Archived: Beech Lodge

Beech Lodge is a residential nursing home providing personal and nursing care to 40 people with learning disabilities, physical disabilities and a range of neurological conditions such as autism. The service comprises of three separate buildings: Beech Lodge, Oak Lodge and Redwood House. At the time of this inspection Redwood House was not being used and did not form part of this inspection, and only one person was living in Oak Lodge. The service is located in a rural setting and is purpose built to provide ground floor accommodation for people with complex health needs and disabilities. At the time of this inspection 21 people were living at the service.

Beech Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

There was unsafe monitoring and management of risks around epilepsy, constipation, medicines, and behaviours that may challenge others. People were not being protected from abuse or neglect and we raised safeguarding concerns for some people at Beech Lodge.

Staff did not always have the correct training and competencies to support people with their needs. Medicines were not being managed safely and audits for medicines did not highlight issues we found.

The provider had acted to manage infection risks during the Covid-19 pandemic. Additional infection prevention and control measures in line with Department of Health and Social care guidelines had been put in place to ensure people's safety. During our inspection the service was clean, and staff had access to and wore appropriate personal protective equipment. Relatives told us the service was clean and well looked after with no bad odours.

There was a lack of sustained learning when things went wrong. Previous concerns around person centred care and people’s independence were still present at this inspection. There was a lack of good governance, and systems to drive improvements were not effective despite input from partner agencies such as the local safeguarding team and health team.

The culture in the service was poor and we saw examples of care and support that were not respectful or promoted independence, such as turning a TV off without asking people who were watching it. One relative told us they were worried about their loved one and kept visiting to check on them.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of Safe and Well led the service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• Model of care and setting did not maximise people’s choice, control and independence.

• The service was rural and located in private grounds. Opportunities for people to access the community were limited.

Right care:

• Care is not person-centred and did not promote people’s dignity, privacy and human rights.

• People did not receive person centred support. For example, activities were in groups and not personalised.

• Staff did not always know when people may be in pain or distress.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive and empowered lives

• The service did not have a positive culture and people were not supported to be as independent as they could. Some people were left for long times without engagement.

Rating at last inspection and update.

The last rating for this service was Inadequate (published 23 March 2021).

After the last inspection where we found breaches of regulation, the provider completed an action plan to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We carried out an unannounced comprehensive inspection of this service on 12, 13 and 15 October 2020. 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, dignity and respect, safe care and treatment, good governance, and staffing.

We undertook this focused inspection to check they 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 Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has stayed at Inadequate. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person centred care, dignity and respect, safe care and treatment, safeguarding, good governance and staffing.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our 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 remains 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.

About the service

Beech Lodge provides nursing and personal care for up to 40 people living with physical disabilities, learning disability and a range of neurological conditions. At the time of our inspection, 22 people were living at the service. The service comprises of three separate buildings: Beech Lodge, Oak Lodge and Redwood House. At the time of this inspection Redwood House was not being used and did not form part of this inspection. The service is located in a rural setting and is purpose built to provide ground floor accommodation for people with complex disabilities.

Beech Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation, the investigation is on-going, and no conclusions have yet been reached.

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

Risks to people's health and wellbeing were not consistently managed. People did not always receive safe support in relation to their epilepsy, medicines and complex eating and drinking needs. People's risk of aspiration was not always documented and this was an area that required improvement. Systems used to monitor people’s health were not always applied consistently. This meant people could not be assured of receiving appropriate care and treatment and were placed at increased risk of avoidable harm. Staff practice did not always ensure people received safe care.

There were not adequate processes in place for assessing and monitoring the quality of the services provided and that records were accurate and complete. Systems had failed to identify that people were not always protected from avoidable harm. Safe care practices were not always recorded accurately within people’s care records. Medicine audits failed to identify shortfalls found at this inspection. Action was not always taken to make changes or sustain improvements following the previous inspection report.

The delivery and planning of care was not consistently person centred and did not always promote good outcomes for people. Support plans did not contain detailed and person-centred information and therefore these did not always accurately reflect the needs of those who used the service. Staffing levels were not sufficient in meeting people's care needs in a person centred way. People were not always treated with dignity and respect.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People and their relatives told us that they felt safe at the service. Recruitment procedures ensured only suitable staff worked at the service. Staff supported people using appropriate equipment to ensure infection control procedures were followed.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, 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 providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture.

