Andrew Smith House - Nelson

Andrew Smith House – Nelson is a residential nursing home, providing accommodation for up to 60 persons, who require nursing or personal care. It specialises in providing care for people living with a dementia, learning disabilities or autistic spectrum disorder, older people, people with a physical disability and younger adults. The service is purpose built and split into four units over two floors. There were 54 people living in the service at the time of the inspection.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. One of the units in the service supported up to 10 people who were living with a learning disability. At the time of the inspection there were eight people living on this unit.

Right Support: a range of policies and procedures were in place which supported and guided staff. Staff were supportive of people’s individual needs and people were noted to be undertaking activities of their choosing. We saw people accessing the community safely, as they wished.

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. We have made a recommendation in relation to ensuring people are involved and supported in making decisions about their care.

Right Care: person centred individualised care was promoted and staff clearly understood the needs of people and supported their privacy and dignity. Training programmes were in place and ongoing. Staff were observed engaging positively with people and promoting person centred support. However, we made recommendations about, ensuring relatives are kept informed about people’s assessed needs and professional reviews.

Right Culture: There was a positive atmosphere in the service. Staff were confident in ensuring people received good, effective care and promoting good outcomes for people. The manager was open and honest and provided evidence of areas to improve the service.

People told us they felt safe, and staff understood how to deal with allegations of abuse. The service continued to manage medicines safely. Risks were assessed and managed. Infection prevention and control was being managed. Where masks were not always being worn, in line with current guidance the manager confirmed they would take action to ensure these were worn safely. Staff recruitment was on-going. We discussed the importance of ensuring newly recruited staff were supported in their role by existing and skilled staff. We made a recommendation about sufficient and experienced staff deployed in the home.

Not all people told us they were asked for consent. Staff training, supervision and appraisals were ongoing. There was evidence of assessments undertaken however not all relatives confirmed they were kept informed and updated, we made a recommendation about this. Records included information in relation to the involvement of professionals. Not all relatives confirmed they had been informed of reviews.

People were mainly positive about the care they received and confirmed they were treated with dignity. Others told us of concerns about living in the service and support they received. We made a recommendation about ensuring people were involved and supported in making decisions. We observed staff ensuring people’s, privacy and dignity was respected. Records were stored securely with passwords and login details for staff to access computers.

Care records contained information about how to support people’s individual needs. Where these required reviewing, we were advised this would be undertaken as soon as possible. People’s end of life care needs were recorded where relevant. Not all people or relatives confirmed they had been involved in reviews. There was a dedicated activities team and evidence of activities undertaken. A system to handle complaints was in place. Not all people and relatives fedback that their concerns had been dealt with we made a recommendation about this.

We saw evidence of surveys and meeting minutes. However, not all people and relatives confirmed they had been engaged and involved. Audits were undertaken including senior audits and action plans going forward. The new manager, who had been the deputy manager told us, and we saw records to confirm the actions planned to address the gaps in the follow up of these. We received mixed feedback about the manager. Staff were positive about the new manager and the improvements since they came to post. Certificates of registration were on display and notifications were being submitted to the Care Quality Commission.

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

Rating at last inspection

The last rating for this service was good (published 2 October 2020).

Why we inspected

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

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Andrew Smith house -Nelson on our website at www.cqc.org.uk.

Recommendations

We have made recommendations about, ensuring people are involved and supported in making decisions about their care, ensuring relatives are kept informed people’s assessed needs and professional reviews, the deployment of sufficient and experienced staff and the management of complaints and concerns.

Follow up

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

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

People felt safe at the home and everyone we spoke with was happy with staffing levels. The provider recruited staff safely and staff understood how to protect people from the risk of abuse. People received their medicines as and when they should. Staff followed appropriate infection control procedures, and people and staff told us the home was always clean. Risks to people's health and wellbeing were managed well and the safety of the home environment was checked regularly.

Staff supported people to achieve good outcomes. Staff received an appropriate induction and training and were able to meet people's needs. 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. Staff supported people with their dietary and healthcare needs and referred them for specialist support when they needed it. The environment had been adapted to meet people’s needs and enable them to remain as independent as possible.

