Woodland Manor Care Home

Woodland Manor Care Home is a care home providing personal and nursing care to 41 people aged 65 and over at the time of the inspection. The service can support up to 64 people.

Woodland Manor Care Home accommodates 64 people across four separate units. Two units provide residential care and two units provide nursing care. The service supports people living with dementia. The home is purpose built, with all bedrooms having an en-suite shower, shared communal dining and sitting room facilities. It has a separate dining room for special occasions, a cafe bistro at the entrance to the home, a cinema and activity room which is accessible to people.

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

People and the majority of relatives we spoke with for feedback were happy with the care provided. Some people would prefer to be at home but overall felt they got the care and support they required. Relatives were generally happy with the care and some relatives gave us examples of where their family members health had improved. All of the relatives, whilst finding the restrictions on visits incredibly tough, acknowledged that the service had done a great job in managing and responding to the COVID -19 pandemic and preventing an outbreak.

Systems were in place to keep people safe. Risks to them were identified and managed. Safe medicine practices were promoted, and measures were in place to prevent cross infection. Accidents and incidents were monitored, and systems were in place to promote learning from accidents/incidents and prevent reoccurrence. Staff were suitably recruited, deployed and the required staffing levels were maintained. The shifts were managed, and tasks were allocated which resulted in people getting the required care in a timely manner.

People were supported by staff who were suitably inducted, trained and supported. The training and induction was tailored to different roles and regular monitoring of staff practice took place to ensure the training was embedded into practice. The management team had a presence on the units and assisted on shifts which further supported staff. People’s health and nutritional needs were identified and met, and they had access to health professionals to further promote their well-being. 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; Whilst systems and policies were in place to support this the registered manager had identified that further training was needed.

We did not review the caring domain at this inspection. However, we observed staff were kind, caring, gentle and responsive to people’s needs. People and relatives were complimentary of individual staff and gave examples where they felt they had gone the extra mile in relation to supporting them and their family member.

Person centred care was promoted and continued to be developed. People’s care, support and communication needs were identified and met. People had access to one to one and group activities and the activity team had supported people and their relatives to keep in touch during the pandemic. People’s end of life wishes, and preferences were identified, where the person and their family members had participated in that discussion. The service was supporting people on end of life care and staff had been trained and supported in that role. Systems were in place to deal with concerns and complaints. Some relatives raised concerns with us about their experiences of care. We have directed them to the provider to explore further.

People were supported by a service that was well managed and monitored. The registered manager had worked incredibly hard to improve the service and bring about positive changes and processes. They had built a strong management team to support them. As a result, communication, team work and staff morale had improved which resulted in positive outcomes for people. Regular auditing and reviewing of practices and processes took place which enabled the registered manager to have oversight of what areas needed further improvement.

People and the majority of relatives were positive about the improvements the registered manager had brought to the service. They described the registered manager as “accessible”, “approachable”, “honest”, “listens and provides clarity’. A relative commented “I think the home is extremely well managed. I have found [registered managers name] firm but caring. She explains herself clearly, she is very hardworking, dedicated to her job and goes that extra mile. I am happy to trust my mother’s care to a home managed by her”.

Staff described the registered manager as “firm”, “fair”, “friendly”, “knowledgeable”, “experienced and professional’. A staff member told us they, “Felt happier, better supported, appreciated, valued and clear of what was expected from them.” Another staff member commented, “It is more friendly here now. Staff work well as a team. Morale is good and staff feel like they can progress. Everyone gets the opportunity.”

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 (inspected on the 6 and 7 November 2019 and republished on the 16 September 2020 once representations to our previous actions could be published). There was continued multiple breaches at that inspection.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. They have provided us with regular updates on the action plan and evidence of their auditing to show the progress made.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since November 2019. During this inspection the provider demonstrated that 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

We carried out this focused inspection to check that the provider 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, Effective, Responsive and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for the caring key question which was not looked at on this occasion was used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to good. 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 Woodland Manor Care Home on our website at www.cqc.org.uk.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Woodland Manor is a care home providing personal and nursing care to 52 people aged 65 and over at the time of the inspection. The service can support up to 64 people.

