Caritate Nursing Home

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

The registered manager had left the service since the last inspection. The provider was advertising for a new manager. They were staying at the service for part of each month, managing the service along with the support of a deputy manager.

The recording of assessments and the monitoring and oversight by staff, of stocks of medicines, when people self-administered their own medicines was now effective. People were regularly reviewed to ensure they were safe to administer their own medicines.

Staff training was accurately recorded and closely monitored. All the nurses had received medicine update training since the last inspection.

The provider had an accurate record of all staff supervision and appraisals that had been completed.

The management of risk had improved. Care plans contained risk assessments and there had been recent reviews when people’s needs had changed. Staff were provided with guidance and direction on how to reduce identified risks.

The provider had improved the recording and oversight of monitoring records. For example, when people were having their food and drink intake recorded. However, these records were not always totalled each day, so it was not always clear if the person had had sufficient intake or not and any gaps in recording would not always be identified in a timely manner. The provider assured us this would be addressed immediately.

The process for monitoring people’s weight had improved. There were clearer records and guidance in care plans to ensure this took place when required.

Accidents and incidents that took place at Caritate were recorded by staff. These records were then reviewed by the provider and audited for any patterns or trends. Any action taken was recorded.

The was a robust programme of audits now in place. All aspects of service delivery were being reviewed by the providers. Where improvements had been identified as being necessary, action was taken appropriately.

There was a system in place to monitor the Personal Identification Numbers (PIN) of all employed nurses. The PIN is compulsory for nurses working in the UK.

The provider had ensured that all the staff were aware of the current government guidance for staff in care homes regarding the use of Person Protective Equipment (PPE). Staff were not required to wear masks at the time of this inspection.

Deprivation of Liberty Safeguards (DoLS) records were being closely monitored by the provider. They were working with the DoLS team, at the local authority, to ensure any required authorisations were applied for appropriately.

The provider had ensured that staff were aware of the statutory guidance ‘Right support, right care, right culture’ as the service supported people who had a learning disability. The provider and staff were working with external healthcare professionals to ensure they were supporting people in line with the principles of this guidance.

The service website contained the required link to the latest CQC report. The provider had updated their Statement of Purpose (SOP) since the last inspection to ensure it clearly stated what care and support was provided at Caritate Nursing Home.

The provider had reviewed the content of the governance report required to be completed by all management each month, in order to inform the provider of the quality of the service provided.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was requires improvement (Published 31 December 2022)

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We use targeted inspections to follow up on Warning Notices or to check specific concerns. 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.

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

Recommendations

We have made a recommendation about the recording and oversight of monitoring records.

Follow up

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

Caritate Nursing home is a residential care home providing personal and nursing care to up to 24 people. The service provides support to people of all ages with a range of health needs, physical disabilities and people living with dementia. At the time of our inspection there were 22 people using the service.

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

Medicine records were not always accurate. A recommendation, which was made in our last report, had not been actioned and the same concerns remained. Some people did not receive their medicines as prescribed. A recent audit had not identified the issues found at this inspection.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; there was a lack of policies and systems in the service to support best practice. Some people were being restricted without an appropriate authorisation. The registered manager did not have a thorough understanding of the legislation laid out in the Mental Capacity Act 2005.

Staff had not been provided with regular supervision and appraisal. Training updates had not always been provided in a timely manner. The registered manager did not have access to some specific training details of the staff as they were held on a different system on another member of staff’s computer.

Nurses professional registration details with the Nursing and Midwifery Council (MNC), required for them to practice, were not routinely monitored. Risks were not always identified or safely managed. Staff did not always have the necessary guidance in care plans to help them support people to reduce the risk of avoidable harm.

Everyone in the service had a care plan. However, it was not always clear from people’s care plans if they required specific care or monitoring. Monitoring charts were not formally checked regularly, so any gaps or concerns would not be identified in a timely manner. Some guidance in care plans was not always being followed by care staff. Staff were not always aware of people’s specific care needs.