Management and oversight of the service had improved significantly since our last inspection. Regular audits and checks were effective in ensuring appropriate levels of safety and quality were maintained at the home. Staff understood their responsibilities and provided people with care which resulted in good outcomes. The home worked in partnership with community agencies to ensure people received the support they needed. People's views were sought about the service and acted upon. People, relatives and staff found the manager approachable and supportive and felt he had made significant improvements to standards of care at the home.

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 13 January 2020). At that inspection we found multiple breaches of regulation and the service was placed in special measures. This meant the service was kept under review and we would re-inspect within six months to check if enough improvement had been made. 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 improvements had been made in the key questions of Safe, Effective and Well-led and the provider was no longer in breach of regulations. 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 carried out an unannounced comprehensive inspection of Andrew Smith House service on 19, 20 and 25 November 2019, due to concerns received about the service. Breaches of regulation were found in the key questions of Safe, Effective and Well-led. These related to inadequate staffing levels, staff not always treating people with dignity and respect, lack of induction and training for staff, failure to recruit staff safely, poor medicines management, lack of effective infection control practices, failure to act upon complaints and lack of effective management of the service. The service was placed in special measures.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions of Safe, Effective and Well-led which contain those requirements. Although we did not look at the key questions of Caring and Responsive at this inspection, the ratings for those key questions from the last inspection, were used in calculating the overall rating at this inspection. At that inspection, the key questions of Caring and Responsive were rated Requires improvement. Therefore, the overall rating for the service has changed from Inadequate to Requires improvement.

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 coronavirus and other infection outbreaks effectively.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Andrew Smith House is registered to provide nursing and personal care for people living with dementia, older people, physical disability, nursing care and mental health care needs. The service can support up to 60 people. At the time of the inspection, there were 55 people who lived in the home. Accommodation is provided over 4 units on two levels. However, at the time of the inspection the two upstairs units were being run as one unit. This unit specialised in providing care to people living with dementia.

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

The service was not safe. A safeguarding referral was raised during the inspection, as we witnessed a staff member ignoring requests for a person to go to the bathroom. We observed other people being left wet and observed some unsafe moving and handling procedures. Some vulnerable people in their rooms were calling out for staff support and it was unclear how often staff were checking on them and re-positioning them. Medication not been managed safely and staff were not recruited safely. There were concerns around infection control and staff we observed were not wearing gloves and aprons. Staffing levels were low. Staff told us they felt under pressure and there was a lack of permanent nursing staff on the complex unit. Agency staff were supporting complex individuals on 1-1’s and did not have access to relevant information about the people’s needs.

Staff did not always receive appropriate inductions and there was a lack of training for new staff. Staff were generally caring and tried hard to support people as best they could in the difficult circumstances. However, we saw a minority of agency staff who were not compassionate towards people and a safeguarding referral was raised during the inspection. Complaints were not being managed effectively and people did not always feel listened too. People were not consulted about meal choices and the menus were not displayed. Activities were taking place but some people we spoke with felt these were minimal and there was not enough stimulation.

Care plans were detailed. 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.

A new manager had recently started at the service, who was in the process of registering to be the registered manager. He was keen to improve the service. However, there had been a succession of managers at the home and people told us that the service had deteriorated. We could see that although some audits had taken place, there was a clear lack of leadership and oversight of the service and staff had contacted us to express concerns about the management of the service. During the inspection the provider met with us and agreed some interim measures to ensure that the risks were minimised.

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 ) and there was one breach 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 we found that improvements had been made in the area of mental capacity and was no longer in breach, we found further breaches of regulation.

Why we inspected

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

Enforcement

We have identified breaches in relation to medicines, dignity and respect, infection control, staffing, recruitment, acting on complaints and good governance.

