Archived: Dunmore Residential Home

Dunmore Care Home is registered for 32 older people, including people living with dementia. There were 20 people at the service at the time of the inspection. Bedrooms are located over four floors. There is a small passenger lift to access all floors. There is some accessible outside space.

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

Due to poor management of risk, people were at risk of harm. We found multiple examples of poor care and inadequate monitoring of risk in relation to malnutrition, dehydration, personal care, oral care, weight loss, incontinence, fire safety, infection control and pressure care. Some people looked unkempt. People were restless; some expressed sadness and worry at the changes in the home, and the lack of social activities. People told us they were bored and there was nothing to occupy them. We observed people sitting for long periods of time in their wheelchair with nothing to do and no interaction with others.

People’s dignity was not maintained; people’s clothes and belongings were lost. Complaints were poorly managed and long-standing issues were not effectively addressed. People told us they did not feel listened to, and relative’s expressed frustration that their concerns were not addressed. They did not feel confident in the new management structure.

There had been many staff changes, including in care, catering, administration, housekeeping, maintenance and management. There had been changes in the running of the home and this had impacted on staff confidence and morale. The changes had not been explained to people. People told us they were not kept informed of changes; they said, “We would like to know more, to be kept in the loop.”

People were unhappy with the food. People told us their lunch was lukewarm, and meals were very rarely hot. Another person sent their meal away complaining to a staff member it was cold. This was an on-going problem according to minutes from a residents’ meeting.

Infection control was poorly managed, particularly in the laundry.

Medicines were administered safely, but audits did not pick up on concerns we identified during the inspection. This included action not being taken when medicines were not stored appropriately, for example not being stored at the appropriate temperature.

Records of care tasks were not always completed. We found gaps in the recording relating to the repositioning people which should have been carried out to help prevent skin damage. Fluid and food intake were poorly monitored putting people at risk of weight loss, malnutrition and dehydration. Care plans did not consistently have the required information to support staff in understanding a person's individual needs.

Staff were recruited safely. However, staff training and induction were not effectively managed. Supervisions did not routinely take place and staff competency checks were poorly completed.

During our inspection, we saw actions and heard conversations that showed us some staff were compassionate and kind. People responded to their kindness and smiled or laughed with them. However, relatives said the atmosphere at the home seemed rushed and staff had less time to interact with people.

People were not routinely supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible or in their best interests. This included people living with dementia; improvements were needed to ensure they had equal choices to those people who were not living with dementia.

Systems and processes were not effective in ensuring the safety of people or the environment. Systems in place to monitor and review the quality of care had not been effective in improving standards, and ensuring the service, and staff, were meeting people's needs safely and effectively.

During the inspection, we raised individual safeguarding concerns for some people living at the home. This was to ensure risks to their health and well-being were assessed and reviewed by health and social care professionals.

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 12 November 2020) with breaches in Safe Care and Treatment and Good Governance.

The provider completed an action plan after the last inspection to show what they would do to improve. This included timescales. At this inspection not enough improvement had been made, and standards had deteriorated further. The provider was still in breach of the two regulations identified at the inspection in September 2020, with an additional seven breaches. This service has been rated Requires Improvement for the last three consecutive inspections which all took place in 2020.

Why we inspected:

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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 were not assured infection control was being managed appropriately.

We have found evidence that the provider needs to make a number of improvements; some of which were urgent. Please see the Safe, Effective, Caring, Responsive and Well-led sections of this full report.

During the inspection, the provider was given short timescales to rectify environmental risks. We checked these had been addressed during our inspection.

Follow up:

We have met with the provider, so they have a clear understanding at the level of our concerns. During the inspection, and afterwards, the provider was required to complete action plans to show us how they would address the risks to people’s 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 of 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.

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.

At this inspection, we identified nine breaches in relation to environmental and individual risks to people’s safety, infection control, person-centred care, maintaining people’s dignity, safeguarding, nutrition and hydration, staff training and deployment, complaints, consent and the running and oversight of the service.

