The Duke's House

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

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

Right Support:

The design of the service and the use of space both inside and outside the home matched people needs and preferences as much as possible. People were now involved in decisions regarding the design of the service.

Staff were skilled in supporting people to express their views and make decisions. People were listened to and they were involved in decision making in many different aspects of their care and support. There was a lot of emphasis on doing everything possible to enable good and effective communication with people living at the home and others.

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.

Right Care:

People were supported and treated well. Staff showed and the service was designed in a way that respected people as individuals.

Staff were positive about the people living at the home. It was clearly important to staff that people did well and it was obvious that staff gained satisfaction from supporting people and they expressed joy when describing to us how people were doing well. This approach from staff had a positive impact on people. We asked one person how they were doing at the home and they told us, “I’m amazing.”

Each person’s care and support was planned with the person and those important to them. People were helped to think about what was important to them, their likes and dislikes, how they wanted to be supported and what they wanted their future to be like.

People family members spoke positively about the care planning process. One person’s relative told us, “I’m involved in care planning, they ask me what I would like for [Name] in the next couple of years and we set goals together. It’s good that they are trying different things… they are very, very responsive. All the staff are brilliant, [registered manager] has built a positive culture and now [Name] looks great, they are happy and doing so well.”

Right Culture:

There was a positive and empowering culture at the home, that had promoted people having positive outcomes. Staff had positive, natural and everyday interactions with people that were kind, enabling and very respectful.

People were leading full, busy and active lives, within their communities. They had been supported to expand their interests and hobbies, have new experiences, and enjoy relationships with people that were important to them.

The registered manager and other staff members were very responsive to any complaints or concerns raised with them.

Family members told us the registered manager had built up trust with them. One relative told us, “I have confidence in them now, they have gained my trust. They went out of their way to win my trust.” Another family member said about the registered manager, “[Name] always keeps her word.” A third family member described there being a generous spirit at the home.

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 13 July 2021) and there were 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 we found improvements had been made and the provider was no longer in breach of regulations.

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

This service has been in Special Measures since 3 April 2020. During this inspection the provider demonstrated that improvements have 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 an unannounced inspection of this service on 22 April 2021. 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.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal 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.

Follow up

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

At our previous inspection three people were living at The Duke’s House whilst building work was taking place. Following the renovations, five people moved into the home from the providers other homes as part of a remodelling of their services.

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

The service design and environment did not meet all people’s needs as outlined in their support plans. Some people’s known actions were those that caused upset and were likely to get a negative response from other people in the home. Our observations and feedback from health and social care professionals, people’s family members and staff; confirmed that the combination of these risks and the atmosphere they created was having a negative impact on people’s wellbeing.

There were enough staff to meet people’s needs. However, staff members told us that at times there was not always enough staff available to support people; and this has had a negative impact on people being able to do things they wish to do.

People’s family members, staff and outside health and social care professionals told us that there had been a very high turnover of staff and the staff team had remained unstable since our last inspection. One health and social care professional told us, “Staff turnover is massive.” Making effective improvements based upon learning from incidents and feedback from people; had been hindered by a high turnover of senior staff, high turnover of support staff and a lack of stability within the service.

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

This service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• The model of care and setting did not meet all people’s needs or maximise positive outcomes for them. The model of accommodation did not promote people living an ordinary lifestyle.

Right care:

• Staff were caring and kind towards people. However, people’s care was not always provided in a person-centred way, based on what was important to them. People's family members told us the provider had not worked in partnership with them in a meaningful way.

Right culture:

• There had been an extended period of change within staff teams and change of leaders within the service. Staff members described fractured teams. Health and social care professionals and people’s relatives criticised the provider’s communication and partnership working. Some people’s relatives told us they thought the provider needed to rebuild relationships and trust with them.

There was a system in place for recording and reviewing any safeguarding concerns. Referrals had been made to the local authorities safeguarding team. People and their family members told us they felt safe with staff members, who treated people well.