Woodland Manor accommodates 64 people across four units. Two of the units accommodate people with dementia, whilst the other two units are described as nursing units. The service is purpose built, with all bedrooms having an ensuite shower. The units have shared communal dining and sitting room facilities and a bathroom. There is a separate dining room for special occasions, a café bistro at the entrance to the service, a cinema, hairdresser and activity room.

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

Sufficient staff were not consistently provided, and some staff were not suitably trained and supported.

Safe medicine practices were not consistently promoted and risks to people were not always identified and managed. Person centred care was not provided. There are also two specific incidents that we are currently reviewing in relation to people’s care.

Some people were supported to make choices in relation to food, drinks and activities. However, 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.

Records were not accurate and up to date. Good governance was not established. Senior management visited the service but the auditing that had taken place had not identified the issues we found. The provider failed to learn from previous inspections and bring about the required improvements. They failed to review the service’s progress in complying with previous breaches of regulations which has resulted in continuous breaches of regulations of the Health and Social Care Act 2008.

We received mixed feedback on people’s experience of care. People were happy with the meals and activities were provided. Some people and relatives told us they felt safe and were generally happy with their care. They confirmed staff were kind and caring and we observed positive engagements with people during the inspection. Other people and relatives felt the high use of agency staff lead to inconsistent care and a delay in getting the support they required.

The service had a new manager in post. They had a proven track record for improving services. They had identified areas for improvement and had an action plan in place to support that.

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 December 2018) and there were multiple 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 enough, improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the relevant key question sections of this full report.

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

Follow up

We served warning notices in respect of breaches of Regulation 9, 11 and 18 of the Health and Social Care Act 2008 with a timescale for compliance. The progress with meeting these regulations will be reviewed at the next inspection.

Special Measures:

This service has failed to achieve a good rating since being registered in 2015. It was previously in 'special measures' from March to June 2018.

The overall rating for this service at this inspection is ‘Inadequate’ and the service is 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.

We carried out a focused inspection in June 2018. That inspection was to follow up on the warning notice we had served in relation to the breach of Regulation 18. We found the warning notice had been complied with and that progress had been made in meeting Regulation 12 and 17. However the service was not fully complaint with Regulation 12 and 17 and we continued to monitor that through the actions plans been submitted to us.

Following the last two inspections, 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. At this inspection we found improvements had been made to the caring domain. However, there were continued breaches of Regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and improvements were still required to ensure the service was safe, effective, responsive and well-led.

Woodland Manor is ‘a care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Woodland Manor accommodates 64 people across four separate units. Two of the units specialise in providing care to people living with dementia. The other two units are described as nursing care units. At the time of the inspection there was 45 people living in the home. The home is purpose built, with all bedrooms having an en-suite shower, shared communal dining and sitting room facilities. It has a separate dining room for special occasions, a cafe bistro at the entrance to the home, a cinema and activity room which is accessible to people.

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

The majority of people and relatives spoken with felt the service had improved since the two previous inspections. This was because they had built positive relationships with staff, the staffing levels were better, team work was promoted and they reported staff seemed happier, communication between people, relatives and the service had improved and activities were more varied and appropriate to the needs of people.

The staffing levels had increased on some units. A host was consistently provided on the ground floor units to serve meals and take the pressure of serving meals away from the care staff. The service still had a high use of agency staff but requested regular agency staff to promote continuity of care. Permanent named staff were allocated to specific units which promoted better continuity of care to people. However, some people and staff felt the staffing levels were not maintained and gave examples where there was a delay in their care needs being met. The rotas and allocation sheets viewed showed the suggested staffing levels were not consistently maintained, but this had not been audited and addressed by the service.

Risks to people were identified but not always appropriately managed. Systems were in place to ensure medicine was safely managed, however time specific medicines were not given at the prescribed times.

People were consulted on their day to day care, however the Mental Capacity Act 2005 was not followed for people who lacked capacity to make decisions about their care.

People had care plans in place but they lacked specific detail on the support required. The provider confirmed that person centred care planning is an on-going process that they are committed to improving. Access to activities had increased and the activity programme had been developed in line with people’s abilities and choices. This was still work in progress.

Records relating to people and the running of the service were not accurate, up to date and suitably maintained. A new audit system had been introduced in October 2018. This was not yet effective and fully established to bring about the required improvements to the service.

