Bell House Care Home Limited

Bell House Care Home Limited is a residential care home providing personal care to people aged 65 and over. The service can support up to 24 people.

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

Medicines were not always managed safely. People did not always get their medicines as prescribed. Records for topical medicines were not completed correctly. Where issues were identified in the home’s stock record system, action was not taken to investigate this.

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 18 June 2021). At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced targeted inspection of this service on 13 April 2021. We undertook this targeted inspection to check whether the management of medicines at the service had improved. We found sufficient improvement had not been made to meet the legal requirements.

Enforcement

We have identified a continued breach in relation to the management of medicines.

Follow up

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

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Bell House Care Home Limited on our website at www.cqc.org.uk.

Bell House Care Home Limited is a care home providing personal care to 14 people aged 65 and over at the time of the inspection. The service can support up to 25 people.

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

Overall improvements were seen at this inspection. We found some areas where further improvements were needed.

Staff were not always wearing face masks correctly. The premises were clean and tidy.

Repositioning checks were not fully documented, although people’s skin integrity was not a concern at this inspection. We have made a recommendation around the provider adding repositioning checks to ensure their records are fully completed.

Improvements were still needed to the living environment. The provider had a rolling programme of refurbishment due to start in January 2022.

Risks to people had been identified and acted on. Improvements had been made in managing risks to people, the safe management of medicines, staffing levels and systems of oversight.

People and relatives agreed the home provided a safe environment where people were protected from harm. Safeguarding records supported this.

The manager responded to all types of feedback and where improvements were needed, they took action in response.

A regular system of audits was used to identify actions which we could see were followed up. We saw oversight from the nominated individual.

There was a positive culture in the home. Meetings for people and staff were taking place. Satisfaction surveys had been sent out and acted on by the manager.

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 19 June 2021) 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 we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 17 February 2021. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bell House Care Home Limited 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 COVID-19 and other infection outbreaks effectively.

This service has been in Special Measures since 19 June 2021. 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.

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.

Bell House Care Home Limited is a residential care home providing personal and nursing care to 15 people aged 65 and over at the time of the inspection. The service can support up to 24 people.

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

There was not sufficient staff available to meet people’s care needs in a timely way. Staff were not always suitably skilled. We found concerns relating to fire safety because not enough staff had received fire safety training. This was resolved following the inspection. Safeguarding procedures were not always followed. The building had not been well maintained, which presented issues relating to the safety and cleanliness of the environment.

There was not adequate management support during our inspection. Quality assurance systems were not effective at monitoring the quality and safety of the service. There were concerns relating to the providers oversight and management of the service. Staff did not always feel supported and listened to by the provider.

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

Rating at last inspection

The last rating for this service was Good (published 15 March 2019).

Why we inspected

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

We received information in relation to safeguarding concerns. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

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

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

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to staffing, safeguarding, maintenance of the building, governance and safe care.

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

Follow up

We will request an action plan 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.

Special Measures:

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

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

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

People’s experience of using this service:

At our last inspection we were concerned there were not enough staff to care for the needs of the people living there at the time. At this inspection we found there were enough staff and there was an improved system for assessing people’s needs before they came to live at the home. This ensured the provider could meet those needs within the staff complement. The provider advised they would keep staffing levels under review as the number of people living there increased.

Staff understood how to manage any risks to people and knew the processes to follow to manage any allegations of abuse. People’s health care needs were well managed, and they received their medicines when they needed them.

Staff had been recruited safely to ensure they were appropriate to work with people at the home. We found the service was clean and tidy which helps to protect people from the risk of infection.

People were supported by staff who received appropriate training and support to carry out their roles and responsibilities. Staff felt supported by the management team.

People received adequate food and drink which supported a healthy and balanced diet. Some aspects of the dining experience could be improved through better deployment of staff. People's likes and dislikes were accommodated within menu planning. The provider ensured that people were referred to healthcare professionals as required.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were able to make choices and were involved in decisions about their care. Staff asked people for consent before providing care.

