Bronte

Bronte is a residential care home providing personal care to 19 people aged 65 and over at the time of the inspection. The service can support up to 20 people. The property is a single-story building with en-suite bedrooms and communal spaces including a lounge, dining room and conservatory. There are large gardens to the front of the property which people are able to use with the assistance of staff.

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

Risks relating to the physical environment had not been properly assessed and systems in place were not being operated robustly enough to identify where improvements were needed. People were at risk of the spread of infection because the poor maintenance of a communal bathroom made it difficult to keep clean and because of some working practices, such as sharing communal bars of soap. Infection control audits were not being completed and general audits had failed to identify areas of concern, such as a carpet with a strong smell of urine.

Recruitment systems were not operated effectively. Staff were recruited without the required checks being recorded, for example, a full work history, appropriate references and a record of job interviews. Staff had not had recent training in relation to fire, safeguarding or medicines administration. We were told that informal training and supervision had taken place in house and the Registered Manager was confident staff had the appropriate skills and knowledge. We recommended the provider ensure that training in safeguarding and medicines administration is brought up to date.

The providers quality assurance and governance systems had failed to identify where improvements were required and there was no service development or improvement plan in place. Where the Provider was aware improvements were required, such as in the communal bathroom, no action had been taken. The Provider did not have any formal oversight of the quality assurance systems.

Lessons had been learnt from a previous allegation of abuse which was inappropriately investigated by the provider. The Registered Manager and staff we spoke to were able to tell us the correct procedure for reporting concerns and told us they felt confident to do so. People’s families told us they felt comfortable raising any concerns and when they had done so previously, they had been acted on.

Improvements had been made to record keeping and regular fire tests were taking place. People’s individual risks were assessed and regularly reviewed.

We received positive feedback about the quality of care from people, their families, staff and visiting professionals. The culture was open and person-centred; one visiting professional told us that staff had worked hard to understand a person’s individual needs. The Registered Manager was well liked and respected and everybody we spoke to gave positive feedback in relation to their openness and communication.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 4 April 2020) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 18 February 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained 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 Bronte 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the safety of the premises, infection control and governance at 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 following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Bronte is registered to provide personal care for up to 20 older people living with conditions such as dementia and physical disabilities. The property is a single storey bungalow which has been extended to provide additional bedrooms. Bronte set within gardens in a small village outside of Exeter. At the time of the inspection, 18 people were in residence.

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

The measures in place to safeguard people from the risks of fire and hot water were not safe. This was because regular checking of these had not been completed. We could not therefore be assured fire safety and risks of scalds from hot water were always fully mitigated against. Not all records were available for inspection. Those records that were seen at inspection showed that only minimal checks of the fire alarm and hot water supply were being carried out until various dates in 2018. Records provided after the inspection could not be validated. The provider could not give an explanation as to why the frequency of the checks had been increased in October 2018 in these records, to weekly (fire) and monthly, for every hot water tap. However, they did state the forms were a pro-forma and should not have been sent to us.

Staff had received safeguarding training in September 2019. They knew to report safeguarding concerns to the registered manager or provider. Any risks to people’s health were assessed and appropriate management plans put in place to reduce or eliminate the risk. The number of staff on duty each shift were based upon each person’s care and support needs. New staff were recruited safely and ensured people would be well looked after. Pre-recruitment checks included written references and a Disclosure and Barring Service check. Medicines were well managed and administered by those staff who had been trained and were competent. People received their medicines as prescribed.

People’s care and support needs were identified by assessment and then recorded in their care plan. These were kept under review. People were included in care plan reviews as much as they were able.

Staff received the training they needed to enable them to do their job well. The provider had an induction training programme to complete at the start of their employment and there was a mandatory training programme for the rest of the staff team. Staff received a regular supervision session with the registered manager and were supported to do their job.

The staff team enabled people to access the healthcare support they needed. Arrangements were in place for people to see their GP or the district nurses as and when they needed. Other health care professionals were arranged via the GP. People received the food and drink they needed to maintain a healthy, balanced diet. Any preferences they had regarding food and drink were accommodated.

