Archived: The Elms

The Elms is a residential care home providing personal care and accommodation for up to 26 older people and people living with dementia. At the time of this inspection 20 people were residing at the service.

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

The home was not managed safely. Medicines, including topically applied creams were not managed in line with current best practice guidelines. The risks related to COVID-19 were not always safely managed and government guidelines were not always followed. Risks to people’s safety were identified and reviewed regularly, however, care plans lacked essential detail on how risks should be mitigated.

Care plans did not always contain sufficient detail to ensure people’s needs and preferences were upheld and some care plans were not reviewed regularly.

Despite the issues we found we received positive feedback from people and their relatives about the quality of care they received. Comments included, “We are more than satisfied that the staff look after [family member] well in very trying circumstances” and “The interactions are caring, it is more like a home from home with a homely feel.”

People were supported by staff who knew how to protect them from abuse and harm. Allegations of abuse were reported to the appropriate authorities.

The provider had made improvements to how they supported people to make decisions and consulted with people’s representatives. 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 supported best practice.

Despite many improvements the monitoring and auditing systems were not always effective and had not identified the ongoing issues we found with care plans, risk management, medicine management, infection control procedures and recruitment.

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 rating for this service was requires improvement (published 7 March 2022) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve and by when. Although we found some improvements at this inspection the provider remained in breach of several regulations. The service remains rated requires improvement for three consecutive inspections.

Why we inspected

We carried out an unannounced focused inspection of this service on 23 December 2021 and breaches of legal requirements were found. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This focused report covers the entirety of the key questions Safe and Well-Led and part of the key question Effective. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make further improvements. The overall rating for the service has remained requires improvement. The key question Well-led has improved to requires improvement based on the findings at this inspection. Please see the safe, effective and well-led sections of this full report.

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

Enforcement

We have identified continued breaches in relation to the recruitment of staff, management of medicines, infection prevention and control practices, person-centred care and the monitoring and auditing of the quality of people's care and support. We have sent a Regulation 17(3) Letter to the provider in relation to their failure to effectively operate systems and processes to assess, monitor and improve the quality and safety of the services provided in carrying on the regulated activities. A Regulation 17(3) Letter stipulates the improvements needed to meet breaches of regulation, seeks an action plan and requires a provider to regularly report to CQC on their progress with meeting their action plan.

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.

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

Follow-up

We will meet with the provider to discuss how they will implement their action plan and make the required changes to ensure they improve their rating to at least good. We will work alongside the provider and the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Elms is a residential care home providing personal care and accommodation for up to 26 older people with physical health conditions and/or people living with dementia. At the time of this inspection 17 people were residing at the service.

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

People we spoke with remarked positively about the quality of care.

People did not always have enough staff available to meet their needs and systems to safely recruit staff were not sufficiently robust. These concerns placed people at risk of not receiving staff support in a timely way and receiving their care from staff without suitable experience and skills for their roles.

People were not always safely supported by staff with their medicines, including topically applied creams and other items.

Infection prevention and control practices did not ensure people's safety.

People were supported by staff who knew how to protect them from abuse and harm. Allegations of abuse were reported to the appropriate authorities.

Risks to people’s safety were identified and guidance was developed to address these risks. However, potential risks to the health and wellbeing of people who were supported to maintain early morning routines were not considered and documented.

People did not always received care that was personalised and planned in accordance with their needs and wishes. People's care plans did not show people and their supporters were assisted to consider risks and benefits of chosen early morning routines in a balanced and informed way.

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; the policies and systems in the service did not support best practice.

Staff received training and support from the provider to meet people’s needs, although there were differing views from staff about the quality of support and guidance from the registered manager.

Monitoring and auditing systems were in place to identify and remedy any issues with the quality of the service. However, we found shortfalls across a range of areas including medicine management and the recording of cleaning schedules which were not identified by the provider’s own quality assurance checks. The registered manager did not demonstrate the knowledge and skills to manage the service because they failed to make necessary improvements to the service and did not promote a supportive and harmonious environment for staff to work and develop.

The registered manager was provided with additional support and mentoring since the last inspection to carry out their responsibilities. Findings at this inspection demonstrated this did not achieve the necessary standard of knowledge and practice to operate a service that safely met people's needs.

