Hadrian House

Hadrian House is a care home providing accommodation and nursing or personal care for up to 50 people. Accommodation is provided over three floors. The ground floor of the service had been identified for use by the Local Authority as a designated care setting for people discharged from hospital with a positive COVID-19 status. At the time of our inspection 46 people were resident at the home.

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

The service was well-led. Governance systems were in place to monitor quality across the service.

Testing for COVID-19 was not always taking place in line with government guidance and some staff did not always follow safe infection control (IPC) practices. Action was taken promptly to address this with the staff involved. People had an identified essential care giver (ECG) and arrangements were in place for visitors to the home. One person raised a concern of not being able to go outside of the home when they wanted to. We have made a recommendation about this.

Systems were in place to safeguard people from abuse and an analysis of accidents and incidents were taking place. Medicines were managed safely.

There were enough staff deployed to support people. Agency staff were used to maintain safe staffing ratios within the home. Some relatives raised concerns regarding the skills of some agency staff and the effect this had on providing consistent care.

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

Rating at last inspection

The last rating for this service was good (published 13 February 2018).

Why we inspected

We undertook a targeted inspection looking at the infection prevention and control measures the provider has in place. We also asked the provider about any staffing pressures the service was experiencing and whether this was having an impact on the service.

We inspected and found there was a concern with some of the infection prevention and control practices of staff. We also received some feedback regarding concerns about care so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

Follow up

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

The service had been identified by the Local Authority as a designated care setting. A designated care setting is intended for people who have tested positive for Covid-19 and are being admitted to a care home from hospital. The provider had designated 18 beds to support people to be able to be discharged from hospital.

We found the following examples of good practice.

• The provider had identified the ground floor within the home to be the designated area. This area was self-contained and each room had en-suite facilities. Safe arrangements were in place for entering and exiting the area.

• A dedicated staff team had been identified to provide care and support to help reduce the risk of cross infection. Staff we spoke with were knowledgeable about infection control procedures.

• The provider had enough supplies of appropriate PPE. Staff were able to explain the procedures for putting on and taking off PPE correctly.

• The premises were clean and tidy. Additional cleaning hours were in place to ensure regular cleaning of touch points was achievable throughout the day.

• Quality assurance audits were completed to ensure safe infection control practices were being followed by staff and to identify any improvements.

We were assured that this service met good infection prevention and control guidelines as a designated care setting

Further information is in the detailed findings below.

This unannounced comprehensive inspection took place on 13 and 14 February 2018. This meant that the staff at Hadrian House did not know we would be visiting the home. At the last inspection in November 2017, we identified breaches of regulations which related to safety, person-centred care, complaints, staffing, fit and proper persons employed and governance of the service. We asked the provider to take action to make improvements. We found significant improvements had been made at the service to ensure compliance with all of the statutory requirements.

The registered manager who was in post had been present at our last inspection. They were on annual leave when we arrived to inspect the service but returned to work the following day. 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.

Initially we spoke to the deputy manager about the service as they were in charge of the home when we arrived. They told us that they felt the service was running well and a lot of improvements had been made.

We carried out observations throughout the whole home and found that considerable improvements had been made to the safety, cleanliness and governance of the service. All of the immediate concerns we highlighted at our last inspection had been addressed and consequential actions had been promptly taken and were monitored by senior staff members or the senior management team.

Prior to our inspection, we reviewed an action plan which has been shared with us, the local authority and the Clinical Commissioning Group (CCG). We saw all of the actions had been completed or on-going progress was being made. At this inspection, we found the necessary evidence required to demonstrate all of the progress which had been made.

People told us they felt safe living at Hadrian House and with the staff who supported them. Relatives confirmed this. Staff demonstrated that they were aware of their responsibilities with regards to protecting people from abuse through discussions with us and the completion of suitable training. Policies and procedures had been reviewed by the provider to ensure they were current and reflected best practice in order to effectively support staff in their roles.

