Ashfield

Ashfield is registered to provide accommodation and personal care to up to 25 people. The home specialises in the care of older people. At the time of this inspection there were 13 people living at the home.

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

People were happy with the care they received and complimentary about the staff who supported them.

There had been extensive refurbishment and decoration of all areas of the premises including new carpets and fresh paintwork and ongoing maintenance of the front and back garden spaces. This gave it a homely feel for people who had also helped decorate the home for Christmas.

People felt safe at the home and looked relaxed and comfortable in their environment.

People received their medicines safely from staff who had received specific training to carry out the task.

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.

People were able to follow their own routines and make decisions about their day to day care and support. Care was personalised to each individual and staff respected people's choices.

People's privacy and dignity were promoted. Each person had a single room where they could see visitors or spend time in private.

There were enough staff to support people with their physical and leisure needs. A wellbeing co-ordinator worked together with care staff to enable people to go out and to participate in activities they enjoyed as a group and individually with staff.

Staff worked with healthcare professionals to make sure people received care and treatment which met their individual needs.

The provider had systems in place which monitored standards of care within the home. This included audits, meetings and satisfaction surveys. This helped to make sure ongoing improvements were implemented.

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 the service under the previous provider was Good, published on 28 January 2021.

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.

Follow up

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

Ashfield provides accommodation and personal care for a maximum of 25 older people.

Some people who use the service are affected by dementia or physical frailty. The service does not provide nursing care. People who live at Ashfield access healthcare through the local community health team. At the time of our visit there were 10 people living at the home.

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

People and their relatives gave us positive feedback about the quality of care and staff approach. We observed many caring interactions and people were treated with dignity and respect by kind and caring staff. Staff knew people well and understood how to care for them in a personalised way. Care planning had been addressed to ensure documentation relating to person centred care and risk assessments were up to date and gave staff the information they needed.

Staff training and staff supervisions were consistent, regular and meaningful with good support from the provider and management team during the Covid-19 pandemic. Staff had been recruited safely and completed a thorough induction when they first started.

Safeguarding concerns were being well managed and triggers were identified and pre-empted to ensure people were safeguarded.

Robust environmental risk assessments had been identified and much work had been done and was ongoing to ensure the premises were safe and homely for people. Thought had been given to adaptations for those living with dementia to promote independence, such as colour, lay out and noise levels. Activities and engagement provision was thorough, person centred, regular and showed clear positive outcomes for people.

Infection control and maintenance was well managed. There were no odorous areas and furniture with good continence management and a robust maintenance programme. The premises were homely, safe, clean and well maintained.

People's needs had been assessed and planned for before they moved into the service and kept under review. Staff supported people to access support from healthcare services when needed.

People enjoyed pleasant meal experiences throughout the day with their involvement and choices.

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.

Medicines were well managed.

People and their relatives felt the service was managed well and that the manager and staff were

approachable. The management team felt well supported by the provider. There was a complaints policy and we saw that procedures were followed when dealing with complaints about the service so that a positive outcome was achieved.

Rating at last inspection

We last inspected Ashfield on 4 March 2020. However, due to the Covid-19 pandemic we were unable to complete the inspection as it was initially planned. Due to the necessary changes made to the planned inspection process, the inspection was converted from a full comprehensive inspection, that would have normally been completed over two days, to a one-day targeted inspection. Targeted inspections do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections cannot change the rating from the previous inspection. This is because they do not assess all areas of a key question. Therefore, the overall rating for this service had to remain inadequate, as not enough areas were inspected in order to change the rating. This resulted in an inspected but not rated outcome looking at Safe and Well Led only.

The previous comprehensive inspection was carried out in June 2019. The rating was Inadequate overall, with inadequate ratings in Safe, Responsive and Well Led and Requires Improvement in Effective and Caring. We identified breaches relating to safeguarding and safeguarding notifications, person centred care, safe care and treatment, staffing and quality assurance. We also served a Warning Notice in with a timescale for compliance relating to Regulation 15 (Premises and equipment).

On 4 March 2020 we identified areas which still placed people at risk from unsafe care. We raised these concerns with the nominated individual and received a comprehensive action plan. During this inspection in December 2020 we found that the nominated individual, director of operations, new manager and management team had ensured all the breaches had been addressed.

CQC has received monthly action plans showing continuing improvement. CQC have worked closely with the local authority, including the commissioning team, to monitor the quality of care at Ashfield. Ashfield has not been under a safeguarding process since March 2020 due to improvements at the service based on feedback from health and social care professionals. The findings from this inspection in December 2020 confirmed there had been improvements in all areas of the service ensuring people received a good standard of care. The overall governance, oversight and consistent management was robust and resulted in positive outcomes throughout people’s lives.