At our last inspection, we found care records lacked essential information to guide staff to care for people. We found improvements had been made and were ongoing. Care plans were person centred and reflected people's current needs and preferences.

People and their relatives gave mixed feedback about the range of activities which took place in the home. This ranged from concern about the lack of activities throughout the day, to people being content with what was on offer. By our second day of inspection, the nominated individual confirmed they had appointed an activities coordinator to develop this area of care.

A complaints procedure was displayed. People and relatives knew how to raise concerns and those we spoke with during our inspection were confident these would be dealt with appropriately.

The provider had introduced the post of deputy manager at the home. This role freed up the registered manager’s time to undertake management tasks. The deputy manager supported staff to develop and had taken responsibility for the development of staff.

The provider and managers were committed to continuing to make improvements at the service to improve the lives of the people who lived there. There had been an improvement in audits which meant they were now identifying where improvements were required. The provider was seeking advice and guidance to ensure they provided a service which followed current best practice to ensure they met the regulations.

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

Rating at last inspection: Requires improvement (report published 24 August 2018)

Why we inspected: to check the service had made the improvements required following on from the last inspection 7 June 2018.

Follow up: We will continue to monitor the service to ensure that people received safe, high quality care.

Bell House 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.

The care home accommodates 24 people in one building. There were 15 people living there permanently at the time of the inspection and a further four were staying there on a temporary basis.

There was no registered manager in place. The previous registered manager had left the service in June 2017 and a new manager had been appointed in November 2017 and had applied to register. 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.

Medicines management was safe and we observed medicines were administered appropriately during our inspection.

Risk assessment and risk management plans had been an issue at our last inspection. We found in some areas this had improved, but at this inspection, we found some areas of risk had not been considered. This put people at risk as it meant staff had not minimised harm to the person.

People living at the home and some of their relatives told us there were times when staffing levels were insufficient. This meant people did not always get an immediate response when they asked for support. Staff told us certain times of the day were busy and they acknowledged a recent increase in new people at the home had affected the time they had to support people.

We found all the areas of the home we inspected were clean which ensured the risk of infection was minimised. The registered provider continued to upgrade the environment internally, with new carpets, doors and decoration of the home.

We found some decision specific capacity assessments had been carried out for people, which were compliant with the Mental Capacity Act 2005 (MCA). However, not everyone who needed a capacity assessment had this in place and not all best interest meetings had taken place to ensure the home was meeting the requirement of the MCA Code of Practice.

People had been referred to other health professionals when the need arose and we saw this had positively affected people’s wellbeing. We received positive feedback about the service from a visiting health professional. However, we also found occasions when professional advice had not been sought promptly.

We observed staff were very kind and caring when they were supporting people with care. People at the home and their relatives told us how kind and helpful some members of staff were and how they treated people with dignity and respect. However, following the inspection we were advised of a situation where people had not been supported with dignity.

Some records contained person centred information detailing people’s life histories, preferences and choices. However, other records lacked detail and were incomplete in this area. We found care plans did not always evidence people’s current care needs.

We found there had been a lack of strong leadership at the home. Not every area of care had been audited in enough detail to determine the quality of the service provided. Where audits had been completed and actions identified, it was not always clear improvements had been sustained as we found similar issues recurring.

Some areas of quality monitoring were effective such as environmental checks and improvements to the environment. The registered provider utilised external companies to maintain equipment and for their servicing arrangements. However, there had been a lack of overall assessment and monitoring of the quality of the service provided to people. The systems and processes were not robust enough to ensure full compliance with the regulations.

We found the service was in breach of several regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Bell House is registered to provide personal care and accommodation for up to 24 older people. The accommodation is single storey and all bedrooms are single rooms some with en-suite toilet facilities. There were 22 people living at the service at the time of our inspection.

