Croft Meadow

Croft Meadow is a residential care home providing accommodation and nursing care to up to 60 people in one adapted building. The service provides support to people living with a variety of health needs, including frailty of old age and dementia. At the time of the inspection there were 58 people using the service.

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

Since the last inspection the registered manager, deputy manager and staff had made improvements which had raised the quality and standard of care people received. Systems to ensure effective oversight and governance of the home had been revised, embedded and sustained in daily practice. People experienced person-centred care from staff who knew them well, had been appropriately trained and were competent in their role.

People were protected from avoidable harm as risks to people's health and safety were identified, assessed and mitigated. People and their relatives told us they felt safe and were cared for by staff who understood their risks and how to manage them. One relative told us, “[Person] is very safe there.” A person commented, “Yes, I am safe.” Staff understood their safeguarding responsibilities and knew how to report and escalate concerns. Accidents, incidents and safeguarding concerns were appropriately investigated with actions taken to reduce the risk of reoccurrence.

People and their relatives told us staffing levels varied but felt there was enough staff to meet their needs. Staff were recruited safely and received supervision where opportunities to develop and feedback about their practice was discussed. People received their medicines in line with prescribers’ guidelines and medicines were regularly reviewed. People were protected from the spread of infection in a clean environment by staff who had completed training in infection control and had their competence assessed. Comments included, “They keep everywhere clean and tidy, I’ve no complaints”, and, “The staff wear their PPE, it is difficult for the residents when staff wear masks, but I know they have to.”

People received a comprehensive assessment and were involved in discussions about their care. 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 had access to external healthcare services and support, including hairdressing, chiropody and specialist health teams.

People had access to a range of activities in an environment that was being upgraded to meet their needs. People were supported to eat and drink enough and maintain a balanced diet. People spoke positively about the food and could choose from a varied menu developed by a chef who collated and acted on people's feedback.

The culture of the home was positive and promoted good outcomes for people. People and their relatives were complementary about how the home was managed. Staff felt supported by the managers and the provider. A staff member said, “I have the best team of people around me. I love it. Shaw (provider) are a good company to work for and things have vastly improved since [registered manager and deputy manager] have been in place." A relative said, “We love the home. It was the first one I looked around and I liked it as soon as I walked in. I was shown around by the deputy manager and they were very friendly. I was impressed that the residents don’t have to share a room and they have their own en-suite.”

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 14 November 2019) and there were 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 we found improvements had been made and the provider was no longer in breach of regulations.

At our last inspection we recommended that the provider consider current guidance on providing stimulating, meaningful and appropriate environments for people who are living with dementia. At this inspection we found the provider had made some improvements to the environment and improvements were ongoing.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 03 October 2019 and 04 October 2019. Three breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care, safe care and treatment and the governance of the service.

This inspection was prompted by a review of the information we held about this service. We also needed to check the service had completed their action plan and they now met legal requirements.

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.

The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

Follow up

We will work with 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.

We found the following examples of good practice.

The majority of people living at the home had received a coronavirus vaccine and their consent had been obtained. People and staff had access to regular testing for coronavirus. All staff completed Lateral Flow Device Tests (LFD) and the provider was arranging for staff to undertake LFD tests at their home before coming on shift. LFD tests provide results quickly and an assurance that staff are well when their tests return a negative result.

In line with Public Health England guidance, the home was closed to visitors during the outbreak, except for relatives visiting a person who was receiving end of life care. The provider had a visiting policy for when the home re-opened. Visitors would need to undertake an LFD test and obtain a negative result before being allowed into the home. Personal protective equipment (PPE) such as disposable masks, would need to be worn, as a minimum. The hairdressing room had been allocated for visits as there was a separate external entrance for visitors. The room would be sanitised between visits, and social distancing guidelines will be followed. Moveable plastic screens will be used in the testing area to protect visitors and staff.

There were sufficient supplies of PPE for staff to use, and staff checked on each other to make sure masks were worn appropriately when working in the home. Staff changed into their PPE before or as they arrived on site; this minimised the risk of cross-contamination. Staff were issued with pocket-sized hand sanitisers for ease of use. Staff worked on the same unit during a shift and people no longer had access to all parts of the home. Care staff did not have access to the kitchen. Potentially contaminated laundry was kept separately from other laundry and was double-bagged and washed on a sluice setting. These practices reduced the risk of the spread of infection. Infection prevention and control (IPC) systems were robust and effective. ‘High touch’ areas of the home were cleaned frequently; the home was very clean and hygienic standards were maintained.