Staff were kind and caring. They had developed open and more trusting relationships with people and their families. People’s communication needs were not identified and met in line with the Accessible Information Standard. A recommendation has been made to address this.

Systems were in place to safeguard people. Staff were suitably recruited, trained and had an awareness of their responsibility to report poor practice. Staff competencies were not assessed. A recommendation has been made to address this.

Systems were in place to induct and train staff. The service had accessed external trainers and was keen to further develop the training on offer. Staff told us they felt supported but staff were not having one to one support meetings at the frequency outlined in the provider’s policy. A recommendation has been made to address this.

Some people, relatives, staff and professionals were happy with the way the service was managed. They felt the manager had brought about positive changes and had developed a more cohesive staff team to support them. The manager recognised the challenges of the service. They told us they had the support and backing of the organisation to improve the service. The manager was committed to improving the service but felt this was not something that could happen overnight.

People were provided with the information to raise concerns and resident and relative meetings took place to enable them to raise concerns and share positive views about the service.

People’s medical and nutritional needs were identified and met. The service had developed good working relationships with other health professionals. There was mixed feedback on the meals provided, with some people telling us they were very good, whilst others were not impressed with the overall quality of some meals.

The home was clean, suitably maintained, health and safety and infection control were appropriately managed.

At this inspection the provider was in breach of Regulations 9,11,12,17 and 18 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.

The concerns and improvements required in the key questions responsive and caring are being reviewed through our ongoing monitoring so we did not inspect them at this inspection. However the ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Woodland Manor is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Woodland Manor accommodates 64 people across four separate units. Two of the units specialise in providing care to people living with dementia. The other two units are described as nursing care units. At the time of the inspection there was 46 people living in the home. The home is purpose built, with all bedrooms having an en -suite shower and shared communal dining and sitting room facilities. It has a separate dining room for special occasions, a cafe bistro at the entrance to the home, a cinema and activity room which is accessible to people.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. At this inspection the deputy manager was acting up to manager. The nominated individual confirmed during the inspection that the deputy manager would be taking on the manager’s role and would be applying to the Commission to be registered.

People and their relatives felt the home had improved since the previous inspection in March 2018.This was because staffing levels had increased across all the units and agency staff were used to cover gaps in the rota. The home had a high sickness rate and a high turnover of staff and the use of agency staff lead to inconsistent care for people. However people and their relatives recognised this was not something that could be solved instantly and were reassured that the on-going recruitment of staff was continuing. The provider had met the warning notice in relation to breach of Regulation 18- Staffing levels. This needs to be sustained and maintained and will be reviewed again at the next comprehensive inspection.

The acting manager had started to address the conflict within the team and the deployment of staff. They had reviewed the staff skill mix and allocated staff to the units they felt best suited their skills and experiences. Staff breaks were planned and staff felt communication within the team and staff morale was improving.

The service was more responsive to accident and incidents. They took action to address recurrent accidents and incidents. Staff were aware of risks to people however further improvements are required to the management of risks and adhering to the advice and guidance of health professionals.

Improvements are required to medicine management and auditing to ensure that people get their medicines when prescribed and that systems are in place to ensure medicines do not run out. This is a continued breach of Regulation 12 which will be monitored through the positive conditions imposed on the provider’s registration following the inspection in March 2018. The progress with this will be reviewed at the next comprehensive inspection.

Staff inductions, training and the frequency and access to one to one supervisions had improved. The provider had met the warning notice in relation to breach of Regulation 18- Ensuring staff are suitably qualified, competent, skilled and experienced. Further service specific training such as key working, person centred care, dementia care would further enhance staff skills and the progress with this will be reviewed again at the next comprehensive inspection.

People were supported to make day to day choices and decisions however the service did always demonstrate they were working to the principles of the Mental Capacity Act 2005. A recommendation has been made to address this.

People had access to a range of health professionals and their nutritional needs were met. The home was clean, suitably maintained and health and safety checks and the servicing of equipment were up to date.

Some improvements had been made to people’s records however records were not suitably maintained, accurate, up to date and further improvements are required to safeguard people.

