Rydal Care Home

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

People told us they felt safe, and staff were very kind but at times staff were stretched, particularly at night. There were enough staff on duty during the day and once the registered manager increased levels on a night, so there were always 9 staff on duty. The area manager confirmed the increase to the numbers of staff at night would be maintained.

Staff had received training around the Mental Capacity Act 2005 and associated code of practice and staff use of capacity assessments and ‘best interests’ decisions had improved. At times though the capacity assessments did not match the information in care plans and did not set out what actions staff had taken to understand if the person was able to make decisions for themselves.

Improvements to the recruitment process had been made since the last inspection, but the registered manager needed to ensure there was a more robust review of information supplied on application forms and ‘Right to Work’ records were up to date.

The assessments were intertwined in the care plans, and this made it difficult to gain a rounded understanding of people’s needs and the main areas they needed support with. These did not always give information about the rationale for admission and, for the step-down units, why the person was there. Risk assessments were in place, however at times the tick box ones did not lead staff to provide information on how to mitigate these risks.

Staff had received mandatory and condition specific training. Staff supervision sessions were regularly completed, as well as spot checks and competency assessments. Medicines management was now effective. Staff who administered medicines had the appropriate training.

People received nutritious meals and catering staff had successfully completed a variety of training around supporting individuals to maintain a healthy diet. Measures were in place to ensure staff knew how associated risks such as choking were to be managed.

Maintenance of the building had improved. Staff adhered to COVID regulations and procedures.

The management team had further developed their governance system and this now more effective at identifying issues. The management team had ensured lessons were learnt when things did not work so well. In general staff found the manager was more responsive when issues were raised and addressed these in a timely fashion.

Relatives found their views were taken on board and they were asked their opinions. Many had taken the time to give positive feedback to on-line websites gathering views about care homes. Staff were passionate about providing good care outcomes and took ownership for their practice.

Rating at last inspection

The last rating for this service was requires improvement (published 22 April 2022).

At the time we found the service was in breach of regulation regarding medicine management, delivery of safe care and governance systems. 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

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

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

This report only covers our findings in relation to the key questions safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Follow up

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

Rydal Care Home is a nursing home registered to provide accommodation for up to 60 people. The home has three floors and specialises in providing care to people living with a dementia. At the time of this inspection 31 people were living at the service.

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

We found risk assessments needed to clearly set out the actions staff should take to minimise risk. They were not consistently updated and did not always lead to the formulation of a care plan to meet specific needs. Assessment information from social workers was not always pulled through to the home's assessment records and care plans/risk assessments. Some information contained in care records was contradictory and either at times inaccurate or not there when it should be.

No information was available in the main care record files to demonstrate people's capacity was considered or 'best interests' decisions made. The registered manager told us these documents had been stored in a different file and would be immediately transferred to the care records. Medicines including controlled drugs were not always managed safely across the home. On the whole COVID-19 guidance was being followed.

We looked at people’s recent moves to different parts of the home and found no evidence in files to show these had been agreed by people with capacity, done under 'best interests' decisions for people who lacked capacity and discussed with relatives. Relatives said they had been told people would move and it had not been a joint decision. People who used the service told us they had not been given an option to stay where they were and felt they were forced to move.

Maintenance of the building had not always been effective. Problems with lack of water to areas of the home and toilets not flushing had been resolved during the inspection.

The overwhelming view from staff was the management style needed to improve. Staff felt there was no point raising concerns as either no action was taken, or some felt repercussions would occur if they did.

A staff member had been initially employed as a care assistant in December 2021 and then promoted to a clinical healthcare assistant practitioner (CHAP). They were not a qualified CHAP. The area manager had not appreciated this would be a problem. The audits had not identified the fact the recruitment systems had not always ensured staff checked the suitability, experience and qualifications of people applying for posts.

Overnight staffing regularly ran below what was recorded on the rota as the number of staff in the building. For example, it would be recorded in the final total there were six staff on duty where in fact only five people were on shift.

The governance systems, which had been put in place at the last inspection continue to be actively used by the company directors. However, the existing paper audits used at the home did not assist the registered manager or staff to critically review the service and identify areas for improvement. This led to gaps in practice being missed such as those in medicine management and care records.