Managers and staff had responded appropriately to the COVID-19 pandemic. People supported each had a COVID-19 risk assessment and management plan in place.

There was a new home manager in place who was making an application to be registered with the CQC. At the time of our visit they had been in post for five weeks. Staff members described the new manager as approachable and in their initial time at the home they had promoted some new ideas that included people living at the home. One staff member commented, "Things appear more organised and friendly." These were very recent changes which would need to become embedded into the service to enable staff to be effective in supporting people.

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 24 September 2020). The service remains rated requires improvement. 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 service has been rated requires improvement or inadequate for the last three consecutive inspections. This service has been in Special Measures since April 2020.

Why we inspected

This was a planned inspection based on the previous rating.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches of regulations in relation to providing person-centred care that was appropriate, met people’s needs and reflected their preferences. In relation to good governance, the provider had failed to assess and monitor the quality of the experience of people who received those services; and had not effectively sought and acted on feedback.

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

Follow up

We will request an action plan 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

This service has been in Special Measures since 3 April 2020. This was following an inspection that rated the service as ‘Inadequate’ overall. Following our inspection, the provider proposed to remodel this service as part of a wider program of change. In September 2020, in line with our methodology we inspected again within six months of the publication of our public report. We were aware that this was in the middle of the providers change program, during which most people had moved out of the home. This meant that at the time of our inspection only three people were living at The Duke’s House, only part of the building was being used and building work was taking place.

In September 2020, most of the planned changes had not yet taken place and a further five people were due to move into the home. Therefore, we completed a focused inspection of the key questions, safe and well-led to ensure people’s safety. However, the ratings for other key questions were not reviewed and the service remained in special measures.

At this inspection the overall rating for this service is ‘Requires improvement’. The service remains in special measures because it continues to be rated ‘Inadequate’ in one of the five key questions. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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, 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.

The Duke’s House is a residential care home providing accommodation, support and personal care for people who have a learning disability, autism or a mental health support need. At the time of our inspection three people were living at the home; the service can support up to eight people. The home is across two three storey Victorian properties which have been joined together, in a residential area of New Brighton. Each person has an en-suite room; there were communal areas, and on the top floor office space and a room for staff to sleep in.

At our previous inspection The Duke's House shared the same staff team, management team, outdoor space, office and many other systems with the providers location The Duke's House 3 which was next door.

At the time of this inspection the provider was in the process of making changes that they had assessed would align the service with the values of Registering the Right Support. The provider was in the process of closing The Duke’s House 3 and remodelling The Duke’s House. Works planned included the redesigning and remodelling of outdoor space and changing some aspects of the outward presentation of the home. The provider told us that these changes will result in The Duke’s House fitting in with properties within the local community.

There were some indicators that the three people living at The Duke’s House had benefited from living with fewer people. Some progress had been made in aligning people’s support with the principles of Registering the Right Support. However, we are aware that most of the changes planned had not yet happened. Many of the changes to the interior of the building had not yet taken place and a further five people were due to move into the home. This will make the home larger than typical domestic style living arrangements, with eight people living in the home supported by a larger staff team. This is the third inspection when the home has not been full; it is not known if the redesign of the accommodation will mitigate any impact on people’s choice, control and independence.

The provider had completed an internal audit of the service against the principles of Registering the Right Support. We recommended that the provider continue to assess themselves against these principles which include the values of choice, control and independence when providing care and accommodation for people.

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

Leadership of the service remained inconsistent and the systems for checking on the quality and safety of the service had not always been effective. The manager in place during our last inspection had left; and the service had been led by interim managers since then. An existing manager who is registered with the CQC from one of the providers other services had recently been appointed as manager of The Duke’s House.

We have made a recommendation about the health and safety systems at the home.

We have also made a recommendation about the management of some medicines.

At times there remained some disconnect between the described ethos of the service, care planning and how staff supported people on a day to day basis. Staff gave us mixed feedback regarding the atmosphere and culture within the home. Some staff still described aspects of the culture as negative.