People’s communication needs were identified. However, care plans did not contain adequate specific guidance for staff around supporting people who did not have the ability to communicate verbally.

Care plans did not always contain direction for staff regarding the provision of oral care for people who were not having any food or drink orally. However, we were shown that staff were recording when they carried out mouth care on room-based records.

Infection control processes and procedures were not always robust. Prior to this inspection the registered manager had agreed to all staff dispensing with the wearing of face masks, even when working closely with people such as during personal care. This was not in line with the current guidance. The registered manager took advice and re-instated the wearing of masks immediately upon the inspector’s arrival.

There was a lack of robust governance of the service provided. The registered manager had delegated most audits and processes to other staff but did not have oversight of their actions or the information gathered.

There was a designated activities staff member to assist people. However, some people reported being bored and we saw no activities taking place during this inspection. Interactions between staff and people was task based.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

The registered manager was not aware of the guidance and people were not being supported in line with the underpinning principles of Right support, right care, right culture. Although other agencies had provided additional support and guidance, specifically for these people, this had not been implemented or used to improve people’s experiences. They were not given opportunities to access their local community or take part in meaningful pastimes that mattered to them. Staff did not have the necessary skills to effectively engage with them.

Some people living at the service were cared for in bed due to their health care needs. These people had been assessed as requiring pressure relieving mattresses to help ensure they did not develop pressure damage to their skin. These mattresses were set correctly for the person using them.

People told us they were happy with the care they received, and people said they felt safe living there. Staff knew how to keep people safe from harm.

People looked happy and comfortable with staff supporting them. Staff were caring. People were supported by staff who knew them well. Many staff had worked at the service for a long time.

Staff were recruited safely in sufficient numbers to ensure people’s needs were met.

People and their families were provided with information about how to make a complaint and details of the complaint’s procedure were displayed at the service.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was good (Published 28 November 2017). At this inspection the rating has deteriorated to requires improvement

Why we inspected

We received information of concern in relation to the governance of the service, staff support and restrictions in place for some people that may not have been appropriately authorised. We carried out a focused inspection covering 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.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Caritate Nursing 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 monitor the service and will take further action if needed.

We have found breaches in relation to medicines management, consent, staff support, and governance of the service.

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

Follow up

We will request an action plan from 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 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.

The home was clean, hygienic and uncluttered in appearance. There were procedures to ensure that infection control risks were reduced. For example, increased cleaning of communal areas.

Procedures were in place regarding self-isolation for people who showed symptoms of COVID-19 or who were admitted to the home from the community or other health care provision. The admission procedure had been reviewed and developed to reduce the risk of infection from COVID-19.

The home had a contingency plan to reduce the risk of cross infection should there be an outbreak of COVID-19 in the home. This included the potential for cohorting people within zones and separating staff teams.

Due to the current national lockdown, visiting was currently restricted. Information was provided to friends and families by telephone call, letter, email and on the home’s website regarding the visiting arrangements. Where visiting was permitted inside the home for compassionate reasons (for example for people receiving end of life care) suitable infection control procedures were in place when visitors entered and moved around the building. The home had designated entrances to the conservatories for visitors to use and a screen was provided to enable safe visiting practices. Visitors were screened for COVID-19 prior to entering the home. Visitors were required to wear masks and, as necessary, other protective personal equipment (PPE).

People were supported to speak with their friends and family using IT systems and the telephone as necessary. The home had purchased a tablet to assist with the communication during this lockdown period.

Appropriate testing procedures for COVID-19 had been implemented for all staff and people who used the service following national guidance regarding the frequency and type of testing. The registered manager kept clear evidence of when the testing took place, for who and the results.

An informal system was followed to assess people for the development of COVID-19 symptoms. This did not include twice daily monitoring of physical symptoms such as temperature checks for people who used services. The national guidance at the time of the inspection recommends this.