Please see the action we have told the provider to take at the end of this report.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special measures

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

Andrew Smith House is registered to provide nursing and personal care for people living with dementia, older people, physical disability, nursing care and mental health care needs. It is situated in Nelson, Lancashire. Accommodation is provided on four units on two levels, with a lift to both floors and wheelchair access to all parts of the home. The home can accommodate up to 60 people. At the time of this inspection, there were 39 people who lived in the home.

Our last inspection report for this service was published on 30 August 2018 and the rating was 'Requires Improvement’ with the question, is this service safe? rated ‘Inadequate’. There were six breaches of regulations 12,17,18,19 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to safe care and treatment, good governance, staffing, employment of fit and proper persons and duty of candour.

Following the last inspection, we took enforcement action and issued the registered provider with warning notices in relation to medicines management and good governance. We also asked the registered provider to tell us what actions they would take to comply with these regulations. At this inspection in February 2019, we found that the provider had made some improvements in relation to the management of risks of injury, medicines management, staff training, duty of candour and fit and proper persons. However, we found continuing areas for improvement in relation to governance arrangements, staff training and medicines management. Our findings showed there were areas which required further improvements and improvements made needed to be imbedded.

We found shortfalls in the assessment of people’s mental capacity. The service remains, 'Requires Improvement'.

This was a scheduled inspection based on the service's previous rating.

People’s experience of using this service:

There had been improvements in the management of risks of injury and oversight on accident and incidents. Risk assessments were in place and incidents were analysed and management plans discussed with staff. The frequency of injuries had reduced for certain individuals who had been at high risk during our last inspection.

Improvements had been made to the safe management of medicines. We noted some areas where improvements were necessary and the registered manager took immediate action to rectify them.

While people were assisted to have choice and control of their lives and consent to receive care had been sought, we found people’s mental capacity to make specific decisions was not lawfully assessed and authority to deprive people of their liberties for their safety had not always been sought.

We made a recommendation in relation to the application of mental capacity principles and seeking authorisation to depriving people of their liberties.

People’s records had been checked to make sure they included up to date and accurate information about people's needs. However, the systems for recording care records needed to be improved. We made a recommendation about effective record keeping for care plans.

Staff had been safely recruited

Improvements had been made to ensure staff were providing effective care for people through person-centred care planning, training and supervision. Consideration had been made for the provision of best practice guidance and support to meet people's individual needs.

People were treated with compassion and dignity by care staff.

We observed a homely and friendly atmosphere throughout the inspection.

Staff spoke passionately about their roles and wanting to provide quality care.

There was good evidence that equality and diversity had been considered, in particular around those with protected characteristics such as disability, race, culture and religion.

Improvements had been made to ensure people received personalised care that was responsive to their needs.

Staff had developed good relationships with people. People clearly enjoyed the presence and attention from the staff.

Improvements had been made to the governance systems, and a new registered manager had been employed. They had made some changes however, this was still in its infancy and further changes were required. The systems internal quality audits needed to be improved to effectively monitor compliance. The registered manager was committed to improve people’s outcomes and had fulfilled their duty of candour.

For more information please see the Detailed Findings below.

Rating at last inspection: The service was previously rated Requires Improvement.

Why we inspected: This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Andrew Smith House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Andrew Smith House is registered to provide nursing and personal care for people living with dementia, old people physical disability, nursing care and mental health care needs. It is situated in Nelson, Lancashire. Accommodation is provided on four units on two levels, with a lift to both floors and wheelchair access to all parts of the home. The home can accommodate up to 60 people. At the time of this inspection, there were 44 people who lived in the home.

The service had a registered manager in place. 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 this service in June 2016. The registered provider was compliant with all regulations at that time and the service was rated overall ‘good’.

During this inspection we found shortfalls in relation to the management of risks associated to receiving care. This was because risks to people and incidents had not always been analysed to identify patterns and ensure lessons were learnt. People’s medicines had not been safely managed and staff recruitment procedures were not robust to protect people. There were significant shortfalls in staff training. Quality assurance systems were not effective in identifying shortfalls or areas where the service was not meeting regulations and failure to drive improvements. In addition, there was a failure to demonstrate how the provider had promoted a culture that encouraged candour, openness and honesty.