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 rating for this service was requires improvement (published 9 September 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve and by when. At this inspection we found the provider remained in breach of regulations. The service remains rated requires improvement for two consecutive inspections.

Why we inspected

This inspection was prompted in part due to concerns received about infection control practices, the safety of people living at the service, staffing levels for care staff and domestic staff, and the standard of management performance at the care home. A decision was made for us to inspect and examine those risks. We also followed up on action we told the provider to take at the last inspection and confirm they now met legal requirements. This focused report covers the entirety of the key questions Safe and Well-Led but only parts of the key questions Effective and Responsive, which were found to be in breach of regulations at the last inspection. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make improvements. Although the overall rating for the service has remained requires improvement, the rating for the key question of Well-Led has declined from requires improvement to inadequate. This is based on the findings at this inspection. Please see the safe, effective, responsive and well-led sections of this full report.

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

Enforcement

We have identified continued breaches in relation to the recruitment of staff, management of medicines, infection prevention and control practices, person-centred care and the monitoring and auditing of the quality of people's care and support. We have sent a Regulation 17(3) Letter to the provider in relation to their failure to effectively operate systems and processes to assess, monitor and improve the quality and safety of the services provided in carrying on the regulated activities. A Regulation 17(3) Letter stipulates the improvements needed to meet breaches of regulation, seeks an action plan and requires a provider to regularly report to CQC on their progress with meeting their action plan.

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.

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

Follow-up

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good and request an action plan to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People and relatives mainly spoke positively about the quality of care and the kindness of staff. However, systems to safely recruit staff were not sufficiently rigorous which placed people at risk of receiving care from staff with unsuitable experience and backgrounds.

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

People and relatives mainly spoke positively about the quality of care and the kindness of staff. However, systems to safely recruit staff were not sufficiently rigorous which placed people at risk of receiving care from staff with unsuitable experience and backgrounds.

Some improvements had been achieved in relation to how people were supported with their medicines; however additional areas of improvement with medicine practices were needed to ensure people’s safety.

Improvements were needed to the infection prevention and control practices to consistently ensure people’s safety.

People were supported by staff who understood how to protect them from abuse and harm. Allegations of abuse were reported to the appropriate authorities.

Risks to people’s safety were identified and guidance was developed to address these risks.

People received care that was personalised and planned in accordance with their needs and wishes.

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.

Staff received training and support from the provider to meet people’s needs, although there were mixed views from staff about the quality of support and guidance.

People and relatives told us the management team were approachable and responsive.

Monitoring and auditing systems were in place to identify and remedy any issues with the quality of the service. However, we found shortfalls across a range of areas including medicine management and staff recruitment which were not identified by the provider’s own quality assurance checks.

The registered manager was provided with additional support and mentoring since the last inspection to carry out their responsibilities. Findings at this inspection demonstrated this was an on-going need.

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 rating for this service was Inadequate (published 30 December 2020) and has been in Special Measures since this date. There were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do to improve and by when. During this inspection the provider demonstrated some improvements have been made and they have met some of the breaches of regulation. 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 focused inspection was carried out to follow up on action we told the provider to take at the last inspection and confirm they now met legal requirements. This focused report covers the entirety of the key questions Safe and Well-Led but only parts of the key questions Effective and Responsive, which were found to be in breach of regulations at the last inspection. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make improvements. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection. Please see the safe, effective, responsive and well-led sections of this full report.

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

Enforcement

We have identified continued breaches in relation to the recruitment of staff, management of medicines, infection prevention and control practices and the provider's own monitoring and auditing of the quality of people's care and support. We have issued a Warning Notice for the repeated breach of Regulation 17(Good governance). 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.

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

Follow-up

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

We found the following examples of good practice.

There was a booking system in place so visits from relatives could be managed safely.

People were admitted from the hospital and the community safely following current government guidelines.

The provider kept adequate stocks of PPE and staff were observed to use this correctly.

Residents were tested regularly for coronavirus in line with current guidelines.

The premises were clean and hygienic and there were systems in place to ensure this was maintained.

The service had an infection prevention control lead who was responsible for ensuring safe practices were followed.

Staff had recently received infection prevention control training.