There was a registered manager in post who had been in post since 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the registered provider had initiated many improvements at the service. This included the regular supervision of staff, and an improvement in training and competency checks particularly around moving and handling and medication administration. The environment had been further enhanced and a programme of refurbishment was on-going. The registered manager and registered provider undertook regular audits at the home, and these had improved from our last inspection, although we still found some of these audits lacked robustness as they had not picked up isolated issues we found when reviewing care plans, which had the potential to cause harm, such as one fall had not been analysed to ensure risk reduction measures could be implemented, and one person had not been assessed for suitable shower equipment. Record keeping and the detail in people’s care plan on the whole had improved and reflected people’s care needs. Staff were more accurately recording when care had been provided.

Staff had received training in how to keep people safe. All the staff we spoke with demonstrated they understood how to ensure people were safeguarded against abuse and they knew the procedure to follow to report any safeguarding incidents. The home had a training programme in place to ensure staff had the knowledge and skills to perform in their role and this included specific areas of learning such as oral health. Staff had received practical moving and handling training and had their competencies checked.

There had been occasions when staffing numbers were not in line with the registered provider’s assessment of staffing levels derived from the dependency tool in use. The home was actively trying to recruit more staff but was struggling to recruit staff with the required values and behaviours.

Standardised risk assessments had been undertaken for those people at risk of malnutrition and pressure sores. The home completed risk assessments when other risks such as choking, medication, fire and falls had been identified. Moving and handling risk assessments and care plans had improved from the previous inspection although further improvements were needed in the amount of detail required to guide staff.

We reviewed accidents and incidents at the home and noted the analysis of accidents and incidents had improved since the last inspection and there had been management overview to determine the root cause of accidents and some measures put in place to prevent further accidents. However, we found one accident where staff had completed the form but not passed it to the manager to ensure all preventative measures had been considered or recorded.

Medicines were stored and administered safely and we observed medicines being administered appropriately during our inspection.

We found the environment was still in the process of refurbishment and to a high standard in most areas. However, one of the corridors leading to the bedrooms was narrow and not ideal for wheelchair users. The communal lounge lacked space to manoeuvre and when everyone was seated there was no space for visitors or staff to sit and chat with people. The home was extremely clean with good infection control practices in place.

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 Staff had received training on the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards, but we still found the registered manager’s understanding on how to assess mental capacity, and the best interest process was lacking. This was not having a major impact on the people living there who all but one had mild cognitive impairment and could consent to their daily care requirements.

People told us they enjoyed their meals. The home had been awarded the Kirklees Healthy Choice Gold Award for being committed to good standards of food hygiene and healthy options.

We found all the staff to be caring in their approach to the people who lived at Bell House and observed they treated people with dignity and respect and they clearly knew the people they supported. The home had received compliments from relatives who praised the care provided at Bell House.

People were provided with care which met their choices and preferences such as what time they got up, went to bed, what they ate and they were encouraged to share their views on how they wanted the service to be run. We found handover records and night check information had improved and was reflective of people’s needs.

The management involved staff, people using the service and their relatives to inform developments at the service and staff spoke highly of the management team who they described as supportive.

There was no activities coordinator in post although one had been interviewed and was awaiting employment checks to be completed. This meant the home was not consistently ensuring meaningful activities for people at the service at the time of our inspection.

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

Bell House is registered to provide personal care and accommodation for up to 24 older people. The accommodation is single storey and all bedrooms are single rooms some with en-suite toilet facilities. There were 22 people living at the service at the time of our inspection.

There was a registered manager in post who had been in post since 2014. 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.

Staff had received training in how to keep people safe. All the staff we spoke with demonstrated they understood how to ensure people were safeguarded against abuse and they knew the procedure to follow to report any safeguarding incidents.

The service was using risk assessments for nutrition and pressure care management and had put risk reduction plans in place for these risks, but we could not find evidence in the files we looked at that all risks had been identified and reduced. The assessment of risk in the home’s risk index did not correlate with the associated care plan to ensure risks were well managed. The moving and handling risk assessment and care plans lacked detail and the falls risk assessment did not accurately identify a person’s risks and measures were not put in place to reduce the likelihood of falls in line with national good practice.