We found there were six breaches of the Regulations. These were breaches of Regulations 12,17,18,19 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

Staff had received safeguarding training and knew how to spot abuse and the reporting procedures. Risk assessments had been developed to minimise the potential risk of harm to people who lived at the home. However, there had been significant incidents that exposed people to risks. Some significant incidents had been reported to the local authority and the Care Quality Commission however, there was no robust formal system to analyse incidents. Accidents and incidents had been recorded and staff had sought medical advice where required however, there was no evidence of lessons learnt. Improvements were required to demonstrate what support people had received following incidents such as repeated entrapment by bedrails.

Staff had been trained in the safe management of medicines. However, there were some shortfalls in medicine management practices in the home.

Safe recruitment procedures had not always been followed to ensure new staff were suitable to care for vulnerable people. Arrangements were in place for training staff however we found significant shortfalls in training. Staffing levels were monitored to ensure sufficient staff were available.

Policies and practices for promoting, honesty, transparency and duty of candour had not been effectively followed when things had gone wrong with people’s care.

There were established governance arrangements and quality assurance processes. The provider had considered best practice and had been involved in the trial of innovative practices in collaboration with other agencies. However, the shortfalls we identified in people’s care showed the quality assurance processes were not robust and needed to be improved to ensure they identified where the service was not compliant with regulations.

Feedback from people and their relatives regarding the care quality was positive. People who lived at the home told us that they felt safe. Visitors, people who lived at the home and care staff spoke highly of the registered manager.

People were happy with the care and support they received and made positive comments about the staff. They told us they felt safe and happy in the home and staff were caring. People were comfortable in the company of staff and it was clear they had developed positive trusting relationships with them. However, our records showed that there were incidents in the home which had compromised people's safety.

The staff who worked in this service made sure that people had choice and control over their lives and supported them in the least restrictive way possible. However, some improvements were required to ensure records of people’s consent were kept.

The information in people's care plans was detailed to ensure they were at the centre of their care. Majority of people's care and support were kept under review however this was not consistent throughout the records we checked. Relevant health and social care professionals provided advice and support when people's needs changed. People’s nutritional needs were met. Risks of malnutrition and dehydration had been assessed and monitored.

The home was clean, and comfortable for people to live in. The environment was dementia friendly and the home had adaptations designed to suit the needs of people living at Andrew Smith House.

People were supported to have 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. Staff respected people's diversity and promoted people's right to be free from discrimination.

There was a strong drive to facilitate community and social inclusion. People had access to a range of appropriate activities both inside the home and in the local community.

People were supported to maintain and develop their independence. The provider had sought people’s opinions on the quality of care provided.

People who used the service knew how to raise a concern or to make a complaint. The complaints procedure was available, and people said they were encouraged to raise concerns and were confident they would be listened to.

The registered manager and staff co-operated with the inspection and were keen to rectify all the shortfalls we identified. They took corrective measures to rectify a significant amount of the concerns during the inspection and soon after. However, we would have expected these issues to have been identified by the provider and rectified without our intervention.

Prior to our inspection we received some concerning information. We brought our inspection forward and looked into the concerns during our visit. During this inspection we found the service was meeting the current regulations.

Andrew Smith House is located in Nelson Lancashire and can accommodate up to 60 people. The service is registered to provide nursing and personal care for people living with dementia, old age, physical disability, nursing care and mental health care needs. Accommodation is provided on four units on two levels, with a lift to both floors and wheelchair access to all parts of the home. There were aids and adaptations to support people to remain independent and outside gardens with car parking for several cars.

The registration requirements for the provider stated the home should have a registered manager in place. There was a registered manager in post on the day of our inspection. 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 and relatives using the service told us they felt safe and well cared for. They considered there were enough staff to support them when they needed any help. The registered manager followed a robust recruitment procedure to ensure new staff were suitable to work with vulnerable people. We found there were enough staff deployed to support people effectively.

The staff we spoke with were knowledgeable about the individual needs of the people and knew how to recognise signs of abuse. Arrangements were in place to make sure staff were trained and supervised at all times.