Care plans included risks which people faced in their everyday lives. Thorough assessments of these risks and how to reduce them were now properly recorded in the care records which enabled staff to care for people safely.

The registered manager undertook periodic assessments of people’s needs to determine staffing levels. This meant that as people’s needs increased, staffing levels were evaluated and increased if necessary in order to adapt and respond to people’s changing needs. There were enough staff on duty at the service, and the registered manager now ensured they were deployed appropriately throughout the service, particularly at mealtimes when the demand for more one to one support increased. There continued to be a shortage of permanent nursing staff, however the registered manager had ensured the continuity of agency nurses and the provider had rolled out a strategic recruitment plan to attract permanent staff into these roles.

Staff recruitment continued to be safely managed and checks were in place to ensure staff were of good character and suitable to work with vulnerable people. Supervision meetings had been held with all staff and a plan was in place to structure annual appraisals over the forthcoming year. Competency checks had been carried out and more were scheduled to take place to ensure staff were supported in their role and competent with the tasks they were responsible for.

Medicines were managed well. People received the right medicines at the right times and the records kept to monitor medicine administration were accurately completed.

The cleanliness of the service had improved. People and their relatives told us how impressed they were with the premises. We saw people’s bedrooms and communal areas were cleaned to a high standard and continuous cleaning by domestic staff took place throughout the day and night.

Since our last inspection, staff had completed mandatory training. A robust training plan was in place to enhance staff skills with awareness courses arranged in topics which would be beneficial to the staff in their various roles.

A new head chef was in post and they were aware of people’s dietary requirements. They told us all of the kitchen staff had been given updated information about people’s nutrition and hydration needs. Special diets were catered for and all meals were well presented, including pureed food. People had a choice of hot meals and alternatives were always made available.

People enjoyed a pleasant mealtime experience. We saw staff were organised and relaxed throughout the service of meals and there was enough of them to support people who required one to one assistance in a timely manner. We observed staff created a sociable and homely environment for people to enjoy their meals.

At our last inspection we were told plans were in place to replace the flooring throughout the home. There was some discrepancy at the time as to whether a final decision had been made about this. We raised concerns that people who lived at the service had not been consulted about the options available. At this inspection, the chief executive officer told us that they had temporarily halted the plans in order to seek the views of people and relatives, not only about the flooring but about a full refurbishment. We saw the new plans were on display in the foyer with a variety of options for people to consider.

The new plans considered the needs of people living with a dementia related condition and we were told that emphasis would be placed on making the environment more dementia friendly but it would remain in keeping with the high quality and stylish decoration which the provider strived to achieve.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of most people to restrict their freedom for safety reasons in line with the MCA. All staff continued to demonstrate an understanding of the MCA and worked within its principals.

The two activities coordinators continued to develop positive relationship with people and we saw them engaging with people in a variety of activities. There was a varied programme of activities planned to ensure people were involved in meaningful activities. New social care plans demonstrated that people had benefitted from one to one time with the activities coordinators which reflected their individual interests. New activities such as bread making had been introduced which not only stimulated memories for people but also stimulated people’s senses and had encouraged them to eat more food.

We found care staff were more relaxed and less hurried in their duties which enabled them to sit and chat to people and join in with activities. All staff treated people with dignity and respect. They displayed caring and compassionate values and behaviours and people told us staff were nice to them. Relatives also spoke highly of the staff. Staff were able to tell us about people’s needs, routines, preferences, likes and dislikes which showed that they knew people well.

An established system for monitoring complaints was in place. Since the last inspection, the registered manager had ensured this was correctly followed. This meant they were able to identify, receive, address, record and respond to complaints appropriately. The registered manger had gone back through the previous records and retrospectively recorded the complaints which had been received. This meant they were now able to look for trends and identify areas of the service which may need further improvement and development.

The registered manager has been intensely supported by the provider’s senior management team during the past three months to ensure that compliance with the regulations was achieved. The registered manager had not been required to work regular shifts as the ‘nurse on duty’ which meant they had been able to utilise their time in a more constructive manner and concentrate on the governance of the service and implementing the improvements and developments as necessary.

