Archived: Windsor Care Home

Windsor Care Home is a residential care home providing personal and nursing care to 27 people aged 65 and over at the time of the inspection. The service can support up to 60 people.

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

Although staffing levels were in line with expectations, staff did not always respond quickly enough when people called for help. Relatives and staff gave mixed feedback about staffing levels and high use of agency staff.

Some risk assessments required further development as they did not always clearly identify the measures required to manage potential risks. Others were generic and lacked personalised information. The provider was reviewing people’s care records.

People gave positive feedback about their care. Most relatives agreed people received good care. Although improvements had been made to ensure staff responded appropriately to people's needs, there were still examples of care being task orientated. Activities were on-going on the ground floor and people were engaged.

The provider continued to have effective IPC practices to help prevent the risk of infections.

Staff supported people to have enough to eat and drink. People were happy with the food choices available to them.

Medicines were managed safely. Safeguarding concerns and incidents were investigated, and lessons learnt shared with staff. Staff knew how to raise concerns and were confident to do so.

The provider was updating training to ensure staff had the correct skills and knowledge. Most staff said they were well supported.

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.

The provider and registered manager continued to work with partners to progress the improvement plan developed following previous inspections. Relatives gave generally positive feedback about the approachability of management. Regular audits were being completed and action taken to address issues.

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 14 December 2020).

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.

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.

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.

Windsor Care Home provides residential and nursing care for up to 60 people. At the time of inspection, 32 people were using the service.

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

The provider had implemented a range of daily and weekly checks to help ensure people remained safe and had dignified care which met their needs. This included a daily check of mattress settings where people were at risk of skin damage.

The provider had started to review people’s care plans to ensure staff had the correct guidance about how people should be cared for. Initial care plans required further development to include people’s preferences and details of individual strategies required to provide personalised care.

Most people’s bedroom doors were open and there were positive interactions between people and staff. People had access to a nurse call which enabled them to access help when needed.

The environment had been made safe. Window restrictors had been fitted to all first floor windows and keypad locking systems prevented access to restricted areas within the home. Personal evacuation plans (PEEPs) had been reviewed and updated.

We were assured by the infection prevention and control measures introduced since we last visited. The provider had designated some staff as IPC champions, to share good practice throughout the service.

Medicines were now managed safely.

The provider planned to develop a structured activity programme which was appropriate for people’s needs.

The provider had strengthened the management team in order to improve oversight at the home. This included an operations manager, a deputy manager/clinical lead and a unit manager.

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 inadequate (published 14 December 2020).

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We undertook this targeted inspection to check the provider had acted following our inspection on 27 and 28 October 2020 and 2 and 18 November 2020 to make the agreed improvements to people’s safety and welfare. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on 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.

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.

Windsor Care Home provides residential and nursing care for up to 60 people. At the time of inspection, 30 people were using the service.

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

People did not always receive safe care. Issues were identified with the cleanliness of the service including infection control procedures. Staff did not always adhere to government guidelines regarding the correct use of PPE. People were not always protected from abuse.

There was a lack of both environmental and personal risk assessments for people. The premises were not safe for people living at the service. Some people did not have access to emergency call bells in their bedroom. Staffing levels were not at an appropriate level to care for people safely or to meet their emotional needs. Areas of the service were not dementia-friendly and were in need of refurbishment.

People’s medicines had not always been managed safely. Elements of people’s care plans had not always been reviewed and for one person extensive parts of their care plan was missing. Capacity assessments had not always been completed for people or best interest decisions made, for example where people’s bedroom doors were kept closed.

Records lacked detail regarding the monitoring of some people’s daily fluid targets. People did not always have access to the food of their choice. Food portion sizes and the variety of food on offer was not always appropriate. People had not always been referred to other healthcare professionals in a timely manner, in particular in relation to substantial weight-loss.

People were not always treated with dignity or respect in relation to their clothes and appearance. The majority of people’s bedroom doors were closed without reason and some of those people were heard to be calling out for assistance..

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.

During this inspection, staff appeared very task-orientated and very little caring or emotional support interactions with people were observed.