Communication and partnership working had improved in some areas. However, family members of the three people living at The Duke’s House told us that although they think that the changes at home sound “great”; the communication with the provider during these changes had been poor. The provider still did not have a coherent vision that was agreed and understood across all health and social care professionals, family members, managers and support staff.

People told us that they felt safe living at The Duke’s House and staff were kind towards them and treated them well. They told us that they felt comfortable speaking with staff members and would be confident if they needed to raise a concern. Family members praised the support staff, one called them “wonderful”; another relative told us that their family member felt “happy and safe at the home”.

The provider had made some positive changes to their approach towards supporting people at The Duke’s House. For example, any restrictive practices in place had been reviewed and a restraint reduction plan had been put in place. Each person had an individual risk screen in place. This outlined the identified risks in a person’s care and support and ensured that guidance was available for staff.

There had been an improvement in the application of the values and principles of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. Some of the redesigning of the home was focused on people increasing their independence, for example, building a second more accessible kitchen area for people to use. Also, some of the internal doors within the home that had previously been locked were now unlocked so that people had access to the kitchen, including food storage and preparation areas.

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 (published 3 April 2020) and there were multiple 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 some improvement had been made; however, the provider was still in breach of regulation.

Why we inspected

We carried out an unannounced comprehensive inspection of this service in December 2019. 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 report only covers our findings in relation to the Key Questions ‘Is the service safe?’ and ‘Is the service well-led?’.

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.

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 changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to assessing the quality and safety of the service provided for people. 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.

This service has been in Special Measures since 3 April 2020. During this inspection the provider demonstrated that some improvements have been made. However, this was a focused inspection and the rating of every key question was not reviewed. The service is no longer rated as inadequate overall but remains inadequate in at least one key question. Therefore, the service remains in Special Measures.

This means we will keep the service under review and, we will re-inspect within 6 months to check for significant improvements. 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.

The Duke’s House is a residential care home providing accommodation, support and personal care to six people who have a learning disability, autism or a mental health support need. The service can support up to eight people. The home is across two three storey Victorian properties which have been joined together, in a residential area of New Brighton. Each person has an en-suite room; also, there were communal areas, and on the top floor office space and a room for staff to sleep in.

The Duke’s House shares the same staff team, management team, outdoor space, office and many other systems with the providers location The Duke’s House 3 which is next door. We inspected both services at the same time; specific information regarding The Duke’s House 3 is reported in a separate report.

The service has not been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. Registering the Right Support, ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was next door to another location provided by Lifeways Inclusive Lifestyles. To the public they look like and in many aspects operate as one care home; between them can accommodate up to 14 people. This is larger than current best practice guidance. In some ways this was mitigated, for example; there were no identifying signs to indicate it was a care home and staff were discouraged from wearing anything that suggested they were care staff when coming and going with people. However, in other ways the care home was in contrast to the surrounding homes. For example, the three front gardens had been converted into one large car park, there were large gates across all entrances and there were no bay window coverings and when the lights were on the public could see into people’s communal areas from the street.

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

Staff were caring in their interactions with people and it was evident that staff endeavoured to have positive relationships with people. Whilst staff as individuals had a caring approach towards people; the provider had not developed, promoted or ensured that there was a caring culture at the home that respected and enabled people.

The home had a very restrictive environment. The provider had taken depriving people of their liberties for granted and had not ensured that people’s fundamental rights were acknowledged and protected.

The systems in place for assessing, monitoring and managing risks when supporting people were inadequate. They had not always ensured that the use of restraint had been safe and effective. This meant that important information regarding people’s safety was not always available for staff.

People’s risk assessments had not always been reviewed following a significant incident. The safe and effective use of restraint had not always been reviewed after significant physical interventions. There was inadequate debriefing and learning from incidents; even when staff members told us that they had raised safety concerns about the management of incidents.

The PBS principle of listening to a person by their communication and their actions had not been consistently applied. The culture at the home had not promoted staff being curious and exploring with them, what views or decisions they were communicating.