New checks on the service had been put into operation and robust auditing showed that the service was routinely monitored and checked to ensure its safety and quality. We considered this needed to be evidenced over a longer period of time to ensure sustainability.

Record keeping had been improved in all aspects of the service. All of the care plans which had been re-written at the time of our last inspection had been reviewed and attention had been given to people’s social, cultural, religious and spiritual needs. These records now provided an overall picture of people’s health and social care needs to staff. Management records related to activities provision, complaints, accidents and incidents were all completed to a good standard with thorough, up to date details documented.

This unannounced comprehensive inspection took place on 21 and 22 November 2017. This meant that neither the provider nor the staff at Hadrian House knew we would be visiting them.

At the last inspection in March 2017, we identified breaches of regulations which related to safety, consent, dignity, staffing and governance of the service. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring, responsive and well-led to at least good. We found improvements had been made in some areas but not enough to ensure compliance with all statutory requirements.

This is the second consecutive time that this service has been rated 'Requires Improvement'.

The registered manager had been in post for six months and had recently become registered with the Care Quality Commission on 3 November 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. The registered manager of the service attended most of the inspection. The head of compliance was also present.

We undertook an initial conversation with the registered manager and the head of compliance to ask them about the actions which had been taken to address the previous issues. We also carried out initial observations around the home. Whilst we found some action had been taken to make improvements, we judged that audits and checks on the service were still not robust enough to ensure compliance with all regulations. Several concerns were raised at this inspection which demonstrated that the actions required had either not been wholly addressed or had not been properly implemented and monitored.

During our inspection, the registered manager and the head of compliance were able to take some immediate action to rectify issues which we drew to their attention.

An updated action plan was sent to us by the head of compliance in September 2017 which showed that most actions were completed and that any outstanding actions had a defined target date of 30 October 2017. The head of compliance told us that they “had made tremendous progress in the home.” We did not find sufficient evidence to corroborate this statement. Although the registered manager and the head of compliance had conducted audits, they had not been consistently or comprehensively carried out and they were not robust enough to identify or fully address the continued issues we highlighted during this visit. Audits completed did not always describe the outcomes of the problems identified and most audits did not contain an action plan.

The newly registered manager had not had sight of our warning notices which were issued to the provider in April 2017. They had also been required to cover a significant number of shifts as the ‘nurse on duty’ due to staff shortages. We considered that this had seriously impacted on their ability to carry out their own managerial duties and fully understand the seriousness of the concerns we had.

We found record keeping continued to be poor. Although every care plan had been re-written we noted that this had been done with a clinical slant and staff had not provided a holistic approach to people’s needs. Social, cultural, religious and spiritual needs had either been overlooked or vaguely addressed. Operational records related to activities, complaints, accidents and incidents for example all lacked detail and completeness.

Individual risks which people faced in their daily lives were not always included in care plans nor had risk assessments carried out to support staff to safely care for people. Medicine management had been improved since our last visit but there were still shortfalls in record keeping.

Some relatives told us cleanliness was an issue for them. During the inspection, we noted areas of the home were unclean including people’s bedrooms and communal kitchen/dining areas.

A care needs based dependency tool was not being used to determine staffing levels. This meant that as people’s needs increased, staffing levels were not being routinely evaluated to continuously adapt and respond to reflect people’s needs. We considered that there were enough care staff employed at the service, but they were sometimes not deployed appropriately throughout the service, particularly at mealtimes and their deployment was not always accurately recorded. The deputy manager post was vacant and the service had a shortage of permanent nursing staff.

Permanent staff continued to be safely recruited. There was high use of agency staff, especially nurses and we were concerned about the process of completing background checks on those staff and assessing their competency.

Supervision and appraisal of staff had not been carried out in line with the company policy. This meant that staff had not been appropriately supported in their role to ensure they remained competent. Competency checks were not routinely carried out with care staff and only two permanent nurses had had their competency recently assessed (one of which was the registered manager). Staff told us they did feel supported by the registered manager as they had worked alongside them on many occasions.