CQC took enforcement action against the provider. The provider made the decision to close the service. People living at Dunmore Residential Home were supported to move to alternative homes by the local authority

Dunmore Care Home is registered for 32 older people, including people living with dementia. There were 13 people at the service at the time of the inspection. Bedrooms are located over four floors. There is a small passenger lift to access all floors. There is accessible outside space.

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

People continued to be at risk of harm because risks to people’s safety were not consistently identified or action taken to mitigate them. Documentation did not show people were routinely having their care needs met or provide the information staff needed to provide safe care. There was a lack of oversight which meant one person, living with dementia, was at risk of falls because they were wearing their reading glasses when mobilising. Another person, living with dementia, had been assisted to bed wearing a pendant alarm, which was found wrapped around their neck in the morning. Systems to keep staff informed about changes in people’s needs were not always effective. People were at risk due to failings in pressure area care and bowel management. There had been some improvement in the management of risks related to malnutrition and dehydration. People had gained weight and there was an improvement in the amounts of fluids being offered and drunk. A new kitchen manager was in post. Further improvements were required however, in relation to recording and the increased monitoring of people at high risk.

There had been some improvements in the training, support and supervision of staff, but further improvements were needed. Training was being delivered online and face to face, however the management team advised staff did not always want to engage and so had not always completed the training. There had been issues with the timing of the training; staff not being informed it was taking place; the only available room being double booked, and the trainer being unwell. The training matrix continued to show significant gaps in key areas of training.

During the inspection we raised concerns about aspects of staff practice. The management team advised they would be addressed through the introduction of staff competencies for all of the staff team. A new induction programme was being introduced with competencies assessed alongside. Newly recruited staff were receiving enhanced mentoring and monitoring due to gaps in their knowledge. Staff were receiving supervision but told us they did not find this supportive, because it was only being completed to raise concerns about their practice rather than discussing their development and experience. Supervision records showed where concerns had been identified in staff practice, but they had not always been effectively addressed.

We found people continued to be exposed to the risk of harm and poor care due to ineffective systems to check the quality and safety of the service. The local authority quality assurance and improvement team (QAIT) had been working with the service to develop governance processes. However, the tools developed were not yet embedded or effective. The concerns we identified during the inspection had not been identified, or action taken to minimise risk in relation to aspects of pressure area care; medicines administration; support with personal care; skin integrity and oral care; accidents and incidents; environmental safety and the quality of manager walk arounds and staff handovers. The provider continued to rely on external professionals to identify failings rather than internal governance processes.

The provider and management team were confident the quality and safety of the service was improving. The management team was in the process of being strengthened, and there was now a stable staff team in place. We received positive feedback from people and relatives about the kindness of the current staff team. A new computerised care planning system had been introduced to improve staff practice and oversight of the care being provided. The provider had increased their oversight of the service, receiving weekly progress reports from the nominated individual. However, despite these developments we were not reassured by their assessment of improvement, given the on-going concerns linked to this service and the findings from this inspection. The service had been in a local authority whole home safeguarding process since 10 November 2021. This was still in progress at the time of this inspection.

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 inadequate (published 3 February 2022) and there were multiple breaches of regulation. We found evidence the provider needed to make a number of improvements, some of which were urgent. Urgent conditions were therefore placed on the providers registration following that inspection. The urgent conditions addressed the management of risks linked to nutrition, bowel management, pressure care and access to call bells. They included ensuring staff had the guidance they needed to manage those risks and were competent to do so. Also, that there was daily oversight and checks of how the risks were managed by the registered provider.

Why we inspected

We undertook this targeted inspection to check whether the provider had met the urgent conditions imposed on their registration. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement and recommendations

We have found evidence the provider had failed to meet the urgent conditions imposed on their registration. People remained at risk of harm, and the provider was given short timescales to rectify immediate risks. We checked these had been addressed following our inspection and were told they had been.

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

Special measures

The overall rating for this service remains ‘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.

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

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

People who were able to comment on their experiences of living at the home told us they were satisfied with their care. Other people living with dementia responded positively to individual staff members. They showed through their actions and facial expressions they felt at ease with staff.