People were encouraged to retain as much choice and control of their daily lives and staff supported them in their best interests. The service was meeting the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

People stated the staff were kind and friendly, and they were able to make their own decisions about the way they were looked after. The staff team were fully aware of each person’s specific needs. Whilst there was a move towards providing personalised care to each person, the registered manager acknowledged the staff team still worked in a task-orientated manner.

People’s care needs, and care plans were reviewed each month and adjusted as necessary. Changes in people’s care and support needs were taken account of and reflected in their rewritten care plan. This ensured people would continue to be looked after with respect for their specific needs. People who developed end of life care needs would continue to be looked after at Bronte with support from health care professionals and family.

Planned activities were arranged each week day afternoon. At the time of this inspection the majority of people expressed a wish not to take part in the group activities, preferring to remain in their own bedroom watching TV, knitting or just having quiet time. There were no restrictions on visitors.

The registered manager provided leadership for the staff team. The audits and checks they had in place ensured people received the care and support they needed. However, the division of roles between the provider and registered manager had led to tasks being overlooked.

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 8 September 2017).

Why we inspected

This was a planned inspection based upon 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.

Bronte is registered to provide accommodation for up to 20 older people who require personal care. At the time of this inspection there were 20 people living there.

The service is run by the providers, one of whom is also the 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.

People told us they were happy living in the home and felt safe. Comments included, “I am very glad to be here” and “They know the risks my father faces so I think he is safe”. Safe recruitment procedures had been followed before new staff began working in the home. Checks and references had been taken up to ensure they were suitable to work with vulnerable people. Staff received induction training at the start of their employment. They also received further training and updates each year to ensure they remained knowledgeable and competent to meet the needs of the people living in the home. All staff had received training on safeguarding adults and knew how to recognise and report any suspicions of abuse. There were sufficient staff to meet people’s needs safely

Medicines were stored and administered safely. People told us staff made sure they received their medicines at the right times.

People received effective support from staff who understood their health and personal care needs. Care plan files contained sufficient information about each person’s health and personal care needs and preferences. Risks to people’s health and safety had been assessed and staff knew how to support people to keep them safe. Staff sought medical advice and treatment promptly when needed. Systems were in place to make sure people attended medical appointments, assisted by staff where necessary. People and relatives we spoke with were confident their health needs were being met. Comments included, “I get all the health treatment I need”

People received a varied range of meals to suit their individual dietary needs and preferences. Comments included, “The food is beautiful. I get a good choice of food” and “Nice wholesome food with lots of vegetables – quite a good selection”

People received care and support from staff who were kind and caring. Staff knew people well and understood their needs. Comments included, “Staff are kind. That goes a long way” and “I love the staff – I am very happy here.” One person told us the staff were always caring, and said, “They put their arms around people and hug them.” We saw staff treated people with kindness, friendliness and helpfulness.

People were cared for by staff who knew them and understood their needs. A care plan was in place for each person living in the home. The care plan files contained sufficient information about each person’s health, personal care needs, risks to their health and safety, and their likes and dislikes. Staff understood the importance of giving people choices and enabling them to make decisions about their daily lives. The service acted in line with current legislation and guidance where people lacked the mental capacity to consent to aspects of their care.

People’s social needs were assessed and people were offered opportunities to engage in a range of activities to suit their needs and preferences. Two activities organisers were employed to provide a range of group and individual activities on five afternoons a week. Staff also supported people on an individual basis, for example by accompanying them for a walk in the garden. A person told us, “Yes. I join in everything.” Another person said “Sometimes I get involved in activities – I do a lot of knitting.”

People lived in a home that was clean and well maintained. There were systems in place to make sure equipment was regularly checked and safe. All areas appeared comfortable and in good decorative order.

People received a service that was well managed. People told us they were listened to, and their opinions were valued, for example, “If I express an opinion they listen”. A relative told us, “They seem to act upon suggestions and ideas”. People also told us there was a happy atmosphere in the home, for example one person said “The atmosphere is very happy here” and another said “I would recommend Bronte to anyone needing care.” The provider had systems in place to regularly monitor the service and ensure the service was running smoothly.

