Last updated 18 April 2019
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 23 and 24 January 2019. The inspection was carried out by two adult social care inspectors, a CQC nurse specialist advisor and two experts by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. One expert by experience attended the inspection and spoke with people to gain their views and opinions of the home. The second expert by experience supported this inspection by carrying out telephone calls to people’s relatives.

Before the inspection we looked at information that we had received about the service and formal notifications that the service had sent to the CQC. We also looked at safeguarding notifications that the provider had sent to us. Providers are required by law to inform CQC of any safeguarding issues within their service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve the ratings for key questions of responsive and well-led to at least ‘good’. The action plan included information around how they would address concerns related to activities and good governance of the home including effective auditing.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.

We undertook general observations and used the short observational framework for inspectors (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During the inspection we spoke with 11 staff including the registered manager, the clinical lead, three nurses, the nominated individual (who also owned the home) and five care staff. We also spoke with 16 people that were living at the home and 13 relatives.

We looked at eight care records and risk assessments, 13 staff files including three nurses and 10 care staff, and other paperwork related to the management of the service including staff training, quality assurance and rota systems. We also looked at four people’s pressure relieving equipment and records and 10 people’s medicines records.