Medicines were managed safely and people had their medicines when they needed them. Staff administering medicines had been trained to do this safely.

Risks to people’s health and safety had been identified, assessed and managed safely.

We found the premises to be clean and hygienic and appropriately maintained. Regular health and safety checks were carried out and equipment used was appropriately maintained.

Staff followed the principles of the Mental Capacity Act 2005 to ensure that people’s rights were protected where they were unable to make decisions for themselves. Staff understood the importance of gaining consent from people and the principles of best interest decisions. Routine choices such as preferred daily routines and level of support from staff for personal care was acknowledged and respected.

People using the service had an individual care plan that was sufficiently detailed to ensure people were at the centre of their care. Care files contained a profile of people’s needs that set out what was important to each person.

People’s care and support was kept under review and people were given additional support when they required this. Relevant health and social care professionals provided advice and support when people’s needs had changed.

We found staff were respectful to people, attentive to their needs and treated people with kindness and respect in their day to day care. Care plans were written with sensitivity to reflect and to ensure basic rights such as dignity, privacy, choice, and rights were considered at all times.

Activities were varied and appropriate to individual needs.

People were provided with a nutritionally balanced diet that provided them with sufficient food and drink that catered for their dietary needs.

People using the service and relatives told us they were confident to raise any issue of concern with the registered manager and that it would be taken seriously and the right action taken.

People using the service, relatives and staff considered the management of the service was very good and they had confidence in the registered manager.

There were systems in place to monitor the quality of the service to ensure people received a good service that supported their health, welfare and well-being.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This a summary of what we found:

Is the service safe?

There was evidence of effective risk assessment in place in the care files we looked at. These had been updated and reviewed recently. Example of risk assessments seen were; falls and bed rails.

We spoke with people who used the service about their medication. They told us they were happy with their medication. One person said, 'I am happy with my medication. I get them every day and the staff stay with me whilst I take them'.

Is the service effective?

We looked at staff files for three currently recruited staff members. We saw evidence of supervision taking place including competency assessments, supervision agreements and appraisals, these had been completed recently.

We were shown evidence that staff who were responsible for medication administration had received up to date training and had also completed competency checks when carrying out medication administration

Is the service caring?

The care plans we looked at had been personalised with people's specific needs and contained detailed information to aid staff to care for them safely and effectively. Example of care plans were, personal care, mental health dependency and pressure care. We noted care plans had been reviewed recently to ensure people were cared for by staff who had the up to date knowledge about them.

Is the service responsive?

We asked people who used the service and their family about the staffing numbers and consistency of the staff team. We were told, 'There are always staff around. When I press my buzzer someone always comes. There is enough people [staff]. There are two staff always around', 'Sometimes you have to wait for some time for a staff member to come'

The registered manager told us they recently introduced a computer based care file for each person who used the service. We were told that there were plans for all related documentation such as letters and referrals to be scanned into this system to ensure all records relating to people who used the service were stored centrally.

Is the service well led?

We discussed how the registered manger ensured there were adequate staffing numbers on duty to meet people's needs. The registered manager told us a dependency assessment tool was not in place. However they confirmed they would look into introducing a dependency assessment to ensure there were sufficient numbers of staff to care for people who used the service.

We discussed with the registered manager what systems were in place to monitor and audit medications. We were shown a medication audit form that had been completed recently. There was evidence of notes seen with actions including a summary of the audit.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This a summary of what we found:

Is the service safe?

The manager told us there had been no application for Deprivations of Liberties Safeguards (DoLS). (The Mental Capacity Act 2005 provides a legal framework to protect people who need to be deprived of their liberty for their own safety).

The Care Quality Commission (CQC) had been made aware of some safeguarding referrals which had been reported to the local authority. We discussed these concerns with the manager and asked to look at the evidence of the investigation that had taken place. We were satisfied with the evidence provided in relation to these concerns.

