Orchard Lodge Care Home

Orchard Lodge Care home is a care home providing accommodation and nursing care to older adults who may be living with dementia or life limiting conditions. The service is a two storey adapted building and can support up to 28 people. At the time of our inspection the first floor of the service was not being used and six people were living on the ground floor.

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

Medicines were not always managed safely. We identified improvements were required for medication recording practices and administration protocols. Whilst we did not find people had come to harm, there was an increased risk. Management oversight in this area should be reviewed.

The provider’s end of life care protocols and procedures required review. We found that guidance was not always available for staff, and further training was required. This had been identified by the provider and manager prior to our review, and specialist training had been sourced. The training took place during our inspection timeframe and we will review its effectiveness at the next inspection.

Relatives told us the manager and provider had offered increased communication updates during the COVID-19 pandemic, however, this had not always been received. Relatives also told us they were left with some uncertainty because the provider had not maintained communication following the service being placed in Special Measures. We have fed this back to both the manager and the provider for their review.

We have made a recommendation for the provider to review their medication and end of life procedures and protocols. Additionally, the provider should consider how best to embed general communication methods with relatives.

People told us they felt safe at Orchard Lodge Care Home. Staff completed safeguarding training and had the skills and knowledge to identify and report any concerns should staff become aware of these.

People’s needs had been assessed, and we found consent to care and best interests had been explored. Referrals took place for specialist health care reviews, and we received positive feedback surrounding this practice.

People’s eating and drinking needs had been assessed and specialist advice and requirements were followed by staff. 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.

Relatives told us staff updated them should the health needs of their relative change, and health professionals said they felt the service was responsive to people’s needs.

People were treated as individuals and were shown kindness and respect. People and their relatives were involved in decisions, and care was individualised, and person centred.

A new manager had been appointed by the provider and they were undertaking the registration process with the Care Quality Commission (CQC) to become the registered manager.

Staff, relatives and people told us they knew who to talk to if they had any concerns and felt confident these would be acted upon. Health professionals told us the communication and responsiveness of the manager and staff was very good.

The provider had developed oversight of the service and planned to further improve outcomes for people.

People were supported to have choice and control of their lives.

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 (inspection undertaken 02 March and 05 March 2020. Inspection report published 03 April 2020). There were multiple breaches of regulation and the service was in Special Measures. The provider completed an action plan after the last comprehensive inspection to show what they would do and by when to improve.

On 14 July 2020 we completed a targeted inspection to ensure that the service had made necessary improvements. We also followed up on concerns raised by the local authority. The targeted inspection looked only at specific areas of concern, and therefore a formal review of breaches did not take place, nor was a new rating generated.

This service has been in Special Measures since December 2018. During this inspection (May 2021) the provider demonstrated improvements had 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 carried out a comprehensive inspection.

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

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.

Orchard Lodge Care home is a residential care home providing accommodation and nursing care to five older adults who may be living with dementia or life limiting conditions. The service can support up to 28 people. The service consists of two floors and has been adapted to support people living with dementia and physical disabilities. At the time of our inspection the first floor of the service was not being used and people were living on the ground floor.

People’s experience of this service and what we found

We inspected this service to check for improvements in the areas we identified at our previous inspection in March 2020. We also received information from the local authority with concerns around there not being enough food and drink available at the service and staff not following infection control practices.

We inspected the care home from 11:00am to ensure that we saw people being supported with food and drink at lunch time.

People were supported safely with their pressure area care and health professionals were involved in this area. There was plentiful food and drink available and people were supported in line with their dietary requirements. Staff wore the correct PPE and the service was visibly very clean. However, improvements could be made to infection control processes when visitors enter the service. We have made a recommendation that this be reviewed.

The culture of the service had improved since our last inspection. However, some staff did not speak to people in a kind manner at all times. We have made a recommendation to the provider to support staff in this area. Some staff also told us that they did not feel comfortable raising concerns with the registered manager or the provider. We have made a recommendation that the provider work to support the staff team to do this.

We reviewed numerous documents and records about people’s care and support. These were detailed and completed correctly by the staff team, giving a good overview of the support which people were receiving. Where shortfalls were found, these were being addressed by the management team.

Staff received training, supervision and competency assessments to ensure that they had the knowledge to support people safely. External health professionals were consulted to support people with their care needs where this was necessary.

Most staff interacted with people in a kind and compassionate manner and felt well supported by the registered manager and the provider. The registered manager was aware that the service still needed to make improvements and had plans in place to make and sustain these.