A new manager started working at the service in at the end of June 2020. They became the registered manager in September 2020 after being interviewed by the Care Quality Commission. Since their appointment they have shown a strong commitment to improve the quality of care at the home and ensure staff have access to appropriate training and supervision. This was work in progress and will be reviewed again at our next inspection.

Some aspects of risks to people’s health and safety needed further improvement. This specifically related to the care of frail people living with dementia who required staff to be vigilant to risks to their health and safety. Work continued to help the staff group understand the importance of accurate records, improve their understanding of person centred care and address unmet training needs and supervision. During the inspection, improvements were made by the registered manager and staff in response to CQC feedback.

Work was on-going to establish effective quality assurance systems to monitor and review the quality of care at the home, and the competency of the staff team.

The current staff group have praised the leadership of the registered manager. They recognised the importance of changing the culture of the home to make it a safe and caring home for people to live. Health and social care professionals have also commented on improved communication between staff and external agencies, which has been beneficial to people living at the home. The providers continued to invest in the service with environmental improvements, additional staff posts and have reviewed their own roles and the effectiveness of their quality assurance systems.

Rating at last inspection and update

The last rating for this service was Requires Improvement (Published September 2020) with three breaches of regulation. After the last inspection, the provider completed an improvement action plan to show what they would do and by when. At this inspection, we saw how some of these changes had been implemented. However, there was still further improvement needed to monitor risks to the health and well-being of some individuals. There were two breaches of regulations. Changes to how the quality of the care was monitored needed to be embedded and sustained. On this inspection, the service remained Requires Improvement.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about people’s safety. These incidents were subject to individual safeguarding investigations. A decision was made for us to inspect and focus on people’s health and well-being, suitability of staff and quality assurance. We inspected and found there had been an improvement in the recruitment process. However, we remained concerned about the management of risk, so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe and Well-led.

Enforcement

We have identified two on-going breaches in relation to keeping people safe and managing and running the service. Following our inspection in July 2020, we issued a warning notice in relation to the running of the home. This provides a timescale for the registered manager and providers to make improvements, and sustain them, otherwise further enforcement action will be considered. The timescale for compliance was 1 December 2020.

Follow up

The provider has sent us a regular updated service improvement plan listing the action taken to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress.

We will carry out another inspection to check if the warning notice timescales have been complied with. If we receive any concerning information we may inspect sooner. We will have a meeting with the provider to discuss the outcome of this inspection.

You can see what action we have asked the provider to take at the end of this full report. For more details, please see the full report which is on the CQC website at www.cqc.org.uk You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dunmore on our website at www.cqc.org.uk.

Dunmore Residential Care Home is a residential care home providing personal care to 23 people aged 65 and over at the time of the inspection. The service can support up to 32 people in one adapted building, with bedrooms located over four floors.

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

People who were able to comment on their experiences on living at the home described staff as kind and caring. Other people living with dementia responded positively to the staff group. They showed through their actions and facial expressions they felt at ease with staff. However, a number of people said they were bored and under stimulated. Relatives who gave us feedback were reassured and positive about the care provided at the home, although others expressed how they had lost confidence following a safeguarding incident which triggered this inspection.

During the inspection, improvements were made by the new manager in response to feedback and their own findings. They had begun working with the staff group to help them identify areas where they needed support, further training and where necessary undertaken disciplinary action. However, ineffective monitoring of the service had resulted in a number of areas for improvement, some of which had been previously identified by CQC and other agencies, such as the management of risk to people’s health and safety. Improvements noted in the previous CQC inspection had not been sustained, and there had been significant changes within the staff and management group.

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.

Rating at last inspection and update The last rating for this service was Requires Improvement (Published 21 April 2020) with one 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 enough improvement had not been made and the provider was still in breach of regulation. The service remains rated Requires Improvement with a rating of Inadequate for the key question Well Led.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about people’s privacy and dignity. A decision was made for us to inspect and examine those risks.

We inspected and found there were a number of other areas for improvement, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

The information CQC received about the incident indicated concerns about the management of people’s privacy and dignity; following which several staff were dismissed. This incident was subject to a safeguarding investigation. As a result, this inspection did not examine the circumstances of the incident. Instead, we focussed on people’s health and well-being, suitability of staff and quality assurance.