The service provides accommodation and personal care for up to 20 older people. On the day of this inspection there were 12 people living there.

The service was inspected on 19 June 2015 when we found a number of serious concerns. The service was rated as ‘inadequate’ and we placed them in ‘special measures’. The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Its purpose is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example to cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

We imposed a condition that the service must not admit any further people until we were satisfied that all breaches of compliance had been addressed and the service was safe. We carried out another inspection on 4, 5 and 11 February 2016 when we found some actions had been taken, but these were not sufficient to ensure the service was fully compliant. The rating of the service remained ‘inadequate’.

We carried out this inspection to check if improvements had been made. During this inspection we found the providers and staff had worked hard to address the previous breaches to ensure that people’s needs were met. Improvements had been made in all areas and the service was fully compliant. The service will now be removed from special measures but we have rated the service as ‘requires improvement’ because it is too early to be certain the service will maintain full compliance in the future. We will continue to monitor the service until we are satisfied the good practice found during this inspection has been embedded and maintained.

People living in the home, staff and visitors told us the service had improved significantly over the last year. There was a cheerful and lively atmosphere with lots of smiles and friendly conversations between people living in the home, visitors and staff. Comments included “They really do try hard. I have no problems at all” “No trouble here. I like it here. I am very happy” and “The staff are all very, very kind. They are all marvellous.”

One of the providers is the registered manager of the service and the other provider is responsible for the day to day management of the service and is referred to in this report as the duty 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.

Safe procedures had been followed when recruiting new staff. Checks and references had been carried out before a new staff member started working in the home. This meant that new staff were suitable for the job they had applied for and there was a robust recruitment process in place. Staffing levels had increased since the last inspection. There was an extra member of staff on duty each day therefore we found the staffing levels were adequate to meet people’s needs. People received assistance when they needed it. People told us there were sufficient staff on duty at all times to meet their needs. Comments included “It’s much better now.”

Staff had undertaken a wide range of training since the last inspection and were able to tell us what they had learnt and how they had put it into practice. Staff attended weekly training sessions to gain a qualification known as the Care Certificate. We saw evidence of regular, planned, one to one supervision sessions for staff. Each staff member had a named supervisor and the records showed staff had received at least three supervisions since the previous inspection. This meant staff now had support to discuss how their role was going and to plan for their training needs.

Medicines were administered safely. Medicines were administered by staff who had received suitable training. Safe procedures were followed when recording medicines. Medicines administration records (MAR) were accurate. There were no unexplained gaps in the medicines administration records. Audits of medicines had been completed and appropriate actions taken to monitor safe administration and storage. The service had ensured the management of prescribed topical creams and lotions was safe.

Staff had received training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been submitted for most people living in the home. There had been improvements in the way the service assessed people’s capacity to give consent, or to make important decisions about their care and treatment. The care plans explained to staff about each person’s capacity to make decisions and ensured staff gained people’s consent before providing care. We observed staff seeking consent before carrying out care tasks.

Staff had sufficient information to ensure people received care that met their individual needs. New care plans had been drawn up in consultation with the resident, some family members, the deputy manager, the duty manager and the registered manager. The new care plans had been completed and were in use. The information was up to date and gave a person centred picture of each person including their individual needs and preferences. Staff knew about each person’s needs and were meeting them in a person centred way in practice. They had been regularly reviewed to ensure the information remained current. This meant staff were now working with up-to-date information to assist them in providing safe and effective care for individuals.

Risks to people's health had been fully assessed and regularly reviewed. People who were identified as being at risk of choking had been referred to the local speech and language therapy team and appropriate actions had been taken to minimise risk. The records contained assessments and regular reviews relating to all potential risks, for example falls, pressure wounds, malnutrition, dehydration and weight loss. The staff had sought specialist advice and treatment where necessary and equipment had been provided to reduce risks.