We found the analysis of accidents and incidents was poor as the information collated lacked description and the management overview to determine the root cause of accidents and their analysis was minimal and inaccurate. The lack of detailed analysis of accidents and the lack of detailed risk assessment to manage all the risks for the people who lived there demonstrated a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found medicines were stored and administered safely and we observed medicines being administered safely and professionally at the home.

We found the environment was in the process of refurbishment and to a high standard in most areas. However, the corridors leading to the bedrooms were narrow and not ideal for wheelchair users and the communal lounge lacked space to manoeuvre. The home was extremely clean with good infection control practices in place. They had recently been inspected by the Infection Control Team and had attained a high score.

Staff had received training to ensure they had the knowledge and skills to perform in their role in some areas, and the service encouraged staff to enrol in national care qualifications. However, the service could not evidence staff had received practical moving and handling training or had their competencies checked. Staff supervision was not up to date and the service was not meeting its own policies in relation to the frequency of supervision. This breached Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as there was a lack of evidence to demonstrate staff had the training, competency and supervision to provide safe care and treatment.

The service was meeting its legal requirements under the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. Staff had received on line training in this area, but we found they lacked understanding on how to assess mental capacity, although this was not having an impact on the people living there who had mild cognitive impairment and could consent to their daily care.

People told us how much they enjoyed their meals. The home had recently been awarded the Kirklees Healthy Choice Gold Award for being committed to good standards of food hygiene and healthy options.

We found all the staff to be caring in their approach to the people who lived at the service and treated people with dignity and respect. Staff knew the people they supported very well and were keen for people to feel they were at home at Bell House. We observed staff to be kind and compassionate throughout our inspection. People living there told us staff were caring. Their relatives spoke highly of the care provided at Bell House.

People were offered choice in their lives including what time they got up, went to bed, what they ate and they were encouraged to share their views on how they wanted the service to be run in line with their own preferences. In relation to recording practices, we found the home utilised care plans which identified people’s needs and how to support them. The service recorded each section had been reviewed every month, however, we noted these reviews did not highlight people’s changing needs and entries in people’s daily logs did not correlate with their care plans. We found handover records and night check information was not accurate or reflective of people’s needs.

The service involved staff, people using the service and their relatives to inform developments at the service including improvements around developing activities to ensure meaningful activities for people at the service. Staff spoke highly of the management team who they described as supportive.

The home had robust auditing systems around cleaning and maintenance of the equipment and the environment. However, we found some of the governance audits had not been robust enough to identify issues with the assessment of risks, moving and handling assessment and recording, the analysis of accidents and incidents and the supervision and monitoring of staff performance. Care plan audits had not found the discrepancies between daily logs and the care plan records. The audits focussed on the paperwork being in place rather than the information being of good quality to inform progress and drive up quality at the service. These demonstrated a breach in Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The service is not safe. On the previous inspection we raised concerns with the provider about some of the windows in both communal areas of the home and peoples bedrooms not having restrictors in place. On this inspection we saw the provider had put some restrictors in place however, some windows still did not have restrictors in place. This meant people were not safe.

We received an action plan telling us actions would be taken to ensure safe management of medicines within the home. For example, the provider told us they would be carrying out weekly and monthly audits of 'as required' medicines. We found weekly audits were being carried out. The manager showed us evidence of both weekly and monthly audits being carried out and also 'spot checks' they had conducted on a weekly basis. This meant the home had safe systems in place regarding medicines.

We saw people living at the home were unsupervised by staff for periods of time. This was despite most people sitting in the main lounge of the home. We also saw there were people sitting in the lounge area of the home who did not have a call bell to use to summon assistance.

Is the service effective?

The service was not effective. The home did not promote a good quality of life for the people that lived there.

