The Limes

The Limes is a residential care home providing accommodation and personal care to up to 46 people. The service provides support to older people, some of whom are living with dementia. At the time of our inspection there were 28 people using the service.

The Limes is all on one level. There are various communal lounges and dining rooms and quiet areas as well as a shared garden. The Limes offers people the choice of single bedrooms but also shared double bedrooms if people prefer. Some bedrooms benefit from ensuite facilities. There is also an office onsite. The layout of the building is designed to support people living with dementia and/or who require support to move around safely.

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

People told us they felt safe living at The Limes. They liked the staff and told us staff treated them well, were kind and knew their likes and dislikes. Staff knew how to keep people safe and what to do if they had any concerns. Some staff were still developing the confidence to report concerns externally to safeguarding teams or CQC. A member of the management team currently still led this.

Since the last inspection, there had been a new registered manager appointed to the service as well as changes and improvements to systems, processes and the environment. This had resulted in many changes for the better but was not yet fully embedded.

People were mostly supported to safely administer and manage their medicines. However, there were some discrepancies that had not been identified during audits. The registered manager put additional measures in place to address this during the inspection.

People were supported by trained staff in all aspects of their daily life. This included going to the pub, maintaining contact with friends and relatives, having meals and drinks out, socialising and meeting their health needs. Staff had received additional training which relatives told us had been seen in improved practices and care. Staff were still being supported to fully develop their knowledge and confidence to implement learning.

People told us the management had improved since the recent start of the new registered manager and this had a positive impact on the quality of care they received. This included the care being more organised, improved communication and staff skills.

The registered manager made sure all staff and visitors followed the latest government guidance for reducing risks about COVID-19 and the spread of infection. Staff had received additional training on this topic to ensure they could keep people as safe as possible.

People had access to health professionals who worked closely with the staff and management team to ensure all health concerns were looked into straight away. The staff team worked closely with community nursing teams to look at shared care to ensure quicker responses, treatment and advice for people.

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.

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 16 December 2021) and there were 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.

This service has been in Special Measures since 16 December 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.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last 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 COVID-19 and other infection outbreaks effectively.

Follow up

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

The Limes is a residential care home. At the time of this inspection, 38 older people living with dementia were residing there. The service can support up to 46 people. The home is on one level and there are gardens attached; some rooms benefited from en-suite facilities.

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

People had been placed at risk of avoidable harm due to poor risk assessing and management. This included around COVID-19, falls, pressure care, food and fluid intake, diabetes management and continence. The governance systems in place had failed to identify and rectify this. This was the eighth consecutive inspection where the service has been rated as either requires improvement or inadequate. Therefore, we do not have confidence the leaders for the service have the skills and abilities to make and sustain improvements.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support this practice. Consent to care and support was not consistently in place.

Local safeguarding policies had not been consistently adhered to and we found two examples of where incidents should have been referred to give the best opportunity for further protection. We could not be assured that people received enough to eat and drink and the service could have done more to ensure those living with diabetes remained healthy. One person had sustained a serious injury where the risks had not been fully mitigated.

The service could not fully demonstrate what care and support was being delivered to people and accurate records had not been maintained as required. The provider’s quality assurance system had failed to identify and rectify concerns and the provider did not demonstrate they had oversight of the service.

The people who used the service were unable to tell us their experiences of using the service due to their level of dementia however we consulted with 11 relatives on their behalf as well as staff. Relatives told us they were kept up to date with their family member’s care and staff told us they felt involved, listened to and valued. However, some relatives did raise concerns regarding risk management and told us they had not recently been involved in their family member’s care plan.

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 16 October 2020) and a recommendation was made regarding COVID-19 management. At this inspection we found the service had deteriorated and multiple breaches were identified.

Why we inspected

The inspection was prompted in part due to concerns received about risk management. We had also received a notification of a specific incident, following which a person died after sustaining a serious injury. We therefore examined the circumstances of that incident at this inspection. The inspection was initially a focussed on the key questions of Safe and Well-led however due to concerns found, this was opened up to include the key question of Effective.

We also 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 have found evidence that the provider needs to make improvements. Please see the Safe, Effective 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.

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 risk management, staff recruitment, safeguarding, meeting food and fluid needs, consent and governance at this inspection.

In response to the concerns identified, we served a Notice of Decision on the provider to remove the location. This decision was appealed by the provider and a decision was made not to oppose this appeal. This was as a result of a further inspection completed in August 2022 that evidenced significant and widespread improvements had been made meaning the enforcement action was no longer deemed proportionate or appropriate.