The frequency of senior manager visits had increased. Auditing was taking place but not picking up all the areas that it should in relation to records and medicine management. The quality audit system was under review and an electronic auditing system was being introduced. This is a continued breach of Regulation 17 which will be monitored through the positive conditions imposed on the provider’s registration following the inspection in March 2018. The progress with this will be reviewed at the next comprehensive inspection.

People and their relatives were complimentary of the acting manager. Some relatives said they had confidence in the acting manager and a relative described her as doing an “Amazing job.” People and their relatives recognised the service had made improvements and felt they were heading in the right direction. They felt the majority of staff were genuinely caring and did a fantastic job.

At the previous inspection in March 2018 the service was placed in special measures and rated inadequate. At this focused inspection the overall rating has changed to requires improvement, therefore the service is coming out of special measures. The provider is in continued breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 201. Positive conditions have been imposed on the provider’s registration following the inspection in March 2018 and they are required to send us monthly evidence of auditing and monitoring of the service. We will continue to monitor the service and compliance with Regulation 12 and 17 through those monthly reports being sent to us.

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 question(s) safe, effective, responsive and well-led to at least good. At this inspection we found the provider was still in breach of regulations 12, 17 and 18 of the Health and Social Care Act 2008. There were further breaches identified in relation to regulations 9 and 13.

Woodland Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Woodland Manor accommodates 64 people across four separate units. Two of the units specialise in providing care to people living with dementia. The other two units are described as nursing care units. At the time of the inspection there was 48 people living in the home. The home is purpose built, with all bedrooms having an en -suite shower and shared communal dining and sitting room facilities. It has a separate dining room for special occasions, a cafe bistro at the entrance to the home, a cinema and activity room which is accessible to people.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.’ At the time of the inspection the service had a registered manager. The registered manager had resigned and was due to leave the organisation later in the month. However they left two days after the inspection ended without giving the provider appropriate notice of an early departure date. A manager from another location was been inducted to take on the manager’s role until a new registered manager was recruited.

Some people were happy with their care, however the majority of people we spoke with were dissatisfied with their care which they contributed to the lack of sufficient staff. They gave examples where there was a delay in their needs being met. All of the relatives we spoke with were unhappy with the care provided. They felt the staffing levels were not safe or sufficient. They gave examples where their family members were not provided with appropriate supervision. Two relatives told us they visited at meal times to ensure they were available to support their family member with their meal. The provider told us for one of those people they will only eat their meal for their relative and the relative had made the decision to be present to support that.

Staffing levels were not sufficient. Throughout the three days of the inspection there was a delay in people getting their meals, medicines, appropriate supervision and support. Staff had completed some aspects of training however staff were not suitably skilled, trained and supported in their roles.

Risks to people were identified but there was no intervention to minimise risks. Accident and incident reports were completed but recurrent trends such as falls were not addressed. The provider told us falls were reported and actions put in place which included third party referrals to other relevant professionals. This was not always recorded or communicated appropriately. Staff were not aware of the risks people presented with and they failed to safeguard people who were at risk from pressure sores, malnutrition, falls and use of lap belts.

The delivery of high-quality care is not assured by the leadership, governance or culture in the service. People’s records and other records such as staff files were not suitably maintained and accurate. The provider had systems in place to audit the service but the auditing failed to address the issues we found.

Systems were in place to safeguard people but appropriate action was not taken in relation to the staffing levels, recruitment of staff and some staff performance issues to ensure people were appropriately safeguarded.

People had care plans in place which were incomplete and were not routinely used by staff to enable them to support people appropriately. People’s life histories were identified but person centred care was not provided. People had access to activities but limited activities were provided for people on the dementia care units. They were left watching television, wandering, distressed or asleep.

People’s communication needs were identified but no support was provided to promote people’s communication and involvement. A recommendation has been made to address this.

Systems were in place to manage complaints but information on how to raise complaints was not provided for people with dementia. The provider told us the next of kin and power of attorney is provided with a copy of the complaints procedure and a copy of the complaints procedure is on display at the main entrance to the home. However this is not in a format that would be accessible to people with dementia. A recent complaint was concluded without the key witness statement. A recommendation has been made to address this.

