Ashbrook Court Care Home

Ashbrook Court Care Home is a residential care home providing the regulated activity of accommodation and nursing care to up to 70 people in one adapted building. The service provides support to older people and people who are living with dementia and/or who may require nursing care. At the time of our inspection there were 70 people using the service. The care home is unitised and supports people across 4 separate units, which have separated adapted facilities.

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

Suitable arrangements were in place to keep people safe. Procedures were followed by staff to safeguard people and staff understood these processes. Risks to people were identified and managed to prevent people from receiving unsafe care and support. Medicine arrangements ensured people received their prescribed medication and staff’s practice was safe. People’s comments were variable regarding staffing levels. However, at the time of inspection the service was appropriately staffed to meet people’s care and support needs. Recruitment procedures were followed to ensure the right staff were employed to care for vulnerable individuals. People were protected by the provider's arrangements for the prevention and control of infection. Arrangements were in place for learning and making improvements.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People received a good level of care and support that met their needs and preferences. Staff had a good knowledge and understanding of people's specific care and support needs and how they wished to be cared for and supported. Suitable arrangements were in place to assess and monitor the quality of the service provided. People, their relatives and staff were positive regarding the management of the service.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published October 2019). 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 Regulation 12 [Safe care and treatment].

Why we inspected

This inspection was prompted by a review of the information we held about this service and prompted in part by notification of an incident following which a person using the service died. The information shared with CQC about the incident indicated potential concerns about the management and safety of risk of the storage of Control of Substances Hazardous to Health [COSHH]. A decision was made for us to inspect and examine those risks. This inspection examined those risks. We found no evidence during this inspection that people were at risk of harm from this concern.

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

We 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 of 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 Requires Improvement to Good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ashbrook Court 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.

We found the following examples of good practice.

Relatives confirmed they had been kept informed of the service’s visiting arrangements at Ashbrook Court Care Home throughout the pandemic. Comments from relatives included, “They [Ashbrook Court Care Home] always update us; in fact, we have just had an update today” and, “We have been informed by newsletter and emails.”

Arrangements were in place for relatives to visit their family member in accordance with government guidance. Additional arrangements had also been made to enable relatives to maintain contact with their family member, for example, telephone calls, window visits, face time audio and video calls.

Suitable measures were in place to screen all visitors and this included temperature checks, the wearing of Personal Protective Equipment [PPE] and rapid flow testing to keep infection risks to a minimum.

People were admitted into the service safely. People’s COVID-19 status was sought prior to admittance and people self-isolated in line with current government guidance.

Appropriate infection prevention control practices were observed for staff, such as the wearing of masks, gloves, aprons and included good hygiene practices.

Staff had received training on infection prevention, including COVID-19 and the correct use of PPE.

Cleaning schedules were in place and being followed. The environment was visibly clean and odour free. Relatives comments relating to the overall cleanliness of the service was positive and included, “It’s quite perfect without any of those smells you get in some homes, it’s excellent, that’s why we chose this home” and, “The home is very clean, we have no concerns with the cleanliness.”

Ashbrook Court Care Home is a residential care home providing personal and nursing care to 63 people aged 65 and over at the time of the inspection. This also includes living with dementia. The service can support up to 70 people in one adapted building. The care home is unitised and supports people across four separate units, which have separated adapted facilities.

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

Medication practices were not safe, and people did not always receive their medicines as prescribed. People told us they were safe. Suitable arrangements were in place to protect people from abuse and avoidable harm. Staff understood how to raise concerns and knew what to do to safeguard people. Risks to people were identified and assessed to keep them safe. Sufficient numbers of staff were available to support people living at Ashbrook Court Care Home and to meet their needs. Recruitment practices were now robust to make sure the right staff were recruited. People were protected by the prevention and control of infection. Findings from this inspection showed lessons were being learned and improvements made when things go wrong.