We saw audits had been carried out but we were unable to see evidence of how the required actions identified had been followed up. We also saw one of the quality audits completed by the manager did not include evidence to show how their findings had been reached. For example, we saw 'Respect client's right to privacy' was ticked as met. We had discussed the full length glass panelled doors on people's bedrooms with the manager and how this impacted on people's privacy. The manager agreed that these needed replacing. We saw this had not been reflected in the audit. This showed that quality audits in place at the home were not effective.

We looked at two people's care records and saw there were gaps in assessments which impacted on how care was delivered to the person concerned. For example, in one person's dependency assessment we saw it did not identify how many staff were required to support the person. We also saw some care plans lacked detail which meant people were at risk of receiving care that was not personalised. For example, in one person's care plan for hygiene we saw there was no detail regarding the person's preference of a bath or shower, or the toiletries they liked to use.

We saw the home had not obtained consent from a person who had bed rails in place. We also saw an assessment of the person's mental capacity had not been carried out. This showed the home did not follow guidance under the Mental Capacity Act 2005.

Is the service caring?

The service was not caring. We looked at the care records of a person who had received palliative care at the home. We saw documentation in the person's daily records, handover sheets and the communication book in place at the home which identified the person was, at times, in a lot of pain. We looked at the person's medication administration record (MAR) and saw the person had not received appropriate pain relief as prescribed by their GP. The provider and the manager told us they were not aware of the person being in pain.

We also saw another person had continued to lose weight and the home had not taken action to prevent further weight loss.

Is the service responsive?

The service was not responsive. People who needed additional support with their healthcare needs from external professionals did not always receive their support in a timely manner. For example, we saw a member of staff who was new to the home had reviewed the care records of one person. They told us they did not know the person and had not been involved in the persons care. We saw the person had lost weight in the last two weeks and in their care plan the new staff member had written 'No changes at present, review monthly'. This meant the issue of weight loss had not been identified and therefore the person was at risk of further weight loss.

Is the service well-led?

The service was not well led. People were not protected against the risks of inappropriate or unsafe care because the provider did not have effective systems to assess and monitor the quality of the service people received. The leadership and management at the home did not assure the delivery of high quality, person centred care. We have asked the provider to make improvements.

The provider had told us through their action plan that they would be reviewing and updating all of their policies. However, we saw this had not been done. We found photocopied policies from another service owned by the provider had been put into the policy file. This showed the provider had failed to review and update the policies. This meant the policies in place at the home were not appropriate to the service.

We spoke with staff following our inspection and they told us they did not feel supported by the provider. They also told us that following our last inspection the provider had not put system in place to ensure staff were able to access support and discuss their concerns without being worried about losing their job. Staff told us the provider often said 'If you don't like the way things are you know where the door is'. They also told us their views were not always taken into consideration. This suggested the home did not promote an open and fair culture.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people living at the home, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The service was not safe. People were cared for in an environment that was not clean. We found people were not being protected from the risk of infection because appropriate guidance had not been followed. We observed staff did not wear correct personal protective equipment when caring for people. We found the provider did not have proper risk assessments in place to ensure the health and safety of people living at the home, staff and visitors. When we looked around the home we were concerned that the windows did not have restrictors in place to limit how wide they could open. We looked at the arrangements in place within the home for managing medicines. We found people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. We have asked the provider to make improvements. There were not enough staff on duty to meet the needs of the people who lived at the home.

Is the service effective?

The service was not effective. The home did not promote a good quality of life for the people living there. We looked at six peoples care records and saw their needs had been assessed before they moved into the home. However, when we looked at care plans which had been developed, we found these did not include up to date information regarding people's care needs. For example, one person who was being nursed in bed did not have a care plan in place for this. This meant there was no information available to staff on how to care for the person.

One person's relative told us, "It's very homely. The care has been good, our relative is not unhappy at all. Since they came in here they have got better. This home is as good as I've seen." However, staff had not received appropriate training to meet the needs of the people who lived at the home. Staff we spoke with were not aware of how best to support people living with dementia. We have asked the provider to make improvements.

