Coniston House Care Home

About the service

Coniston House Care Home is a purpose-built care home providing accommodation and personal care for up to 43 people. Care is provided across two floors. At the time of this inspection there were 33 people living in the home.

We found the following examples of good practice.

The home facilitated face to face visits, in line with government guidance. The registered manager told us this was essential to help support people's psychological and emotional well-being. Alternatives to in-person visitation, such as virtual visits, were also supported.

A ‘booking in’ procedure was in place for all visitors, which included a health questionnaire and evidence of a negative lateral flow test. This helped prevent visitors spreading infection on entering the premises.

People and staff were tested regularly for COVID-19. Staff employed at the home had been vaccinated, to help keep people safe from the risk of infection.

Infection control policies and audits were in place. However, the infection control practices did not reflect current guidance. This was in relation to processes for supporting people who had tested positive of COVID-19.

Most parts of the home were clean and well maintained. However, we identified one part of the home that needed to be cleaned. Cleaning schedules and audits were in place to help maintain cleanliness and minimise the spread of infection.

Staff were trained and competent in infection prevention and control (IPC) best practices and how to put on and take off PPE. However, we noted there were no posters around the home to act as a visual reminder and prompt for staff and visitors on infection prevention and use of PPE. The home had adequate supplies of appropriate PPE. We have signposted the provider to resources to develop their approach.

The registered manager maintained links with external health professionals to enable people to receive the care and intervention they needed. Virtual consultations took place as and when necessary.

We found the following examples of good practice

The provider had developed clear guidance and protocols for visitors in response to the recent government guidance. This included clear information for visitors about what the new guidance was and how they were able to book a visit. Additional alternative visits remained available, which included window visiting and video calls. The provider had also developed guidance around essential family carer visits.

The provider had completed audits of how the home was prepared for and managing all aspects of the pandemic.

Staff had received a combination of inhouse and online training about Covid 19 and the use of personal protective equipment (PPE). Stocks of PPE exceeded current guidance. Staff were seen to be wearing appropriate PPE. There were designated areas to ensure PPE could be put on and taken off safely.

The registered manager had ensured communication between the staff team continued to be effective by using a variety of methods to keep staff up to date. This included socially distanced handover, use of a secure social media platform and the use of video conferencing.

The registered manager had overseen some refurbishments in the home which included replacing flooring with materials which were easier to clean. We saw high standards of cleanliness throughout the home.

The provider had clear contingency plans in place to manage the impact of any outbreaks. The home had experienced three outbreaks which had been successfully contained.

The home has been in special measures since early 2016. Since that time there has been a new registered manager, new area manager and a number of new staff to the home. At the last inspection in July 2017 we found six breaches to the regulations. We were particularly concerned around how the home supported people who were falling and found appropriate timely action was not always taken to support these people. We issued a notice to ensure no further people were admitted to the home until the falls management at the home had improved.

Following the last inspection, we met with the provider to confirm an action plan to show what they would do and by when, to improve provision and meet the requirements of the regulations. The action plan showed us how the home intended to improve the ratings to the key questions of safe, effective, responsive and well led to at least good.

At this inspection we found the home had addressed the action plan. Enough improvement work had been completed by the home’s management team and staff, to show they had met all the previous identified breaches and were now safely managing falls. We found the home was now supporting people effectively to reduce the risks of further falls. This gave us confidence to allow the home to admit further people to the home in line with a developed readmissions plan.

Coniston house is a purpose built care home over two floors. Each floor has its own lounge and dining area. The lower floor houses the main kitchen and laundry facilities and the upper floor now has its own newly built satellite kitchen. This has greatly improved facilities to the top floor including access to drinks and snacks.

The home supports up to 43 people and at the time of the inspection there were 30 people living in the home. The low number was primarily due to the previous restriction on admissions. The home provides residential care and specifically focuses on providing residential support to people living with dementia.