Enforcement

We have identified three breaches in relation to keeping people safe, recruiting staff, managing and running the service.

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. We will have a meeting with the provider.

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

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

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

Dunmore residential home is a care home without nursing and is registered to provide accommodation and support for up to 32 people. People living at the service were mainly older people, living with poor health, or early memory loss. At the time of the inspection there were 19 people living at the service.

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

The inspection took place over three days. Due to unforeseen circumstances we were unable to complete the inspection within the initial two days, so an additional third day of inspection was carried out at a later date. By the third day of inspection we found significant improvements had been made. However, we found a number of areas where further improvements were needed. We need to be certain the improvements will be sustained and will be fully effective.

The service did not have a registered manager in post. However, a manager had been appointed and had made an application to be registered. Prior to this inspection there had been a high staff turnover. All the management team and a high percentage of the staff had left, some of whom had worked at the service for many years. This had impacted significantly on the quality and safety of the service. At the time of our inspection the service was being supported by the local authority quality assurance and improvement team (QAIT) due to concerns over the quality of the care being provided. The provider had decided to voluntarily suspend all new placements to the service until improvements were made. Feedback received from the QAIT team after the third day of inspection was positive about the progress made since the new manager had been in post.

People told us they felt safe living at the service. However, during the first two days of the inspection we identified significant concerns over people’s safety. Records of people’s care and risks were poorly completed, out of date or absent. For example, records of people’s fluid intake were consistently inaccurate, and no clear system was in place for the escalation of concerns about people’s fluid intake. This meant there was a risk people received unsafe or inconsistent care, because staff did not have up to date records of people’s changing needs. On the third day of the inspection we found while improvements had been made, further improvements were required to ensure peoples safety. There was a more robust system of assessing, monitoring and managing risks and this was having a positive impact on people’s safety and wellbeing. However, people had not always been referred in a timely way to external health professionals, and it was not always clear that risk management plans were being followed by staff to minimise the risk of pressure area damage.

People we spoke to on the first two days of the inspection could not remember being involved with drawing up their care plans, some of which were out of date or incomplete. Most did not contain information about people’s history, background, hobbies and interests. Plans and guidance on supporting people with anxious or distressed behaviours were not in place. On the third day of the inspection we found improvements were being made. Action had been taken to support staff understanding of people living with dementia who showed distressed or anxious behaviours and behavioural charts were in place to try and identify any triggers. The service was introducing an electronic care planning system and were developing a ‘focus’ care plan with the support of the quality assurance and improvement team. This would provide a template for all care plans when transferred to the new system, with detailed information about people’s needs and preferences.

During the first two days of inspection we found people’s medicines were not always being managed safely. However, with the support of the local authority medicines optimisation team, this was no longer the case by the third day of the inspection.

On the first two days of the inspection there were insufficient permanently employed staff. Vacant shifts were covered by agency staff who did not know people or have a good understanding of their needs. By the third day of inspection there was a permanent staff team in place and agency staff were no longer required. The new staff team was getting to know the people they were supporting, and gaining confidence and skills.

People were supported by staff who had been recruited safely. However, during the first two days of inspection we found there was no clear understanding of staff training needs, or systems for staff supervision and appraisal in use. By the third day of inspection we found staff were receiving the induction and training required for their role. The training was documented on a training matrix which gave the manager a clear oversight of what training was still required. Staff had received group supervision with one to one supervision due to start. They told us they felt well supported, and we observed they were skilled and effective in the way they supported people.

On the first two days of the inspection the manager was aware the service did not have clear understanding of people subject to restrictions under the Mental Capacity Act 2005. By the third day they had reviewed and resubmitted all of the Deprivation of Liberty Safeguards (DoLS) applications to ensure they were accurate. Mental Capacity Assessments were due to become part of the overall care planning process when the service moves to a computerised care planning system in the near future. Newer staff had not received significant training in the Deprivation of Liberty Safeguards or on issues of consent, although this was in progress by the third day of the inspection.

Systems for supporting people or their relatives to have a say on the quality of the service had lapsed, however by the third day of the inspection a residents and relatives meeting had been reinstated and was positively received.