Staff received appropriate training and newly appointed staff received an induction. The dining experience for people using the service was positive and much improved. People received enough food and drink to meet their needs. People were supported to access healthcare services and to receive ongoing healthcare support as required. The service worked with other organisations to enable people to receive effective care and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and those acting on their behalf told us they were treated with care, kindness, respect and dignity. Staff had a good rapport and relationship with the people they supported, and observations demonstrated what people told us.

Though each person had a plan of care detailing their care needs and how these were to be met by staff, shortfalls were identified with some aspects of record keeping. Care plans relating to people’s end of life care arrangements were not sufficiently detailed. The service was not fully compliant with the Accessible Information Standard to ensure it meets people’s communication needs. People and those acting on their behalf were confident to raise issues and concerns and felt listened to, but improvements were required to ensure the investigation of complaints was robust.

Governance arrangements were much improved, but progress was still required to make sure improvements made were sustained in the longer term.

We have made recommendations about record keeping and complaints management.

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

Rating at the last inspection

The last rating for this service was requires improvement (published March 2019) and there were three breaches of regulation. This referred specifically to Regulation 9 [Person-centred care], Regulation 12 [Safe care and treatment] and Regulation 17 [Good governance]. Enforcement action was completed whereby the Care Quality Commission imposed conditions on the provider’s registration. The provider completed an action plan after the last inspection to show what they would do and by when to improve. This was updated each month with a copy forwarded to the Care Quality Commission.

The service remains rated requires improvement, but the Commission acknowledges significant improvements have been made. This service has been rated requires improvement for the last three consecutive inspections. At this inspection we found improvements had been made and the provider was in breach of one regulation. This related to medicines management.

Why we inspected

This was a planned inspection based on the service’s previous rating.

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.

Our previous comprehensive inspection to the service was on 23 and 24 August 2017. The overall rating of the service at that time was judged to be ‘Requires Improvement’ and no breaches of regulation with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 made.

This inspection was completed on 22 and 23 October 2018 and was unannounced. There were 65 people living at the service.

A registered manager was in post. 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.

Quality assurance checks and audits were not as robust as they should be, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm and where their health and wellbeing was compromised. Appropriate steps had not been taken to ensure the management team had sufficient oversight of the service which ensured people received safe care and treatment. The lack of managerial oversight at both provider and service level impacted on people, staff and the quality of care provided. The management team were unable to fully demonstrate where improvements to the service were needed, how these were to be and had been addressed; and lessons learned to ensure compliance with regulatory requirements and the fundamental standards.

The management team had not ensured the service was being run in a manner that promoted a caring and respectful culture. Although some staff were attentive and caring in their interactions with people using the service, we observed other interactions which were not respectful or caring and failed to ensure people were treated with respect and dignity. Not all people using the service received appropriate opportunities for meaningful social activities.

The standard of record keeping was poor and care records were not accurately maintained to ensure staff were provided with clear up to date information which reflected people’s current care and support needs. Where people were judged to be at the end of their life, information relating to their end of life care needs were not recorded and not all staff had received appropriate training. Suitable control measures were not always put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered, and risk assessments had not been developed for all areas of identified risk.

Recruitment procedures required improvement to make sure these were robustly completed for all staff employed to ensure safer recruitment practices. Not all staff had received a robust induction and the role of senior members of staff was not effective in monitoring staff’s practice, performance and providing sufficient guidance and support. Training and development was not sufficient in some areas to demonstrate that people's care and support needs were fully understood by staff and embedded in their everyday practice. Staff had not received regular supervision.

People’s capacity to make day-to-day decisions had been considered and assessed. Nonetheless, improvements were required to ensure staff had a better understanding of the main principles of the Mental Capacity Act and how to apply these to their everyday practice, particularly relating to choice and consent.

People’s healthcare needs were supported and people had access to a range of healthcare services and professionals as required. Medication practices and procedures were generally satisfactory. The service worked with other organisations to ensure they delivered joined-up care. The registered provider’s arrangements for the prevention and control of infection at the service was satisfactory.

We asked the registered provider to send us an action plan which outlined the actions they would take to make the necessary improvements. In response, the registered provider shared with us their action plan detailing their progress to meet regulatory requirements and to achieve compliance with the fundamental standards. At this inspection considerable progress had been made to meet regulatory requirements, however further improvements were still required.