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.

The service didn’t always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people did not fully reflect the principles and values of Registering the Right Support. There were limited opportunities for people to develop skills and increase their independence. People’ support plans were not focused on; and the design of the home’s environment did not support this and promoted people’s reliance on staff members.

Some aspects of the design and adaptation of the environment was not working for people. Some people had been supported to decorate and personalise their rooms; they told us that they liked their rooms. However, overall the environment of the home was not homely and was mostly bland, featureless and uninviting.

There were enough staff to meet people’s support needs safely. However, staff had not received appropriate support and training to enable them to be effective in their role. The provider had not maintained their programme of training and refreshment training for staff.

The previous managers of the service had left. The home had a new deputy manager and a new manager who was in their induction period and was not registered with the Care Quality Commission. The provider told us that they were supporting the service during this period using managers from other areas of the organisation. However, the provider had not ensured that the home had a positive culture. Staff including senior staff told us that there had been a very negative culture at the home.

The provider had a lack of oversight of the safety and quality of the service being provided for people.

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 25 July 2018).

Why we inspected

The inspection was prompted due to concerns received about the leadership of the service from a whistle-blower. A decision was made for us to inspect and examine any risks.

We have found evidence that the provider needs to make improvements. Please see the is the service safe; is the service effective; is the service caring; is the service responsive and is the service well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the identification and management of risks. The environment of the home and people’s support not always reflecting their needs and preferences. The provider had not ensured that people’s fundamental rights were acknowledged and protected.

Staff had not received appropriate support and training to enable them to be effective in their roles. The provider had not ensured that the CQC had been informed of all notifiable events; and the provider had not assessed and improved the quality and safety of the service provided for people.

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 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.

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.

The Duke's House is a 'care home'. 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.

The Duke's House is registered to provide accommodation for up to eight people. The service specialises in providing support to people with a learning disability and or autism who need support with their personal care. On the day of our inspection there were six people living at the service.

The Duke's House has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.' Registering the Right Support CQC policy'.

At the last inspection on 2 August 2016 the service was rated Good. At this inspection we found the service remained Good.

Why this service is Good.

The service had a relaxed feel and people could move freely around the service as they chose. People were supported to have maximum choice and control over their lives and participate in activities they enjoyed.

People’s individual needs had been assessed and the information used to develop support plans. These provided staff with guidance about the care and support people needed and how they wanted this to be provided. People were consulted about their care to ensure wishes and preferences were met.

People told us they chose how to spend their day and were encouraged to be independent in all aspects of their lives such as taking responsibility for undertaking their own cleaning, laundry and personal shopping.

People received a varied and nutritional diet that met their preferences and dietary needs.

People were supported by a consistent staff team who knew them well. Staff had been recruited safely and had the skills and experience to meet people’s needs and provide effective care.

People received their medicine safely and were supported to access the support of health care professionals when needed. People were protected from the risk of abuse because staff understood how to identify and report it.

Staff considered peoples capacity using the Mental Capacity Act 2005 (MCA) as guidance. The registered provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS).

The management and the staff team worked in collaboration with external agencies to provide good outcomes for people. Staff felt any concerns would be taken seriously and acted on. Processes were in place to assess and monitor the quality of the service provided and drive improvement.

Further information is in the detailed findings below.

The Duke’s House is in a large, Victorian building and is a home providing accommodation and support for up to eight people. At the time of our inspection, there were five people living in the home. These people lived with a range of learning disabilities , mental or physical health conditions. Each person had their own room and shared the communal living areas and garden area. The home is situated near shops and public transport.

The service required 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. There was a registered manager in post who had been there for several years.

We saw and were told by relatives, that the registered manager was open and transparent and that they were very approachable. Relatives felt the management of the home was good. The registered manager was also supported by two deputy manager posts, although one of these had recently been vacated due to internal promotion.

We looked at records relating to the safety of the premises and equipment, which were correctly recorded. We toured the home and observed that staff and people interacted in a friendly and positive way with people.