Infection control policies and procedures had been updated in line with the national guidance relating to COVID-19. Staff had access to paper copies of all policies and procedures. When the guidance was updated staff were required to sign a copy to say they had read and understood the changes. Information advising of the change and the action they needed to take was sent to individual staff electronically. The training for staff regarding infection control had been updated to include guidance relating to COVID-19.

The registered manager had completed risk assessments regarding the environment and risks to staff and people who used the service. The registered manager was aware of staff members who were at increased risk from COVID-19 and measures that would be required to keep them safe, should there be an outbreak in the home. The registered manager planned to include this information in formal written risk assessments.

Plentiful supplies of PPE were available in the home. This included masks, gloves, aprons, gowns, visors, goggles, overshoes and head coverings. Signage was in place in some areas of the home regarding the requirement for wearing PPE. When visiting resumed following this lockdown the registered manager intended to increase the signage at each entrance to provide a visual reminder to visitors. Additional signage would be used to advise all staff of the PPE to be worn when a person was assessed at higher risk of infection. For example, for a new admission or for someone showing symptoms or testing positive for COVID-19.

Staff breaks were staggered to reduce the risk of groups of staff congregating together. Staff were observed to be within 2 metres (the recommended social distancing range) without wearing a mask. This occurred when the staff were in staff only areas such as the kitchen and the staff room and when donning PPE. This increased the risk of cross infection.

There was a registered manager in post who was responsible for the day-to-day running of the service. 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 carried out this unannounced inspection on 13 November 2017. At this comprehensive inspection we checked to see if the provider had made the required improvements identified at the inspection of 17 July 2017.

In July 2017 we found there were gaps in the recording of people’s care and treatment, in the recording of best interest decisions and a lack of detail in some people’s care plans. We had other concerns about how risks in relation to people’s care were managed and the system for monitoring the quality of the service was not entirely effective.

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met all the outstanding legal requirements from the last inspection.

On the day of the inspection there was a calm, relaxed and friendly atmosphere in the service. We observed that staff interacted with people in a caring and compassionate manner. People who were able to talk to us about their view of the service told us they were happy with the care they received and believed it was a safe environment. Comments from people and their relatives included, “[Person] is well looked after”, “Staff are good”, “No problems at all”, “I am happy living here” and “I have nothing to complain about.”

Where people were unable to tell us about their experiences we observed they were relaxed and at ease with staff. People’s behaviour and body language showed that they felt cared for by staff.

Staff ensured people kept in touch with family and friends. Relatives told us they were always made welcome and were able to visit at any time. One relative told us, “I have always felt really comfortable visiting. Staff tell me it is my home as well.”

The environment was clean, well maintained and there were no unpleasant odours. Bedrooms were personalised to reflect people’s individual tastes.

While safe arrangements were in place for the storing and administration of people’s medicines, there were some gaps in Medicine Administration Records (MARS). There were some missing signatures where two staff had not signed to confirm the accuracy of handwritten entries for prescribed medicines. Topical creams had not been dated on opening and there were missing records of when staff applied creams for people. We found some creams that were out of date. There were discrepancies between records of medicines given and the stock held for some people. We have made a recommendation about medicines recording.

Staff were supported by a system of induction training, one-to-one supervision and appraisals. There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse.

People received care and support that was responsive to their needs because staff were aware of the needs of people who lived at Caritate. Staff supported people to access healthcare services such as occupational therapists, GPs, speech and language therapists (SALT) and chiropodists. Relatives told us the service always kept them informed of any changes to people’s health and when healthcare appointments had been made.

Care plans were well organised and contained personalised information about the individual person’s needs and wishes. Care planning was reviewed regularly and whenever people’s needs changed. People’s care plans gave direction and guidance for staff to follow to help ensure people received their care and support in the way they wanted. Risks in relation to people’s care and support were assessed and planned for to minimise the risk of harm.