Ashbrook Court Care Home is registered to provide accommodation with nursing or personal care for up to 70 people, some of whom may be living with dementia. There were 55 people receiving a service on the day of our inspection.

A registered manager was in post. 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.

Quality assurance checks and audits carried out by the registered provider and the management team of the service were in place and had been completed at regular intervals in line with the registered provider’s schedule of completion. The registered provider and management team were able to demonstrate a better understanding and awareness of the importance of having good quality assurance processes in place. This was a significant improvement and this had resulted in better outcomes for people using the service. Feedback from people and those acting on their behalf and staff were generally positive. This referred specifically to there now being confidence that the registered provider and management team were doing their utmost to make the required improvements. Nonetheless, some improvements were still required to ensure that areas for improvement as highlighted as part of this inspection and where issues were highlighted as part of the management teams auditing arrangements was available to show actions required had been addressed.

Improvements were still required to ensure that people’s care plan documentation was accurate and up-to-date. Where care plans for people who could be anxious or distressed were in place, the reasons for people becoming anxious and the steps staff should take to comfort and reassure them including staff’s interventions and the outcome of incidents, required review and development. Suitable arrangements to mitigate risks or potential risk of harm for people using the service required further review and development as not all risks to people’s safety were identified or recorded. The registered manager and business manager confirmed following feedback at the time of the inspection that further care plan reviews would be undertaken to ensure the above was addressed as a priority.

The majority of staff spoken with at the time of the inspection described the management team as supportive and approachable. However, suitable arrangements were still needed to ensure that staff received regular formal supervision. Staff told us and records confirmed that a range of training opportunities were available and provided to them. Nonetheless, improvements were required to ensure where training remained outstanding this was completed. Improvements were also required to ensure staff training relating to dementia awareness was embedded in their everyday practice. An assurance was provided by the registered manager that this would be addressed.

People confirmed that social activities were available. However, improvements were still needed in the way staff supported people to lead meaningful lives and to participate in social activities of their choice and ability, particularly for those living with dementia or who had complex care needs. Although further improvements were still required, it was recognised that this primarily related to Redwood Unit. However, consideration should also be made to address some people’s comments as detailed within the main text of the report in relation to them feeling bored and not having anything available to occupy them during the day and staff not being able to spend meaningful time with them to sit and chat.

Suitable arrangements were in place to take action when abuse had been alleged or suspected. People were protected from abuse and avoidable harm and people living at the service confirmed they were kept safe and had no concerns about their safety. Safe recruitment practices were in place and being followed so as to keep people safe. We observed that staff followed safe procedures when giving people their medicines, medicines were stored safely and records showed that people were receiving their medicines as prescribed.

Comments about staffing levels at the service were variable as not all people felt there were sufficient staff available and the most common complaint was that staff did not have the time to sit and talk with them. Although these concerns were expressed the deployment of staff across the service was observed to be appropriate and there were sufficient staff available to meet people’s needs to an appropriate standard. Systems were in place to determine the dependency needs of people using the service and these were used to support the service’s staffing levels.

Staff understood and had a good knowledge of the Deprivation of Liberty Safeguards [DoLS] and the key requirements of the Mental Capacity Act [2005]. Suitable arrangements had been made to ensure that people’s rights and liberties were not restricted. People were now routinely asked to give their consent to their care, treatment and support and people’s capacity to make day-to-day decisions had been considered and assessed. Nonetheless, minor improvements were required to ensure particular decisions which had been made were accurately recorded.

People were supported to have enough to eat and drink. Significant improvements were now in place to monitor and record people’s nutritional and hydration intake so as to identify at the earliest opportunity those people who were at risk. Suitable arrangements were now in place to support people where they required assistance to eat and drink. People were supported to maintain good healthcare and have access to healthcare services as and when required.