Although training had improved, the training report and matrix showed there were gaps in staff skills in relation to courses which the provider deemed mandatory and in specific courses which would be beneficial to them in their role.

We observed the mealtime experience to be unsatisfactory and it did not demonstrate a positive person-centred approach. Staff were not deployed correctly to ensure people were assisted with their meals in a dignified and timely manner. The mealtimes we observed were not well organised and they continued to lack an opportunity for socialisation.

Hot meals were offered and we saw some people had asked for alternatives which they had been given. The food looked attractive, healthy and well balanced. Some people told us they enjoyed their meals whilst others waited so long for assistance that their meals went cold. Special diets were catered for and the kitchen staff were familiar with most people’s dietary requirements. We have made a recommendation about the provision of Halal food.

At the last inspection, we noted that although the home was beautifully decorated but there was little emphasis put on making the environment dementia friendly. This remained unchanged. However, the registered manager and head of compliance told us there were some plans in place to improve this. We have made a recommendation about this.

The two activities coordinators displayed a really good relationship with people and we saw them engaging with people in communal areas. They had arranged many trips out into the community and had a varied programme of events in place for people to participate in. However, the records kept mainly described communal activities and outings. We found there was little reference to time spent with people on a one to one basis, providing meaningful and stimulating activities which met with their individual interests and hobbies.

The provider had not ensured that an established system was operated correctly to identify, receive, address, record and respond to complaints properly. Furthermore, complaints had not been monitored over time to look for trends and identify areas of the service that may need to be addressed.

People told us they felt safe living at Hadrian House. Relatives confirmed this. Staff were trained in the safeguarding of vulnerable adults and they were able to demonstrate their responsibilities with regards to protecting people from harm. Policies and procedures were in place to support all staff with the delivery of an effective service although these were not always followed properly.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of most people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Due to the shortfalls at the service, staff were not fully supported to deliver a wholly caring service. We saw care workers treated people with dignity and respect. Staff displayed friendly, kind and caring attitudes and people told us staff were nice to them. We observed people enjoying a pleasant relationship with staff and it was evident they knew each other well.

We have identified three on-going breaches and three further 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.

This unannounced comprehensive inspection took place on 10, 14 and 15 March 2017. This was the second rated inspection of the service since its registration with the Care Quality Commission (CQC) in May 2011. We previously inspected the service in May 2016 and rated the service as ‘Good’, however at that time we identified one breach of the regulations which related to the management of medicines.

A registered manager was in post and this manager had not changed since our last inspection of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We initially looked at how the service managed medicines. We found that the service continued to fall short of expectations and this led us to conduct another fully comprehensive inspection. We saw that PRN and topical medicine protocols were still not in place for each individual person and medicine care plans were not up to date or accurate. We also saw multiple examples of medicine administration records (MARs) which continued to contain gaps in the recording of administration without a corresponding explanation. Therefore, we could not be certain that people had received their medicines appropriately and as prescribed. Additionally we found concerns around the receipt, storage and disposal of medicines.

The governance of the service was not thorough and effective. Following our last inspection in May 2016, the provider and registered manager had not returned an action plan to CQC as requested as part of the requirement notice which was served to them in relation to the breach of regulation 12, safe care and treatment. Neither had they drafted their own action plan to address the shortfalls in the management of medicines which we identified. This meant those shortfalls had not been addressed when we visited on 10 March 2017.

Internal audits and monitoring of the service had taken place however this had not been robust enough to identify the issues we highlighted during our inspection. The provider had recently made changes throughout the senior management team and they told us about the improvements they planned to make regarding governance and oversight of the service. Following this inspection, the senior management team sent us an internal action plan to tell us how they planned to immediately address the shortfalls throughout the service.