Coniston house is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Coniston house does not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Coniston house 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.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

At the last inspection in July 2017 we found the home was in breach of Regulation 12 in relation to how the home managed and supported people with falls. We also found them in breach of regulation 18 in that there were not enough suitably trained staff to meet people’s needs. We found these two breaches to have a high impact on the safety of people in the home and issued a notice to ensure no further people were admitted to the home. At this inspection we found the home had worked to greatly improve falls management and staff had increased to ensure people’s needs were suitably met. We have lifted the restriction on admissions and the home can now safely assess and support further people as deemed appropriate by the home.

At the last inspection we found the home in breach of Regulation 9. We found people’s assessments did not include all the required information to sufficiently meet people’s needs. At this inspection it was noted that all assessments were person centred and up to date. People’s needs were now being met.

At the last inspection we found the home in breach of Regulation 11. We found that consent was not always acquired from people about the care and support they received. We also found people had sometimes given consent on behalf of people when they did not have the authority to do so. At this inspection we found the home had made big improvements in this area. We found everyone had an up to date capacity assessment and consent was acquired from appropriate people, where people were found to lack capacity to give consent themselves.

At the last inspection we also found the home in breach of regulation 13 safeguarding and Regulation 17 good governance. Again we found the home had worked to improve the management of safeguarding situations and that monitoring and improvement planning had much improved.

We found the home was no longer in breach of any of the Health and social Care Act (Regulated Activities) Regulations at this inspection.

We have issued two recommendations following this inspection. One ensuring end of life care was more detailed and the other ensuring staff updating the care plans used all the available information.

At this inspection we found there was a staff team who well trained and motivated to meet people’s needs. Staff had taken on dedicated roles in the improvements at the home and there were staff champions for key support areas. This included champions in areas of care and support in nutrition, dignity, medicines, infection control and safeguarding. This had led to improvements in all of these areas. We also noted most staff was working towards an NVQ with three staff working towards level 5.

People living in the home and visitors all told us how much the home had improved. The environment continued to be developed with focus on supporting and orientating those people living with dementia. We found staff were friendly and clearly knew and respected the people they were supporting. The home’s domestic, catering and maintenance staff all took pride in what they offer to the role and the people in the home. We found activities in the home had improved greatly with focused activities taking place for groups of people and individually for those people who preferred this.

The home received two complaints in the eight months between inspections, they were managed appropriately and information on improvements was shared. We saw from resident and relatives meeting minutes and questionnaires that they were involved with the improvements at the home.

The home completed appropriate monitoring and audits of the service provided and took appropriate action when concerns were identified. The home was taking part in a number of local initiatives to improve outcomes for people in the home including triaged referral services and direct links to telecare and the falls team. We saw this all improved the quality of the service people received living in the home.

The overall rating for this service is Good and the provider has been taken out of special measures.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has a large communal lounge and separate dining room to the ground floor and a smaller shared lounge and dining room to the upper floor. The home can provide residential support for up to 42 people. At the time of the inspection there were 34 people living in the home. The kitchen and main dining area is on the ground floor of the building and both floors are accessible by a lift and stairs. The lack of an upstairs kitchen area is impacting on the quality of provision on this floor and we are assured this will be addressed as soon as possible.

The registered provider is RocheCare (UK) Ltd which also has two other care homes and a domiciliary care agency. RocheCare are currently building a purpose built home to support people living with dementia.

The provider had a registered manager who was registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection the service was rated as requires improvement overall and requires improvement for all key questions except safe which was rated as inadequate. At the last inspection we found the home in breach of five of the Health and Social Care Act (Regulated Activity) Regulations 2014. We asked the provider to send us action plans to assure us they were taking steps to meet the requirements of the regulations. At this inspection we found one of the regulation breaches had been met and the home were no longer in breach of Regulation 19 which is associated with the safe recruitment of staff. We found the home had also met the action plan for regulation 12 and we no longer had concerns with the safe management of medicines. However we found the home still in breach of Regulation 12 – Safe care and treatment, as we had serious concerns around the safe management of falls and were not assured risk assessment and risk management plans were completed as and when they were required. We also had new serious concerns around the staffing numbers and breached the home in this regulation. We took immediate action to assure ourselves people living in the home were kept safe.

When we returned to the home on the third day of the inspection, there were more staff on the rota and proactive action had been taken, to better support people at risk of falls.