The Elms is a residential care home providing personal care and accommodation for up to 26 older people, including people living with dementia. There were 21 people living at the service at the time of our inspection visit.

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

People were not properly protected from avoidable harm. Accidents and incidents including falls and unexplained bruising were not analysed to enable lessons to be learnt and improvements implemented. People's medicines were not safely managed.

People were not consistently protected from the transmission of infectious diseases including COVID-19 as the service did not comply with government policy for safety within care home settings. The registered manager did not always correctly protect people who use the service from the risk of abuse. An allegation of abuse was not reported to the statutory authorities. Recruitment practices were not sufficiently robust and staff training documentation did not evidence that staff received the appropriate support to understand and safely meet people's needs.

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 policies and systems in the service did not support this practice. People's care plans contained generic consent forms where people gave their consent to a range of procedures and treatments, irrespective of whether they were assessed to have capacity to do so or not.

Care plans were not written in a person-centred way and did not always correspond with people's care.

Relatives/close friends were pleased with the quality of the service and told us their family members/close friends were happy living at the service.

The management structure at the service did not ensure the registered manager received the support and guidance required for the role and its responsibilities. The registered manager did not demonstrate how the quality of care was monitored and did not ensure detailed audits took place. Some staff reported that the culture of the service was not supportive and did not foster positive working relationships.

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 good (published 25 December 2019).

Why we inspected

We received concerns in relation to how the provider protected people from the risk of abuse and harm, including how people were safely supported with their moving and positioning needs by staff. Also, concerns were brought to our attention as to whether the provider appropriately supported people with their medicine needs and ensured the service was managed in a transparent, proper and safe manner. 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 key questions of effective, caring and responsive. We therefore did not inspect them. However, during the inspection we noted concerns in relation to how people were supported to give their consent to care. We also found concerns about the standard of staff training and the quality of individual care plans. Our specific findings regarding these concerns are recorded in the effective and responsive sections of this full report. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

We have found evidence that the provider needs to make improvements. The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection. Please see the safe, effective, responsive and well-led sections of this full report.

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

Enforcement

We have identified breaches in relation to the reporting of safeguarding allegations, person-centred care planning and the safe recruitment of staff. There were also breaches for the safe management of medicines, poor infection prevention and control practices, and significant concerns in relation to good governance. 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.

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.

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

The Elms is a residential care home providing accommodation and personal care to 26 older people, some of whom have dementia. The service can support up to 26 people.

People’s experience of using this service

The provider safeguarded people from abuse and mitigated risks to their health and safety. Lessons were learned when things went wrong and the provider ensured there were enough suitably qualified and appropriately vetted staff to care for people. The home was clean and tidy on the days of our inspection and staff took reasonable action to prevent the risk of infection. People’s medicines were managed safely.

The provider ensured care was provided in line with legislation and current standards of practice. People’s nutritional and health needs were met. Staff were appropriately inducted and received ongoing support to provide people with care. The home was appropriately designed and decorated to meet people’s needs.

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 were involved in making decisions about their care and their equality and diversity was respected. People’s privacy and dignity was respected and promoted and they were supported to be as independent as they wanted to be.

People took part in activities they enjoyed and there was a clear complaints procedure in place which was followed. Care plans covered all areas of people’s needs and the registered manager took reasonable action to determine people’s end of life care needs.

People using the service, their relatives and staff were involved in the running of the service. The registered manager understood and acted appropriately in accordance with their responsibility to be open and honest. The registered manager and care workers understood and carried out their roles. The provider appropriately monitored the quality of the service and took action to improve the quality of care. The provider worked in partnership with other professionals.

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 good (published 9 May 2017).

Why we inspected

This was a planned inspection based on the 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.

The Elms is a care home for up to 26 people who require personal care, some of whom have dementia. On the day of the inspection, 25 people were using 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.

At our last inspection of the service on 18 March 2016, we found the provider was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing. The registered manager did not always support staff in their roles. Staff did not receive regular one to one supervisions or appraisals to reflect on their practice.

We undertook a comprehensive inspection on 28 February 2017 to check that the service now met the legal requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Elms’ on our website at www.cqc.org.uk. At this inspection, we found the action taken to address the breach was sufficient to make the required improvements.