Daily handover meetings updated staff on what was happening at the home and current guidance; these meetings provided an opportunity for staff to discuss any issues. Meetings were held in an area of the home large enough to enable staff to socially distance from each other.

We had been informed that a member of agency staff who had tested positive for coronavirus continued to work at the home. We discussed this concern with the manager who assured us this was not the case. The agency staff member had tested negative using an LFD test when they came on shift, but subsequently received their result from a polymerase chain reaction (PCR) test which was positive. As soon as it was known the agency staff member had tested positive, they started their period of isolation and did not work at the home. The home contacted other staff and people who lived at the home who had received care from the agency staff member, and all undertook a PCR test.

The provider had a range of policies to support their working practices. These included a standard operating procedure during the pandemic, admissions policy, risk assessments, IPC systems and guidance, and weekly IPC audits.

Croft Meadow is situated in Steyning, West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. It is a residential ‘care home’ for up to 60 people some of whom are living with dementia, physical disabilities, older age or frailty. At the time of the inspection there were 43 people living in the home.

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

The management of the home had changed since the last inspection. An interim manager had worked alongside the deputy manager and they had been instrumental in making positive changes. Systems and processes had been introduced to provide better oversight of people’s care. There was an increased focus on person-centred care and improvements were continuing to be made to change the culture and challenge practice that did not promote this. There was an increased confidence that once the systems and processes that had been introduced had a chance to be embedded and sustained in practice, that further improvements would be made. We found that the improved systems had not always identified areas of practice that needed improvement.

Significant improvements to improve the safety of care people received had been implemented. Medicines management and oversight of people’s hydration and nutrition had improved. Some further improvements were needed and those that had been made needed to be embedded and sustained in practice to ensure that all aspects of people’s needs were safely met. These relate to wound care and modified diets for one person.

Staffing levels helped ensure people’s needs were met in a timely way. The provider had worked with the local authority if there were concern about people’s care. People were protected from the spread of infection. There was an emphasis on learning from incidents to ensure changes could continue to be made to ensure people’s safety.

People told us they were happy and that staff were kind, caring and compassionate and most of our observations confirmed this. There were however, situations when staff did not always demonstrate respect for people and did not communicate or use language that was dignified or appropriate. One person’s assessed needs had not been met as they had not been supported to clean their teeth for a number of days.

The provider had not always ensured that staff had access to training which the provider considered essential for their role or competency checks following training. There were better systems to ensure people received sufficient amounts to eat and drink to maintain their health. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; some of the policies and systems in the service did not support this practice.

The provider had worked with external health and social care professionals to assess and review people’s care in line with best practice guidance. People’s health needs were met through this coordinated approach to their care. People were supported to maintain their nutrition and hydration. People told us staff were experienced and knowledgeable. Staff appeared to know people’s needs well.

Two units of the home supported people living with dementia, the environment and information available to them had not always been adapted to meet their needs. We have recommended that the provider access guidance in relation to providing stimulating, meaningful and appropriate environments for people who are living with dementia.

Rating at last inspection and update

The last rating for this home was Inadequate, it had entered into special measures and there were breaches of Regulations. (Supplementary report published 19 July 2019) We served a Notice of Decision to impose conditions on the provider’s registration. The provider also completed an action plan to show what they would do and by when to improve. The home had been in special measures since the last inspection. During this inspection the provider demonstrated that some improvements had been made. Not all improvements had been embedded and sustained in practice and the provider was still in breach of Regulations. The home is no longer rated as Inadequate overall or in any of the key questions. Therefore, the service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating. We have found evidence that the provider needs to make further improvements. Please see all the sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified three breaches in relation to person-centred care, safe care and treatment and the leadership and management of the home. You can see what action we have asked the provider to take at the end of this full report.

Follow-up

We will continue to monitor the intelligence we receive about this home. We will request an action plan from the provider and meet with them to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and the local authority to monitor progress. We plan to inspect in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

• Croft Meadow is situated in Steyning, West Sussex. It is a residential ‘care home’ registered for up to 60 older people, some of whom are living with dementia or frailty and other associated health conditions. At the time of the inspection there were 54 people living in the home.

People’s experience of using this service:

• There were serious concerns about the care people had sometimes received and the provider’s lack of oversight to ensure that appropriate improvements were made.