Staff had worked hard to identify people’s social needs. There was clear evidence in the care plans to show staff had discussed with people the things they enjoyed doing. Two activities organisers visited the home each week to provide a variety of activities such as games, arts and crafts. During an activities session on the first day of our inspection there was lots of smiles, laughter, singing and clapping. Staff also spent time on a one-to-one basis with people, for example by accompanying them to go for a walk. People could choose to join in as they wished and were able to socialise in a way that suited them.

At the last inspection we found improvements were needed to make sure quality assurance systems were effective in identifying shortfalls in the service offered. At this inspection we found more robust quality monitoring had been put in place. The providers had implemented a new system of checks including a manager monthly service review, regular audits, spot checks and completed a quality assurance survey. They had also attended various training events to update their knowledge. They told us their aim was to ensure the quality of the service continues to improve.

Staff demonstrated a positive and caring manner. They were cheerful, friendly, smiling and welcoming. We saw staff communicating well with people seeking consent and explaining the care they were offering, for example moving and handling procedures. Staff understood the importance of treating people with dignity and respect, for example by drawing curtains and shutting doors when carrying out personal care. People told us the staff were always kind and caring.

At this inspection we found actions had been completed to improve the security of the premises. During this inspection we saw the risk of unannounced visitors had been addressed. The providers had carried out risk assessments on all exits from the home to ensure people were protected from harm.

The service provides accommodation and personal care for up to 20 older people. On the day of this inspection there were 18 people living there, including one person who was in hospital.

At the last inspection of the service on 19 June 2016 we found many improvements were required. The service was rated as ‘inadequate’ overall and placed in special measures. We imposed a condition that the service must not admit any more people until such time as we were satisfied they had made improvements to address the failings we had found. At this inspection we found some actions had been taken to address the breaches of regulation, but these were not fully effective and the service continued to be in breach of a number of regulations. People continue to be at risk due to staff not having the right skills, training and knowledge to meet their needs. Risks are not clearly identified and staff were not given instructions about how to manage risks.

The providers are a husband and wife team. One of the providers is the registered manager of the service and the other provider is responsible for the day to day management of the service and is referred to in this report as the duty 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.

Safe procedures had not always been followed when recruiting new staff. Checks and references had not always been carried out before new staff began working with people. This meant it was not possible to show that new staff were entirely suitable for the job they had applied for.

Medicines were not administered safely. Medicines were administered by staff who had not received suitable training. Poor practice was observed including medicines left on top of an unlocked medicines trolley while the member of staff took medicines to people in their rooms. Safe procedures were not followed when recording medicines. Medicines administration records (MAR) were not always accurate. There were unexplained gaps in the medicines administration records. Audits of medicines had only just started and were incomplete. We also found improvements were needed in the way the service managed creams and lotions.

Staff had received training on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been submitted for most people living in the home. However, the provider had not assessed people’s capacity to give consent, or to make important decisions about their care and treatment. The care plans did not explain to staff about each person’s capacity to make decisions, or guide staff to gain consent before providing care. We observed staff seeking consent before carrying out care tasks.

Staff did not have sufficient information on people’s needs to ensure people received care that met their individual needs. New care plans had been drawn up in consultation with the resident, some family members, the deputy manager, the duty manager and the registered manager. However, the new care plans had not yet been introduced to the staff. They had been written in recent months and had not been reviewed. Some of the information was incorrect or out of date. The providers planned to introduce the new care plans to the staff in the very near future. The providers told us they did not expect the new care plans to be fully operational for at least another two months. This meant staff were continuing to work without the right information to assist them in providing safe and effective care.

Risks to people's health had not been fully assessed or regularly reviewed. Some improvements were noted but some areas were still not fully met. Some people were at risk of choking but there was no evidence this had been assessed. Advice or guidance had not been sought from the speech and language therapy team (SALT). Some people were on soft or fork mashable diets but we were unable to see evidence of how staff had reached the decision to provide a soft diet. The providers agreed to seek advice urgently from GP’s and/or the SALT team.