At this inspection in December 2020 we found there had been good, sustained improvement stemming from robust overall governance and there were no longer any breaches of regulations. The service is no longer in ‘special measures’. The service has demonstrated improvements, it is no longer rated as inadequate for any of the five key questions. The Warning Notice had also been fully met.

Why we inspected

The inspection was carried out to ensure that improvements had been made.

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.

After the inspection

There are no longer any restrictions on placements. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

Why we inspected

This inspection took place on 4 March 2020 because of the time that had passed since the last inspection, based on the previous rating. However, due to the Covid-19 pandemic we were unable to complete the inspection as it was initially planned. Therefore, our inspection was based on our findings from the visit on 4 March 2020. Due to the necessary changes made to the planned inspection process, the inspection was converted from a full Comprehensive inspection, that would have normally been completed over two days, to a one-day Targeted inspection.

Targeted inspections do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections cannot change the rating from the previous inspection. This is because they do not assess all areas of a key question. Therefore, the overall rating for this service has to remain inadequate, as not enough areas were inspected in order to change the rating. We plan to return in the near future to carry out a further inspection which can potentially change the rating of the service.

On 4 March 2020 we identified areas which placed people at risk from unsafe care. We raised these concerns with the nominated individual, and they are taking further actions to address these concerns. The provider completed an action plan after the last inspection to show what they would do and by when to improve. Improvements had been made but the provider continues in breach of regulations.

In September 2019, a new nominated individual began working for the provider. Their role includes Director of Operations, they have a staff team with their own quality assurance responsibilities. CQC met with this new team in October 2019 and has continued to regularly meet with them. CQC have worked closely with the local authority, including the commissioning team, to monitor the quality of care at Ashfield. Since this inspection dated 4 March 2020, Ashfield is no longer under a safeguarding process due to improvements at the service based on feedback from health and social care professionals.

Areas relating to care needed to be improved, including inconsistencies in care plans. There were gaps in staff training and supervisions for staff were not up to date. Staff said most people’s risk assessments were up to date but a range of risk assessments for three people with complex needs had not been updated. The organisation was reviewing how staff were trained in completing electronic care records but due to the Covid-19 pandemic some training had been delayed. Staff were not always recording safeguarding concerns formally and therefore alerts were not always made to safeguard people.

Staff said the manager was working tirelessly to make improvements to the quality of the care. The nominated individual said there was a temporary staffing problem, hindering further improvements, due to improvement action having led to the dismissal of some staff. They explained new staff had been recruited and were awaiting DBS, but temporarily there was a heavy reliance on agency staff for both day and night shifts.

Staff praised the approachability of the manager despite the pressures the service was under. Since the last inspection, a number of environmental improvements had been made, including new furniture, carpets and décor in some areas of the home. New colour schemes and signage were planned to make the home a more accessible place for people living with dementia. Whilst there were no new admissions to the home, bedrooms were being decorated and refurnished.

Enforcement

We did not look at all the previously identified breaches of regulations due to the changed circumstances of this inspection. Therefore, these breaches must remain in place until we carry out another inspection. These breaches were regulations 9 and 15.

On 4 March 2020, we judged regulation 18 in relation to staffing as no longer in breach. We have made a recommendation for this regulation instead. We identified four on-going breaches in relation to safe care and treatment, protecting people from potential abuse, notifying the Care Quality Commission in line with statutory requirements, and ensuring systems were in place to monitor and manage the service.

Follow up

We will request a further action plan from the provider to understand what they will do to improve the standards of quality and safety. We will continue to work alongside the provider and 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.

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

Ashfield 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.

People's experience of using this service:

We last inspected Ashfield in November 2018 when we rated the service as 'Requires Improvement' in the key questions of safe and well led. This was because although the service had identified many of the issues we found, we could not be assured actions they told us they were planning to take would be effective at resolving the issues, as they were not yet in place. We found concerns relating to safeguarding referrals, inaccurate risk assessments and lack of robust environmental risk assessments. We made a breach of Regulation 15 HSCA RA Regulations 2014 Premises and equipment. We also recommended the provider sought and followed best practice guidance on the adaptation of the premises to meet the needs of people living with dementia. We also recommended the service took advice on the provision of person-centred activities that meet people's interests, wishes and choices, including the implementation of activities for people living with dementia.