People we spoke with told us they liked living at the service and one person told us, “I like my room. I used to be in a different room which was dark, and it was difficult for me to see. I changed to this room and it is much better. The girls are lovely.”

The manager and the provider were open and honest with the inspectors during and after the inspection process. They acknowledged the concerns which had been highlighted to them and are currently taking action and working towards resolving the issues. This action has included employing new staff, the creation of additional roles and involving an external consultant to assist the management team in identifying and assessing the quality and safety in the service.

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 20 December 2018).

Why we inspected

We initially visited this service to carry out a targeted inspection of infection control procedures. However, after the first day of inspection we received concerns in relation to staffing levels and the safety of people living in the service. As a result, we carried out a comprehensive inspection to review all five key questions of safe, effective, caring, responsive and well-led.

We found evidence the provider needs to make improvements. The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection. Please see the safe, effective, caring, responsive and 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 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 person-centred care, dignity, consent, safe care and treatment, safeguarding, premises, governance and staffing at this inspection. We have also made four recommendations.

The provider had also failed to notify CQC of certain incidents and accidents which had happened in the home. This was a breach of regulation.

Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

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 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 and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

We last inspected the home in May 2017. We found significant improvements had been made to improve the overall quality of the service. However, further improvements were still required to improve the safety of medicines, staff training and competency on the Mental Capacity Act 2005 and the effectiveness of quality assurance procedures. We reported the provider had breached the regulation relating to Good Governance and rated the home Requires Improvement overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question, is the service well-led, to at least good. At this inspection we found the provider had continued to make improvements to the overall quality of the service. Quality assurance checks were completed consistently and were effective in identifying areas for improvement. People, relatives, staff and health professionals gave us good feedback about the registered manager.

Windsor Care Home 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.

Windsor Care Home accommodates 60 people in one adapted building. There were 47 people living at the home at the time of this inspection, some of whom were living with dementia.

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

People and relatives gave consistently good feedback about the home and the care provided. Staff and visiting health professional gave similarly positive feedback. Throughout our time at the home we observed positive interactions between people and staff.

People said they felt safe living at the home. Relatives and staff also felt the home was safe. Staff had a good understanding of the procedures for keeping people safe. For example, safeguarding and the whistle blowing procedure. They knew how to report concerns and said they wouldn’t hesitate to do so if needed.

Although we observed there was a visible staff presence around the home, we received some mixed feedback about staffing levels. Management felt staffing levels were appropriate. However, the provider did not have an effective approach to monitoring and reviewing staffing levels. We have made a recommendation about this. The provider had effective recruitment procedures to ensure new staff were recruited safely.

Medicines were managed safely. People told us they received their medicines when they were due. Records showed medicines were received, stored and disposed of correctly.

The provider completed health and safety checks and risk assessments to ensure the environment and equipment were safe. There were also up to date procedures to keep people safe in emergency situations. Staff members raised a safety issue with us about using hoisting equipment with certain specialist beds. The registered manager advised that options had been considered but had not been appropriate. However, we noted this issue had not been formally risk assessed to confirm people and staff were safe. The registered manager confirmed a risk assessment would be completed straightaway.

Staff supported people who displayed behaviours that challenge with sensitivity. Staff understood people’s needs and knew the most effective strategies to follow when people were anxious.

The provider had good systems to investigate and monitor incidents and accidents. An in-depth analysis was completed every three months which reviewed these incidents and identified lessons learnt.

Staff received good support and training. Records confirmed supervisions, appraisals and training were up to date.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were supported with their nutritional needs and to access healthcare services when required. We noted improvements were required to support people living with dementia to make meal choices and to ensure sufficient staff were available over lunchtime.

People’s needs had been assessed. This was used as the basis for developing detailed and personalised care plans. Complaints had been fully investigated and the outcome communicated to the complainant. Complaints were analysed periodically and used to identify areas for improvement. People and staff were encouraged to give feedback about the home.