Overall staff morale was low and there were differing opinions from staff about the leadership of the service. Some staff told us they felt supported by the management team and had received regular supervision and appraisal. Staff supervision and team meetings had not been held as often as planned however some staff told us they felt able to approach the registered manager whenever necessary. Equally there were some staff who felt undervalued by the management.

A robust induction programme such as the ‘care certificate’ had not been fully implemented at the service and because of this; some staff had not had their competency assessed against the minimum standards which are expected. Formal ‘on-the-job’ competency checks of experienced staff were not conducted. Training which the provider deemed mandatory had not always been refreshed in line with the targets they had set themselves and specific training to meet the needs of the people who used the service such as dementia awareness and challenging behaviour was not routinely arranged. This meant the provider and registered manager could not assure themselves that staff were competent in their role or that they were formally supported to develop their skills and knowledge. Staff continued to be recruited in line with safe working practice.

Individual care records were in place and contained personalised information in them about people preferences, routines and wishes. However we did not consider the staff approach to care documentation to be person-centred. We examined seven individual care records thoroughly and reviewed others. We found that the majority of them contained inaccuracies or incomplete forms and some documentation held within the records were not always signed and dated by people, their relatives (if appropriate) and staff. Evaluations of care plans and reviews of risk assessments were not routinely being carried out.

Record keeping was poor in aspects of the service such as care planning, medicine administration, food and fluid monitoring and weight records which caused us concern and we asked the registered manager to address some individual issues immediately. Risks which people faced in their daily lives were not always identified and addressed to reduce the possibility of people coming to harm. Those we reviewed had not always been completed accurately. Records were not always stored securely which did not support the confidentiality of people who used the service.

We observed staff interacting with people throughout the inspection. Interactions were not always dignified and respectful between staff and people who were diagnosed with dementia. The registered manager and provider told us they would take immediate action to address this issue although they told us that some staff felt under pressure due to the inspectors presence. Other staff displayed kind and caring attitudes and people told us staff were nice to them. People enjoyed a friendly relationship with the staff and it was apparent they knew each other well.

The Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’. It also ensures unlawful restrictions are not placed on people in care homes and hospitals. In England, the local authority authorises applications to deprive people of their liberty. We found the provider was complying with their legal requirements with regards to DoLS with a systematic process but decisions made in people’s best interests were not always appropriately taken or correctly recorded. In most records there was evidence that people had consented to their care and treatment.

The service offered people choices at mealtimes. The food appeared appetising and well balanced. Alternative options were available for people who didn’t want what was offered. Special diets were catered for, such as vegetarian, diabetic and soft diets. Catering staff were familiar with people’s dietary requirements. We observed mealtimes to be functional but they lacked an opportunity for stimulation and socialisation.

People we spoke with during the inspection told us they felt safe living at Hadrian House. Staff were trained in the safeguarding of vulnerable adults and they demonstrated an awareness with regards to protecting people from abuse and their responsibilities if they suspected wrong-doing. Policies and procedures were in place to support staff with the operation of the service; however we found some working practices were not always in line with company policy.

People told us they generally felt there was enough staff employed at the service and staff responded to them when called upon. There were mixed opinions amongst the staff team about staffing levels. Some staff told us they felt hurried in their duties and other’s felt they were able to meet people’s needs. Staff, including nurses felt there was not enough time to complete documentation appropriately. We felt there was an issue with the staffing in one area of the home and we reported this to registered manager and provider who told us they would look into the matter immediately.

Accidents and incidents continued to be recorded, investigated and monitored. An audit tracker was in place to identify types, places and times of events to monitor trends. The registered manager had reported these events to external agencies as required.

Routine safety and maintenance checks were carried out around the premises. Personal Emergency Evacuation Plans (PEEPs) had not been routinely reviewed. We found examples of people who had not had their PEEP recently evaluated; including those whose mobility needs had changed. The premises were clean and well-presented however equipment such as wheelchairs and some dining room furniture and flooring were encrusted with food and had staining from drink spillages.

There were two activity coordinators employed at the service which meant there was ample activity provision available on weekdays. We saw information was on display about forthcoming events and activities and we observed people engaging in a variety of activities which were meaningful and interesting to them.