On the first two days of inspection we found the providers governance systems, which should help identify risks or where improvements were required, had not been effective. This meant the service had deteriorated in all areas since our last inspection and people had been placed at risk of harm. By the third day of the inspection a comprehensive quality assurance programme was in the process of being embedded and a service improvement plan had been developed with clarity around timescales and responsibility.

By the third day of inspection the manager had improved monitoring and accountability at the service. They were themselves highly visible. They had reviewed the staffing structure, rotas and job roles. Staff now worked in ‘zones’, and daily checklists were used to ensure all necessary tasks were completed. There was an open, transparent and positive culture at the service. Staff told us they felt valued and part of a dedicated team.

Although we had concerns initially that people were not receiving person centred care in line with their preferences, this was not the case by the third day of the inspection. We saw some examples of supportive and compassionate care from staff. Staff were positive about supporting people and had a clear understanding of their needs.

Dunmore had an activity programme which meant people had opportunities to be active and reduce risks from social isolation. Links were being established with local services to enable people to spend more time in the local community.

People were not all positive about the meals served, but the manager could tell us about very recent changes they had made to increase people’s choice and variety.

Systems for managing complaints or concerns were in place, and staff were aware of how to report any concerns about people’s well-being or potential abuse.

We have made a recommendation the environment is assessed for adaptations that may help support people with dementia of who are living with physical disabilities. Otherwise all areas seen were clean, warm and comfortable, with housekeeping staff taking pride in their work. Infection control risks were being managed well.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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 10 August 2017).

Why we inspected

The inspection was prompted due to concerns received about people’s care and safety, staffing and management and leadership. A decision was made for us to inspect and examine those risks.

We have found evidence the provider needs to make improvement. Please see the safe, effective, responsive and well led sections of this full report.

The provider is acting to mitigate those risks.

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

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.

Although Dunmore had a change to their registration status in 2016, the home has been long established with the same owners and registered manager in place. 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 and relatives told us the home was very well managed. The registered manager, deputy manager and several of the staff had worked at the home for many years and they knew people well. People spoke positively about the registered manager. One person said, “Yes, she is very good. If you want to, just call for (registered manager’s name). She’s very caring”, and another said, “You can talk to her, definitely.” Throughout our inspection we saw people, their relatives and staff freely approached the registered manager to speak with them. The atmosphere in the home was friendly and we saw positive interactions between people using the service, their family and staff.

Staff told us they were well supported by the registered manager. Regular staff meetings and staff supervision and appraisals ensured staff were provided with information important in their role as well as ensuring their care practices were in line with the home’s procedures and the manager’s expectations.

People told us they felt safe living at Dunmore and commented, “Yes, perfectly alright. No trouble at all” and “I don’t have any worries. I am pleased to be somewhere safe.” Relatives also told us they felt their family members were safe at the home. Staff confirmed they had been provided with safeguarding adults training and they had an understanding of their responsibilities to protect people from harm. Staff were clear of the actions they would take if they suspected people were at risk of abuse.

People said there were enough staff on duty to meet their needs, however at busy times during the morning they sometimes had to wait a few minutes for staff to attend to them. No one said this had caused them any distress or caused any care needs to go unmet. People and staff confirmed routines were flexible and people could get up and go to bed when they wished. Robust systems were in place to ensure staff were recruited safely. Staff files contained the necessary pre-employment checks including references from previous employers and disclosure and barring service (police) checks. This ensured as far as possible, only suitable staff were employed at the home.

People received their medicines as prescribed. Medicines were being safely administered, stored and disposed of. Regular audits of medication administration records (MAR) were undertaken by the registered manager and the provider’s general manager to look for gaps or errors and to make sure safe procedures had been followed. Senior care staff with the responsibility to administer medicines had received training and had their competence to follow safe practices assessed by the registered manager.

Care plans showed risks to people’s health and safety had been assessed and staff were provided with information about how to minimise these risks. Assessments included the risk of falls, skin damage and poor nutrition and hydration, as well as those associated with healthcare conditions such as diabetes. Should an accident occur these were documented and reviewed by the registered manager to identify how the accident came about and what actions could be taken to reduce the risk of a reoccurrence. Regular checks of the building were carried out to keep people safe and the home well maintained. Equipment such as hoists were serviced to ensure they were maintained in a safe working order.