At this inspection we identified two further breaches to the regulations than at the previous inspection. These were as identified above in relation to the staffing numbers and we also found people were not safeguarded from the risk of abuse. We found the home had not reported unwitnessed and unexplained injuries to the safeguarding team as required and we also found where people’s movement was restricted it had not been appropriately assessed. This was primarily around people’s access to their own bedroom and being supported on a separate floor to their sleeping accommodation. This had been a concern at a previous inspection and the home was required to understand and implement the principles of the Mental Capacity Act to ensure people were lawfully restricted.

We found the care records were not always consistent in detailing the needs of people in the home. Staff told us they did not always have time to update the records as were needed to support people in the home. Some people were not receiving the support they needed and the information was not available as to how best to support them. This included those people who no longer had a dedicated day and night routine. This aspect of their care and support needs had not been developed. On the third day of the inspection there were more staff and also more terminals for staff to access the electronic care record. This included more hand held mobile devices. This meant there was now a better opportunity for staff to update records. The home had further work to do to ensure they met the requirements of regulations associated with person centred care.

The staff culture at the home had been changed and the home was a more positive place to inspect. We saw staff speaking to people with kindness and respect. Staff we spoke with felt better supported and enjoyed their job. This was evident in the interactions we observed with staff and people in the home. We heard singing and laughing regularly over the course of the inspection.

More work was required to ensure the audit and monitoring system was effective. This included better identification of concerns, more effective action planning and sufficient oversight to ensure actions were met in a timely and productive way. The area manager was aware of the work to be done within the home and was working well with the team at the home. However, the management at the home needed more time to ensure they were completing the action required of them, to drive improvements. The addition of more staff to work with supporting people in the home should ensure the management team are better able to drive and sustain the improvements required.

This is the second inspection within a period of 12 months where one key question remains as inadequate. This was following an initial inspection rated as inadequate overall. The home is making steps in the right direction and now has the key question of caring rated as good. But as a consequence of the remaining inadequate key question of safe the service remains in special measures.

This service will continue to be kept under review and, if needed we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This could lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This action 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, and 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.

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

The inspection took place on the 9 and10 August and was unannounced. This means the home did not know we were coming on the day we arrived to inspect.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has large communal areas on both floors and can provide residential support for up to 42 people. At the time of the inspection there were 35 people living in the home. The kitchen and main dining area is on the ground floor of the building and both floors are accessible by a lift and stairs.

The registered provider is RocheCare (UK) Ltd which also has two other care homes and a domiciliary care agency.

The provider had a registered manager who was registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the last inspection the service was rated inadequate overall and inadequate for three key questions, these were safe, effective and well led. Caring and responsive were rated as requires improvement. At the last inspection there were 10 breaches to the Regulations identified. Seven of these were given requirement notices and three were classed as a greater risk and the provider was issued with warning notices. The Regulations where warning notices were issued were Regulation 12 (Safe Care and Treatment), Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment) and Regulation 17 (Good governance).

The manager in place at the last inspection was not registered with the Care Quality Commission and was removed from post during the inspection. At the time of the last inspection the provider was in the process of recruiting an area manager. As concerns were identified the provider and area manager were very proactive in identifying the actions they were to take to address the issues raised. The CQC raised a number of safeguarding alerts to ensure people were safe. We took assurances by the placement of the area manager and other competent managers in the home, that the risks to people in the home, would be managed going forward.

The provider began recruiting for a new manager as soon as the last one was removed and the manager currently in post has registered with the CQC. Since being in post the new manager has begun work on all of the areas identified as a concern. Some areas have been completed but others require more time to embed to enable us to identify if improvements are sustained. The introduction of a new electronic care planning system and a new electronic medication system have both shown improvements but also identified where more work is required.

At this inspection we have identified the home have met five of the 10 previously breached Regulations. Five of the Regulations remain in breach and a number of recommendations have been made to ensure improvements are sustained.

At the last inspection we issued a warning notice for Regulation 13, (Safeguarding). This has now been met. There are some concerns under Regulation 13 but these do not constitute a breach of regulation and two recommendations have been made. These are for the home to ensure all staff receive prompt training in safeguarding and the Mental Capacity Act and for the home to ensure everyone has a consistent message with regard to locking people’s bedroom doors.