Rating at last inspection

The last rating of this service was inadequate (published 03 April 2020)

Why we inspected

We undertook this targeted inspection to follow up on breaches found at the last inspection, to ensure that the service had made the necessary improvements. We also followed up on concerns found during visits by the local authority around the availability of food and drink, health professional involvement in people’s care and the accuracy of people’s care records.

CQC have introduced targeted inspections to follow up on Warning notices or breaches 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.

Please see the safe and well-led section of this full report.

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

Follow up

The rating for this service remains unchanged and the service remains inadequate and in special measures.

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.

Orchard Lodge Care Home is a residential care home providing personal and nursing care to nine older adults who may be living with dementia or life limiting conditions. The service can support up to 28 people. The service consists of two floors and has been adapted to support people living with dementia and physical disabilities. At the time of our inspection the first floor of the service was not being used and people were living on the ground floor.

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

People living at the service were not kept safe. Clinical decisions in areas such as pressure care were being made without a thorough assessment or referral to an appropriate professional. This put people at risk of harm. People were not being supported to live healthy lives or to see relevant health professionals in these cases. Lessons were not being learned and the service remains inadequate and in breach of regulations at this inspection.

Nursing staff and care staff members did not have the experience or knowledge to support people safely. New staff were working together when supporting people with complex needs which put both them and the people being supported at risk. Staff training was not effective and staff knowledge in areas they had been trained in was not being checked for competency by the manager or the provider. Staff were recruited safely and there were enough staff to meet people’s needs.

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 always support this practice.

Staff treated people with kindness and respect for the most part. However, on some occasions people’s privacy was not maintained and people who chose to stay in their rooms had long periods of time without interaction or engagement. Staff were not supported to get to know people as individuals by the provider.

People did not always receive person centred care. People’s preferences, likes and dislikes were recorded in care plans, but not always understood or used by the staff team. People were not always supported to communicate in their preferred methods. The activities coordinator at the service engaged people in several activities which people enjoyed, and this had been an improvement from our last inspection.

The manager and provider did not have effective systems in place to monitor the quality of the service. Audits were not effective in identifying where improvements could be made at the service. Whilst there had been some improvements since our last inspection, progress was slow. The provider had received ongoing support from the local authority but had been unable to sustain improvements. The continued breaches found at this inspection indicate that people are not receiving good quality care and in some cases are at risk of harm.

People were supported safely with their medicines. The service was clean and staff followed good infection control measures. The premises were suitable to meet people’s needs. People received support to eat and drink and maintain a balanced diet. People had been supported to put plans in place for the end of their life. There was a complaints policy at the service and relatives were confident that any concerns would be taken seriously.

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 inadequate (published 26 September 2019) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. This is the fourth time that this service has been rated as inadequate.

Why we inspected

This was a planned inspection based on the previous rating. It was also carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to the safe care and treatment of people, the knowledge and training of the staff team, person centred care and the overall governance and management of the service at this inspection. 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 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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service therefore remains 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 six 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.

Orchard Lodge provides nursing care and accommodation for older people, many of whom are living with life limiting conditions. The premises is a purpose built building with two floors. The service is registered to provide care for up to 28 adults. At the time of the inspection 13 people were living there.

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

People were not protected from the risk of harm because care plans and risk assessments were not amended when their needs had changed, and staff did not always follow guidance that was in place. People were not protected from infection because parts of the service were not clean or in good repair, and staff did not follow good practice guidance on reducing the risk of infections.

People were at risk of receiving inadequate nutrition because information about their requirements was not effectively shared with kitchen staff. Monitoring systems were not used effectively to identify causes of unusual weight loss or gain.

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.

Staff were kind, but engagement with people was task based. Many people spent most of their day alone as they were cared for in bed and only saw staff when they needed support, such as at mealtime or with personal care. This put them at risk of isolation. The garden and some parts of the premises were in disrepair. This was not a safe and dignified environment for people to live in.

Activities offered did not always meet people’s preferences and choices. Activity records showed that a range of activities took place, but these were mostly not provided in response to people’s personal interests.

The provider did not model good practice or promote person centred care. Some improvements to the service had been made since the last inspection. However, progress towards making the required improvements was slow and quality monitoring systems were not effective. The continued multiple breaches found indicated that people were not receiving good care that considered their individual needs and preferences, and the right to a good quality of life.

The provider was in breach of a condition imposed on their registration and in doing so demonstrated they either did not understand or they intentionally failed to fulfil their regulatory responsibilities demonstrated a failure to understand their regulatory responsibilities.

Staff understood their responsibilities to protect people from the risk of abuse. Staff received training and supervision to support them to carry out their duties. There was a system in place for managing and monitoring complaints.