The complaints procedure remained in place. We reviewed recent response letters and saw evidence of internal investigations into the issues raised had taken place and complainants had received a timely response in line with the policy. Feedback continued to be sought from people, relatives and staff.

We have identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 namely, Dignity and respect, Need for consent, Safe care and treatment, Staffing and Good governance. You can see what action we told the provider to take at the back of the full version of the report.

Hadrian House is located in North Tyneside and is registered to accommodate up to 50 older people, some of whom are living with dementia. Accommodation is provided over three floors with the second floor having some adaptation to support people living with dementia. The home was full at the time of the inspection.

The home had a registered manager who had been registered with the Care Quality Commission since January 2016. A registered manager is a person who has registered with the Care Quality Commission (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.

Staff were aware of the need to safeguard people from potential abuse and had a good understanding of safeguarding issues. They had received training in relation to this area and were able to describe the action they would take if they had any concerns. There had been 12 recent safeguarding alerts at the home; the majority noting low level concerns. The home had worked with key agencies around these safeguarding events.

Risk assessments were in place both in relation to the wider operation of the home and linked to the individual needs of people using the service. Regular checks were made on fire and safety systems to ensure they worked effectively. Equipment was checked to ensure it was safe to use. Window restrictors were initially found to be noncompliant with the guidance issued by the Health and Safety Executive, but were fully rectified before the inspection had concluded.

People told us they did not have to wait long for support and help and said they felt there were enough staff at the home. The manager told us she had recently introduced a range of new shift patterns to ensure that maximum staffing was available at key times, such as when people were getting up or going to bed. Suitable recruitment and vetting procedures were in place for new staff.

We found some issues with the safe and effective management of medicines at the home. There were gaps in the recording of medicines and some people receiving “as required” medicines did not always have appropriate care plans. The recording of topical medicines (creams and lotions) was not robust, with records not detailed or incomplete. This meant we could not be certain these medicines had always been given correctly.

Staff told us they had access to a range of training and updating. Records showed that a system was in place to monitor training at the home and ensure it was up to date. Additional training was available to further enhance staff skills. Staff told us, and records confirmed regular supervision and annual appraisals took place.

People told us meals at the home were good and they enjoyed them. Alternatives to the planned menu were available. There was good access to a range of drinks. Staff supported people with their meals appropriately and in a dignified manner. Kitchen staff demonstrated knowledge of people’s individual dietary requirements. People’s weight was monitored and there were regular reviews of people’s nutritional needs.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. Where necessary applications had been made to restrict people’s freedom under the MCA. Staff understood the concept of acting in people’s best interests and the need to ensure people made decisions about their care. Records showed people had provided their consent or that best interests decision had been made. The provider had notified the CQC about the outcome of DoLS applications as they are legally obliged to do so.

People and their relatives told us they were happy with the care provided. We observed staff treated people patiently, properly and with good humour. Staff were able to demonstrate an understanding of people’s particular needs. People’s health and wellbeing was monitored, with ready access to general practitioners and other health professionals. Staff were able to explain how they maintained people’s dignity during the provision of personal care and demonstrated supporting people with dignity and respect throughout the inspection.

Care plans reflected people’s individual needs and were reviewed to reflect changes in people’s care, although reviews were often limited in their detail. Care plans also reflected advice from visiting professionals such as the behaviour analysis and intervention team (BAIT). A range of activities were offered for people to participate in, including one to one time. People said they enjoyed the activities and could choose whether to participate or not.

There had been six formal complaints within the previous 12 months. These had been dealt with appropriately. Information about how to raise a complaint was available around the home. People said they knew how to make a complaint and they would speak with the manager if they had any concerns.

A range of checks were carried out by the manager and the provider’s Head of Compliance and Head of Clinical Governance. The home had a range of champions to help support best practice in key areas.