Staff knew the care needs of the people they supported and people told us that staff were kind and caring. In general, staff responded to people’s need for support and demonstrated appropriate concern for their wellbeing and people told us they were happy with the care and support provided by staff.

The majority of staff spoken with told us that the overall culture across the service was now open and that they felt supported by the management team. Staff told us that communication between staff and the management team was better and that morale within the staff team had much improved.

Ashbrook Court Care Home is registered to provide accommodation with nursing or personal care for up to 70 people, some of whom may be living with dementia. There were 59 people

receiving a service on the day of our inspection.

Ashbrook Court was inspected in July 2015 and June 2016 and rated as Requires Improvement on both occasions with concerns that included good governance. The provider and registered manager sent us an action plan to tell us how and when they would meet the regulations. At this third rated inspection of Ashbrook Court of February 2017, we again found breaches of regulation and that the service was not well led. The actions taken by the provider to date had not ensured compliance with regulation so as to provide people with safe, quality care.

The overall rating for this service is ‘Inadequate’. This means that it has been placed into special measures by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had resigned their post and was due to leave the service immediately following this inspection.

The service was not well led and there were demonstrated persistent weaknesses in the provider’s approach to monitoring, improving and sustaining the quality of the service. While people living and working in the service had the opportunity to say how they felt about the home and the service it provided, the action plans developed to recover the service were not sufficiently robust to ensure that required improvements were implemented and maintained. Concerns regarding care planning identified in the 2015 inspection had been improved by the 2016 inspection, yet this was found to be failing again at this inspection of February 2017.

People's medicines were not safely managed. Risk management plans were not in place or kept up-to-date to support people and keep them safe. Records were not always available to identify and to guide staff on how to meet people's assessed care needs. People did not always have the opportunity to participate in social activities and engage in positive interactions to ensure person centred care.

Up-to-date guidance about protecting people’s rights had not been followed so as to support decisions made on people’s behalf and to comply with legislation.

Improvements were needed to support staff to complete available induction programmes, including for agency staff, and to ensure that those people working in the service were suitable to be with vulnerable people. Continuity of staff was lacking and this impacted on people’s experience of their care and support.

Staff were knowledgeable about identifying abuse and how to report it to safeguard people.

People enjoyed the meals served. Arrangements were in place to support people to gain access to health professionals and services as needed.

People were supported by kind staff who treated them with dignity and respect. Visitors were welcomed and relationships were supported.

People felt able to raise any complaints and felt that the provider would listen to them. Information to help people to make a complaint was readily available.

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

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

At our inspection on 28 and 29 July 2015 we found that the provider was not meeting the requirements of the law in relation to the training and support of staff, governance and care planning. At our inspection on 13 and 14 June 2016 we established that while further progression was still needed in some areas, sufficient improvements had been made in others. However, the further improvements and areas of risk was of concern because the management of the service had not used the quality assurance systems effectively to continually improve the service for people and further failings had been identified in areas that were not failing at our July 2015 inspection. There was therefore a continued failing in good governance. Systems were not robust and had not identified risks to people or shortfalls in ensuring people’s dignity was upheld.

Improvements were needed to recording aspects of the care and treatment people received, such as their food and fluids intake, repositioning or application of their prescribed creams as well as to guidance for staff on how to support some areas of people’s care. Records of the support people received to participate in social activities and meaningful engagement also needed to improve.

Improvements were noted to staff training and support systems as well as to people’s opportunities to express their views about the service.

Systems were in place to ensure the management of risks to the environment so as to ensure people’s safety. This included the safety of the premises and equipment used. Equipment such as that relating to fire and electrical equipment had been tested and checked to ensure it was safe and in good working order.

Staff were knowledgeable about identifying abuse and how to report it to safeguard people. The registered manager understood and complied with the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Staff were aware of their role in relation to MCA and DoLS and how to support people so as to ensure their rights were respected and met.

People were supported by sufficient numbers of staff to meet people's needs effectively. Medicines were safely stored, administered and supported in line with current guidance to ensure people received their prescribed medicines to meet their needs. People told us that they received the care and support they required.