Right support: The model of care and setting did not maximise people’s choice, control and Independence and measures had not been taken by the provider to mitigate this. The service was in a rural location which did not form part of a local community and there was an absence of local amenities and public transport options. External and internal signage identified the service as a care home and staff wore uniforms which clearly identified they were employed to support people.

Right care :There was a lack of person-centred care and the support people received did not promote dignity, privacy and human rights. People’s needs and preferences were not always known respected. People did not have access to meaningful occupation or opportunities to join local clubs, interests groups and form friendships away from the service. The building did not respect people’s privacy and dignity for example, there was a lack of assistive technology to promote people’s independence and nursing stations and offices were situated close to the communal areas and people’s bedrooms. The provider had taken measures to ensure people’s bedrooms were personalised with photographs and personal effects.

Right culture :The ethos, values, attitudes and behaviours of leaders and care staff did not ensure people using services lead confident, inclusive and empowered lives. People were not empowered to have choice and control over their lives. People did not always receive person centred support to live meaningful and active lives. People did not have opportunities to form community connections and make choices about who they lived with and the support they received.

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 11 December 2019) and there were two breaches of the Health and Social Care Act 2008 (Regulated Activities) in relation to Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance).The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about safeguarding, unsafe care practices, staffing and the culture and leadership of the service. A decision was made for us to inspect and examine those risks.

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.

In January 2018 the Care Quality Commission imposed provider wide conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

We carried out an unannounced comprehensive inspection of this service on 17 and 18 October 2019. Breaches of legal requirements were found in relation to Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance) . The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they 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 Safe, Caring and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

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

Enforcement

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

We have identified two continued breaches and three new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to person-centred care, safe care and treatment, good governance, staffing and dignity and respect.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

Special Measures

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.

F

Beech Lodge provides nursing and personal care for up to 40 people living with physical disabilities, learning disability and a range of neurological conditions. At the time of our inspection, 27 people were living at the service. The service comprises of three separate building: Beech Lodge, Oak Lodge and Redwood House. At the time of this inspection Redwood House was being used as a day centre and did not form part of this inspection. This is because day centre services are not regulated by the Care Quality Commission (CQC). The service is located in a rural setting and is purpose built to accommodate the needs of people with complex disabilities.

Beech Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation, the investigation is on-going, and no conclusions have yet been reached.

Beech Lodge had been built and registered before the CQC policy for providers of learning disability or autism services 'Registering the Right Support' (RRS) had been published. The guidance and values included in the RRS policy advocate choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen.

Beech Lodge requires further development to be able to deliver support for people that is consistent with the values that underpin RRS. For example, further work was required to ensure activities were meaningful and people had sufficient access to the community.

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

Risks to people were not always assessed and mitigated. For example, risks associated with behaviours which challenge, choking and skin breakdown. Safeguarding policies and procedures were in place, however, improvements to practice were not always made following a safeguarding concern being raised.

Systems and processes to assess, monitor and improve the quality and safety of the service were not consistently operated effectively. Medicine audits failed to identify shortfalls and drive improvement. Accurate documentation was not consistently maintained. The delivery and planning of care was not consistently person centred and did not always promote good outcomes for people. Lessons were not always learnt or used to drive improvement following local authority reviews, safeguarding concerns or deprivation of liberty authorisations.

People and their relatives told us that they felt involved in their care. However, the care planning process failed to consistently demonstrate people's involvement. Care plans were not always presented in a way that people could easily understand.

People and their relatives told us that they felt safe at the service. Recruitment procedures ensured only suitable staff worked at the service. Staff supported people using appropriate equipment to ensure infection control procedures were followed. Staffing levels were sufficient in meeting people’s care needs. Staff understood and recognised the signs of potential abuse.

Medicines were administered in a dignified and person-centred manner. The storage, disposal and ordering of medicines was safe. Environmental checks were in place and staff’s competency to safely move and transfer people was assessed. A complaints policy was in place and people told us that they felt confident raising any concerns with the management team. A range of activities were available, and staff had built positive rapports with people.

Risks associated with percutaneous endoscopic gastrostomy (PEG) and moving, and handling were managed well. Staff knew people well and demonstrated warmth towards the people they supported. People and staff were involved in the running of the service and staff felt able to raise new ideas and discuss any concerns with the management team. Relatives spoke highly of the service and of the kind and caring interactions between staff and their loved ones.