Staff told us the manager was supportive and approachable. Comments suggested they were happy working at the home. Regular staff meetings took place and workers said they were able to raise issues for discussion.

With the exception of some medicine records, other documents and records at the home were well maintained and kept securely. The home had made links with a number of other organisations in the local community.

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

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

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, 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?

Care records contained risk assessments and instructions on how these risks should be managed. For example, moving and handling and preventing falls. They also contained personal evacuation plans in the event of an emergency.

Systems were in place to make sure that management and staff learnt from events such as accidents, complaints, concerns and investigations. This reduced the risks to people and helped the service continually improve.

The CQC monitors the application of the Mental Capacity Act 2005 and operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS is a legal process used to ensure that no one has their freedom restricted without good cause or proper assessment. There was a policy in place related to people's mental capacity and deprivation of liberty safeguards. Records showed, and staff told us, they had received training on this. There was evidence to show that mental capacity assessments and deprivation of liberty checklists had been completed.

Is the service effective?

The staff we spoke with were able to describe the individual needs of the people they cared for and how these needs were met.

People's health and care needs were assessed and the care plans provided staff with information about how each person's care needs should be met.

The service worked well with other agencies and prompt referrals were made to health care professionals which helped ensure people's health care needs were addressed.

People were provided with a choice of suitable and nutritious food and drinks to meet their needs. People told us they enjoyed the food served to them. Comments included, "Very good food, very good indeed" and "The food is good, I enjoy it." The chef was aware of special diets which people required and had completed training in nutrition for older people.

Is the service caring?

We spoke with six people who used the service and their comments included, "I have a lovely room and the staff are very nice," "This is a nice place" and "The staff are very nice to me."

We spoke with six relatives who were visiting the home. They told us they felt their relatives were well looked after. Their comments included, "My mother has been at the home for three years and during that time she has been well looked after and they never hesitate to contact me if there is anything they need to tell me" and "I can't fault the care that my Mam receives.

We observed the interactions between staff and the people they cared for. We saw staff interacted well with people and were attentive and sensitive to their individual needs.

Is the service responsive?

There was a complaints procedure displayed in the home and each person was provided with a copy of this. A complaints book was maintained to record any complaints received in the home and the outcome of the investigation.

We saw prompt referrals were made to health care professionals when required and appropriate training was provided for the staff to help meet individual needs.

Is the service well-led?

The manager of the home was registered with the Commission and there were systems in place to monitor the quality of the service people received. People were asked their opinion of the service and meetings were held every month to discuss day to day issues in the home.

The manager and designated staff carried out regular audits which included medication, care records, infection control and environmental safety and security. The quality assurance manager also carried out audits every month to ensure standards were met and any improvements were implemented.

The people who lived in the home, their visitors and the staff told us the manager was very approachable if they had any concerns or suggestions and she respected their opinions.

The manager told us that following a flood in June 2012, extensive building repairs to the premises had been undertaken and we saw these were almost completed.

Relationships between staff and people were clearly good. People and relatives told us and we saw in practice, staff treated them with respect and helped them to remain as independent as possible.

We found people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke with were positive about the care and support people received. One relative told us, "It's a privilege to see how well people are looked after and cared for."

We found that the provider had suitable arrangements in place to manage medicines.

People were complimentary about the staff. One person told us, "We have found nothing but help from all the staff here. Me and my family haven't any concerns whatsoever." We concluded appropriate checks were undertaken before staff began work and effective recruitment and selection processes were in place.

We saw that people's personal records, staff records and other records relevant to the management of the home were accurate and fit for purpose.

Following a flood in June 2012, the basement of the home which included the laundry, kitchen and staff room was being repaired and refurbished. The kitchen had reopened in December 2012. The manager explained that prior to December, meals on wheels were provided. She said that these had proved unpopular with people who lived there. We looked around the kitchen and spent time with people during lunch and tea and concluded that people were provided with a choice of suitable and nutritious food and drink.

We found that people who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We concluded that the provider had secured high standards of care by creating an environment where clinical excellence could do well.