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 (report published 08 May 2019) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. It was also carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to safety and managing risk, infection control, support in relation to nutrition, person centred care, and the overall management oversight of the service and a breach of a condition of the provider's registration, at this inspection. 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 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service therefore remains 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 of 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.

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.

We carried out this unannounced comprehensive inspection of Orchard Lodge Care Home on 17 and 19 December 2018. During our last comprehensive inspection in June 2016 we rated the service as ‘Good’ with a rating of requires improvement in responsive. This was because care plans were not kept up to date and showed little evidence of people or their families being involved in the process. During this inspection the rating changed to ‘Inadequate’. This is because we identified that previous concerns had not been adequately addressed and we found additional serious concerns about some aspects of the service. This was in relation to how the service kept people safe, considered their social needs and how the service was led.

We found the provider was in multiple breach of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. 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.

There was a registered manager in place who was also a registered nurse. 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.

Care records, including preadmission assessments, care plans and risk assessments were insufficiently detailed to ensure people received safe, person centred care that met their individual needs.

Some people did not have a fully functioning supply of heating and hot water in their bedrooms. This was a long - term issue and, although the provider had made attempts to address it, an effective solution had not been carried out. Poor maintenance of the premises placed people at risks of harm, by infection, inhalation of mould spores from damp, and exposure to cold or wet weather.

Staff were not deployed effectively to support people safely and people were left at risk of falling.

Although staff were kind when they spoke with people, interaction was very limited and many people were at risk of social isolation and lack of stimulation. An activities coordinator was in post and had good ideas of how to improve engagement with people. However, these ideas were not acted on when the activities coordinator was not working.

Staff did not always promote people’s dignity and respect. and inappropriate language was sometimes used to describe people. Confidential information was not always stored securely.

People’s social needs were not being meaningfully explored with them. Lifelong interests were not being promoted by the service. Staff were not chatting and engaging with people.

Quality monitoring checks by the provider had not identified many of these issues and therefore action was not taken to address them. Where action was taken it had not been fully effective and people were left in unsafe conditions until the Commission took action to address the issues with the provider.

The culture of the service was task based, and the registered manager did not have a strong understanding of how to promote person centred care.

Although the registered manager responded to relative’s complaints, the way in which this was done was dismissive and complaints were not used to make improvements to the service.

The staff received training and regular supervision to support them to carry out their duties.

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.

Orchard Lodge provides nursing care and accommodation for older people many of whom are living with life limiting conditions and some who are living with various forms of dementia. The premises is an older style, purpose built building with two floors. The service is registered to provide care for up to 28 adults. At the time of the inspection 19 people were living there.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Rating at last inspection:

At our last inspection on 17 and 19 December 2018 the service was rated Inadequate and placed 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.

Why we inspected:

We carried out this focussed inspection in response to information of concern we received about the service following our inspection in December 2018. At the time of this inspection we were aware of incidents being investigated by the local authority safeguarding team. As a result, we carried out this focused inspection to look at those concerns and this report only covers our findings in relation to those. This inspection did not assess performance against all five key areas and focussed only on the areas ‘Safe’ and ‘Well Led’. The ratings from the previous comprehensive inspection for the other three key questions were included in calculating the overall rating in this inspection. We will be returning to the service to provide a comprehensive overview of each key question.

People’s experience of using this service:

People were not protected from the risk of harm because risk assessments, care plans and monitoring processes were not detailed enough to support staff to provide safe care.

People were at risk of dehydration because the provider had not kept accurate records . Staff were unaware of the need for target amounts of fluid each person should receive to prevent dehydration.

People were not protected from experiencing unacceptable levels of pain. This was because the service did not have adequate assessment tools in place to monitor pain when people were unable to tell staff verbally.

People were not protected from the risk of neglect. This was because the manager did not always identify, take action to address or report this, particularly when this risk was as a result of the person refusing care.

Care records did not contain information to show how staff made decisions about the administration of medicines at the end of people’s lives.

Care plans did not contain information about people’s needs and preferences in relation to end of life care, including information about care, medicines, spiritual, cultural and emotional needs. The service supported many people who were diagnosed with life limiting conditions and people who had recently died in the service, did so without their end of life care being effectively planned.

Management oversight of the service was not effective. The provider had made little to no progress to improve the shortfalls we reviewed at this focussed inspection since the comprehensive inspection in December 2018.

Records continued to be poor in quality and were not completed accurately or in enough detail to ensure people received safe, person centred care.

