Highfields Nursing Home

Highfields Nursing Home is a residential care home providing personal and nursing care for 27 people aged 60 and over at the time of the inspection. Some people living in the service live with dementia. The service is registered with the Care Quality Commission for up to 42 people. Highfields Nursing Home accommodates people in one adapted building over 2 floors. There were communal lounges and dining facilities for people within the service.

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

Infection control standards were poor due to the lack of robust cleaning processes. There was a lack of provider checks on cleaning, equipment and environmental safety.

Medicines management and administration was not always safe. Medicines audits to identify errors, staff training and competency were out of date.

Quality monitoring processes and systems in place were not up to date and there was a lack of ongoing improvement in place.

Records relating to people's care contained information and guidance to enable staff to provide the safe care and support people required. Risk management was in place for people who were at a high risk of falls and who may present a risk to others from their behaviour.

Staff knew people well and showed kindness and compassion towards people. We received positive feedback from relatives and visiting professionals about the service.

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.

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 21 October 2022) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

This service has been rated requires improvement for the last 7 consecutive inspections.

We will describe what we will do about the repeat requires improvement in the follow up section below.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

The inspection was prompted in part due to concerns received about shortfalls in responsiveness to people’s health care needs and effective working with health partners. 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 COVID-19 and other infection outbreaks effectively.

We found evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, Effective and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

We carried out an unannounced inspection of this service on 26, 27 September and 10 October 2023. At our last inspection, 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 the breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (good governance).

We undertook this inspection to check they had followed their action plan and to confirm they now met legal requirements.

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

Enforcement and Recommendations

We have identified breaches in relation to the administration of medicines and infection and prevention control measures; Regulation 12 (Safe Care and Treatment), the failure to ensure people were protected from the risk of harm and abuse, Regulation 13, (Safeguarding); systems and processes to monitor the quality of care, Regulation 17 (Good Governance) ; the failure to ensure staff were suitably trained and competent, Regulation 18 (Staffing) this inspection.

The provider has taken prompt action to mitigate the risks identified at inspection and has provided evidence of improved processes and risk management which they are implementing. We will review this at our next inspection.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Highfields Nursing Home is a residential care home providing personal and nursing care for 27 people aged 60 and over at the time of the inspection. Some people living in the service live with dementia. The service is registered with the Care Quality Commission for up to 42 people. Highfields Nursing Home accommodates people in one adapted building over two floors. There were communal lounges and dining facilities for people within the service.

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

The leadership, management and governance arrangements did not provide assurance the service was always well-led, that people were safe, and their care and support needs could be met. The provider had not ensured that their systems and processes were robust in enabling staff to provide safe and effective care for people.

Records relating to people's care did not always contain information and guidance to enable staff to provide the safe care and support people required. Risk management was not in place for some people who were at a high risk of falls and who may present a risk to others from their behaviour.

The provider had quality monitoring systems and processes in place. Some of these were not used effectively to reduce risks for people. Medicines management was not always safe. Medicines were not always stored and managed correctly.

Infection control standards and staff personal protective equipment (PPE) compliance within the service had improved since the last inspection. The provider and registered manager now had oversight of cleaning and environmental safety.

Staff were safely recruited and had completed all training which the provider had identified as necessary. Staff were kind and respectful and understood people well.

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.

Rating at last inspection and update.

The last rating for this service was inadequate (published 24 December 2021) 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 the provider had made some progress towards the improvements required. However, further improvements were still needed and the provider was still in breach of Regulation 17 (Good governance).

This service has been in Special Measures since 24 December 2021. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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

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

You can see what action we have asked the provider to take at the end of this full report.

The provider has taken prompt action to mitigate the risks identified at inspection and has provided evidence of improved processes and risk management which they are implementing. We will review this at our next inspection.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe and Well Led sections of this full report.

We carried out an unannounced inspection of this service on 17 August 2022. At our last inspection, 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 the breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (safe care and treatment) and Regulation 17 (good governance).

We undertook this unannounced focused inspection on 17 August 2022 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to Requires Improvement. 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 Highfields Nursing Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified a breach in relation to Regulation 17 Good Governance at this inspection.