People and relatives felt the home was safe. They commented on how staff were able to provide kind and compassionate care. Relatives told us they had a positive relationship with the registered manager and staff. They did note a marked difference between the two staff teams with one being friendlier than the other and found at times issues they raised were either not addressed or if they were the issue quickly returned.

Staff we spoke with were very passionate about providing good care outcomes.

Rating at last inspection

The last rating for this service was requires improvement (published 25 May 2021).

Why we inspected

The inspection was prompted in part due to concerns received about the management and operation of the home. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

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

Enforcement

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

We have identified breaches in relation to the safety of people and the management and monitoring of the service. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service and we will continue to work with partner agencies. We will also request a specific action plan to understand what the provider will do immediately to ensure the service is safe. We will work alongside the provider and the local authority to closely monitor the service. We will return to visit in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

Rydal Care Home is a nursing care home registered to provide accommodation for up to 60 people. The home has three floors and can specialise in providing care to people living with a dementia. At the time of this inspection 31 people were living at the service.

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

Since August 2020 two successive managers had been appointed. The current manager was appointed to the post at the beginning of 2021 and they have applied to become the registered manager. The feedback we received was very complimentary about the new manager. People felt the manager had made improvements. They were confident the improvements would continue to be made.

We found the audit and analysis documents had been enhanced following our January 2021 inspection. An electronic governance system had been introduced, which was used by Rydal Care Home staff and the provider’s board of directors to maintain oversight of the services. These systems were being embedded and reviewed to ensure they were robust and supported staff to meet all requirements.

Staff recruitment procedures had been strengthened to ensure staff were employed safely. We discussed with the quality and compliance director and the manager where refinements could be made to audit systems for recruitment to ensure all necessary information was in place.

The management team had sustained the improvements made to staffing levels and there were enough staff on duty to keep people safe. The reliance on agency staff had significantly reduced. At times staff gave little notice they were not fit for work but the provider had arrangements to cover this situation. The manager confirmed they reminded staff of the need to give notice they would be absent in a timely manner.

People and relatives felt the home was safe. They commented on how staff were able to provide kind and compassionate care. Some relatives felt communication around visiting procedures could be enhanced.

Care staff adhered to Covid-19 guidance on working in a care setting. There was enough personal protective equipment (PPE) such as aprons, gloves and masks. Staff had undertaken training in putting on and taking off PPE. Visitors were screened before entering the building.

The manager closely analysed information about accidents and incidents to determine if all reasonable steps were being taken to minimise the risk of falls and people sustaining injuries. They could outline how changes to practice had reduced the number of falls people experienced.

The provider had introduced an electronic medicine administration system, which they found effective and efficient means for supporting staff administering medication. The manager had introduced an innovative system to assist agency nurses readily identify people via the use of the use of photo and room number.

The home had undergone a major refurbishment programme, which had enhanced the environment, and further work was planned.

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

Rating at last inspection

The last rating for this service was inadequate (published 22 February 2021).

This service has been in Special Measures since September 2020. 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 an unannounced focused inspection of this service on in August 2020. Breaches of legal requirements were found. The provider completed an action plan after the inspection to show what they would do and by when to improve person-centred care, safe care and treatment, safeguarding service users from abuse and improper care, the premises and equipment, staffing and recruitment practices.

We undertook this focused inspection to check 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 and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

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

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.

Rydal Care Home is a nursing care home registered to provide accommodation for up to 60 people. The home is split into four units. Two of the units specialise in providing care to people living with dementia and the third was not in use. At the time of this inspection 36 people were living at the service.

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

The management had made improvements to the service. All the requirements of the warning notice we served following our last inspection had been met. We found the area manager and new manager had acted to ensure audits were now being undertaken and used to improve the service.

We found some of the audit and analysis documents needed to be enhanced to enable the provider and staff to understand if systems were working effectively. We discussed how these could be improved to ensure they were more robust and supported staff to critically review the service. Following our discussion, the quality and compliance director reviewed the audit templates and enhanced these documents.

Improvements had been made to how staff managed accidents and incidents. The manager could outline how changes to practice had reduced the number of falls people experienced.

Staff recruitment procedures had been strengthened to ensure staff were employed safely. The management team had sustained the improvements made to staffing levels prior to our last inspection in August 2020. There were enough staff on duty to keep people safe. The reliance on agency staff had reduced, as more staff were recruited.