We also issued a warning notice for Regulation 12, (Safe Care and Treatment). There are a number of aspects to this regulation including medication. The home had been in continued breach of the safe management of medication at the last inspection. At this inspection we found a number of steps had been taken to improve medication management including the use of a new electronic medicines system. However there are some issues, which have mostly been newly identified, that have resulted in a regulation breach. At the last inspection we found concerns with systems the home had in place to manage emergencies, these have all now been rectified and action has been taken. Regulation 12 also covers risk assessments. We found at this inspection a set of approximately 20 risk assessments had been completed and were about to be rolled out to the staff. The assessments covered health and safety aspects of the home and specific scenarios for staff and people in the home. With reference to individual risk assessments we found that these were not routinely updated when risks changed and we have set a recommendation to ensure the provider addresses this. We were assured through other developed systems, including the deputy manager twice daily meetings to review people in the home, that risks were managed effectively.

At the last inspection we found breaches in Regulation 10 which promotes people’s dignity and respect, Regulation 14 which ensures people receive enough nutrition and hydration and Regulation 16 which ensures complaints are managed. We found the home was now meeting these regulations.

At the last inspection we found there was not enough suitably trained staff to meet the needs of people living in the home. At this inspection we found staffing had increased and the home had taken steps to ensure everyone completed an immediate induction to the role. We have found the provider has met this regulation but steps should be taken to ensure the dependency tools used to identify the staffing levels are reviewed and changed as people’s needs change. We have also recommended the home’s training schedule is reviewed, to ensure the frequency of training is relevant and allows for changes in the regulations and best practice guidance.

We also issued a warning notice at the last inspection for Regulation 17 which addresses Good Governance. It was found at the last inspection that there were not any methods to identify and manage poor quality. Audits and monitoring systems were not used and there were not any routes for feedback, for the home to assure itself, people were happy with the service they received. At this inspection we found the home had taken steps to address these concerns. Questionnaires had been developed and distributed, the home manager had resident meetings and an open office evening and the activities coordinator assessed people’s satisfaction. We also found a new suite of audits had been developed and were being used monthly and quarterly and the new area manager also completed an audit. However, these audits had not had time to embed and they had not identified some of the concerns we found during the inspection. At this inspection we also found there was an issue with how records were kept and maintained. This was primarily because a number of new systems and records were now being used and as above they had not had time to embed. The system required further thought and evaluation to ensure it continued to satisfy the needs of the Regulation. For this reason we have found a continued breach in Regulation 17.

There were three further continued breaches in Regulation 11 (Consent), Regulation 9 (Person Centred Care) and Regulation 19 (Fit and Proper Person’s Employed).

We found the home had not appropriately completed assessments on people’s capacity and as such had not acquired appropriate consent.

The home had taken steps to ensure people’s primary needs were met but more work was needed to ensure people were supported specifically for their individual needs. People at the home were living with some form of dementia. The home needed to assess people’s specific needs in this regard and ensure those needs were met. This would require additional training for staff at the home to best meet people’s needs. We have also recommended the provider reviews current best practice guidance for the environment to ensure it best meets the needs of people living with dementia.

The final regulation we found the home to be in continued breach of was Regulation 19. We found the home had not always acted on information they received in respect of employees in an appropriate way. We saw the manager started to take action on this on the day of the inspection but this needed to be completed routinely and embedded in the homes recruitment and retention procedures.

At the last inspection the home had an overall rating of inadequate and was placed in special measures. After six months we have re-inspected and one key question remains as inadequate. As a consequence the service remains in special measures.

This service will continue to be kept under review and, if needed we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This could lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This action 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

The length of this inspection is unusual and should not be expected again. As explained throughout this report and to the providers during the inspection; the length of this inspection was deemed appropriate due to the circumstances of the findings during the first two days of this inspection.