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 (report published 4 February 2019)

Why we inspected:

The inspection was prompted in part due to concerns received about insufficient staffing levels and poor moving and handling. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the Key Questions of Safe, Responsive and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make improvement.

Please see the Safe, Responsive and Well-Led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement:

We imposed conditions on the provider's registration, due to repeated and significant concerns about the quality and safety of care at several services they operate. The conditions are therefore imposed at each service operated by the provider, including Beech Lodge.

The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

We have identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) in relation to Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance).

Follow up:

We will request an action plan for the provider to understand what they will do to improve the standards of quality. We will also 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 and care commissioners to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Beech Lodge is registered to provide accommodation and nursing care for up to 40 people. The home comprises of three separate building: Beech Lodge, Oak Lodge and Redwood House. At the time of this inspection Redwood House was being used as a day centre and did not form part of this inspection. This is because day centre services are not regulated by the Care Quality Commission. The home is purpose built and well-equipped. It caters for young adults with physical and learning disabilities or autism. At the time of our visit there were 17 people living in Beech Lodge and nine people living in Oak Lodge.

We previously carried out an unannounced comprehensive inspection of this service in July and August 2017. Beech Lodge was awarded an overall rating of ‘Good’, rated as ‘Good’ in all question areas, apart from the ‘Well Led’, which was rated ‘Requires Improvement’ as there was no registered manager in post.

At this inspection we found that the overall rating had remained good, rated as 'Good' in all question areas, apart from the ‘Well Led’, which was rated ‘Requires Improvement’ as there was a lack of provider overall oversight.

This inspection was brought forward as services operated by the provider have been subjected to a period of increased monitoring and support by commissioners. As a result of concerns raised about other locations operated by the provider, the provider is currently subject to a police investigation. Since May 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Beech lodge was designed, built and registered before the guidance was published regarding Registering the Right Support and other best practice guidance. The model and scale of care provided was not in keeping

with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs. The provider was not meeting this aspect of the registering

the right support guidance. Whilst the home was appropriately adapted and nicely decorated there were no plans in place to develop the model of the service to reflect the registering the right support guidance.

The registered manager informed us that he attended structured management meetings regularly. However, the registered manager had not received supervision since March 2017. He had innovative ideas to take forward such as a multi-disciplinary meeting form to further improve communication between all health professionals and had had no opportunity to discuss his plans and development on a one to one basis.

The registered manager was present during our inspection. The manager had been in post since March 2017. 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 spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made. Care plans reflected people’s assessed level of care needs and care delivery was person specific, holistic and based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking, and moving and handling. For example, pressure relieving mattresses and cushions were in place for those who were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy. There was a good level of information and guidance for staff to follow for those people who lived with complex needs. For example, oxygen therapy, moving and handling and percutaneous endoscopic gastrostomy (PEG) directives were clear and accompanied by photographs of how equipment for each should be used. A PEG supplies nutrition and medicines via a tube straight into the stomach for people who cannot eat or drink. There were safe systems for the management of medicines and people received their medicines in a safe way.

Staff and relatives felt there were enough staff working in the home and people said staff were available to support them when they needed assistance. All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns. For example, the local authority and CQC. Pre-employment checks for staff were completed, which meant only suitable staff were working in the home. There was a consistent use of agency staff and the registered manager ensured that the agency staff used had the necessary skills to work at Beech Lodge. People said they felt comfortable and at ease with staff and relatives felt people were safe.

People were supported with their nutrition and hydration needs. Clear guidance was available for staff to follow when people had specific dietary needs. People spoke positively about their mealtime experiences and told us they were always offered choice and enjoyed their food. Staff had received essential training and there were opportunities for additional training specific to the needs of the service. This included the care of people with diabetes, dementia and Parkinson’s disease. Staff had formal personal development plans, including two monthly supervisions and annual appraisals, so they understood people’s needs and provided appropriate support.

People were supported to make decisions in their best interests. The provider assessed people's capacity to make their own decisions if there was a reason to question their capacity. Staff and the registered manager had a good understanding of the Mental Capacity Act. Where possible, they supported people to make their own decisions and sought consent before delivering care and support. Where people's care plans contained restrictions on their liberty, applications for legal authorisation had been sent to the relevant authorities as required by the legislation.

Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them. People we spoke with were very complimentary about the caring nature of staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with laughter and smiles.