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

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Highfields Nursing Home is a residential care home providing personal and nursing care for 30 people aged 65 and over at the time of the inspection. The service is registered with CQC for up to 42 people.

Highfields Nursing Home accommodates people in one adapted building over two floors. There are various communal areas for people to sit and relax.

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

The service was not clean and hygienic. There had been a shortage of domestic staff and the workload had fallen on staff and the management team. Audits of cleaning were out of date.

Infection control standards were poor due to the lack of cleaning. There was a lack of management checks on cleaning and environmental safety.

Medicines management and administration was not always safe. Medicines audits to identify errors or issues were out of date.

There had been nursing staffing shortages and the registered manager had been forced to cover clinical shifts. This meant they were not able to perform all their management duties and quality monitoring of the service had fallen behind.

Incidents and accidents were not always analysed, as a result, the opportunity to identify themes and trends and learn lessons was missed.

Staff meetings did not take place and staff told us they felt overworked and undervalued by the provider. Staff performance was not monitored. Staff, people and relatives were not asked for their opinion of the service.

It was not clear if all staff training was up to date due to the complex nature of the training matrix in place.

Quality monitoring processes and systems in place were not up to date and there was a lack of ongoing improvement in place.

Processes to monitor people’s standards of care was not clear and we found gaps in recording that had not been addressed. People mostly had comprehensive care plans in place with risk assessments. We found one that was out of date.

The service worked in partnership with other organisations to support people.

People told us staff were kind, available to them and knew what they were doing.

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 Requires Improvement (published 30 April 2019).

Why we inspected

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.

We received concerns in relation to the management of people’s nursing care needs, the reporting of falls, and a lack of reporting. As a result, we undertook a focused inspection to review the key questions of Safe 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 Requires Improvement to Inadequate. This is based on the findings at this inspection.

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

Following our inspection, the provider has taken action to mitigate some of the concerns we found.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Highfields 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 Regulation 12 Safe Care and Treatment and Regulation 17 Good Governance at this inspection.

Follow up

We will request an action plan and meet with the provider following this report being published to discuss how they will make changes to improve the standards of quality and safety. We will work alongside the provider and with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

About the service: Highfields Nursing Home is a care home that was providing personal and nursing care to 24 older people including people with a physical disability and people living with dementia.

People's experience of using this service:

• The provider had not acted on concerns raised at our previous inspection regarding the hallway carpet and laundry flooring, both of which posed an infection control risk. We made a recommendation to the provider to address this.

• Relatives and staff told us there were not always enough staff available to meet people’s needs.

• Staff felt well supported by the management team but did not always feel valued by the provider.

• Not all mental capacity assessments and best interest assessments had been updated in consultation with people’s loved ones. However, action was being taken to address this.

• People’s likes, dislikes and preferences were taken into consideration and support was individualised.

• People were supported by staff that understood the principles of the Mental Capacity Act (2005) and respected people’s choices.

• Quality assurance systems and processes had been implemented but were not embedded in practice. The registered manager understood the legal requirements of their role.

• The home was clean, odour free and a dementia friendly environment.

• People felt safe living at Highfields Nursing Home, they were supported by staff that had been safely recruited and received training relevant to their roles.

• People were supported by staff that were kind and caring. People’s privacy and dignity was respected.

• People had access to a wide range of activities and were encouraged to be as independent as possible.

• People knew how to complain and felt confident complaints would be responded to.

• The provider was committed to developing the skills and knowledge of the care team. Staff received training appropriate to the needs of the people they were caring for.

• People had good health care support When people were unwell, staff promptly sought support from the appropriate health professionals

Rating at last inspection: Requires Improvement (11 August 2018), with Inadequate in well-led

Why we inspected: This was a planned inspection based on our previous rating of requires improvement.

Enforcement:

At the previous inspection we found the service to be in breach of Regulation 9 Person-centred Care and Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. At this inspection we found the service were no longer in breach of these regulations.

Details of action we have asked the provider to take can be found at the end of this report.

Follow up: Following our inspection, we requested an action plan and evidence of improvements to be made in in relation to premises and equipment. We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. Should further concerns arise we may inspect sooner.