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.

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.

The Limes is a residential care home providing personal care to 34 older people at the time of the inspection. The service is registered for 46 people but does no longer use many of their bedrooms as doubles. All accommodation is on the ground floor.

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

We have made a recommendation about ensuring current guidance is available and followed on infection prevention and control especially in relation to COVID -19.

People, relatives and staff were all positive about The Limes. People we spoke with were complimentary about the care and support they received and had no complaints. Relatives felt they were involved and were kept informed. One relative said, “I cannot fault it and I have told you the truth.” One other relative felt that there could be more activities for people to join in but was satisfied with the care.

People receive care and support from sufficient staff that have the appropriate training. People were supported to stay safe, monitored and their freedom of choice is respected.

People, relatives and staff said that they found the registered manager to be approachable, caring and supportive. One staff member said of the provider, “I know the owner of the home contacts us regularly to ask for any updates, how we are coping and any ways he can help/support us.”

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 requires improvement (published 17 October 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

The inspection was prompted in part due to notifications received about falls resulting in injury, a person going missing and a decision was made for us to inspect and examine those risks.

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.

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.

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.

Since the inspection the provider has taken steps to address some of the shortfalls identified including medicines management.

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

Follow up

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.

The Limes is a residential care home providing personal care to 39 people aged 65 and over at the time of the inspection. Most people were living with dementia. The service can support up to 46 people. The home is an adapted building and all on ground level.

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

The provider has been consistently non-compliant with the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 since July 2014. The governance systems in place have consistently continued to fail to make sustained improvements. Whilst the registered manager completed monitoring audits to assess the quality of the service, no systems where in place to do so above this level of management. Furthermore, the registered persons had failed to notify the Care Quality Commission (CQC) of some events they are required to do so by law. The consistently poor governance arrangements had resulted in people not always receiving a high-quality and person-centred service.

The risks associated with people choking and experiencing falls had not been fully assessed and mitigated. Some of the tools the service used to assess risks to people were not nationally recognised and did not accurately rate the risk. This put people at risk of harm. We also found a room open that people living with dementia could access. It contained equipment that may cause harm. However, the risks associated with the premises and working practices had been identified and managed. Medicines were managed safely, and processes were in place to help to protect people from the risk of abuse and those associated with infection. Accidents and incidents were recorded and analysed to help to prevent future occurrences.

Most people received a person-centred service however we identified that where people had not, this had impacted negatively on them. People’s individual leisure needs were not consistently met, and people told us there were not enough activities or stimulation; our observations confirmed this. People felt no need to raise complaints but told us they would feel comfortable in doing so if they needed to. We saw that where people had raised a complaint, this had been appropriately managed.

People had mixed opinions on whether there were enough staff and our observations concluded there were concerns regarding the deployment and effectiveness of some staff. This was because of seeing the service over a two-day period where we saw two separate staff teams work in differing ways, one more effective than the other. The majority of staff demonstrated skill in their roles and interacted with people in a kind and warm manner. However, we did see examples of where this was not the case. Staff received training and ongoing support and felt valued which benefited those people that used the service. People told us they felt respected and that their dignity was maintained; their relatives agreed.

People received enough to eat and drink and had their health needs met. Staff sought consent from people prior to assisting them and were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 30 July 2018) and there was one breach of regulations regarding medicines management. 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 regarding the management of medicines. However, differing concerns were found which means the provider was still in breach of regulations.

The last rating for this service was requires improvement. The service remains rated requires improvement. This service has been rated requires improvement, or inadequate, for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safe care and governance at this inspection. A further breach was also identified regarding the provider’s responsibility to inform CQC of certain events.

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 request regular information from 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.

Our previous inspection had identified seven breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.This was because risk assessments for people and the premises were not adequate. There was also a lack of understanding by staff of safeguarding issues. Recruitment processes were not robust. People were not supported with their nutritional needs. Neither were people supported with their independence and choice. We also found that quality monitoring was poor. At this inspection we found that improvements had been made. However, the service was not ensuring that people received their medicines in safely.

Following the last inspection in July 2017, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well-led to at least good. This action plan has been completed. After the July 2017 inspection and the rating of Inadequate the service was placed into special measures. Following this inspection and the rating of Requires Improvement the service has been removed from special measures.

The Limes 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 Limes accommodates up to 46 people in one adapted building. On the day of our inspection there were 31 people living in the service.