People were able to take part in a range of group and individual activities. A full time activity coordinator was in post who arranged regular events for people. These included quizzes, craft work, board games and relaxation exercises. The service owned a mini-bus and this was used by staff to take some people to regular activities and others for days out.

Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. Where people needed assistance with eating and drinking staff provided support appropriate to meet each individual person’s assessed needs. People and their relatives told us, “Staff ensure [person] has fat free meals because of his health condition” and “The kitchen makes me special meals when there is something on the menu I can’t eat.”

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Staff demonstrated the principles of the MCA in the way they cared for people. Where people did not have the capacity to make certain decisions the service acted in accordance with legal requirements. Applications for DoLS authorisations had been made to the local authority appropriately.

There was a management structure in the service which provided clear lines of responsibility and accountability. Staff had a positive attitude and the management team provided strong leadership and led by example. Comments from staff included, “Manager is lovely, she is very approachable”, “If we need anything the manager sorts it straight away” and “There has been a big improvement compared to the last few months. This manager has a different approach, everything is about the residents.”

People and relatives all described the management of the home as open and approachable. Relatives told us, “I can talk to the manager at any time if I have any concerns or queries”, “I have every confidence in the management of the service” and “I have never doubted our decision for [person] to move to Caritate.” There were regular meetings for people and their families, which meant they could share their views about the running of the service. People and their families were given information about how to complain. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.

There was a registered manager in post who was responsible for the day-to-day running of the service. 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 and associated Regulations about how the service is run.

We carried out this unannounced inspection on 17 July 2017. At this comprehensive inspection we checked to see if the service had made the required improvements identified at the inspection of 13 and 14 February 2017.

In February 2017 we found that people’s consent to their care was not always appropriately recorded and informal consent was not consistently sought by staff before providing care to people. We had concerns relating to gaps in the recording of how people’s health care needs were being monitored. Medicines were not safely managed and there was a lack of effective quality monitoring systems.

At this inspection we found improvements had been made to the management of medicines, how people’s consent was sought and to the recording of people’s consent. However, we still had concerns in relation to gaps in the recording of people’s care and treatment and the system for monitoring the quality of the service.

Safe arrangements were in place for the storing and administration of medicines. There were some missing signatures where two staff had not signed to confirm the accuracy of handwritten entries for prescribed medicines. Some people had been prescribed creams and these had not been dated upon opening. We found some creams that were out of date. However, the registered manager told us systems in relation to this would be improved and we judged that this had not had an impact on the safety of how people received their medicines.

People, or their advocate’s, consent to their care and treatment was appropriately recorded. We observed that staff asked for people’s consent before assisting them with any care or support.

Food and fluid intake charts for some people were not completed thoroughly enough to be able to check exactly how much food and fluid the person had taken. Where some people’s care plans stated they should be re-positioned, and their skin checked at particular intervals during the day, there were no records to say that these checks had taken place. Although, we found no evidence that people’s skin integrity and food and fluid intake needs were not being met. While a new system of audits, to monitor the quality of the service provided, had been developed audits in relation to the care provided had not been implemented at the time of the inspection.

At this inspection we had other concerns about how risks in relation to people’s care were managed, the lack of detail in some people’s care plans and gaps in the recording of best interest decisions.

Where some people had lost weight and there were no risk assessments in place to give guidance for staff about how to minimise the risk of further weight loss. Concerns raised by staff about the accuracy of the weighing scales had not been investigated. Where people had been assessed as being at risk from developing skin damage, pressure relieving mattresses were in place. We found mattresses were not set at the correct setting for individual people’s weight and there was no system in operation to check if mattresses were set at the correct level. For another person, the risks associated with them not having timely access to anti-biotics, due to their complex respiratory disease, had not been identified.

Care plans lacked detailed guidance for staff to follow and some had not been updated to reflect the care being provided to people. A listening device had been put in place for one person, who was at high risk of choking, and this had not been updated into their care plan. There was also no record that a best interest process had been carried out because the person did not have the mental capacity to consent to this monitoring.