Staff were knowledgeable about people’s care needs and had the skills to support them. People told us they were happy and well cared for by staff who knew them well. One person said, “I like the people who look after me. They are very kind and nice.” Another said, “It’s very friendly, and I like it.” Relatives also shared this confidence that people were cared for by well-trained staff. One relative said, “We are very, very happy with the home.” People were encouraged to do as much for themselves as possible and staff promoted their independence. One person told us, “I feel I want to be independent” and went on to say they did as much for themselves as they could, for example, making their own bed and tidying their room. People said they were involved in planning their care and relatives confirmed they were also involved in discussions about how their relatives were cared for. Each person had a care plan detailing their care needs and guiding staff about how to meet these safely and in line with their preferences. Regular 'residents' meetings' were held to invite people and their relatives to share any concerns and suggestions were welcomed about how to improve the home.

Staff had a good understanding of the principles of the Mental Capacity Act 2005 (MCA) and people’s right to make decisions about their care and treatment and to say how and where they wished to be supported. Staff confirmed a number people living at the home lacked the capacity to make decisions about their care. Care plans showed evidence of capacity assessments and best interests decision outcomes. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the MCA. The registered manager confirmed that some people, due living with memory loss, would be unsafe if they left the home without supervision from a family member or a member of staff. Because of this all exit doors were locked with a keypad to prevent people from leaving unnoticed. Applications had been made to the local authority for authorisation of this restriction.

Staff told us they enjoyed working at the home and said they all worked well together as a team.

During our inspection we spent time observing interactions between staff and people living at the home. It was clear staff had built positive relationships with people and they demonstrated care in the way they communicated with and supported people. Staff were kind, patient and respectful towards people.

People were provided with support from a range of health care professionals to maintain their health. Where people had been identified at risk of a deterioration in their health, such as being at risk of infections, staff were guided with information about what to be observant for and what actions to take should they have concerns over people’s health conditions. Care plans included a nutritional risk assessment which was regularly reviewed to assess how well people were eating and drinking. People's weights were regularly monitored to identify any weight loss quickly. People told us they liked the food and had a good choice available to them. Comments included, “I love it. We get lots of choice” and “It’s very good. I have a choice, (name of cook) will always change it if I don’t like it.” Menus were planned around people’s likes, dislikes and dietary needs, and people were invited to contribute to the menu planning.

At the time of the inspection, the conservatory previously used as the dining room was no longer available. Dining areas had been established in the two lounge rooms, and although staff had to rearrange the tables to enable people to walk around these, people told us meals times were being managed well in the circumstances. In addition, access to the patio areas was restricted to a small area outside the kitchen. We heard some people asking for reassurance from the staff that once the building work was completed they would have more accessible outside space. Staff confirmed a patio area would be available outside the main lounge room.

The home had employed an activity co-ordinator who consulted with and supported people to be involved in a variety of activities, in and out of the home. They involved people in group or one to one discussions about topics of interest, such as people’s hobbies as well as supporting people to visit the shops or local garden centre. Recent activities included exercises, card games, discussions as well as visiting entertainers, such as singers and keyboard players. Records showed the activity coordinator spent time with people who were being cared for in their rooms either through choice or ill health.

People and relatives were aware of how to make a complaint and all felt they would have no problem raising any concerns. One person said, “They (staff) have always been very helpful to me, if something worried me.” The home had received three complaints in the past 12 months which had been investigated and resolved. They had also received many letters of thanks. People, relatives and staff were asked for their views about their care and support provided at the home. Surveys had been sent in May 2017 and results had been audited by the activity co-ordinator who prepared a report for the registered manager. This report showed people felt positive about the home. The registered manager used a range of quality monitoring systems to continually review and improve the service and made a report to the provider each month. The registered and deputy managers regularly attended local meetings with other care home managers and the community nurses to share good practice. The provider and registered manager understood their responsibilities in relation