At the last inspection in February 2014 the provider was found non-compliant with the regulation around the safe handling and administration of medicines. An action plan was sent to the Care Quality Commission to say how the provider would meet this regulation and we took a specialist advisor who was a pharmacist with us on the 17th of November 2015 to ascertain if the action plan had been met. We found approximately half of the action plan had not been met including an increased and more structured format for audit and improvement. Over the course of the inspection the provider took steps to meet the action plan but there were ongoing concerns regarding the suitability of audit and improvement systems.

Coniston House is a large, two storey purpose built detached property in Chorley. The property has large communal areas on both floors and can provide residential support for up to 42 people. At the start of the inspection there were 39 people living in the home. The kitchen and main dining area were on the ground floor of the building and both floors were accessible by a lift and stairs.

During the first half of our inspection process the home had a manager in post. However they were not registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, Registered Managers are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. We found the manager in post at the start of our inspection had not fully understood their role in ensuring services met the regulations of the Health and social Care Act 2014. We found we were misled at the beginning of the inspection by the manager. This made our initial findings inaccurate and we were unable to use the evidence to support the home was meeting the regulations. This included being told information was available when it was not and actions had been undertaken and when we sought clarification and corroboration we found they had not been completed. The provider removed this person from post following feedback during the inspection and took immediate steps to ensure the service had suitable management cover until a full time manager could be appointed and register with the CQC.

During the first two days of the inspection we found a number of serious concerns. We saw there were not enough suitably qualified members of staff to meet the needs of people living in the home. We discussed this with the provider on day three of our inspection as only the manager was available prior to this point. We discovered the rota was not being covered when people called in sick and the homes dependency tool had not been used for some time to ascertain if there was enough staff. The provider immediately increased the staffing numbers for the home following our discussions with them.

During the first two days of the inspection we saw all people were being taken down to the ground floor lounge. This meant a number of people who were vulnerable were restricted to a relatively small part of the home. We found incidents of verbal and physical abuse had become normalised and staff and other people were the victim of this type of abuse. We found the home were not adequately safeguarding all those who lived in the home. We found when the staffing increased both floors of the home began to be used and this decreased the risk of incidents. However we continued to find until the end of our inspection that the provider were not reporting and responding incidents and accidents appropriately.

During the inspection we found concerns that required immediate action to ensure people were safe. This included an increase in staffing numbers and applications to be made under the deprivation of liberty safeguards to ensure people who lacked the capacity to make their own decisions were not restricted unlawfully. We found the provider was proactive in taking the steps required to address these two concerns once the manager had been removed. However there were a continued number of restrictions made to people including locking of bedroom doors without proper assessment and consents.

Over the course of the inspection we saw the home was using different care planning systems. Initially we found this put people at risk of their needs not being met. This included people who had lost significant amounts of weight not being supported to ensure they did not become malnourished. People who required specific types of support as identified within the social workers pre assessment information wee not being supported to ensure these support needs were met. This included specific skin conditions and a requirement to monitor one person’s calcium and vitamin levels. Where we saw specific risks we raised safeguarding alerts with the Local authority to ensure people were kept safe.

Over the course of the inspection the provider made the decision to revert back to paper records. This was done to ascertain if all staff were going to be able to become confident in the electronic records before they began using them to support people. On the last day of our inspection we were given a list of names of people whose care plans had been updated in their paper records and were an accurate record of peoples support needs. We reviewed four of these records and found this was not the case. We acknowledged that with the support of social workers from both the review and safeguarding team’s staff were aware of people’s current needs. With this supply of additional records and support mechanisms people’s needs were mostly being met. However the provider did not currently have an accurate record of assessments or care plans completed and used by the support staff within the home. This left a risk that people’s changing needs would not be met.

We found breaches within 10 of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included concerns over how the home monitored food and fluid consumed by those people at risk of malnutrition, how the home managed health and safety checks within the building and ensured people were safe in the event of infectious diseases including gastroenteritis. We were also concerned with how staff had recently been recruited to the home and how staff were supported once in role at the home. This included a recent potential recruitment where an application form was not used and key information around the suitability of a candidate was not gained by the employer.

