people safe and to advise staff on how to safeguard people’s needs.

There was not an effective system to evidence that staff received appropriate training. The training matrix illustrated not all staff had completed the provider’s mandatory training in a timely manner.

Staff members did not always have the necessary information to safely support people with their medicines.

Accidents and incidents were recorded. However, we did not see any processes in place to highlight any common themes or required learning.

All people were weighed weekly; however, it was not clear how the service was using this information in relation to people’s ongoing health needs.

People’s rights were not safeguarded as the provider had not sought conformation those acting on their behalf had the legal authority to do so.

People were not always safe as the provider failed to ensure the physical environment was free from hazards

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 service had a number of events in the past 12 months, which included ponies visiting the home, going out for pub meals and arts and crafts.

People told us that they felt they were treated with dignity and respect by staff.

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 requires improvement (report published 20 December 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last five consecutive inspections.

Why we inspected

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

Enforcement

We have identified two breaches. Regulation 12 the registered person failed to ensure risks relating to the safety, health and welfare of people using the service were assessed and managed safely and the registered person failed to ensure the proper and safe management of medicines. Regulation 17 the registered person had not established an effective system to enable them to assess, monitor and improve the quality and safety of the service provided.

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

At this inspection we found improvements had been made, but more were needed and the service remains rated as Requires Improvement.

Marlyn House is a Residential 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.

Marlyn House accommodates up to 18 people in one adapted building. At the time of the inspection there were 10 people using the service.

There was a manager in post at the time of our inspection, they had made an application to register with us however this had not yet concluded. 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 not always safeguarded from abuse. The provider did not always notify us of incidents at the home. Quality audits were not always used to drive improvement.

People were not always supported by sufficient safely recruited staff. People were not always supported to live in an environment which was suitable to meet their needs.

People were not always supported to maintain their health and well-being. People were not supported by staff that were consistently caring. People’s preferences were not fully understood by staff. People had access to a range of activities, but lacked engagement in the community and the ability to follow their individual interests.

We have made recommendations about person centred care and support, meaningful activities and the environment you can see more about this in the full report.

People’s medicines were administered as prescribed. Risks to people were assessed and planned for to keep people safe. People were protected from the risk of cross infection. The provider learned when things went wrong.

People had their needs assessed and plan were in place to meet them. Staff were supported in their role and had access to an induction and training. People received consistent support. People could choose their meals and were supported to eat and drink.

People had choice and control of their lives and staff were aware of how to support them in the least restrictive way possible; the policies and systems in the service were supportive of this practice.

People were supported to make choices and staff promoted people’s independence. People’s communication needs were assessed and planned for. People had their privacy and dignity protected.

People understood how to make a complaint and there were systems in place to respond to these. Nobody was receiving end of life care so this was not considered. People and their relatives were engaged in the service and felt able to approach the manager. Staff felt supported in their role and were involved in the service.

The location has previously been rated as Requires Improvement. At this inspection the provider had made improvements to those areas, but other areas were found to require improvement. We may consider enforcement action if there is a continued lack of improvement at our next inspection.

We carried out an unannounced inspection at Marlyn House on 20 March 2018. Our last inspection was on 6 March 2017.

Marlyn House 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 care home accommodates 18 people in one adapted building. At the time of our inspection, there were 14 people living there, some of whom were living with dementia. There is a communal lounge and separate dining room on the ground floor and a garden area that people could access with the support of staff.

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. 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 our last inspection, we rated the service as ‘requires improvement’. We found the provider was not meeting the regulations because applications had not been made for legal authorisation when people were being deprived of their liberty. Improvements were also needed to ensure staff were deployed to meet people’s needs at all times, that people’s medicines were always managed safely and that there were effective systems in place to identify shortfalls and drive improvements at the service. The provider submitted an improvement action plan to show what they would do and by when to address the breach of the regulations and to improve the service to at least ‘good’ in the key questions safe, effective and well led.

At this inspection we found the provider had met the legal requirements when people were being deprived of their liberty. However, we found that further improvements were needed and identified new breaches of the regulations. This is the third consecutive time the service has been rated as ‘requires improvement’.

We found that people’s rights were not always being upheld when they were unable to make certain decisions for themselves. 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; the policies and systems in the service did not support this practice.

We were unable to satisfy ourselves that the provider followed safe recruitment procedures. The registered manager was unable to provide us with records for staff who had been recruited since our inspection and the information they provided after the inspection did not demonstrate that all the necessary pre-employment checks had been carried out. Staff received training but the registered manager did not have suitable systems to ensure this was kept up to date and in line with best practice.