Arrangements were in place to support people to gain access to health professionals and services.

People had choices of food and drinks that supported their nutritional or health care needs and their personal preferences.

People living and working in the service had the opportunity to say how they felt about the home and the service it provided and be listened to.

This is a summary of what we found:

Is the service safe?

When we arrived at the service the staff asked to see our identification. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The staff demonstrated a good knowledge of how to safeguard vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that staff were attentive to people's needs. Staff we spoke with were able to demonstrate they knew people well. Staff treated people with dignity and respect.

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's care records showed that, where appropriate, support and guidance was sought from health care professionals, including a doctor, speech and language therapist, chiropodist and district nurse. This told us that the service worked well with other professionals and that people's needs were met.

Is the service well-led?

The service had a new care manager in post and had started to put a number of quality assurance measures in place. The manager was very proactive in monitoring and looking for ways to improve the service. The care manager was in the processing of registering with the CQC as required.

Below is a summary of what we found during our inspection. The summary is based on our observations during the inspection.

We looked at six people's care records. Other records viewed included staff training records and rotas, medication administration documents and policy and procedures. We spoke with the registered manager, business manager, staff members, people who used the service and their relatives.

If you want to see evidence supporting our summary please read our full report.

We considered our inspection findings to answer 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?

Is the service safe?

People told us they felt safe living in the service, although people did have concerns about the staffing levels. We saw that there were not always enough staff to ensure that people received that care they needed in a timely way. We saw staff were rushed in their work so their time with people was not as meaningful as it could have been.

Improvements in the service were needed to reduce the dependency on agency to provide people with a more consistent approach to their care delivery. The provider also needed to consider how staffing levels were calculated to ensure that staffing levels were aligned with the dependency and needs of people who used the service.

We found that some improvements were needed to staffs' practices and systems for monitoring this in relation to medication management. This was needed to ensure that people could be confident their medication was being managed safely.

Staff told us that they felt they had a good induction, received a good level of training and were supported. However, records detailing staff training showed us that some staff's training had not been refreshed and up dated regularly.

Is the service effective?

People's care records showed that care and treatment was not always planned and delivered in a way that was intended to ensure their safety and welfare. The records were not regularly reviewed or updated which meant that staff were not provided with up to date information about how people's needs were to be met. This was also a concern due to the level of staff who were not permanent staff members and were from an agency.

We saw that the service did have some systems for monitoring the quality of care. However we found these were not effective as they had not identified some risks.

Is the service caring?

We saw that staff did not always interact with people who used the service in a respectful manner. Staff spoke with people in a childlike manner using terms that were not suitable such as, 'come on papa, eat your lunch like a good papa', 'come on, walkie, walkie', 'yes lovie', 'come on darling, be a good girl'.

After a fire alarm sounded we saw that some people using the service were upset and confused. We were concerned that staff did not routinely comfort, reassure or check people understood what was happening.

People's preferences and diverse needs had not always been recorded and we could not be sure that care and support was provided in accordance with people's wishes. This included choices about how people wanted to be cared for if they were nearing the end of their life.

Is the service responsive?

People's care records showed that where concerns about their wellbeing had been identified the staff had not always taken appropriate action to ensure that people were provided with the support they needed. We saw that in some cases this meant that changes to identified care needs had not been made promptly.

Is the service well-led?

Whilst there were systems in place to monitor and analyse the service provision they were not effective or the information was not being used to improve the experiences people had. We saw that there were areas where the service was not working well. In addition consideration and formal assessment had not been completed as to the impact on staff and people who used the service from more people being provided with complex needs moving to the service.

The business manager present on the day of the inspection acknowledged that there was shortfalls and spoke with us about how they were going to address the concerns. However we were concerned that these had not been picked up by the registered manager or the provider prior to our inspection.

We also saw that some staff behaviour was having an impact on the quality of care and the day to day experience people had. We were concerned about how this was being managed and addressed to ensure a positive culture was promoted and developed by the leadership.

We spoke with seven of the 63 people who were using the service and four visiting relatives. We also spoke with seven staff members.