The premises had staircases that could pose a risk to people using the service. Some people living with dementia could access parts of the building which would cause them harm if they were not supervised. However, the registered manager had assessed risks to people and put plans in place to minimise potential harm to people.

Risks to people were identified, reviewed and managed appropriately. Staff were aware of the risks to people and had guidance on how to minimise the prospect of harm. The registered manager had reviewed other risks associated with the safety of the premises and working practices to protect people from avoidable injury.

Staff were supported in their role by the registered manager and their colleagues had received supervisions and appraisals to review their performance and development needs. People received care from competent and skilled staff who had regular training.

Prior to the inspection, the CQC was made aware of an incident that had happened at the service. The issue had been investigated and resolved by a local authority safeguarding team. During the inspection, an inspector and inspection manager conducted a fact finding exercise on this specific incident. The CQC will review the evidence gathered to inform its view about an aspect of people’s care at the service in relation to the incident.

People were protected from the risk of potential abuse. Staff had received training on how to identify and report abuse to help keep people safe. The registered manager and staff understood and followed the provider’s safeguarding procedures to deal with concerns. The registered manager had worked with a local authority safeguarding team on concerns raised at the service and made changes where a shortfall was identified.

There were enough numbers of suitably skilled and competent staff deployed at the service to meet people’s individual needs. Appropriate recruitment procedures were followed to ensure staff were suitable for their roles. People received the support they required to take their medicines from staff trained and assessed as competent to do so. Medicines were administered and stored safely in line with the provider’s procedures.

People accessed healthcare services when needed to maintain good health and to have their dietary needs met. People were provided with a healthy diet and sufficient amounts of food and drink and their nutritional needs were met.

People consented to receiving care and support. The registered manager and staff understood and supported people in line with the principles of the Mental Capacity Act 2005 and the requirements of the Deprivation of Liberty Safeguards. Staff knew people well and understood their needs. Staff were kind and caring to people using the service. People's care was provided in a way that promoted their dignity and maintained their privacy.

People were involved in the planning of their care and support. Staff provided personalised care that met people’s individual needs and took account of their preferences. Staff supported people to pursue their hobbies and to take part in meaningful activities. People and their relatives knew how to raise a concern and were confident of the complaints process. The registered manager sought people’s views about the service and used feedback received to improve their care.

People and staff were happy with the registered manager and how the service was managed. An open and positive culture was maintained at the service. Staff knew what was expected of them when providing people’s support and felt supported in their roles. The quality of the service was subject to regular checks and improvements were made when necessary.

This unannounced inspection took place on 18 March 2016. We last inspected The Elms on 31 December 2014. The service met all the regulations we checked at that time.

The service has 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.

At this inspection we found that the provider had breached Regulation 18 (2) (a) of the Health and Social Care 2008 (Regulated Activities) Regulations 2014. The breaches of the regulations relate to staffing. The registered manager had not always supported staff in their roles. Staff had not received one to one supervisions or annual appraisal to reflect on their practice. You can see what action we have told the provider to take at the back of the full version of this report.

People in the service received safe care and support. People received their medicines safely and as prescribed from staff assessed competent to do so. The registered manager assessed risks to people and ensured staff had guidance to keep them safe. Staff understood how to recognise and report any abuse to protect people from harm.

There were sufficient staff on duty to meet people’s individual needs and to support them with their interests. The service recruited suitable staff by using a robust recruitment procedure. Staff received appropriate training to undertake their role. Although we found staff felt supported by management, there were insufficient formal supervisions. Staff understood people’s communication needs and knew their choices and preferences.

People were happy with the care and support they received. People received support from skilled and competent staff. Staff spent time and were not hurried when they supported people. Staff knew people well and had developed positive relationships with them. The service supported people to maintain relationships with their friends and family. Staff respected people’s dignity and privacy. Staff understood how to treat people with respect.

Meetings were held with people to get their feedback about the service. The staff team worked effectively to ensure people had a positive experience of the service. Staff upheld people’s rights and supported them in line with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).These legal safeguards ensure that people who lack mental capacity are not unlawfully deprived of their liberty. The registered manager ensured staff protected and promoted people's human rights in line with current legislation.