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

Our inspection of July 2017 found that risks to people living in the service had not been identified or managed effectively. At this inspection we found that significant improvements had been made. Risk assessments were in place and appropriate actions were in place to mitigate any identified risks. However, there was one area which still caused us concern. This was with regard to the crushing of medicines. Some medicines are not suitable to be crushed and the advice of a pharmacist should be taken before crushing medicines. We found that in some cases medicines were being crushed and this could be putting the person at risk. We raised this with the service during the inspection and they have now made appropriate referrals. People were also being administered their medicine covertly. This is medicine which area administered without the person’s knowledge for example concealed in food. The service had not always followed the appropriate best practise guidelines when doing this.

People felt safe while being supported by the staff. Staff had a good understanding of how to keep people safe and their responsibilities for reporting accidents, incidents or concerns. Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe. Staff had been trained in a range of skills which enabled them to provide people with effective care and support. There were sufficient staff to meet people’s assessed needs.

People told us that staff treated them with respect and courtesy. During our inspection we observed this in practice with staff responding to people’s needs in a caring and compassionate manner. 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. Appropriate applications had been made to the local authority were it had been identified that people needed to have a restrictions to their liberty authorised.

People’s nutritional needs were met. Where necessary people’s food and fluid intake was monitored effectively. People told us, and we observed that meal times were an enjoyable experience.

The service management team had a clear vision for the development and improvement of the service. People and staff told us that they were approachable and responded well to any suggestions. However, quality control measures in place had not identified the concerns we have raised regarding medicines.

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

The Limes provides accommodation and support to a maximum of 46 older people some of whom were living with dementia. It is not registered to provide nursing care. At the time of our inspection there were 44 people living in the home.

At the time of our inspection visit there was registered manager 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.

We last inspected this service on 13 and 14 June 2016 and found the provider was in breach of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued requirement notices in respect of these breaches. Following our inspection in June 2016, the provider sent us an action plan to tell us about the actions they were going to take to meet these regulations. They told us they would be compliant with two of the regulations by September 2016 and with a further regulation by November 2016.

We carried out this inspection to check if the improvements had been made in order to achieve compliance with the regulations. At this inspection we found insufficient improvements had been made and governance arrangements in the home were not effective enough to rectify the breaches found at the previous inspection. The provider was still in breach of regulations for: safe care and treatment, safeguarding service users from abuse and improper treatment, and good governance. We found that there had been a deterioration in the quality of care in other areas, which meant the provider was in breach of a further five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant that risks to people had increased.

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

We found people were not being provided with safe care. Risks to people’s health and safety were not always identified. We found in cases where risks had been identified, that insufficient action had been taken to manage and mitigate the risk of any further harm. The systems in place had also not identified risks to people from the premises. The service remained in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not always protected from improper treatment and had been subject to inappropriate restraint. Systems and processes in place were not effective to ensure people living in the home were adequately protected from improper treatment. The service remained in breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Recruitment processes were not robust and did not fully mitigate the risks of employing staff unsuitable to their role. The registered manager had not taken action to fully assure themselves that staff employed were fit and proper. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff did not always understand the importance of seeking consent from people living in the home. The service did not fully adhere to the mental capacity act which meant people’s rights to provide consent were not always fully protected. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s nutritional and hydration needs were not always met. People did not always receive adequate support with their meals or access to suitable foods. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not always supported in a caring manner that promoted their dignity and independence. People’s privacy was not always respected. Their independence and ability to choose for themselves was not always promoted. This was a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The care provided did not to take in to account people’s individual needs and preferences. Staff did not always support people to make their preferences known. Where preferences where known these were not always acknowledged or provided for. Care plans did not always contain sufficient information or guidance, including on how people wanted to be cared for. The activities on offer did not always meet people’s individual needs which meant they were not always inclusive. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had failed to implement effective systems to assess, monitor and improve the quality and safety of the service. This had resulted in some people experiencing poor care and support. They had also failed to maintain an accurate and complete record in respect of each person who used the service. Necessary improvements to the service had not been made. The culture in the home was not always person centred or respectful. This had not been identified by the provider or management in the service and consequently improvements in this area were required. The service remained in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Improvements were required in the safe management of medicines. We found systems in place were not always effective at ensuring people received medicines that were appropriate to their needs. Guidance for ‘as required’ medicines did not provide adequate guidance for staff regarding when this should be administered.

Staffing levels appeared adequate in the home, although we observed that staff could be better deployed to help ensure people’s needs were fully met.

There was varied feedback regarding the competency and expertise of the staff. Staff training was in place although not all staff had attended this training, and training rates for some individual staff members were very low.

People could access their local GP however we found staff did not always advocate on behalf of people to access other health care services.