• Risks were not always well-managed in relation to choking and there were concerns about people’s safety.

• Medicines management was not always safe. Two people had not always had access to medicines to manage their health condition in accordance with prescribing guidance. There was a risk that their condition was not well-managed and their mobility could have been affected. Some medicine errors had occurred.

• Staffing levels were not always aligned to people’s assessed needs and assessed level of support.

• There were concerns about the lack of oversight and failure to make significant, timely improvements since the last inspection. There was mixed feedback about the leadership and management of the home. Staff told us that they felt well-supported. One relative told us, “There is no leadership here. Staff have left because of the lack of management.” Another relative told us, “Over the past year things have deteriorated.”

• The provider’s values were not always promoted in practice. Concerns about people’s care had not been rectified and improved upon in a timely manner to ensure people received the care they had a right to expect.

• Quality assurance processes had not always identified the concerns that were found at the inspection. When issues had been identified there was insufficient, robust action taken to ensure improvements were made.

Rating at last inspection:

• At the last inspection the home was rated as Requires Improvement. (Supplementary report published 28 March 2019).

Why we inspected:

• Prior to the inspection we had received information of concern in relation to people’s care.

• This was an unannounced focused inspection to look at the key questions of Safe, Responsive and Well-led. This was because at our last inspection, on 11 and 12 October 2018, the provider was in breach of Regulations 12, 13 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action against the provider and gave them a date by which the Regulations should be met. This inspection took place to check that improvements had been made and that the provider was now meeting the Regulations.

Enforcement:

• The provider had not met the Warning notice for Regulation 17 that had been issued following the last inspection on 11 and 12 October 2018. The provider was in continued breach of Regulations 12 and 17. There was a new breach of Regulation 9, person-centred care.

• The overall rating for this home is 'Inadequate' and the home is therefore in special measures.

• Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

• If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

• 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.

• 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 the intelligence we receive about this home and plan to inspect in line with our re-inspection schedule for those services rated as Inadequate.

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

Croft Meadow is situated in Steyning in West Sussex and is one of a group of homes owned by a national provider, Shaw Healthcare Limited. Croft Meadow is registered to accommodate 60 people. At the time of the inspection there were 58 people accommodated in one adapted building, over three floors, which were divided into smaller units comprising of ten single bedrooms with en-suite shower rooms, a communal dining room and lounge. These units provided accommodation for older people, those living with dementia and people who required support with their nursing needs.

The management of the home had been through a period of transition. The home had a registered manager who had been on long-term leave from work. A registered manager is a ‘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 home is run. The management team consisted of team leaders, a deputy manager, a clinical lead registered nurse and the registered manager. An operations manager also regularly visited and supported the management team.

The provider's and staffs' practices were not always responsive to people's specific needs. Not all people received their medicines in a timely way. Some people had specific healthcare conditions that required their medicines to be given at specific times. Records showed that people had not always had their medicines according to the prescribing guidelines. One person, had consistently been given their medicines outside of these times. People did not always have timely access to medicines to manage their symptoms or healthcare condition.

Not all risks to people’s safety had been identified, considered or mitigated. Some people smoked and had documented risk assessments to guide staff’s practice to ensure people’s safety. One person who smoked used an emollient cream to maintain the condition of their skin. Staff had not learnt from a safety alert that had been issued in relation to this. Risks to the person had not been considered and measures had not been taken to mitigate the potential risks. The provider had not done all that was reasonably practicable to assess and mitigate risk. This was an area of concern.

Staff had not demonstrated a caring approach when caring for one person who had not been protected from the risk of harm. The person had been assessed as being at high-risk of malnutrition. They had not had their weight monitored frequently, as outlined within the provider's policy and within the person's care plan. It was not evident if they had access to fortified food in increase their calorie intake. There were concerns that risks for the same person were not always identified or managed appropriately. There had been two separate incidents where the person had come to harm. The provider had not considered these in accordance with their safeguarding policies and procedures. This was an area of concern. Following the inspection, CQC made a safeguarding referral to the local authority.

There were concerns about the provider’s oversight and overall ability to maintain standards and to continually improve the quality of care. Areas that were identified as part of this inspection had not always been picked-up and acted-upon by the provider’s own quality assurance audits. When the provider had identified issues that needed improvement, it was not evident what action had been taken to ensure those improvements were made. This was an area of concern.

People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible. The policies and systems in the home did not always support this practice. This was identified as needing to improve.