The home was a service where all people living there had a diagnosis of dementia. We found it particularly concerning that on the first day of our inspection, few staff knew the principles of the Mental Capacity Act 2005 (MCA) Over the course of the inspection some training was provided but further work needed to be done to consolidate the learning and bring it into practice at the home. The home had documents for gaining people’s consent. However these were not completed in the files we looked in. Nor had anyone been assessed formally under the capacity assessment to determine if they were or were not able to give their consent to specific decisions. Over the course of the inspection we saw some staff asked people for their consent before delivering interventions but most staff assumed people were not able to give consent and provided direction rather than giving people choice.

We noted within people’s files that information regarding people’s use of glasses, hearing aids and dentures was available but we did not see comprehensive evidence that staff were aware of who wore which pair of glasses. On the first two days of the inspection we found nine pairs of glasses unaccounted for in the staff room.

A complaints procedure was not available during the first two days of our inspection but by the last day we saw the procedure was clearly available on notice boards and a new copy had been developed for the resident information pack.

The home did not have an embedded system of quality audit and improvement. Over the course of the inspections systems had begun to be developed and we could see steps had been taken to identify themes and trends in falls and other incidents. However this work was not yet embedded to establish the improvements it would make in keeping people safe and reducing the risk of falls.

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 improve

Care plans were in place and regular reviews were recorded. The majority of care plans we viewed were person centred and provided clear guidance for staff to follow. Personal profiles had been drawn up, giving good information regarding the individual's history, abilities and preferences. We saw that when issues were identified care plans had been updated to reflect the changes.

However we found some inconsistencies regarding pre admission assessments, risk assessments, care planning and the support people received.

The relatives we spoke with provided positive feedback about the care provided at Coniston House. Comments included; 'It is a lovely place. I have no complaints. The staff are very good.' And 'Everything is going very well. I am extremely satisfied.'

There were short falls regarding staff training, written guidance and reporting practices regarding adult protection. Safeguarding arrangements need to be strengthened.

During this inspection we found that the home had made the required improvements.

The manager monitored care plans and risk assessments to ensure these were regularly reviewed and updated. Regular reviews helped to ensure that changes were identified and responded to.

The relatives we spoke with were satisfied with the standard of care at the home. Comments included; 'Everyone is very helpful.' And 'The move here was handled well. We have no complaints.'

Medication management had improved. Some people were prescribed medication to be taken when required, such as for pain relief or constipation. There was now written guidance to advise staff when this should be given. This helped to promote consistency of use and ensured medication was given when needed.

The quality of the service was being monitored. Audits and checks highlighted areas for improvement and action was then taken to address any shortfalls.

People told us their health needs were being met. One person living at the home told us, 'When I was ill in bed they kept an eye on me. The staff kept popping in. They are very good.' The relatives we spoke with told us they were kept informed of important events.

There was a need to strengthen the care planning and review process. Although there was no evidence that people's needs were not being met, the current arrangements did not ensure that full, thorough and regular reviews of people's needs were carried out.

We found that medication practices needed to improve. People were not fully protected against the potential risks associated with medicines.

The induction and training of staff helped to ensure staff were equipped for their role. Staff meetings and individual staff supervision sessions provided good opportunities for staff to share their views. Staff told us 'We can go to the manager or the deputy with anything.'

At the last inspection we identified some areas of non compliance and we saw that some improvements had been made. However there were still elements of the action plan outstanding. Improvements to the quality of the service had not been made in a timely manner.

A comprehensive complaints procedure was available. Records were kept of any complaints received and the action taken. Systems were in place to promote learning and service improvement from complaints.

The majority of relatives we spoke with were satisfied with the quality of care provided.

The relatives we spoke with were generally satisfied with the quality of the service. We were told that staff were polite and friendly and that relatives were kept up to date with any changes or health problems.

Staff told us they had good information about the needs of those they cared for and they received good support from the manager and senior staff.

We saw people were treated with respect and there was good information about each person's past life, which helped the care staff to get to know them, their past skills and interests.

We found some inconsistencies regarding assessments, communication and responding to changes which could result in people's needs not being fully met. Improvements could make meal times a more enjoyable social experience.

Medication arrangements needed to be improved and we saw some risks at the home that had not been identified or made safe. Quality monitoring was not effective.