Staff were available to meet people’s physical care needs but people’s emotional needs were not always met and care was often task focused. People did not feel involved in the planning of their care and their diverse needs were not always respected. People were not always offered choices and were not supported to follow their interests and engage in activities that interested them. Improvements were needed to ensure people could access the garden areas safely to promote their wellbeing. Procedures needed to be developed to ensure the home environment was consistently clean and hygienic and people were always safe from the risk of infection.

Staff understood people’s needs and knew what action to take to protect them from avoidable harm. However, risk management plans needed to be more detailed to ensure new or temporary staff always had the information they needed to support people safely. People received their medicines when needed but improvements were needed to ensure medicines were always reviewed regularly and recorded safely. Staff were aware of their responsibilities to protect people from the risk of abuse but were not always sure of how to escalate their concerns to the local authority for investigation if they needed to.

People and their relatives were not always satisfied that action was taken when they raised concerns and complaints. The provider did not have a consistent approach to investigating complaints to make sure improvements were made where needed. The provider did not have effective systems to gather and act on people’s feedback to make improvements where needed.

The provider’s governance and quality assurance systems were ineffective; they had failed to identify the concerns identified at this inspection and had not made or sustained the necessary improvements since our last inspection. There were no systems in place to ensure lessons were learnt when things went wrong. The registered manager had not notified us of important events that occurred in the service, as required by their registration with us.

Staff respected people’s privacy and promoted their dignity. People enjoyed the food at the home and had access to their GP and other health care professionals when needed. People were encouraged to maintain relationships with family and friends and visitors were not restricted.

We found a number of breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

Marlyn House provides accommodation and or personal care for up to 18 people, some of whom maybe living with dementia. On the day of our inspection 17 people were living in the home.

There was a registered manager at the home. 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 deployment of staff needed to be improved to ensure people were always supported to have a positive mealtime experience. Further improvements were needed to ensure people’s medicines were consistently managed in a safe way. Action was still needed to the systems used to assess and monitor the quality and safety of the service, to ensure shortfalls were consistently identified to bring about the required changes.

Staff sought people’s consent before providing care and supported people to make choices over their daily routine. However, the registered manager and staff did not always follow the legal requirements to ensure people’s rights were protected when they lacked the capacity to make their own decisions. The provider had failed to act on concerns raised at the last inspection. The registered manager had not understood their responsibility to identify people at risk of having their liberty restricted to ensure this could be assessed and legally approved. People were offered opportunities to engage in group social activities but were not always encouraged to follow their individual interests to maintain their wellbeing.

People felt safe living at the home and their relatives were confident they were well cared for. If they had any concerns, they felt able to raise them with the staff and registered manager. Risks to people’s health and wellbeing were assessed and managed and staff understood their responsibilities to protect people from the risk of abuse. The provider followed recruitment procedures to ensure staff were suitable to work in a caring environment. Staff received training and support to meet people’s needs.

Staff knew people well and encouraged them to have choice over how they spent their day. Staff had caring relationships with people. Staff promoted people’s privacy and dignity and encouraged them to maintain their independence. People were able to access the support of other health professionals to maintain their day to day health needs. People’s care was regularly reviewed to ensure it continued to meet their needs.

People were happy with the care they received and regular reviews were carried out to ensure it remained relevant. People were supported to maintain important relationships with friends and family and staff kept them informed of any changes.

There was a positive, inclusive atmosphere at the home. People and their relatives were asked for their views on how the service could be improved. Staff felt supported by the registered manager and were encouraged to give their views on the service to improve people’s experience of care.

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

Marlyn House provides accommodation and or personal care for up to 18 people, some of whom maybe living with dementia. On the day of our inspection 16 people were living in the home.

There was a registered manager at the home. 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 were insufficient staff to meet people’s needs at all times and people had to wait for assistance during busy times. The provider followed procedures to ensure staff were suitable to work with people.

Further improvements were needed to ensure the systems to assess and monitor the quality and safety of the service were effective in identifying shortfalls and driving continuous improvement. The registered manager did not always notify us of important events that happened in the service to ensure we could check that appropriate action had been taken.

People received their medicines when they needed them but improvements were required to ensure medicines were stored, recorded and managed effectively. Staff gained people’s consent before providing care but there was a lack of understanding of the legal requirements where people lacked the capacity to make their own decisions.

Staff were provided with training and support to meet people’s individual needs. Staff knew people well and encouraged them to have choice over how they spent their day. Staff were kind and caring, promoted people’s privacy and dignity and encouraged them to maintain their independence. People were supported and encouraged to eat and drink enough to maintain a healthy diet. People were able to access the support of other health professionals to maintain their day to day health needs.

People received personalised care and were offered opportunities to join in social and leisure activities. People were supported to maintain important relationships with friends and family and staff kept them informed of any changes. People’s care was reviewed to ensure it remained relevant and relatives were invited to be involved.