Staff had access to learning and development opportunities. There were concerns with regards to staff's understanding about MCA and DoLS as well as supporting people with their specific healthcare conditions. This was an area of practice identified as needing to improve.

At the previous inspection on 10 February 2016, an area identified as needing improvement related to people’s access to activities and stimulation to meet their social and emotional needs. At this inspection, it was evident that improvements had been made. People were supported to take part in activities, events and trips to offer stimulation. People who spent time in their rooms had access to interaction and stimulation from staff. People were complimentary about the social aspects of the home. Comments from people included, “I enjoy myself, I laugh a lot” and “I do enjoy most of the entertainment and I get out into the lovely well-looked after garden when the weather is good”.

People were cared for by sufficient numbers of staff to meet their needs. Staff knew the signs and symptoms to look for if there were concerns about a person’s care. The provider had worked with the local authority when there were concerns about people’s wellbeing.

People were protected from infection and staff demonstrated correct techniques to ensure that cross-contamination was minimised.

People had access to external healthcare professionals. There was a coordinated approach to people’s healthcare.

People were complimentary about the food and drink. They told us they had choice and staff respected their right to change their mind. One person told us, “The meals and food are very good. I like most meals but they would do something else if I asked”.

People were happy living at the home. They told us that staff were kind, caring and compassionate. Comments from people included, “Staff are kind and considerate, I can talk to them all very easily” and “I’m very fond of the staff, they are very good to me. They do ask how I am”.

People's privacy was maintained. They were involved in their care. People were supported to plan for their end of life care.

People were aware of how to raise concerns and complaints. Residents’ and relatives’ meetings, as well as surveys enabled people to voice their opinions and make suggestions about the way the home was run.

People had space to be with others, spend time on their own or enjoy the gardens in warmer weather. People were complimentary about the environment and told us that it was laid out well and met their needs.

People, relatives and staff were complimentary about the management of the home. People and their relatives told us that they could approach the management if they had queries about people’s care.

We found breaches 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. 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.

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

There were group activities in place and two activity co-ordinators in post. Although we saw an activity co-coordinator providing a stimulating storytelling group with enthusiasm people told us that there were not enough staff to support them with one on activities and we observed on the day of our inspection that there were not enough staff to provided activities across the three floors of the home or to provide regular input to people who stayed in their rooms. This was discussed with the registered manager who agreed that this was an area that needs improvement.

People and their relatives told us people were safe living at Croft Meadow. One relative said “We wanted to know [the person] was safe and we absolutely know [the person] is here”. People were safe as they were supported by staff that were trained in safeguarding adults at risk procedures and knew how to recognise signs of abuse. Medicines were managed and administered safely. Accidents and incidents had been recorded and appropriate action had been taken and recorded by the manager.

We observed lunch, people had enough to eat and drink. They were given choices of food from a menu. Drinks were available throughout the day. One person told us “I think the food is very good here”. The service monitored people’s weights and recorded how much they ate and drank to keep them healthy.

Consent was sought from people with regard to the care that was delivered. Staff understood about people’s capacity to consent to care and had a good understanding of the Mental Capacity Act 2005 (MCA) and associated legislation, which they put into practice. Staff had received all essential training and some were working toward an award in health and social Care. They received supervisions from their line managers.

People told us that staff were kind, caring and approachable. One person told us, “They are all really lovely and as helpful as they can be”. We observed staff treating people with dignity and respect and involving them in their care. Another person said of staff, “They are very nice, we get on very well”.

People’s care plans were up to date and contained information about their individual preferences and needs. The complaints policy was available and complaints were responded to in a detailed and timely way. There were relatives meetings and we were told that information was shared with people and staff by the registered manager. Relatives told us “As relatives we feel we can go and talk to the manager anytime and there have been a few minor things and they got sorted out straight away”.

The registered manager and deputy manager promoted a positive culture where person centred practice was promoted. They ensured people, staff and relatives were valued. There was a range of audit tools and processes in place to monitor the care that was delivered. This ensured the management team were assuring the quality of the care and support provided.

Our inspection team comprised an inspector and a nurse specialist. We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

People's diversity, values and human rights were respected. We observed care being offered to people. Staff were seen to be supportive in a manner that was individual to the person's needs, respectful and maintained people's dignity, privacy and independence. We saw that staff were knowledgeable about people's needs and preferences.