At this inspection we found the action taken had not been sufficient to address the improvements needed and the service rating has deteriorated to inadequate.

At this inspection in June 2019, there continued to be no registered manager at the home with the current manager leaving. On the third day of the inspection a new manager was managing the service following a period of management induction and continuing support. There was a lack of consistent management oversight and governance of the service. Despite visits from the area manager, quality assurance systems were not effective, and staff did not feel involved or listened to. Audit systems had not identified all areas for improvement such as environmental and safeguarding risks, adequate staffing deployment and management and lack of effective fall, behaviours, continence and pressure care management.

We also found our two recommendations had not been followed resulting in a lack of stimulation and social activity for people and a lack of dementia care provision.

Staff had some understanding of how to support people to keep them safe but did not always follow care plans or safe practice to ensure people received care safely consistently. The management of behaviours which could be challenging to others, continence and pressure care were not managed well as there was no consistent or regular checking to ensure these areas were addressed to keep people safe. The provider had not ensured safeguarding procedures were always followed to keep people safe, for example identifying incidents as safeguarding issues.

People with complex needs such as those who were partially sighted, lived with mental health issues or dementia did not always have their needs effectively managed.

Staffing deployment and management meant there was limited time for staff to support people with activities and there was limited social interaction unless for tasks. Communal areas were not laid out to be inclusive and comfortable.

Infection control and maintenance was not well managed. There were odorous areas and furniture due to poor continence management. There was no overall robust maintenance programme to ensure timely actions were taken to keep the premises clean, well maintained or safe for people.

People received enough to eat and drink but there was a lack of people’s involvement in menu choices and sometimes morning or afternoon drinks were not offered.

Staff had been recruited safely and completed an induction when they first started.

Medicines were well managed.

Rating at last inspection: At the last inspection the service was rated as requires improvement. The last report was published on 7 February 2019. 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/ sustained and the provider was still in breach of regulations.

Why we inspected:

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

Enforcement: We have identified six breaches in relation to; safeguarding, falls, continence and pressure care management, staffing deployment and management, premises (health and safety and maintenance) and lack of dementia care adaptations, person centred care and communication needs, notifications and overall governance.

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.

After the inspection

We met with the provider and area manager to gain assurances that our concerns were being addressed as a matter of urgency. We asked for weekly staff rota reports and an environmental risk assessment, which we received. The suitable checks of the environment and equipment were in place and actions were being taken. We also made a safeguarding alert to the local authority about our concerns.

Since the above actions were taken the provider has told us they continue to address all the areas of concern. We attended the whole service safeguarding meeting with the local authority and this process continues. The provider has agreed a voluntary suspension on new placements. The local authority will be reviewing some people at the home. Community nurses will be visiting the home to ensure concerns are being addressed. We continue to hold corporate provider meetings where the provider has told us about the positive changes they are making. There is a newly appointed quality assurance team starting in September and the new manager assured us they were addressing the concerns at Ashfield. For example, additional care workers have been recruited and cook hours increased, a deep clean completed, continence management has been improved, communal areas changed and an activity co-ordinator is being sourced. Work identified in the environment risk assessment has been commenced. The provider is also carrying out weekly visits to the home to support the new manager.

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

Action we told provider to take (refer to end of full report).

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

Ashfield is a ‘care home’ without nursing, operated by South West Care Homes Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

People living at Ashfield were older people, many living with long term health conditions or dementia. The service accommodated up to 25 people in one adapted building, with a chairlift to access the rooms on the first floor. 22 people were living at the service at the time of the inspection, with one other person in hospital.

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

At the last inspection of the service on 5 and 10 January 2017 the service was rated as ‘good’ in all areas. On this inspection we found this had not been sustained and we have rated the service as requires improvement overall. The key questions for Safe and Well led have been rated as requires improvement. The service had identified many of the issues we had found, and taken or were planning to take some actions to address risks to people. However, we could not be assured the actions they planned to take would be effective in mitigating the risks as they were not all in place. These concerns did not yet give us confidence governance was reliable and effective, because many changes were still ‘work in progress’.

We also asked the service to make a safeguarding referral as we were concerned medical advice had not been sought in a timely way for one person after an accident. This was being looked at by the safeguarding team from the local authority.

There were enough safely recruited staff on duty to meet people’s needs. Staff had not all competed their training according to the service’s training matrix. However, staff and people told us they felt they had the skills and knowledge to support people effectively and had access to senior staff for advice and support. Systems were in place to learn from accidents or incidents and for staff supervision.