We carried out a previous inspection on 9 and 11 May and 4 June 2016 at this service where we found that people were not receiving safe care. The service was rated inadequate and placed in special measures. We found people were not protected against risks to them and their rights had not always respected. Medicines had not been safely managed and there were insufficient staff on duty. Staff had not been supported to deliver safe care. Quality assurance systems were ineffective.

We previously carried out an inspection of this service on 12 and 13 October 2016, where we rated the service inadequate and the service remained in special measures. CQC had cancelled the registered manager’s registration. People remained at risk of harm and their rights were not respected. The management of medicines remained unsafe. Staff had not received the support they needed and people did not have access to regular drinks and snacks. Quality assurance procedures remained ineffective because they had not resulted in improvements.

We previously carried out an inspection of this service on 14 and 15 December 2016. Improvements had been made and the service was taken out of special measures. However further improvements were needed to improve the safe management of medicines, staff training and competency in following the principals of the Mental Capacity Act 2005. Ineffective quality assurance procedures remained.

Windsor Care Home provides residential and nursing care for up to 73 older people, including people who may be living with a dementia type illness. There were 43 people living at the home at the time of this inspection.

At the time of this inspection, a new manager was in place and they had submitted an application to become a registered manager with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that significant improvements had been made to improve the overall quality of the service. People, their relatives and staff expressed their satisfaction about the improvements at the service. They felt listened to and had been kept up to date with changes. People were much happier living at the service and staff told us they enjoyed their jobs. Staff told us the manager was supportive of them and overall they felt the service had significantly moved forward. More effective quality assurance process were in place, however these required further development as not all had identified areas for improvement had been fully completed. This meant that the service needed to make further changes to be well-led.

Staff understood the procedures they needed to follow to ensure people remained safe. Systems were in place to monitor people at risk, however staff had not always taken continuous action to minimise these risks and improvements were needed to the premises. Robust recruitment procedures were in place for new staff and there were enough staff on duty at all times. Medicines were managed safely. Further improvements were needed to ensure people received safe care.

Staff were supported to carry out their roles by way of regular supervision, appraisals and training. Staff understood and followed the principles of the Mental Capacity Act 2005 and best interest decisions had been made. People had received support with their nutrition and hydration and people had regular access to health and social care professionals when they experienced deterioration in their health. This meant staff were effective when providing care and support to people.

People told us they were happy living at the service and were well-cared for. People told us their privacy and dignity was respected and maintained. Relatives spoke positively about staff. People and their relatives were encouraged to be involved in planning and reviewing their care. Staff were aware of local advocacy services for people who needed independent advice and support with decision making. This meant people received good care.

People received personalised care and support. Staff were aware of people’s individual needs, wishes and preferences and care records contained the information staff needed. Daily records reflected care plans. People told us there were enough activities at the service and they actively participated in them. Everyone we spoke with was aware of how to make a complaint, though no-one wished to do so. All had confidence that they would be listened to and their complaint taken seriously. This meant staff were responsive to people’s needs when care and support was provided.

We carried out an unannounced inspection on 14 December 2016 and another visit on 15 December 2016. Windsor Care Home provides nursing and personal care to people, including people who may be living with dementia. The home is registered for 73 places.

During this inspection we found the provider was continuing to breach four regulations. Medicines were still not managed in a safe way. This was because some people’s medicines had not been ordered in a timely way so had become ‘out of stock’. Also records had not been completed correctly placing people at risk of medicine errors. Some people’s capacity to make decisions was not always assessed in line with legal requirements, although this was an area that was improving.

Some staff had not completed the appropriate training to enable them to carry out their roles effectively, although this was an area of on-going improvement. Some necessary training had been provided and more was planned, but there was still no evidence to show whether nurses had completed training in nursing tasks such as catheter care or end of life care.

As a consequence of the continuing breaches we also concluded the provider’s quality assurance systems were not effective in making sure people received a safe and good quality service. For example, although the provider’s checks had identified shortfalls in the safe management of medicines these had not resulted in improvements.

A manager had been in post since September 2016 and was in the process of applying for registration. 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.

You can see what action we told the provider to take at the back of the full version of the report.