Is the service caring?

People were supported by kind and attentive staff who obviously knew people well. We saw that care staff were patient and encouraging when supporting people.

We spoke with the relatives of two people who all told us they were very happy with the care provided at the home. One person's relative told us, 'She seems to like it here and she's doing better than she was at home. She would enjoy playing dominoes and socialising more, there isn't a lot going on for people here.' The relative of another person told us, 'The staff here are always friendly.'

The staff we spoke with told us they felt they all did their best but they felt unsupported by the provider. They told us when they raised concerns these were ignored or they were shouted at. One staff member told us "I have left work and cried sometimes. It's so stressful. The provider does not listen. I have wanted to leave but I really care about the residents."

When we looked around the home we saw people's bedrooms had been personalised and contained personal items such as family photographs. However, we saw that some areas of the home required repair and updating. For example, in one person's room we saw bare plaster behind their bed. In one of the corridors we saw several breaches in plasterwork on the walls. We spoke with the provider about this who told us they did not have a maintenance programme in place.

Is the service responsive?

The service was not responsive. We saw several documents within the care records which had not been completed. These included risk assessments, care plan reviews and other assessments. For example an 'Activities of daily living individual assessment' document was within all six records we looked at. This gave the opportunity to identify people's preferences, interests and life histories. We saw this document had not been completed. We also saw in all six records we looked at, the care plans in place for each person were the same with the person's name entered in a blank space. For example, care plans for medication, nutrition and pressure care were the same for all four people. This meant the care, treatment and support provided at the home was not individualised or person centred.

Care and support was not always provided in accordance with peoples' wishes. People's preferences, interests and diverse needs were not taken into consideration. For example we found people were not receiving baths and showers in accordance with their documented preferences. This meant peoples' needs were not being met.

Is the service well-led?

The service was not well-led. People were not protected against the risks of inappropriate or unsafe care because the provider did not have effective systems to assess and monitor the quality of the service people received. The leadership and management at the home did not assure the delivery of high quality, person centred care. We have asked the provider to make improvements.

The home manager told us they had been in post since April 2014. Staff we spoke with told us they felt well-supported by the new manager. One of them said, 'The manager is really lovely; very approachable and encouraging.' However, in the time period between our second and third inspection the manager resigned from their post.

We spoke with eight staff during our inspection and six of them told us the provider was unsupportive and did not listen to them. One staff member told us "We do not have the correct training for our role. We were shown how to use a hoist and use a slide sheet. The provider told us that was our moving and handling training." Another staff member we spoke with told us they had only had one session of supervision since they started working at the home. We observed a lack of organisation and direction of staff. Staff told us they were not always clear about their responsibilities and they said their views were not always taken into consideration. This suggested the home did not promote an open and fair culture and did not support learning and innovation.

We spoke with two staff, including the manager and one person who used the service.

We observed and heard the staff speaking with people in a respectful manner.

Staff had received up to date movement and handling training on the use of hoists and hoisting equipment.

Arrangements were in place to ensure that repairs and the maintenance of the premises were carried out in a timely manner.

We found the care records were up to date and people were receiving their care as planned. We also saw the care records were kept securely and could be located promptly when needed in line with the Data Protection Act 1998.

People told us that they enjoyed living at the home and we saw evidence in the documentation we looked at that people were involved in making choices and decisions about their care.

We saw information in the care records that people had access to health care professionals and this included doctors, district nurses and chiropodists. This shows that people's health care needs were being met.

Most of the staff were observed to speak with people in a respectful manner however; some staff did not. A compliance action has been made and the provider has been asked for evidence as to how they intend to address this.

There were enough qualified, skilled and experienced staff to meet people's needs.

Arrangements were not in place to ensure the decorative condition and maintenance of the home were carried out in a timely manner.

We found the records were kept securely and could be located promptly when needed in line with the Data Protection Act 1998. However, we also found that one of the four care plans inspected was not up-to-date. A compliance action has been made.