Improvements had been made to infection prevention and control practices. Staff adhered to Covid-19 guidance on working in a care setting. There was enough PPE such as aprons, gloves and masks. Staff had undertaken training in putting on and taking off PPE. We found the installation of electronic equipment used to take people's temperature and to remind them to wear masks effective.

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

Rating at last inspection

The last rating for this service was inadequate (published 24 October 2020).

Following our last inspection, we served a warning notice on the provider. We required them to be compliant with Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by 18 December 2020.

Why we inspected

We undertook this targeted inspection to check whether sufficient action had been taken in response to the Warning Notice we served following our last inspection. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on Warning Notice to check whether the provider had met the requirements of this notice. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 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.

Rydal Care Home is a nursing care home registered to provide accommodation for up to 60 people. The home is split into four units. Two of the units specialise in providing care to people living with dementia and the third was not in use. At the time of this inspection 46 people were living at the service.

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

Risks which affected people's health, safety and wellbeing were not always documented. This meant that staff did not always have adequate information to manage and mitigate risks to people. Accidents and incidents had not been thoroughly recorded and action had not been taken to reduce risks.

Staff did not have access to adequate supplies of personal protective equipment (PPE). The service did not have enough infection prevention and control measures in place. Government guidance in relation to COVID-19 was not followed.

Prior to starting our inspection there had not been enough staff on duty to keep people safe. Staff had been unable to appropriately assist people to attend to their personal care. Just before and whilst we were inspecting the provider increased staffing numbers to the previous safe levels.

Whistle-blowers had made us aware a large number of staff had left the service prior to the inspection. The information the manager supplied about this was incorrect and we found more staff had left to what we had been told. The high staff turnover combined with the need to rapidly increase staffing levels to a safe number meant shifts at times had 90% of agency staff covering them. Permanent staff told us they hoped this situation was resolved quickly as it was stressful supporting high numbers of agency staff on a shift, who were not familiar with the needs of people who used the service.

The manager in post had failed to follow safe recruitment practices. Staff had not been trained to undertake their roles or in key areas such as falls prevention.

The manager had not ensured action was taken to ensure electrical works and repair faults on doors were carried out in a timely manner. We raised this with the provider's nominated individual, and they confirmed the repairs would be carried out immediately.

Safeguarding concerns had not been reported by staff and management. The manager who had been in post was not clear of their role and responsibility in relation to safeguarding.

Quality assurance processes were in place to monitor the quality and safety of the service, but these did not identify serious concerns we found and contradicted practice we observed. There was a clear lack of provider oversight and they had not ensured effective and competent management was in place.

Most staff members we spoke with raised concerns about the management of the service.

We did observe people appeared comfortable and happy with staff interaction with them.

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

Rating at last inspection

The last rating for this service was good (report published 20 February 2019.)

Why we inspected

We received information of concern from whistle-blowers and healthcare professionals about the new manager cutting staffing levels, which were leading to people being unsafe. Relatives raised concerns around people sustaining injuries, a lack of personal care and there not being enough staff. As a result, we carried out 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 substantial improvements. Please see the safe and well-led sections of this full report.

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

Enforcement

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

We have identified breaches in relation to the safety of people and the risk of harm. We also identified breaches in relation to the management and monitoring of the service, recruitment, premises and staff training at this inspection.

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

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

Follow up

We will continue to monitor information we receive about the service and we will continue to work with partner agencies. We will also request a specific action plan to understand what the provider will do immediately to ensure the service is safe. We will work alongside the provider and the local authority to closely monitor the service. We will return to visit in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

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: Improvements had been made to the service following our first inspection in December 2017 and the focused inspection we completed in September 2018. The provider and registered manager had improved the systems for assessing the performance of the service.

Staffing levels met people’s assessed needs however, the provider was reviewing the current dependency tool, as it was not fit for purpose. Staff had received a wide range of training including around working with people who may display behaviours that challenge. Checks were made on the ongoing competency of staff.

The cook and staff had received ‘focus on under-nutrition’ training. Staff were encouraging people who were under-weight to eat fortified foods. We found a range of menu choices were available and consideration had been given to ensuring people from different cultures received acceptable meals.

People participated in a range of activities that met their individual choices and preferences. Staff provided the structured support people required. This promoted a good quality of life. However, we noted that more could be offered to support people from different cultural backgrounds.