People received their medicines as prescribed. We have made recommendations in relation to the management of medicines and competency assessments for staff. We have also recommended that the service ensures they contact people’s GP and record this after any admission or re-admission to verify if any prescribed medicines had changed since their last visit or the pre-assessment was completed.

People were protected from abuse. Staff understood what constituted abuse and were aware of how to report concerns about people’s wellbeing. People told us they ate well and enjoyed their meals.

Care plans contained sufficient detail to enable staff to respond to people’s needs in a person-centred way. We saw staff understood how to support people in ways that made use of known information about the person’s history and choices. Risk assessments were in place to support people for example with pressure damage, choking risks, poor nutrition, falls and moving and positioning.

People’s rights with regard to the Mental Capacity Act 2005 were well understood. Where Deprivation of liberty authorisations (DoLS) had been granted, conditions of the DoLS were well understood. This meant people’s rights were being supported.

Ashfield is a long established care home, set in a converted period building in a residential area of Exmouth, close to the town centre, shops and facilities. Areas of the building were looking tired although a programme of updating and renovation was under way and significant improvements had already been made. The premises were not well adapted to meeting the needs of people living with dementia. The registered manager told us they had plans to do this. We have recommended the registered persons seek and follow best practice guidance on the adaptation of the premises to meet the needs of people living with dementia.

Activities were provided that people enjoyed, but some people told us there was not much for them to do. The registered manager told us they had plans to increase the number of activities for people in a more person-centred way, particularly for people living with dementia. We have made a recommendation about this.

Relatives and friends were able to visit the service at any time, and complaints procedure were well understood. The registered manager was not however recording all concerns as complaints, so it was not possible to see if issues were recurring. They have told us they will do so in future.

People told us the registered manager was approachable and responsive. People told us the staff worked well as a team, and we saw many friendly, positive episodes of engagement between people and staff. Management scrutiny and oversight had been strengthened since the last inspection which the registered manager told us they found supportive. Systems were in place and being further developed to ensure the quality and safety of the services provided.

We found a breach of regulation on this inspection and you can see what action we have asked the provider to take at the end of this report. We also identified a number of good practice recommendations.

Ashfield provides accommodation and 24 hour care for up to 25 older people. There were 20 people living at the home on the first day of our inspection. One of these people was in hospital and one was staying at the home for a short period of respite.

We had previously carried out a comprehensive inspection of this service in June 2015. Four breaches of legal requirements had been found at that inspection. These were regarding medicine management, notifying required events to the Care Quality Commission (CQC) that had taken place in the home, complaints management and reviewing people’s care needs. We returned and undertook a focused inspection in December 2015 to look at the actions taken to improve the medicine management at the home. We found improvements had been made and the service was no longer in breach of Regulation 12 which relates to medicine management. We did however make a recommendation to the provider about the management of medicines at the home.

At this inspection we found they had taken action and medicines were safely managed. We also looked at this inspection at the other three breaches found in June 2015. We found action had been taken regarding these concerns and the requirements had been met.

There was a registered manager at the service who registered with the Care Quality Commission (CQC) in January 2016. A registered manager is a person who has registered with 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. The registered manager was very visible at the service and undertook an active role. They were committed to providing a good service for people in their care and demonstrated a strong supportive approach to people, their relatives and staff. They were supported by the responsible person and the provider’s operational team who visited regularly.

There were sufficient numbers of suitable staff to keep people safe and meet their needs. The registered manager had increased the staff levels at the service since our last visit. They continued to monitor people’s needs and adjusted the staff levels as required. Staff undertook additional shifts when necessary to ensure these were maintained.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. They understood where people lacked capacity, a mental capacity assessment needed to be completed with best interest decisions made in line with the MCA. They had submitted applications where required to the local authority Deprivation of Liberties Safeguarding team (DoLS) to deprive some people of their liberties. Staff had a good understanding about giving people choice on a day to day basis. The registered manager and senior staff had received MCA training to help them understand their responsibilities. Plans were in place for other staff to undertake MCA training.

People were supported by staff who had the required recruitment checks in place. Staff had received an induction. Staff had completed the provider’s mandatory training. They were also supporting staff to undertake higher qualifications in health and social care.

Staff had completed safeguarding training and were knowledgeable about signs of abuse and how to report concerns. Staff felt confident any concerns they raised would be investigated and actions taken to keep people safe.

People were supported to eat and drink sufficient amounts and receive a balanced diet. The provider’s new computerised recording system enabled an accurate recording and monitoring of people’s diet and fluid intake. People were positive about the food at the service.