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

Highfields Nursing Home is registered to accommodate up to 42 older people in one building. Some of these people were living with dementia. At the time of the inspection, 23 people were using the service.

A registered manager was not present during the inspection. 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. The previous registered manager left the service in February 2018. Since March 2018, the home has been managed by an area manager. A new home manager started working at the service on 18 June 2018 and was in the process of applying to become registered with the CQC. We will monitor the progress of this application.

During our previous three inspections, we found the provider had consistently not met the minimum standard of ‘Good’ care for all people. At each of these inspections, we rated the service as ‘Requires Improvement’. During this inspection, we checked to see whether sufficient improvements had been made to increase this rating to ‘Good’. We found they had not and we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Therefore, due to the continued lack of sustained improvement at this service we have rated the question, ‘Is the service well-led?’ as ‘Inadequate. The overall rating of ‘Requires Improvement’ remains.

You can see what action we told the provider to take at the back of the full version of the report.

People’s medicines were not always appropriately managed. Risks to people’s safety and managing behaviours that may challenge had been assessed, however care was not always provided in line with people’s assessed needs. There were enough staff to support people safely; however, there was limited time for staff to engage in meaningful interaction with people. People felt the home was clean and tidy and staff had received training on reducing the risk of the spread of infection. Some parts of the home did require cleaning and updating to further reduce this risk. Accidents and incidents were regularly reviewed, assessed and investigated by the area manager.

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, although some assessments of people’s capacity to make decisions required more detail. Staff received an ongoing training programme however staff performance was inconsistently monitored. People’s physical, mental health and social needs were assessed and provided in line with current legislation and best practice guidelines. However, there was an inconsistent approach to ensuring people’s day-to-day health needs were always met. The majority of people liked the food however, records showed when people were at risk of losing weight they were not always weighed as often as stated as needed in their care plan. The ground floor environment needed adapting and improving to ensure people who had mental or physical disabilities were able to lead fulfilling lives.

Not all staff treated people with respect or dignity. We observed some poor interactions when staff were supporting people. We also observed some caring interactions; however, the time staff spent engaging with people, other than to complete to day-to-day tasks, was limited. Efforts had been made to include people in making decisions about their care. Where they were not able, information about how to access an independent advocate was available. People were encouraged to carry out some daily living tasks for themselves. People’s records were handled in accordance with the Data Protection Act and there were no restrictions on people’s friends or families visiting them.

People’s care records were person centred and guidance was provided for staff on how each person would like to be cared for. However, care was not always provided in line with people’s preferences. There were limited opportunities for people to engage in activities or to follow their own hobbies and interests. Only six staffing hours a week was assigned to support people with their interests. People told us this was not sufficient , with some telling us they were bored at the home. People’s religious and cultural needs were met at the home. Not all information and records were presented in a way that would be accessible for all. People and relatives did not always feel complaints were handled appropriately, although records showed complaints had been responded to in line with the provider’s complaints policy. The quality of the end of life care planning documentation was variable.

The service was not well led. The service has a history of non-compliance with the fundamental standards and/or failing to meet the minimum standards of ‘Good’ that services should never fall below. Although we found improvements in the quality of the care planning and risk assessments at this inspection, there were still a number of areas that needed improving. The area manager had implemented quality assurance systems that were designed to ensure that the quality of the care provided was monitored regularly. However, these were not yet managed effectively to help identify the issues we found during this inspection.

A manager was present during the inspection however they were not yet registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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. Our systems showed an application to become registered had been received and we will continue to monitor its progress.

During our previous inspection on 11 August 2016, we identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to the safe management of people’s medicines.

During this inspection we checked to see whether improvements had been made. We found some improvements had been made but further improvements were still required. People’s medicines were stored and administered safely, however the recording of when people had taken their medicines was not always completed. We also found minor issues in the way medicines were handled when staff were carrying out their medicines round.

People were protected from the risk of harm because staff could identify the potential signs of abuse and knew who to report any concerns to. Assessments of the risks to people’s safety were carried out, but some risks such as ensuring pressure relieving equipment was set at the correct level, were not always managed effectively. Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the manager and was investigated. People were supported safely by staff but there were concerns with the number of staff available to support people on the first floor of the home.