Staff effectively investigated and reported any safeguarding matters. The registered manager had acted on concerns, and complaints received by the service and had taken steps to resolve these matters. They ensured that all incidents were critically analysed and from this review lessons were learnt and embedded into practice.

All the people we spoke with told us that the registered manager and staff listened to their views, acted to resolve concerns, when needed, and met people’s needs. We found that staff needed to consistently record capacity assessments and ‘best interests’ decisions.

Works were underway to create a more dementia friendly environment. An enclosed garden area had been created, which would provide sensory stimulation and meaningful occupation for people.

Rating at last inspection: Requires Improvement (report published 17 October 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection. The service had improved and was rated Good overall.

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

We carried out an unannounced comprehensive inspection of this service on 6 and 12 December 2017. This was the first inspection since the new provider registered to operate this service. We rated the service to be Requires improvement in two domains. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to having good governance systems in place.

Following the inspection, we asked the provider to complete an action plan to show what they would do and by when to improve.

Rydal Care Home is a ‘care home’. People in care homes receive accommodation and 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. Rydal Care Home accommodates up to 60 people across three separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia. At the time of this inspection 45 people were using the service, of which 26 people required nursing care.

The manager became the registered manager in March 2018. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like 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 last inspection we found the quality assurance procedures in place lacked ‘rigour’. Although some auditing and analysis had been carried out, this was not always effective. We highlighted that the way staff completed the dependency tool would benefit from review, as the information could lead to insufficient staff deployed to meet people’s needs.

At this inspection we found that overnight at times there were seven staff on duty. We found on each unit high numbers of people who needed two staff to support them. To evacuate the building with current staffing levels it would take six staff at least five journeys using three of the six evacuation chairs to move people from the upstairs unit.

There was a lone worker on one unit who could not readily call for assistance due to the nurse call alarm not being connected to the other two units.

The area manager and registered manager told us that the expectation was that eight staff were on duty overnight and they would ensure this was always the case. They also undertook to review staffing levels to ensure these were adequate to support people in the event of an emergency.

The staff we spoke with did not know the fire evacuation plan and we found they would benefit from practicing this as a drill.

The registered manager told us they would immediately ensure day and night staff completed a simulated evacuation. They told us that this would be incorporated into the routine fire drills.

People were happy and told us they felt safe.

The registered manager was aware of risks within the service and was undertaking an analysis of risks. The staff had a clear understanding of safeguarding procedures and ensured that action was taken if any concerns arose. Staff ensured any risks were closely managed.

Appropriate recruitment checks were carried out. But we discussed how the application form could be enhanced. The area manager confirmed changes would be made to the forms.

The provider ensured maintenance checks were completed for the equipment and premises. Works were underway to decorate the service in ways that were dementia friendly. An enclosed garden area was being created, which would provide sensory stimulation and meaningful occupation for people. The registered manager had sought support from a variety of sources, such as the Prince’s Trust and colleges to improve the environment.

Medicines were closely managed and this ensured people received their medication exactly as prescribed.

We found that the service was clean and staff adhered to appropriate infection control procedures.

A comprehensive range of audits and quality assurance tools had been put in place but it was too early to determine if these would be totally effective.

The registered manager regularly sought peoples’ views and acted upon their comments.

The registered manager had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken.

This was the first inspection since the new provider registered to operate this service.

Rydal Care Home is a ‘care home’. People in care homes receive accommodation and 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. Rydal Care Home accommodates up to 60 people across three separate units, each of which have separate adapted facilities. Two of the units specialise in providing care to people living with dementia. At the time of this inspection 50 people were in receipt of care from the service.

No registered manager had been in post since April 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like 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. A new manager had been in post since September 2017 and had recently submitted an application to the Commission to become the registered manager.

The regional manager had been in post since July 2017 and when they had taken on oversight of the service they had found a number of issues had arisen following the departure of the previous registered manager. They found staff morale had been low and a number of staff were looking to leave. Within a few weeks they had ensured the service stabilised and since then had worked hard to make improvements to the service.

We found the quality assurance procedures in place lacked ‘rigour’. Although some auditing and analysis was carried out, this was not always effective. For instance, the tool the provider had supplied for monitoring care records did not assist staff to look at wider issues, so they had not considered if the current process of using care plans to assess people’s needs and dependencies was effective.