There was insufficient soap in some bathrooms and several toilets were dirty or stained.

The remainder of the home was clean and in good order apart from recent damage done by one person, which was in the process of being repaired.

We looked at the recruitment files for staff. We saw that safe recruitment practice occurred with the recently recruited staff.

The provider had complied with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and its associated codes of practice in the delivery of care. We found that the staff had followed the requirements and principles of the Mental Capacity Act 2005 (MCA). Staff we spoke with had an understanding of what their role was and what their obligations where in order to maintain people’s rights.

We found that the care plans and risk assessment monthly review records were all up to date in the files looked at and there was updated information that reflected the changes of people’s health.

We viewed rotas for the staff. The staffing levels were sufficient in all areas of the home at all times to support people and meet their needs and the relatives we spoke with considered there were adequate staff on duty.

Records we viewed showed that the required safety checks for gas, electric and fire safety were carried out.

At the time of our visit there were five people living in The Duke's House. We talked with two people who used the service and with three members of staff as well as the deputy manager for the home and the area manager for the provider. We looked at various paper records including three care plans and eight staff files.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

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

Is the service safe?

There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available or on call in case of emergencies. Staff had been appropriately and properly recruited, ensuring that Criminal Records (CRB) or Disclosure and Barring Scheme (DBS) records had been checked. Staff were trained in safeguarding principles and procedures.The home had a safeguarding policy which was regularly monitored. Medication storage and administration was done in accordance with guidelines. Appropriate risk assessments had been carried out and action plans put into place for safe practice. A person living in the home told us, "I feel safe".

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Proper policies and procedures were in place for this.

Is the service effective?

People appeared happy. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. Staff had received training to meet the needs of the people living at the home.

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Is the service caring?

People were supported by kind and attentive staff. We saw that care workers were patient and gave encouragement when supporting people.

People and their families had been involved in the creation of their care plans where possible and continued to be involved throughout their stay in the home. We noted that peoples preferences about, for example, activities, room layouts or clothing choices, were respected by the staff. The people who used the service people were supported, where necessary, to make these choices and decisions.

Is the service responsive?

People's needs had been assessed before they moved into the home and frequently reassessed whilst they lived there. They had key workers who related to them specifically, but they were also happy with other team members and spoke well of them. Records confirmed that people's preferences, interests, aspirations and diverse needs had been recorded. Care and support had been provided that met their needs and wishes.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. People and relatives had been asked for their feedback on the service.

The home completed various other audits throughout the year, which contributed to an annual audit. An action plan had been produced to address any areas of concern raised through all of the audit and feedback processes.

The provider had a number of premises and homes and for all, used the same IT package for much of its record keeping and policies. The manager was able to demonstrate effective knowledge of this and show us that she had acted according to policy regarding such things as recruitment, safeguarding procedures and CQC notifications.

Relatives spoken with were happy with the care provided. One relative said: 'I couldn't be happier with the quality of care' and another said "The staff are brilliant." We found care plans contained specific guidance for staff on how to look after people. In particular there was clear guidance for staff regarding the use of de-escalation techniques needed for individuals who could present with distress reactions.

We observed that the home was generally clean throughout. However the manager was not aware of the appropriate guidance for the prevention of infection control but the provider employed a health and safety officer to monitor infection control.

We found there was a robust recruitment process in place to ensure only suitably skilled people were employed to look after people at the home.

We found there was a complaints system available for people who lived at the home for them to express any concerns.

One person who lived at the home said 'Staff treat me nice, they help me with shopping.'

A relative told us 'The home has done really well with our family member, she is happy there. I am involved in the planning of her care, there is a meeting which we all attend to discuss her care.'

We looked at four care files, these were well organised and had a person centred approach. The service helped the people who lived at the home to maintain contact with the families; they sent regular cards and letters to advise family members of the activities they had done that month and how well they had maintained their bedroom.

We made general observations within the home of the wellbeing of people and observed staff had a positive rapport with the people who lived at the home.