People were supported by staff who had completed an induction and training programme, with the majority of this training being up to date. Staff received supervision of their work; however the frequency was not always consistent.

The principles of the Mental Capacity Act (2005) had not always been followed when decisions were made about people’s care. Deprivation of Liberty Safeguards were in place and managed effectively. People spoke positively about the food provided at the home. We observed an organised lunchtime experience for people on the first floor, however people on the ground floor’s experience was more disorganised. People had access to external healthcare professionals when they needed to.

Staff were kind, caring and compassionate and responded quickly to people when they showed signs of distress or had become upset. Staff understood people’s needs and listened to and acted upon their views. People’s privacy was maintained although additional private space throughout the home was limited. People were treated with dignity and respect. People’s diverse needs were respected. People were involved with decisions made about their care and were encouraged to lead as independent a life as possible. People were provided with information about how they could access independent advocates. People’s friends and relatives were able to visit whenever they wanted to.

People were supported with activities when the activities coordinator was present at the home. Staff responded quickly to people when needed. People’s care records were person centred, focusing on people’s preferences. People felt able to make a complaint and were confident it would be dealt with appropriately.

The new manager led the service well and was respected and well-liked, by people, their relatives and the majority of staff. People were encouraged to provide feedback about the quality of the service and this information was used to make improvements. Quality assurance processes were in place or due to be implemented to ensure people and others were safe in the home. We were unable to judge whether these improvements were effective and sustainable due to the limited time they had been in place.

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

During our previous inspection on 19 January 2016, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the safe management of people’s medicines and the management of the home.

During this inspection we checked to see whether improvements had been made. We found some improvements had been made but further improvements were still required.

Some improvements had been made to the way people’s medicines were managed and people received them safely. However the records and protocols used to ensure safe administration were not always in place or accurately completed. Assessments of the risks to people’s safety were carried out, but more regular reviews were required. Some of the assessments did not reflect the current risks to people’s safety.

Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the registered manager and was investigated. There were enough staff to keep people safe. Parts of the environment required reviewing to ensure they were safe for people to use. People were protected from the risk of harm because staff could identify the potential signs of abuse and knew who to report any concerns to.

People were supported by staff who had completed a detailed induction and training programme. However staff did not always receive regular supervision of their work. The principles of the Mental Capacity Act (2005), including Deprivation of Liberty Safeguards, had not always been followed when decisions were made about people’s care. People spoke positively about the food provided at the home. We observed an organised lunchtime experience for people on the first floor, however people on the ground floor’s experience was more disorganised. People had access to external healthcare professionals when they needed to.

People were treated with respect and dignity by staff. People felt staff were kind and caring. People’s records contained limited information about their life history; however plans were in place to improve this. People had been involved in initial decisions about their care and support needs. People were encouraged to lead independent lives. Information for people on how to access independent advice about decisions they made was accessible.

People told us there were limited activities at the home and our observations confirmed this. Staff responded quickly to people when needed. Parts of people’s care records were person centred, focusing on people’s preferences. People’s diverse needs were respected. People felt able to make a complaint and were confident it would be dealt with appropriately. The registered manager’s complaints log was unavailable for us to review during the inspection.

There had been some improvement of the registered manager’s auditing processes since the last inspection, but further work was required to ensure the issues raised within this report were identified and addressed in a timely manner. The registered manager was aware of their responsibilities to inform the CQC of incidents that could affect people’s lives, but they had not notified us when a decision to approve the deprivation of person’s liberty had been authorised. People, relatives and the majority of staff spoke highly of the registered manager. People were encouraged to become involved with the development of the service, however some people were not aware how to.

We identified a continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of this report.

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 were supported by staff who could identify the different types of abuse and knew who to report any concerns to. People told us they felt safe at the home and that there were enough staff to support them. Notifications of potential safeguarding incidents were not always forwarded to the CQC.