We saw that potential risks to people were appropriately assessed and planned for. The service routinely screened for risks associated with mobility, falls, medication and environment. These risk assessments were reviewed regularly to determine if any changes had occurred. There were instructions for staff on how to reduce risks to people in these care areas.

Staff told us that they used personal protective equipment (PPE) to protect against infection. We saw that staff wore blue aprons for kitchen duties and assisting people to eat their meals and white aprons and disposable gloves to deliver personal care. We talked with people who used the service and asked for their views. One person told us that they did not see the cleaning staff as their room was cleaned when they were out. However, they confirmed that they thought their room was clean and described it as, 'very good'.

Medicines were stored safely. We saw that all medicines were either kept in a locked cupboard or trolley within a dedicated, temperature controlled storage room. We looked at the records relating to the recording of the administration of medicines (MAR) charts. We saw that the MAR charts were completed correctly and entries were signed off by the team leader or registered nurse as medicines were administered.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Is the service effective?

Where they were able, people expressed their views and were involved in making decisions about their care and treatment. One person told us that they could get up independently, usually at 7.00 am and that they liked to have breakfast before getting washed and dressed. They told us that the staff always treated them with respect and, 'Yes, they always knock' on the door before entering. We spoke with two other people who used the service. They told us that they were fully involved in all aspects of their care and that staff treated them with respect and dignity.

In the care records we saw, people's capability had been assessed. For example, in what ways they were fully independent and what level of support might be needed, from a verbal prompt and light assistance to full assistance.

Is the service caring?

We sat near a table where two people were being supported to eat their lunch and we observed that they were offered food in a relaxed manner and could eat at their own pace. We saw that one person was offered another plate so that they could separate the food they did not like from food that they wanted to eat. We observed one person being encouraged to eat by staff who said, 'Is it nice?' At one point, the same member of staff had to break off helping this person as another person was in distress at the next table. We saw the staff member reassuring the person in distress, then returning to the table. On their return, they apologised for leaving them in the middle of the meal.

We spoke with a relative who was visiting and they confirmed that their family member was always treated with respect and dignity. They told us that their relative enjoyed helping out and would push the laundry trolley around the corridor, supported by staff. They told us that it was, 'Always nice and relaxed here'.

Is the service responsive?

It was apparent that a lot of thought had been given to caring for people who had a wide range of care and support needs and that provision had been planned accordingly. The environment at Court Meadow was homely and had a relaxed feel.

Thought had also been given as to how to create an interesting environment for people receiving care in bed. For example, articles relating to one person's particular interests were suspended from the ceiling above their bed. This meant that an interesting environment had been created so that people could interact with their surroundings.

Is the service well-led?

The manager told us that they undertook monthly internal audits at Croft Meadow and we were shown the records that evidenced this. We saw that these audits covered a range of areas, for example, that people's care plans had been reviewed and updated on a monthly basis. The audit then recorded which member of staff was responsible for which action.

At the time of our visit, we 'sat in' on a residents and relatives' meeting. We were told these were organised on a monthly basis and saw the minutes that evidenced this. Items under discussion included outings in the summer and staffing. One person was concerned about the staffing levels as they thought the staff were always busy. The manager said that staff could move flexibly between floors and that additional staff could be brought in, as required. Another person said, 'Staff are wonderful'. A relative said, 'I've found here that nothing needs to be a problem.

People were not always given choices about their care and treatment. People's dignity was not always respected. People we spoke with were happy with the care they were receiving. One person said, "I have been here for two and a half years and seen changes."

We used a number of different methods to help us understand the experiences of people using the service. People who lived in the home all told us "staff are nice but always busy" and "there's not enough equipment".

We viewed records relating to staff recruitment and found that the provider was operating effective recruitment procedures. We found the lack of consistent recording systems meant that there was a risk that information may not be kept up to date and people may not be protected against the risks of unsafe or inappropriate care and treatment.

A visitor told us that the care their friend received was excellent 'The staff are very caring, I can not fault them, I have no concerns '

We saw that people's privacy and independence were respected, people experienced safe and effective care based on detailed care plans and risk assessments that documented people's preferences and met individual needs.

People using the service were protected from abuse as they were supported by a staff team who had appropriate knowledge and training on safeguarding adults. We saw policies on whistle blowing and safeguarding.

We saw evidence that staff received ongoing training and supervision which provided them with the skills and knowledge to meet the needs of the people they were supporting.

The Provider had effective systems in place to monitor quality assurance and compliance.