The registered manager and the provider has engaged positively with the commission through this inspection process and we noted that plans were being put in place to make improvements to the service.

Follow up:

The service continues to be in special measures. Following the inspection in December 2018 we took urgent action to impose conditions on the provider’s registration. These conditions stopped the provider accepting new admissions to the home and required the provider to tell us the actions they had taken to address our concerns. Following this focussed inspection, the conditions will remain in place. We have asked the provider to send us weekly updates on action they have taken to improve the service. We will continue to check this service and will be returning within the timescales set out in our programme of inspection when we will check each key question.

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

Orchard Lodge is a nursing care home in Leighton Buzzard, providing accommodation for people who require nursing or personal care, diagnostic and screening, and the treatment of disease, disorder or injury. The home had capacity to house up to twenty-eight people but there were twenty-five people living there at the time of our inspection.

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

The service was not always responsive to the changing needs of the people who lived at the home because people were not always involved in the assessment and planning of their care. People’s care records were also not always updated to reflect their changing needs. However, people were encouraged and supported by the staff team to follow their hobbies and interests, and there was an effective system in place for handling complaints.

People who lived at the home were safe because the provider had systems in place to safeguard them from avoidable harm. These systems included the safe recruitment and training of staff who supported people and carrying out risk assessments of the home environment. Personalised risk assessments were carried out to minimise avoidable risk of harm. The effective and safe administration and management of people’s medicines also formed part of the system the provider had in place to ensure people’s safety.

People’s care and support was effective because the staff employed to the service were trained, skilled and understood their role. They supported and encouraged people to eat a healthy and balanced diet and to have access to other health and care services when necessary. They sought people’s consent before they provided any care or support and were compliant with the requirements of the Mental Capacity Act 2005.

People were cared for by staff who were kind, caring and empowering. They supported people in ways that promoted their privacy, dignity and respected their views. They provided support that was personalised to people.

The management team ensured the service ran appropriately providing visible leadership and oversight at all levels. This ensured the provision of a good level of care and support to the people who lived at the home.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found.

Is the service safe?

People had up to date risk assessments in place which were reviewed regularly by the provider. The provider carried out regular fire safety checks to ensure that people were safe from the risk of fire in the home and that staff were aware of what actions to take in the event of an emergency. We did however note that the home did not have enough storage available which meant that visitors and staff were not always safe from possible trip hazards in the home.

Is the service effective?

People's care needs were assessed before they entered the care home and were reviewed after admission to ensure that care plans were developed to reflect people's individual needs. We observed that people had their personal care needs met. People told us that the staff were 'approachable' and 'kind'.

Is the service caring?

We observed that staff were responsive to people's needs, and treated them with respect and dignity. People we spoke with told us that the, 'staff are good' and when they rang for assistance the staff would respond quickly. One family member we spoke with told us, 'If anyone needed a home to go to, I would tell them to come to Orchard Lodge' and a visiting professional also stated, 'this is the best home in Leighton Buzzard.'

Is the service responsive?

We saw that care plans were reviewed and updated on a regular basis to reflect the changing needs of people. People told us that if they wanted a change to their care the staff would respect their wishes. We saw that food was prepared on site and people told us that their preferences were noted. We also saw that the kitchen staff recorded the food requirements for people with special diets to ensure that they were receiving appropriate nutrition. We were told by a visiting professional that the home 'is always calm and under control. Staff are always aware of what is happening in the home.'

Is the service well led?

The service had a registered manager in place, to oversee the day to day management of the home.

The manager of the home was aware of all aspects of the home. Staff told us that the manager was, 'like a sister' and a pleasure to work with.' They told us that the manager was always approachable and was fully informed about the people who used the service and their needs. Quality assurance systems were in place together with regular audits to ensure that the home was meeting the standards required.

People who used the service and staff were asked for their opinions and feedback was acted on.

We observed a friendly and homely environment, with positive interactions between staff and people. People looked relaxed and well cared for, and we saw that staff took time to talk with people. One person's relative said they were generally happy with the care provided and that the environment was nice. People who spoke with us told us they felt cared for and well supported by staff. Two people said the care was "wonderful", and one person said, 'It's lovely here, staff are nice."

Clear processes were in place to ensure that the home was clean and tidy. We spoke with six members of staff, who told us that there was always enough supplies of protective equipment to enable them to carry out their job safely. They also said that they felt very well supported by the management and that the manager had an "open door" policy which enabled them to seek guidance when required.

The provider had effective processes in place to ensure that people were supported to raise concerns. We saw evidence that confirmed complaints were responded to in a timely manner.