No actions had been taken since the last inspection to identify people’s social needs. There was no evidence in the care plans to show they had discussed with people the things they enjoyed doing. An activities organiser visited the home for three hours each week. There was no evidence to show that staff spent time with people the rest of the week for any activities other than provision of personal care. We saw people sat in the lounge or in their rooms for long periods without any social interaction.

Staffing levels had increased since the last inspection. They had lost some staff and had recruited additional new staff from overseas. There was an extra member of staff on duty each day therefore we found the staffing levels were adequate. Some newly recruited staff had no previous relevant experience or training and were still in their probationary period. New staff were still getting used to routines. The increase in staff meant people were likely to receive assistance when they needed it. However, people were at risk of poor care because many of the newly recruited staff did not have the knowledge, experience or skills to meet their needs safely. Staff were about to begin to attend weekly training sessions to gain a qualification known as the Care Certificate.

We were unable to see evidence of regular, planned supervision sessions for staff. The provider told us they planned to introduce supervisions in the near future. However, only two supervision sessions had been recorded since the last inspection. This meant staff did not have support to discuss how their role was going and to plan for their training needs.

The provider did not have an effective quality monitoring system in place. The provider had drawn up a system but had not yet begun to implement it. One of the providers had begun to carrying out a medication audit, but this had not been completed. The audit had failed to pick the failings we had found during our inspection.

The providers had failed to evaluate and improve their practice to ensure the quality of the service is continually improved. The providers have not received any further training since the last inspection. They were not planning to gain any further qualifications, although one of the providers planned to attend future training sessions booked for the staff team.

Staff demonstrated a positive and caring manner. They were cheerful, friendly, smiling and welcoming. We saw staff communicating well with people seeking consent and explaining the care they were offering, for example moving and handling procedures. Staff understood the importance of treating people with dignity and respect, for example by drawing curtains and shutting doors when carrying out personal care. They used a fleece blanket to place over people’s lower half to protect their dignity when using the hoist. People told us the staff were always kind and caring.

At the last inspection we found the security of the home was not fully effective. During this inspection we found actions had been taken or were in the process of being taken to improve the security. They had ordered new doors to be fitted to the conservatory that will be fitted in the near future to improve security. In the meantime a temporary alarm had been fitted to the door. The providers agreed to carry out risk assessments on other exits from the home to ensure people were protected from harm.

During the inspection we identified repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk from harm because the provider’s actions did not sufficiently address the on-going failings. There has been on-going evidence of the provider’s failure to sustain full compliance since 2012. We have made these failings clear to the provider and they have had sufficient time to address them. Our findings do not provide us with confidence in the provider’s ability to bring about lasting compliance with the requirements of the regulations. We are taking further action in relation to this provider and will report on this when it is completed.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. People continued to be at risk of harm because the provider’s actions did not sufficiently address the on-going failings. This was despite the support provided by the local authority to address those failings. There has been on-going evidence of inability of the provider to sustain full compliance since December 2012. We have made these failings clear to the provider and they have had sufficient time to address them. Our findings do not provide us with any confidence in the provider’s ability to bring about lasting compliance with the requirements of the regulations. We are taking further action in relation to this provider and will report on this when it is completed

At the time of this inspection there were 13 people living at Bronte. We were supported on this inspection by an expert by experience. This is a person who has personal experience of using or caring for someone who uses this type of service. They were also able to speak with those people whose first language was not English. There were five people who spoke Chinese, Cantonese or Hakka.

We spoke with 10 people and five relatives about their experiences of the care provided at Bronte. We also spoke with a community nurse who regularly visited people living there. We spoke with the provider and manager and with five staff.

Is the service safe?

People had been cared for in an environment that was safe, clean and hygienic.

Care plans had been improved since the previous inspection. However, where risks had been identified there remained insufficient written guidance on how to minimise those risks. From our discussions with staff, people living in the home, and with relatives, we were satisfied that staff had the knowledge and experience to meet people's needs safely.

At our last inspection we noted the front door was left open and unattended. The providers told us they would take appropriate action to improve the security of the home. When we arrived at this inspection the front door was again open and unattended. The providers told us this was a mistake and gave assurance they would take action to make sure security of the home was maintained.

Is the service effective?