There was mixed feedback regarding how the service responded to complaints, although where complaints were recorded we saw the manager had investigated and responded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

The Limes provides accommodation and support to a maximum of 46 older people some of whom may be living with dementia. It does not provide nursing care. At the time of our inspection there were 41 people living in the home.

We last inspected this service on 04 and 06 November 2014 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider was in breach of the Regulation 13 which corresponds with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not managed safely. The provider was also in breach of Regulation 22 and Regulation 10 which corresponds with Regulation 18 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were insufficient numbers of staff to meet people’s needs and there was insufficient quality monitoring occurring in the service.

At this inspection in June 2016, we found a continued breach Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found additional breaches of Regulation 12 and Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

There was a registered manager 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.

Improvements regarding the management of medicines had been made people had received their oral medicines as prescribed and they were safely stored.

People were not protected from avoidable harm and abuse because staff did not always identify when safeguarding referrals were required and systems did not operate effectively to ensure these were reported. Not all risks to people were adequately identified or managed, this included risks relating to the management of the premises.

There was not always enough stimulation and activities for people and there was mixed feedback regarding whether staffing levels were sufficient to meet people’s needs. We have recommended the service review their staffing levels against people’s individual needs to ensure there are sufficient staff.

Staff sought people’s consent to their care. We have made a recommendation that the service continues to make improvements regarding mental capacity assessments and best interests decisions.

People’s preferences and needs around meals were accommodated and people were supported to eat and drink enough. Staff ensured people received support from health care professionals in a timely manner.

People were supported by kind and caring staff, who ensured people were treated respectfully and with dignity. People felt involved and able to make decisions regarding their care.

People’s care plans were not always detailed enough and did not contain information that was specific to them. Not everyone had been given the opportunity to review and discuss their care plans. People felt able to raise concerns and concerns were investigated and responded to.

Improvement had been made regarding quality monitoring systems; however these had been ineffective at identifying some areas for improvement. Actions had not always been taken to make sufficient improvement in some areas.

The registered manager was approachable and ensured they listened and consulted people, relatives, and staff on how the service was run. Staff understood their responsibilities and took accountability for the role. The registered manager addressed poor performance and staff told us the registered manager had improved the standard of care provided.

This inspection was in response to concerns that had been raised to us about the care and treatment provided to people at the home. We did not speak to people using the service as part of our inspection on this occasion.

Below is a summary of what we found. The summary describes what we observed and the records we looked at.

Is the service safe?

The risks of harm to people were increased because the service did not routinely assess people's needs before they moved into the home, or periodically after their admission. This meant that the provider could not be sure people's needs could be met.

Essential risk assessments were not in place to identify where adjustments needed to be made to keep people safe. People who were at risk of falls did not have an appropriate assessment in place. There were no assessments in place to identify the risk of people developing pressure sores.

Is the service effective?

The service referred people to other health and social care providers appropriately. Community nursing staff were contacted when people needed treatment in respect of sore pressure areas, or when they were admitted to the home from hospital with pressure sores.

Care plans were not in place that directed staff about the treatment regime and their role in caring for a person with a pressure sore. People's specific needs were not always assessed and included in their care plans. Records suggested that some of the care plans had not been reviewed regularly. Care plans were therefore not able to support staff consistently to meet people's needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. Staff spoke politely to people and were cheerful.

Is the service responsive?

The service did not undertake a full needs' assessment before people moved into the home, or returned to the home from hospital. This meant that they could not be sure they understood and could respond to the person's specific needs. Periodic assessments of need and risk were not completed so that the service could be sure they were responding to changes in the person's condition.

Is the service well led?

Care and support was not being provided to people by staff based on assessments of risk. This meant that we could not be sure that care was safe and appropriate to the person's needs. There was no evidence that care plans were being monitored by senior staff to ensure that they were being completed and updated accurately and in a timely way.

We did not speak with people using the service at this inspection because the information we needed to gather referred to documentation and the management arrangements of the home.

On this visit we saw that staff had received training about safeguarding people from abuse and they were able to speak clearly about what they would do if they suspected abuse was occurring. There was guidance in place so that staff would be able to refer any concerns to the appropriate authorities in a timely way.

Senior managers were receiving guidance and support to set up robust quality monitoring systems in the service. Medicines were being monitored, although this was not being recorded. A complaints process was in place with records made of any concerns or complaints received. Care plans were being monitored each month in addition to daily checks by senior carers. Risk assessments and risk reduction plans had been written and were being typed ready to place within the care plans.