Staff treated people with dignity and respect at all times and in a caring and compassionate way.

People received their medicines in a safe way because staff who administered medicines had received training and had their competency regularly monitored.

People had access to activities at the service. People were encouraged and supported to be independent and to avoid social isolation.

People’s needs and risks were assessed before and on admission to the home. Risk assessments were undertaken for people to ensure their care needs were identified. Care plans reflected people’s routines and wishes. They gave staff guidance about how to support people safely.

People were involved in making decisions and planning their own care on a day to day basis. People were referred to health care services when required and received on-going healthcare support.

There had been significant improvements made to the exterior and some internal areas of the home. The provider and registered manager had recognised where further improvements were needed in areas of the home, some which were worn and tired. These would be addressed as part of the refurbishment program at the home. The premises were well managed to keep people safe.

The provider had a quality assurance and monitoring system in place which included regular audits with annual surveys. Where concerns were identified actions were put into place.

The registered manager actively sought the views of people and staff through regular meetings. There was a complaints procedure in place. There had been numerous complaints at the home in the earlier part of 2016 which had significantly reduced for the later part of the year. The registered manager had a clear understanding of how to respond to concerns and tried to deal with grumbles before they became complaints.

Before our inspection we reviewed all the information we held about the home. We examined previous inspection reports and notifications received by the Care Quality Commission. The service was last inspected in July 2013 and Outcome 13: Staffing was found to be compliant.

On the day of our visit there were 25 people living at Ashfield. We looked at the care files of four people with complex needs who may require assistance at night on occasions. We spent time with people in the lounge and observed their care. We spoke to the manager who was applying to be registered with CQC and three care staff to find out if the care and services people received met their needs, particularly at night. All the people we spent time with were unable to tell us their experiences directly due to living with dementia.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The service was safe because people's health and care needs were understood and met by a trained and supported staff. Risks to people's health and welfare were understood and managed in line with their agreement. The manager told us they had recently worked some night shifts as part of ongoing monitoring and had not found any issues with staff provision at night. Staff were able to discuss any issues during regular one to one supervision sessions. There was monitoring of events and incidents and measures were put in place minimise any identified risks such as falls and skin damage.

People's health and well-being was promoted. Care plans provided instructions to staff about the care each person wanted and needed. Staff were very knowledgeable about people's individual needs and there were comprehensive night time care plans showing exactly how the person's needs were met at night. We saw evidence of multi-professional visits and appointments in a timely way, for example GP, speech and language therapist, and community psychiatric nurses and that advice was followed and recorded. Care plans included considerations of the Mental Capacity Act (2005) such as best interest decision making and staff demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and how they applied to their practice. We found the location to be meeting the requirements of the Mental Capacity Act (2005). People's human rights were therefore properly recognised, respected and promoted and appropriate family/advocates were involved.

When we visited on 17 July 2013 we found that the provider had taken prompt and robust action and was meeting required standards.

We observed that people were treated with dignity and respect. There had been substantial improvements in updating of care plans and in the quality of recording in those plans. The provider had been pro-active in working with health professionals to make improvements.

20 people were living at Ashfield during our latest inspection. We spoke with ten of those people. They told us that care workers treated them well. Comments included, "They are kind and I don't have any complaints" and "They are polite to me". A relative we spoke with on the telephone told us, "The staff are very kind".

There had been improvements to the environment and layout of communal areas of the home. New equipment had been purchased and was in use. Some fixtures and fittings had been replaced.

Rotas showed that additional staff were used at busy times and the organisation of work had improved. Quality monitoring systems were more effective and were evolving.

We observed that care workers spoke to people in a kindly, respectful way and engaged them in conversation while completing tasks. We found that because some people's doors were left open during the night their dignity and privacy was not always protected.

People and their families had been involved in decisions about care. People's choices in daily living were respected. Records showed that people had given consent to the care which was delivered. Individual's needs had been assessed and risk assessments had been undertaken in respect of their care. In some cases these had not been updated to reflect people's changing needs. Inconsistent and contradictory care records meant that there was a risk of unsafe care. People's toileting needs were not always met.

Staff received appropriate training but sometimes there were insufficient staff to meet people's needs. Varied, nutritious food was provided but some people were not supported or encouraged to eat. Some equipment was lacking. Repairs and maintenance were not always undertaken in a timely manner.

Some necessary improvements to the service had been identified and addressed but overall the quality assurance system had not been effective.