During this inspection we found the provider had made improvements to two regulations. People now received the right support with their nutrition and hydration needs. Also care was now planned to meet people’s individual needs and risks to people’s safety were now assessed and managed.

People said they were comfortable and felt safe at the home. Staff understood how to report any concerns and were confident these would be dealt with by the manager. There were enough staff on duty to support people. Staff had been recruited in a safe way to make sure they were suitable for their role.

Relatives felt staff were becoming competent in their roles and they had more confidence in the service. Staff felt supported by the management team. They now had individual supervision sessions with a supervisor to assist them with their professional development.

People and relatives told us staff were kind and caring. Staff were respectful and helpful when supporting people. There were friendly good relationships between staff and the people who lived there, and staff took time to sit and chat with people.

People and visitors felt the range of activities had improved and there were now two activities staff to provide daily social events. More one-to-one activities were being developed for people who were bedfast or preferred to spend time in their own rooms.

People were kept informed about the service at monthly meetings and were asked for their views about how the home could improve. They had information about how to make a complaint or comment and these were acted upon. People, relatives and staff felt they could talk with the manager at any time and said they were approachable and “on the ball”.

During the previous inspection we concluded people who used the service were not safeguarded because incidents were not reported or acted upon. People were not fully protected against the risks associated with medicines because the provider did not manage medicines appropriately. People were not protected against the risks associated with infection because of inappropriate staff practices relating to hygiene. People were not protected against the risks of receiving unsafe care because care was not planned and delivered to meet their individual needs or risk assessed to ensure their safety and welfare.

During the last inspection we also found people’s dignity was not being upheld. People’s capacity to make decisions and their consent were not always sought in line with legal requirements. People's hydration and nutritional needs were not being managed in a way that was safe or met their needs. The service failed to deploy enough staff across the home in order to safely meet the needs of people who used the service. Staff had not been subject to robust recruitment processes and checks. Staff had not completed the appropriate training to enable them to carry out their roles effectively. The provider’s quality assurance systems were ineffective and did not make sure people received a safe and good quality service.

We carried out this inspection on 12 and 13 October 2016. The first day of the inspection was unannounced so the provider and staff did not know we were coming.

Since the last inspection the registered manager had left and their registration was cancelled by CQC. A new manager had recently taken up post and was in the process of applying for registration. 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.

During this inspection we found there were continuing breaches in relation to six regulations. Potential risks to people's well-being were not assessed or set out so staff had no guidance about how to manage those risks. For example there were no risk assessments about potential choking for people who had swallowing difficulties.

Medicines were still not managed in a safe way. This was because people did not always receive their medicines in the right way and records had not been completed correctly placing people at risk of medication errors.

People were still not always being supported to meet their nutritional needs in a safe way. Some people were being given the wrong texture of food which could present a choking risk. People did not have access to drinks whenever they wanted which did not promote good hydration.

During this inspection we found that where people may not have capacity to make decisions around their care, staff had not always completed capacity assessments to check or carried ‘best interest’ decision meetings with others. For example if people used a lap belt whilst they were in their wheelchair, we could not find evidence of whether they consented to this or documented capacity assessment about whether this was done in their best interests.

There were still significant gaps in training of care staff and competency checks of nurses, although there were plans for improvement in this area. The new manager had begun to plan one-to-one individual supervision sessions for each staff member. However, only senior members of staff had had these so far.

The provider’s quality assurance processes were still ineffective. Although audits had been carried out to check some areas of quality and safety, such as care plans and medicines, these had not resulted in improvements.

At the last comprehensive inspection this provider was placed into special measures by the Care Quality Commission (CQC). This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

We did find that improvements had been made to safeguarding processes, staffing levels, recruitment of staff and people’s dignity. The new manager understood safeguarding processes and had worked with the local authority to look into any concerns. All staff were being retrained in safeguarding and staff who had raised any concerns told us these were being listened to and acted upon. There were sufficient staff on duty to support the 50 people who lived there at the time of this inspection. The provider had agreed to maintain these staffing levels during the process of improvement to the service.