The service was effective because we saw and heard evidence to show people were satisfied with the care they received. Where health needs were identified the home liaised closely with health professionals to ensure people received the treatment and care they needed. Staff received training and support to ensure they delivered effective care in accordance with assessed needs. For example the local community nurses had provided training for staff on moving and handling to ensure individual needs were met safely.

Is the service caring?

We observed staff supporting people during the day in a gentle, sensitive and caring manner. We saw staff and people smiling and chatting to each other while staff were assisting people to move around the home. People told us they were happy with the care they received. For example, a relative told us a person had been poorly recently and they had wanted them to remain at Bronte rather than going to hospital as they were confident Bronte was the best place to provide the care the person needed. They felt the staff knew their relative well and understood how they wanted to be cared for. Comments included, 'The carers are good and they look after me well' and 'They can't be more helpful. They help me to get washed and dressed in the morning and put me to bed. They also give me a bath about once a week.'

Is the service responsive?

The service was responsive because they had systems in place for ensuring people's views were listened to, including annual questionnaires and quarterly resident's meetings. We saw they had taken action to address any areas where changes or improvements were needed.

Where people's needs had changed the service had taken actions to ensure care was adjusted to meet those needs.

The service did not always respond fully to people's dietary preferences. Most people told us the food was satisfactory. The manager and cook told us people were offered a choice of meals each day. However, it was the perception of most people we spoke with that they were not offered a choice of meals and they could not ask for an alternative if they did not like the meals they were given. Comments included 'The food is pretty good. Not much choice, I mean it's the same food all the time', 'The food is alright. You just eat what you're given. There's no choice' and 'I don't really like the food. There is no choice.'

Is the service well-led?

The service was well-led by the registered manager and provider. They lived close to the home and were fully involved in the day to day care of people and daily maintenance of the home and gardens.

There were 15 people living in the home at the time of our inspection. We spoke with 13 people who lived at the home, five staff and three people visiting the home. We also spoke with the GP practice who visited the home. We looked at the care records of five people and the records of four staff.

People living in the home told us they were happy with the care they received and told us they felt safe in the home. One person said, 'I am happy here and the care they provide for me is good'. Whilst another said, 'The carers are kind to me and they talk to me. I feel safe'. However we found that the way people were supported was inconsistent and there was a risk of people's care needs not being met because staff did not follow guidance in care plans or because care plans were not up to date.

People's nutritional needs were met but improvements could be made in the way the menu was promoted in the home and people's choices and preferences were listened to.

In December 2012, we made a compliance action to improve hygiene and infection control measures. Whilst we saw some improvements had been made there were still concerns about the way this aspect of care was managed. However the provider listened positively to our concerns and told us about measures they would put in place to improve the areas of concern.

Staff recruitment was carried out in line with the policies of the provider. This included checking on people's suitability to work with vulnerable people through references and checks required by the UK border agency.

We saw some improvements in the provider's quality assurance processes since our inspection in December 2012 where we highlighted compliance actions. However, there were still areas for improvement, for example gaining people's views, checking on hygiene and infection control and maintaining records. Care records were not routinely updated following incidents or changes in a person's condition and staff were not familiar with the detail in some people's care files.

There were 15 people living in the home at the time of our inspection. The people living in the home told us they liked the home and were happy with the care being provided by the staff. One person who lived in the home said 'I'm happy living here' and 'the staff are kind and hard working'. A visitor we met told us staff were 'observant and kept a close eye on the needs of people in the home'.

People appeared comfortable whether in their own rooms or in the public areas of the home. We saw that staff had a good knowledge of the needs of people in the home. Staff were observed to address people by their preferred names and were polite and respectful at all times.

People we spoke with said they always found the home clean and tidy however we found some aspects of cleanliness and hygiene were not always appropriate. For example we found some equipment and surfaces needed cleaning and routine wearing of protective equipment didn't always take place.

We saw that people were safe in the home however the provider didn't always have quality assurance processes in place to monitor the quality of their service; for example safe storage of equipment and routinely maintaining documents relating to people and the running of the home