On the whole people and staff felt there were sufficient staff on duty each day to meet people’s needs but we observed that at times staff were stretched. We found the way staff completed the dependency tool would benefit from review, as they were judging people who required one-to-one support as ‘medium dependency’, which was incorrect. Using this information could lead to the provider’s dependency tool calculating that less staff were needed than was actually the case. The quality assurance checks to monitor and improve standards at the service had not picked up that the staff were not completing accurate dependency assessments.

Appropriate recruitment checks were carried out. Staff were supported to constantly develop in their roles and all the staff discussed the wide range of training they had been able to complete. However, staff had not received training around how to support people who may become anxious and display behaviour that challenges others. The manager and regional manager were aware of this gap and were sourcing courses for staff.

The provider ensured maintenance checks were completed for the equipment and premises. They completed health and safety checks and adhered to fire safety guidance. However, we found that one of the two lifts had been broken since before the providers had taken over the service but this had not been repaired. The regional manager told us action was being taken but the previous provider had initially told them they would deal with this issue but had not. We found that effective quality monitoring processes would have identified the impact the lack of a lift was having for the management of the downstairs unit on the general nursing unit and resolved this in a timely manner.

People were happy and told us they felt safe. The relatives we spoke with felt the service delivered safe care but at times the communication between staff and themselves could be improved. The staff had a clear understanding of safeguarding procedures and ensured that action was taken if any concerns arose. Staff ensured any risks were closely managed.

We reviewed the systems for the management of medicines and found that people received their medicines safely. Medicines were closely managed and this ensured people received their medication exactly as prescribed.

The manager was aware of risks within the service and was undertaking an analysis of risks. The service had emergency plans in place and took action when they became aware someone was at risk. Accidents and incidents were appropriately monitored and analysed and the manager and staff critically reviewed all incidents to determine if lessons could be learnt.

We found that the service was clean and staff adhered to appropriate infection control procedures.

We found staff were passionate about providing a service that gave all equitable choices and experiences. Staff knew the people they were supporting well. The manager and staff were focused on delivering a personalised service. However, we discussed with the manager how the assessments could be enhanced, as the provider only supplied pre-admission template and therefore there were no documents for staff to use to assess the current position. This meant staff had to go through the whole care file to find out detailed information about individual’s physical and mental health conditions and any changes to their health.

We found there was no documentation to support the capacity assessments made, or corresponding ‘best interests’ decisions. The manager and staff reported that the previous manager had removed all of this documentation and they would ensure it was re-instated. Also, we found that not all Deprivation of Liberty safeguards (DoLS) authorisations were in place, albeit the staff recorded when these were sent they did not always update the records about any outcome. Staff were also unaware of actions best interests assessors had recorded on the DoLS forms.

Staff supported people to make decisions for themselves and spoke with people about their wishes and preferences. People were supported to be as independent as possible and could access advocacy services if needed. The manager, staff and activity coordinator regularly sought peoples’ views and acted upon their comments. A volunteer ran a relatives meeting and this year held a meeting in a local restaurant, which provided the opportunity for informal discussions about the service and the creation of a support network.

People were treated with dignity and respect. We found that staff were compassionate and people told us the staff were always kind and caring towards them. We saw that staff continually engaged in conversations with people and took an active interest in individual's lives. People told us they were aware of how to raise a complaint and felt that any issues raised would be thoroughly investigated and resolved.

We heard how the activity coordinator had developed a range of interesting activities for people to engage in, formed links with local organisations and worked with volunteers. However, we found the service would benefit from additional activity workers as the coordinator was not always able to cover all the units. Also, they were reliant on staff volunteering to accompany people on trips.

People were supported to maintain a healthy diet and to access external professionals to monitor and promote their health.

People, relatives and staff described the manager as being an effective leader. Staff told us that they could contribute their ideas about how to make improvements at the service. We found the regional manager and manager immediately acted upon any issues and in between our visits addressed all the points we raised on the first day. Staff received regular supervision and they were in the process of receiving annual appraisals.

The manager had informed CQC of significant events in a timely way by submitting the required notifications. This meant we could check that appropriate action had been taken.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to good governance. You can see what action we told the registered provider to take at the back of the full version of the report.