We asked about the use of agency staff in the home. The manager told us agency staff were used to cover sickness of holidays. We were shown evidence of the checks that had taken place for these staff to ensure they had the appropriate qualifications in place.

We saw that medications for people living in the home were not administered safely. We saw gaps in medication charts and we could not see evidence of referral to the GP when medication was being refused by people living in the home.

We saw in one care file there was a care plan in place in relation to safeguarding. However we noted the current risk assessment for them was not in their care file.

Is the service caring?

We spoke with one person living in the home. They told us, 'I am happy, cared for and looked after'. Relatives of people living in the home all told us they were happy with the care they received in the home.

We undertook two Short Observational Framework Interventions (SOFI) on the day of our inspection. We saw staff were attentive to the needs of people they were in direct care intervention with however; we saw little conversation with the other people in the lounge on one of the SOFIs we under took. The SOFI we carried out in a second lounge in the home identified staff were speaking kindly to people living in the home and were observed to be attentive to people's needs and responding to people in a positive way.

Is the service responsive?

We asked the manager about how they ensured there were enough staff to meet people's needs. We were shown the duty rota and saw there were staff in place to cover all areas of the home. We were told any gaps in cover would be addressed using either bank or agency staff.

Relatives of people living in the home told us there was plenty of staff in the home and they saw regular staff on duty. We were told, 'On the whole there is the same staff. There is always staff milling around and they are always in the lounge' and, 'Sometimes there can be no one in the lounge'. The person we spoke with confirmed that this was not for long periods of time.

We saw details of an upcoming date for relative meetings in the home, and relatives we spoke with confirmed meetings were taking place in the home and they were able to attend if they wanted to.

Is the service effective?

We spoke with two visiting health professionals on the day of our inspection. We received some positive feedback. We were told, 'The home is willing to work with us, and all suggestions we make are taken up'.

In two of the care files we saw that there were care plans in place however, we noted these had not been reviewed for several months. We could not be confident these records reflected people's current needs. In one person's file we could not see a care plan or risk assessment relating to their needs in communication.

We saw there was an activities coordinator in the home. We saw evidence of a comprehensive activities programme in place. People living in the home we spoke with confirmed they were able to take part in activities if they wanted to and we saw activities taking place on the day of our inspection.

Is the service well led?

The manager is registered with the Care Quality Commission and we saw copies of their certificate on display in the entrance hall of the home. We received positive feedback about the manager. We were told, '(Named manager) is the best boss I have ever had. She listens to any problems and would bust a gut to help you. She is approachable and understanding. The staff are much happier since she came here', "(Named manager) is supportive' and, '(Named manager) is okay, supportive, I am able to go to her with concerns'.

We asked about audits taking place in the home. The manager showed us copies of regular internal audits taking place. We saw evidence of audits taking place for example; pressure sores and care plans. We saw details of investigations into incidents taking place with actions and outcomes noted in them.

We saw evidence of staff meetings taking place and staff we spoke with confirmed they were taking place and that they were able to discuss their views

We spoke with three people who used the service all were complimentary about the care they received. Comments made were, 'I have signed my paperwork. I know my key worker', 'The staff are always around', and 'The staff are lovely I am quite happy, the staff look after me'.

We spoke with three members of staff who confirmed they had received training in the protection of vulnerable adults (POVA). All staff we spoke with were able to identify signs of abuse and appropriate procedure to follow if they suspected abuse had occurred.

We spoke with staff who told us they received regular supervision and annual reviews of their performance. We saw evidence of this in some of the staff files we looked at.

The staff we spoke with were complimentary about the manager. Some comments received were, 'The home is a lot calmer now this manager is here. X is very approachable' and, 'X is very good, any issues there are she is quick in bringing them up, she is very approachable'.

We saw the staff had access to an in house policy on complaints for them to follow. There was guidance about the complaints procedure in all people who used the service on display in their bedrooms.

We found that suitable arrangements were in place to manage an effective complaints process for identifying, receiving and handling complaints for people living at Andrew Smith House.

We found care plans and risk assessments had been completed for the people living in the home with regular reviews of people's care and nursing needs in place.