There was a positive atmosphere at the home. People and their relatives knew how to raise concerns and complaints and were confident they would be resolved to their satisfaction. The provider sought people’s views on the service and this was acted on where possible. Staff felt supported by the registered manager and provider and were encouraged to give their views on how people’s experience of care could be improved.

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

Is the service safe?

Care records contained detailed information for staff about people's needs and the support needed to ensure they were safe. Risk assessments identified risks in daily living and the measures in place to reduce those risks. Risk assessments had been reviewed regularly. This provided a current profile of risk for each person.

People received effective and safe support to take the medicines they had been prescribed because detailed records had been kept and evaluated by the manager. Staff had training and regular assessments of their competency to administer medicines. This meant people were protected against the risks associated with the unsafe use and management of medicines.

Improvements had been made in relation to cleanliness and the control of infection in the home since our last inspection. We saw that following an outbreak of infection the manager had taken appropriate steps to control and prevent the spread of infection. The manager had consulted medical and specialist infection control staff to ensure appropriate actions were in place to prevent the spread of infection in the home.

We monitor the operation of the Deprivation of Liberty Safeguards 2009 (DoLS) that apply to hospitals and care homes. This usually involves a restriction in a person's liberty to ensure their safety or the safety of others. Authorisation has to be sought from the local authority that may authorise the DoLS. We saw that since our last inspection one person had been made subject to a restriction under DoLS to ensure their safety and welfare.

Is the service effective?

People's health care needs had been recorded in records. Where health needs had changed, timely referrals had been made to a range of health professionals. We spoke with a visiting health professional who told us, "The home provides excellent care to the letter. Early referrals are made if staff have concerns. We can be confident that staff will follow instructions."

People who used the service and relatives we spoke with did not have any concerns or complaints about the service. It was clear from what we saw and from speaking with staff that they understood people's care and support needs.

Is the service caring?

A person using the service told us, "The staff are very good. I like to spend time in my room and they are happy with that. I need to use the lift and staff always help me."

A relative told us they were very happy with the care provided and told us, "X needs a lot of care. Staff understand exactly what is needed. They have helped (the person) through very difficult times. I have no complaints".

Staff were able to tell us in detail about people's needs and how they supported them. This knowledge matched the information we had seen in care records. We saw that staff showed patience and gave encouragement when supporting people.

Is the service responsive?

When people's health care needs changed external health professionals were contacted. Their actions and recommendations had been recorded in care information and acted upon.

We saw from the review of people's care needs that plans of care had been adapted when there had been a change in the person's needs or wishes,

A relative told us that when they had made a suggestion about a practical issue relating to their relative that staff had responded positively to the suggestion.

Is the service well-led?

Staff were clear about their responsibilities. They told us that they were supported by managers, they were listened to and could approach managers at any time for advice or support. This helped to ensure that people received a good quality service.

The provider and registered manager shared an office and both worked daily in the home. Lines of responsibility were clear. The manager makes daily decisions about matters relating to care and support. The provider supported the manager and was responsible for finance, the environment and matters relating to the operation of the home.

We found that the provider was not monitoring the quality of the service relating to the environment. Better auditing and recording of the maintenance of the environment is needed. We have asked the provider to tell us how they will make improvements.

Regular staff meetings had been held. Staff told us they felt able to raise any concerns in meetings or to make suggestions for improving the service. This was reflected in the minutes of meetings we saw.

We found that the care people received was planned with them and their relatives to meet their needs. We were told: 'If my relative is happy I am happy. My relative is very happy here'.

There were clear arrangements in place to ensure that if people required support from another provider that this was managed safely.

We had some concerns about the cleanliness of some areas of the home and the proprietor was positive about the improvements that they would make. Whilst we were at the home the proprietor arranged extra hours for the domestic staff to ensure that the areas that required attention were remedied.

We saw that recruitment processes meant that only people of suitable character were employed to look after the people who lived at the home. The manager told us they rarely had to advertise.

We found that suitable steps were taken to monitor the running and maintenance of the home. The proprietor told us that they would review arrangements for monitoring cleanliness and infection control.

When we last visited in September 2012 we had concerns with three outcomes. At this visit we reviewed these three areas, and found improvements in two of the three areas, the third area was being updated at the time of our visit.

One person we spoke with told us: 'They prompt me with what I need and support me to be independent'. Another person who lived there told us: 'They have time to come and chat with me. They come several times a day'.

We saw four different choices of meal served at lunchtime, and a variety of hot and cold drinks on offer throughout the day.

We saw that the records for each person who lived at the home were in the process of being updated. However these records provided sufficient information for staff to provide suitable and safe care to meet the needs of each individual person.

We found that staff records were in the process of being updated at the time of our visit. We saw that the staff folders had clear information about their training needs. However, only the newer folders contained all of the information about staff and the recruitment process.