People told us they felt safe living at Caritate and with the staff who supported them. People and their relatives told us, “Very nice staff, they are very good to me”, “Very pleased with the home, they look after my daughter well” and “I am very lucky to live here.” We met with several people living at the service but some were unable to tell us their views about the care and support they received. However, we observed people were relaxed and at ease with staff, and when they needed help or support they turned to staff without hesitation. People had good and meaningful relationships with staff and staff interacted with people in a caring and respectful manner.

People and their relatives told us they were confident that staff knew people well and understood how to meet their needs. The relative of one person told us, “Since living at Caritate staff have managed my daughter’s diabetes and skin condition well. Staff have also helped her to lose weight and she is healthiest I have seen her.”

There were sufficient numbers of suitably qualified staff on duty and staffing levels were adjusted to meet people’s changing needs and wishes. Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff knew how to recognise and report the signs of abuse. Staff supported people to keep in touch with family and friends.

Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. Where people needed assistance with eating and drinking staff provided support appropriate to meet each individual person’s assessed needs. People told us they enjoyed their meals and they were able to choose what they wanted each day. One person said, “The food is lovely, very good.”

There were activities on offer for people to take part in within the service and in the community. However, some people living at the service were unable to join in the activities on offer due to their complex health and communication needs. Two weeks before our inspection a full-time activities coordinator had been employed and they had started to develop a more personalised approach to activities. This would enable people, who were currently not engaging in any meaningful activities, to be offered activities suitable for their needs.

People and their families were given information about how to complain. There was a management structure in the service which provided clear lines of responsibility and accountability. Staff told us they felt supported by the registered manager commenting, “The new posts of team leader and seniors are good. I feel very positive about it, we are going in the right direction” and “We have had a difficult time, but things are getting better.”

Before our inspection safeguarding concerns were raised with Cornwall Council about the care of some people living at the service. Investigations into these concerns were still in progress at the time of this inspection. An action plan to improve the service had been developed with Cornwall Council. Despite only having been in post since April 2017 the registered manager had made good progress with the action plan and all actions were due to be completed by 31 August 2017. All of the concerns found at this inspection were part of the action plan. The registered manager also took action to rectify some of our concerns during and immediately after our inspection.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

Caritate Nursing Home provides nursing care for up to 24 people with a range of health care needs and physical disabilities. At the time of the inspection, there were 19 people living at the service.

The service was managed by two registered managers. 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 carried out a focused inspection on 2 October and 17 November 2016. During that inspection, we found breaches in regulations. We found that there was not an established, effective accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons. In addition at the previous inspection, we found that the service was not meeting the requirements of the Mental Capacity Act (2005), including the Deprivation of Liberty Safeguards (DoLS).

At this inspection, we found improvements had been made in these areas. People’s rights were protected as the principles of the Mental Capacity Act 2005 (MCA) were followed by staff. Applications had been made to the supervisory body when necessary to authorise people’s care and treatment under the Deprivation of Liberty Safeguards (DoLS). However, we noted that people’s consent was not always appropriately recorded. The registered manager took action to address this issue. We also observed occasions where staff did not seek consent before assisting people with aspects of their care or before accessing their bedroom.

We found some concerns relating to the coordination and documentation of people’s health care needs. In particular in relation to one person who had a number of complex health concerns. We also found one person’s nutritional needs were not being effectively monitored due to inconsistent completion of charts by some staff.

We found some issues relating to medicines management. There was no system to report or record errors or omissions and medicines audits were not being undertaken at the service. We observed an excess of some stock and some staff signing medicine as being administered before the person had taken it.

As part of the service’s quality assurance procedures senior staff submitted monthly reports to the registered managers, for example, the lead nurse, maintenance person and the head chef. These reports were reviewed in order to identify concerns that might require action. However, this process had not identified the concerns with medicines management, consent and the recording and coordination of some health care needs.