Assessments of the risks to people’s safety were carried out and reviewed. People had personal emergency evacuation plans (PEEPs) in place, although the content differed from the home emergency pack used when emergency services may need to evacuate people quickly from the home. Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the registered manager and were investigated. The registered manager’s recommendations were not always recorded. People’s medicines were not always safely managed and recorded. Stock levels were not always correct, a person had not received their medicines when they should have and appropriate guidance to support staff when administering ‘as needed’ medicines were not in place.

The principles of the Mental Capacity Act (2005) had been applied when decisions had been made for people. The appropriate processes had been followed when applications for Deprivation of Liberty Safeguards had been made.

People spoke positively about the staff and felt they provided them with effective care and support. Staff had recently received supervision of their work but previous supervisions were limited in number. There were some gaps in the training staff had completed but plans were in place to address some of these gaps. The majority of the people we spoke with told us they liked the food and drink provided at the home. Referrals to dieticians were not always made in a timely manner. People had access to external health care professionals; however the care they received from staff was not always recorded appropriately in their care records.

People felt the staff were kind and caring and treated them with respect. We observed some positive interactions between staff and people; however we also saw some examples which were not always respectful. People were provided with information on how to access independent advice about decisions about their care. There was limited space in the home for people to have private time to themselves.

People’s care records contained an initial assessment of their needs and care plans were put in place to enable staff to respond to people’s needs. However these did not always reflect people’s current needs. Opportunities for people to engage in the hobbies and interests that were important to them were limited. People felt able to make a complaint and felt they would be listed to and the complaint would be acted on.

The registered manager’s auditing processes were not always used effectively and had not identified the issues raised within this report. The registered manager had not ensured that the CQC were always provided with the appropriate statutory notifications. The registered manager interacted positively with people; however, some staff told us they did not feel valued. There were limited opportunities for people, relatives and staff to give feedback on how to improve the service. A number of statutory notifications had not been sent to the CQC.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of this report.

If you wish to look at our findings in detail please see the full report.

Is the service safe?

There were sufficient numbers of staff on duty to meet the needs of the people and there was always a nurse on duty to manage any emergencies.

People were supported in a clean environment.

People told us they felt able to approach staff with any concerns or complaints.

People told us that they were happy with the care that had been delivered.

Is the service effective?

Staff had a good understanding of people's nursing and support needs.

All complaints that had been received had been dealt with promptly

Staff told us their training was useful for them to support people to the best of their abilities.

Is the service caring?

We saw that staff listened to people in the service and gave encouragement when supporting them.

People told us the staff were kind and patient with them. One person told us, 'I've never been rushed at all.'

People confirmed to us that staff offered them choices of activities and meals every day.

Is the service responsive?

Systems were in place to allow people choice, involvement and independence.

Care records captured people's preferences and interests. Care had been provided in accordance with each person's wishes and we saw people's care records had been regularly reviewed and updated where necessary.

People had access to activities they liked and wanted to be involved in.

Is the service well-led?

There was a quality assurance system in place and staff told us they were clear about their roles and responsibilities. The staff told us they felt well supported by the manager.

There was a professional atmosphere to the service when we visited.

We checked staff training records and found that most staff had completed safeguarding training and refresher training was planned.

We saw improvements had been made by the service regarding the prevention, control and management of infection.

The service had not disposed of medicines in an appropriate time frame. Medicines audits had been completed however the service had failed to take appropriate action in response to their audit findings.

We spoke with four members of staff. One staff member said, 'There are more staff now and it has made a difference.'

We saw that each person's care plan contained information about themselves however we found that care plans and risk assessments had not been reviewed regularly.

We saw a ground floor bath room was used to store equipment and unused clinical waste bins. We looked at the laundry room and found the system for washing and cleaning laundry, linen and towels was disorganised. Our observations meant that people may not always be cared for in a clean, hygienic environment.

We spoke with members of staff, one staff member said, 'There's enough staff if staffing levels are what they should be according to the rota, sometimes we've been short staffed.'

During our inspection we observed that staff were not always available to assist people or that people had to wait for help from staff.

We spoke with a relative of a person who used the service. They told us, 'Staff are competent and know what they're doing; they've listened to my problems and helped.'

We checked the staff training matrix and noted that some staff had received training. We noted that further training had been booked for staff including courses in dementia training, end of life care and medication.