We looked at five people's care records as well as records relating to staff rotas and training as well as records relating to the management of complaints.

We considered our inspection findings to answer 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;

Is the service safe?

People told us that they would feel able to speak up if they had concerns or worries and felt that they would be, and had been, listened to. One visitor said, 'We can raise any issues with the staff who bend over backwards to help us.' A person who used the service said, 'You can talk to the staff, they are kind and friendly and you could tell them anything.'

We saw that the staff were provided with training in safeguarding vulnerable adults from abuse, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). This meant that staff were provided with the information that they needed to ensure that people were safeguarded from abuse.

Is the service effective?

We saw that where people's care needs had changed, such as on their nutritional intake, their care plans and risk assessments had been changed to reflect this. This meant that staff were provided with up to date information about how people's needs were to be met safely and effectively.

The service worked to provide adequate numbers of regular staff who were suitably trained to meet people's needs. This meant that people were cared for by staff who knew them and who were familiar to them, and able to meet their needs.

Is the service caring?

People told us they felt cared for at the service. A relative said, 'Staff are wonderful and work very hard, they are very attentive and [person's] needs are met. Sometimes they struggle as some days are busy. There is a turnover of staff but they are all so loving and caring. I never leave and think is [person] going to be okay, it makes me feel she is safe here.'

A relative told us, 'Staff here have really cared for us and made us welcome. They communicate well with us.'

Is the service responsive?

The manager was responsive to concerns we raised following our observations of a lunchtime meal service. The manager told us they would review this and take immediate action to change and improve it.

The manager had responded to complaints and comments received.

The service responded to people's individual need and supported individual ability and independence. A relative we spoke with said, 'The food is lovely, everyone gets help. Some days [person] can feed herself, the food is cut small, other days she needs help and they do it. They go out of their way to help people and keep any skills they can.'

Is the service well-led?

The provider had procedures in place to support the manager to lead the service. The management team at the service had autonomy to manage staffing levels in line with people's needs and to implement disciplinary actions where staff did not provide a reliable service.

We found improvements had been made in all areas that we inspected. However, improvements regarding infection control were not completed until during or shortly after our inspection. This meant we were not able to test if this compliance has been sustained.

We found people were protected from the risks of inadequate nutrition and dehydration. People told us they were consulted about the food on the menu and offered choices.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. This included the management of prescribed creams.

There were enough qualified, skilled and experienced staff to meet people's needs. The provider had increased the number of staff on each shift since our last inspection. People made positive comments about the staff. They told us that staff were always available when they needed them. One person showed us their call system buzzer and said, 'They [the staff] always come when I call.' We spoke with three people's relatives. One told us, 'The carer's are fantastic. They deal with a lot of challenging behaviour. They treat the people with respect.' Another relative told us they were, 'Very pleased with the care. The staff are very good. They treat [my relative] well.'

We found that people were not provided with a choice of suitable food and drink. In addition, people's food and drink did not meet their religious or cultural needs.

The majority of the home was clean and smelled fresh. However, we found some areas of the home that had not been properly cleaned. We also found that some equipment was damaged which made effective cleaning difficult.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to administer prescribed creams safely.

There was not always sufficient staff on duty to meet people's needs. This was particularly the case at weekends and when staff were absent at short notice.

We found the provider had an effective system in place to regularly assess and monitor the quality of service that people received. The provider took account of complaints and comments to improve the service.

We spoke with three people who used the service. One person said, 'I am always having a chat with staff. They are very friendly here.'Another person said, 'Everything's good here.' One person who had been at the home for some time said, 'I have always had good care here.'

People were regularly consulted on the care and treatment offered but records of signed agreements were not always in place.

We found that people's medicines were safely managed. The medication record of medications to be returned to the pharmacist was not always completed or that pharmacists had receipted the medications returned to them.

Staff were provided with training, supervision and professional development opportunities. People told us that staff were knowledgeable and able to support people's needs.

The provider had an effective complaints procedure in place and that people were aware of how to make a complaint.