Feedback on the service was sought through the distribution of quality assurance surveys and via a comments book which was accessible to people and their relatives. However, there were no staff meetings or residents’ meetings to provide people and staff the opportunity to raise concerns or share ideas collectively. Some staff felt they were not listened to or respected by senior and nursing staff.

Staff had received training in order to carry out their roles effectively, however a number of staff had lapsed in their mandatory training. We were told this was being actively addressed by the registered manager.

Feedback from staff, people and their relatives about the registered managers was generally positive. Relatives we spoke with felt involved in their family members care and this was reflected in people’s care records. Complaints were investigated and responded to in a timely manner and learning was used to assist learning and drive improvements. One person told us they had not been supported to make a complaint and this was reported to the registered manager who said they would look into this allegation.

People and their relatives told us the staff were caring and we witnessed kind and compassionate interactions between people and staff. We saw suitable levels of care staff who were able to respond to people in an unhurried way.

People’s care records were well organised and contained details about people’s likes, dislikes background and history. There was suitable guidance for care staff around people’s preferred routines and how they chose to spend their time. Care records were regularly reviewed and updated. People had access to activities in the home such as arts and crafts and there was a volunteer who attended the service to assist with this. There were visitors to the service such as entertainers and a petting animals service. There was a mini bus which was used to take people to appointments.

People were supported by staff who were safely recruited and who had undergone checks to ensure they were suitable to work with vulnerable people. People’s safety was protected as staff understood their role in recognising and reporting signs of abuse or mistreatment.

The service was visibly clean and free from adverse odours throughout. There were suitable levels of PPE (personal protective equipment) and we observed staff following good hand washing procedures. There were checks of the building and equipment to ensure they were safe and fit for purpose.

Caritate Nursing Home is a care home which provides nursing care and accommodation for up to 24 people. Caritate Nursing Home provides short term and longer term care for people, including younger adults, who are living with physical disability and people who may have physical and mental health needs.

The service had two registered managers 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 found the service was not meeting the requirements of the Mental Capacity Act (2005), including Deprivation of Liberty Safeguards. This is a legal framework that protects the rights of people who are unable to make certain decisions. Where people were deemed as lacking capacity, assessments had not been completed to ensure that staff were appropriately supporting people to make decisions and choices. The staff had a good understanding of how to support people to make day to day decisions but they did not have a good understanding of their legal obligations with regard to the Mental Capacity Act for more complex decisions.

We saw at least one example where potentially a person was deprived of their liberty. There was no documentation to demonstrate that this deprivation was made in the best interests of the person and the registered person had not submitted an application to the local authority for authorisation in relation to this deprivation as required by the Act. CQC is responsible for monitoring Deprivation of Liberty Safeguards. If such a Safeguard is authorised the provider is required to notify CQC, at the time of the inspection we had not received any notifications with regard to this.

Whilst the majority of feedback we received was positive there were at least three occasions where the staff and providers did not work with families and/or other social care professionals in the best interests of the people they were caring for. The Registered managers did not show an understanding of their roles and responsibilities particularly when things had gone wrong. The actions taken by the provider, when there were issues raised with them, did not foster continued and good working relationships. There was not a culture of learning from events and of being open and transparent.

There were breaches of Regulation 11: Need for Consent and Regulation 16 Receiving and acting on complaints of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition we have made a recommendation that the provider consider how they work with families and carers. You can see what action we told the provider to take at the back of the full version of the report.

We saw care plans were detailed and gave direction as to the care and support people needed. They had been regularly reviewed. However some risk assessments had not been reviewed regularly. We saw the care plans were developed and reviewed with the person using the service and /or their relatives where appropriate.

We saw the home was clean and tidy. There was information about infection control readily available throughout the home although the infection control policy had not been updated since 2008.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for by staff who were properly supported to deliver care and treatment safely and to an appropriate standard.

We saw evidence of ongoing audit in areas including complaints, falls and health and safety. Results of satisfaction surveys were shared with people who used the service and their representatives.