The service was flexible and responded positively to people’s requests. Staff regularly reviewed people’s health and the support they required to reflect their current level of needs. The registered manager always sought people’s views and opinions about the service and acted on their feedback.

People’s cultural needs and personal preferences were met in relation to their diet. People enjoyed the freshly home cooked food provided at the service. Staff engaged people in activities of their choice and reduced the risk of isolation and boredom.

People accessed the healthcare services they required and staff monitored their wellbeing. Important decisions in relation to people’s health was subject to thorough professional oversight which ensured people received appropriate and timely health interventions. Staff knew what to do in case of emergencies to keep people safe.

People understood how to make a complaint and felt confident the registered manager would act on their concern. There were processes in place to monitor quality and understand the experiences of people who used the service. The registered manager carried out checks on the quality of the service and made any necessary improvements.

At this inspection we checked if the provider had met with the required standard on the management of medicine. We answered the questions: Is the service safe? Is the service well-led?

We checked the medicine administration records (MAR) for 29 people living at the service, observed the administration of medicines and we spoke to staff.

Is the service safe?

Medicines were administered and handled safely. MAR were accurately completed. People's medicines were stored securely. Unused medicines were returned to the pharmacy and a record was kept for these.

Is the service well-led?

The service was well-led. The service had sent notifications to us as required relating to the absence of a registered manager.

The provider had appointed an interim manager to run the home and we were notified of this.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, staff supporting them and from looking at records. We spoke to three of the 26 people using the service, two relatives of people using the service, two health professionals and three members of staff. We also reviewed five care records and five staff records.

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

Is the service safe?

Staff were trained to support people safely. Risks were assessed for people and actions were in place to address identified risk. Staffing level was adequate and staff were trained and competent in their roles. There was a plan for how staff should respond to emergencies. Medication was handled safely. The service had care staff on duty 24 hours a day. People told us they felt safe living at the service. Appropriate equipment was provided for people who had mobility needs and staff had received training in using these.

Is the service effective?

People's care was planned and delivered in a way that met people's individual needs. The provider involved other healthcare professionals in the planning and coordination of people's care and treatment. Staff responded to alarm calls promptly and flexibly to meet the needs of people. One person using the service told us, 'I only need to call and they [staff] will all come running.' People were supported to take part in activities taking place at the service and in the community.

Is the service caring?

Staff understood the needs of people they supported. People using the service told us that they were treated with dignity and respect. One person said, 'Staff are nice and they look after me well.' A relative told us, 'staff are good and interested in the people they look after.' We observed staff interacted and responded to people in an open and positive manner. We observed that staff knocked on people's doors before entering. Staff communicated with people in the way they understood.

Is the service responsive?

Care plans and risk assessments were reviewed monthly to reflect people's changing needs. People got the assistance they required to eat and drink. The provider liaised with other health and social care professionals to address any concerns to a person's care and welfare. We saw staff attending to people and responding to call bells.

Is the service well-led?

The provider worked with other agencies in meeting the needs of people using the service. There were quality assurance systems in place to identify, assess and monitor the quality of service provided. We saw records of complaints and actions taken to address them. People using the service and their relatives told us that senior members of staff took complaints and comments seriously and they sort things out quickly. People told us that the manager carried out spot checks to find out how people were doing. We found that people's records were not always maintained or kept up to date.

On the day of our inspection we found that the registered manager had been absent for over five months and this was not reported as required. The deputy manager was in charge of the day to day running of the service at the time of our inspection.

Residents' needs were reviewed regularly and care plans kept up to date. A resident told us, 'The care plans are updated regularly and I can have a look at them at any time. I say what I need.' Relatives commented that staff identified changes in their parents' health or mood and took action find the reason for these changes.

There was a variety of activities taking place at the service. Residents who preferred to stay in their rooms were able to do so.

Residents had enough to drink and eat. They were complimentary about the food and if they did not want the food that was on the menu, they were offered alternatives.

Residents and relatives commented on the care taken to appoint the right people when new staff were needed. Appropriate checks were made before new staff started working.

The manager, deputy manager and other staff were vigilant and addressed issues that arose that might affect the safety and wellbeing or residents.