Staff were kind and caring in their brief interactions with people. People’s privacy was generally promoted. Staff and relatives of people on the dementia care units felt they were not treated equally and fairly in line with the Equality Act 2010. They gave examples where they felt they were treated differently. The provider disputed this was the case and confirmed they worked in accordance with the Equality Act 2010.

People had access to a GP and other professionals such as the tissue viability nurse and community mental health nurse. The GP confirmed they had a positive relationship with staff at the service. People had access to a varied menu and systems were in place to get feedback on the menus to bring about improvements.

The home was suitably maintained. Equipment relating to fire safety, hoists, the lift and electrical appliances were serviced. The home had housekeeping staff who were responsible for the cleaning of the home and laundry. The home was clean although some relatives were dissatisfied with aspects of the cleaning.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this time frame. If not enough improvement is made within this time frame so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of this registration.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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. The Care Quality Commission is now considering the appropriate regulatory response to resolve the problems we found during our inspection.

We found a number of 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 this inspection has now been added to the report.

Woodland Manor is a care home with nursing which provides accommodation and personal care for up to sixty four people. At the time of our inspection there were thirty five people living in the home.

Woodland Manor is made up of four units each which accommodate 16 people. At the time of our visit three units were operational.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. An interim manager was in post and providing management of the service. The nominated individual was looking to recruit a manager to become the registered manager of the service.

This inspection was a responsive comprehensive inspection and was carried out in response to information of concern we had received. This was the first inspection of the service since it had been registered with us in December 2015. Therefore we looked at all of the domains to enable us to provide a rating for the service.

People and their relatives were generally happy with the care and were complimentary of individual staff members. They described staff as “Compassionate, patient, kind, enthusiastic, genuinely caring, so amazing, professional, genuine and always helpful”. They told us the home had a happy welcoming atmosphere. However some people, relatives and staff told us the staffing levels were not always adequate. Two relatives told us it lead to inconsistent care for people.

At this inspection we found some people did not get the required level of staff supervision and support they required in a timely manner. People had risks assessments in place but not all areas of risk were identified. Risks were not reviewed and updated in response to changes in people’s conditions.

Some people’s medicines were not given as prescribed and medicine required for use in an emergency was not available.

Systems were in place to safeguard people and keep people safe. However the deficiencies identified in staffing, risk management and medicines did not always promote people’s safety. There was also a delay in recognising and reporting safeguarding incidents which meant systems in place to safeguard people were not followed. We have made a recommendation to improve those practices.

People had care plans in place. Some were detailed and specific, whilst others were contradictory and not updated as people’s needs changed. We have made a recommendation to address this.

Some people’s records were not suitably maintained and fit for purpose. This was because fluid and turning charts were incomplete, pressure damage assessments had conflicting scores and falls risks assessments were not updated to reflect increase in falls and management of the risk.

People were involved in making decisions on their care. The principles of the Mental Capacity Act 2005 were not followed for people who lacked mental capacity. This was because an MCA assessment was not carried out in respect of decisions on care and treatment. We have made a recommendation to address this.

People’s health and nutritional needs were met. The majority of people and relatives were happy with the meals provided. People had input from other health professionals to promote their health and well-being.

Staff completed inductions. The provider had in place training to enable the staff to be competent in their roles. Staff felt supported. Formal one to one meetings and team meetings with staff were being re-established. Daily stand up meetings had been introduced and monthly head of department meetings were scheduled to commence.

Staff were kind, caring and promoted people’s dignity. Some staff consistently promoted people’s privacy, whilst other staff did not routinely do this.

The home had activity co-ordinators in post who provided a service to people over seven days. Activities were linked to people’s interests and hobbies. People and relatives were very complimentary of the activity co-ordinator and the opportunities they provided to people.

Systems were in place to manage complaints. However complaints were not managed in line with the organisations policy. We have made a recommendation to address this.

Aspects of care were being monitored. Quality auditing was not fully established to ensure effective auditing. We have made a recommendation for monitoring of the service to improve.

The home had an interim manager who had made positive improvements in the short time they had been in post. They had identified and prioritised areas for improvement. They had put structures in place to support staff in their day to day work. People, relatives and staff were complimentary of the manager and their management style. They described her as “Effective, supportive, approachable and accessible”.

The provider was in breach of three regulations 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.