A range of activities were available for people to participate in if they wished and people enjoyed spending time with staff. Activities were provided throughout the day, seven days a week and were developed in line with people's preferences and interests. Further ideas for the prevention of social isolation were being discussed by the management team, such as sensory table equipment that will promote engagement with individual people. Technology was used to keep families in touch using skype and email. Staff had received training in end of life care supported by the Local Hospice team. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. The service worked well with allied health professionals.

The provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed, including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service. Relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

Staff said the management team was fair and approachable, care meetings were held every morning to discuss people's changing needs and how staff would meet these. Staff meetings were held monthly and staff were able to contribute to the meetings and make suggestions. Relatives said the management was very good; the registered manager was always available and they would be happy to talk to them if they had any concerns.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Beech Lodge is registered to provide accommodation and nursing care for up to 40 people. The home comprises of three separate building: Beech Lodge, Oak Lodge and Redwood House. At the time of this inspection Redwood House was being used as a day centre and did not form part of this inspection. This is because day centre services are not regulated by the Care Quality Commission. The home is purpose built and well-equipped. It caters for young adults with physical and learning disabilities or autism. At the time of our visit there were 18 people living in Beech Lodge and nine people living in Oak Lodge.

We previously carried out an unannounced comprehensive inspection of this service on 6 and 8 July 2015 where it was awarded an overall rating of ‘Good’ and rated as ‘Good’ in all domains apart from the ‘Well Led’ domain which was rated ‘Requires Improvement’ as there was no registered manager in post.

This inspection was planned due to a previous overall rating of ‘Good’ published for Beech Lodge in August 2015. However since that inspection, we had been made aware that following the identification of significant risks relating to people's care, the service had been subject to a period of increased monitoring and support by commissioners. The service had been the subject to safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a criminal investigation. Our inspection did not examine the incidents and safeguarding allegations which have formed part of a criminal investigation. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and August 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

During our inspection the manager was present. The manager had been in post since 6 March 2017 and had submitted an application to register with CQC. 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.

Everyone commented positively about the new manager and we found that they had implemented improvements at the home. These included a new interactive menu planning system that people could use to decide what they wanted to eat, further support and guidance for staff in order that they had the skills and knowledge to support people and more detailed care planning documentation.

The provider had quality monitoring processes in place and the manager had used these to drive improvements at the home. A range of quality and safety audits had been conducted and since the intervention of outside agencies processes had been amended to share learning from potential safeguarding situations.

People were supported to raise concerns. Information was provided in different formats in order that it was accessible and helped people to know their rights. Individualised support plans were in place that provided information for staff on how to deliver people’s care in the way they wanted it. Discussions with people and staff, and observations and examination of records confirmed that staff supported people in line with their wishes and the contents of their support plans.

An activity programme was in place that offered people a choice of events that they could participate in and enjoy. The home had its own minibus to transport people to community events. However, this was not always available when being used by people to attend medical appointments and as a result some people did not access the wider community as much as others. This is an area for development that was recognised by the manager. The adaptation and design of the home meant that people were able to move freely and access its facilities.

Positive, caring relationships had been developed with people. We observed people smiling when spending time with staff who always gave people time and attention. Staff supported people to maintain relationships with people who were important to them. Visitors were welcomed. People were supported to express their views and to be involved in decisions relating to their care. Staff were skilful in communicating with people and understanding their wishes. They also promoted people’s privacy and dignity. Staff said that they received sufficient support and training to undertake their roles and responsibilities.

Risks to people were managed safely. Risk assessments and care plans were in place for areas that included risk of choking, pressure areas, behaviour, moving and handling and nutrition. Staff followed the contents of these documents in order to reduce risks to people’s wellbeing and safety.

People who were able told us that they felt safe. Staff were able to identify the correct safeguarding procedures should they suspect abuse. Appropriate recruitment checks were undertaken before staff began work which offered further protection to people.

Sufficient numbers of staff were allocated to shifts and deployed in order to provide safe care and support. Throughout the inspection we saw that staff were available to provide care and support when needed.

People were supported to maintain good health and had access to a range of healthcare professionals and services. Medicines management was safe. Discussion with staff and examination of records confirmed that people were referred to health care professionals promptly when needed and that their advice was acted upon. People received effective support to enjoy their meals and their dietary needs were met.

The manager and staff demonstrated understanding of their responsibilities in relation to the MCA and DoLS. Throughout the inspection staff were seen seeking peoples consent. People’s care plans included information on their specific communication needs that also reinforced people’s rights to consent.