All necessary checks and clearances were carried out for potential new staff and they were only recruited if these were satisfactory. During this inspection we saw staff engaged people in discussions and activities, and supported people in a way that upheld their dignity.

Some people and relatives felt it was a safer place and that improvements were being made to staffing. One visitor said, “There’s always somebody around. I feel comfortable knowing she’s here.”

We found people had access to health care services and staff were more responsive to seeking medical intervention if people were poorly.

The people who were able to express a view about the service they received said that they were happy with the care. One person said, “There are some very compassionate people who do the job with care.”

There were some opportunities for people to go out and for community events to come into the home, although this was limited for people who had to spend their time in bed.

Relatives and staff said the new manager was approachable and acted on their comments. Relatives felt there had been recent improvements since the change in management. One relative told us, “There seems to have been a bit of an impetus.” They were pleased that “they are not changing the staff around as much”. Another visitor said, “It's getting better.”

Windsor Care Home is a residential and nursing home that provides care to older persons and people who may be living with a dementia. It can accommodate up to 73 people. At the time of our inspection 63 people were living at the home.

The registered manager has been registered with us since 1 October 2010. 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.

During the inspection we found that the service had breached a number of regulations. People did not receive care and support in line with assessments to ensure that associated risks were managed and care was delivered safely. People were not protected against the risks associated with infection due to the service failing to adopt and implement appropriate infection prevention and control measures. People’s hydration and nutritional needs were not being managed in a way that was safe and promoted their health and well-being.

The service failed to deploy enough staff across the home in order to safely meet the needs of people who used the service. Staff that were employed at the service had not been subject to robust recruitment processes and checks. Staff had not completed the appropriate training to enable them to carry out their roles effectively.

The service failed to protect people from abuse, or allegations of abuse. This was because there was not a sufficiently robust system in place to ensure that relevant authorities were made aware of allegations of abuse. This also meant that there were insufficient systems in place to prevent further abuse or allegations occurring.

Staff did not understand or act in accordance with the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS), which meant they failed to act lawfully to support people who lacked capacity to make their own decisions.

Medicine administration was not always carried out safely. Appropriate arrangements for the ordering and supply of required medicines were not in place. Medicines were found to be out of stock and care plans did not reflect or support the administration of medicines that was required.

Appropriate checks of the building and maintenance systems were undertaken to ensure risks to people's health and safety were minimised.

The service did not promote a culture that was open, inclusive and empowering. There was a lack of confidence from people, those acting on their behalf and staff, in the process of raising concerns and issues with the service. The process that was in place to monitor the on-going quality of the service was ineffective.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

The service 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.

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.

During our inspection on 21 May 2014, we also checked that other essential standards of quality and safety were being met. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service responsive?

' Is the service caring?

' Is the service well led?

Below is a summary of what we found:-

Is the service safe?

We spoke with six people who used the service and three relatives to find out their opinions of the service. We also sought the opinions of the local authority team which commissioned services from the home. All spoke positively about the service.

People were treated with respect by the staff. Appropriate arrangements were in place to manage medicines and we considered that people were protected from the risks associated with their use.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The provider had made two applications under these safeguards and notified CQC about this. These applications had been approved by the responsible local authority. We found proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

We saw that risks to people's safety had been identified and assessed to ensure that appropriate care and support was provided to keep people safe. For instance, some people had low beds and safety mats placed by the beds to reduce the likelihood of serious injury if they were to fall from their bed.

Appropriate checks were undertaken before staff began work which helped ensure that the staff were fit and appropriate to work with people in a caring capacity.

The provider had implemented effective audit processes, to ensure the service was safe and to identify ways to improve. These included checks on the premises to make sure they were safe for people to use.

Is the service effective?

We found that people who were using the service received the care and support they needed. The staff we spoke with could describe how they met people's needs. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. One person who used the service told us, 'It's smashing.' A visitor told us, 'This is the best (my mother) has been in; she is getting properly looked after.'

People were happy with the care that was delivered, and particularly the social stimulation provided by staff. A relative commented, 'There are lots of activities; sing-alongs, entertainers and outings.'

Appropriate arrangements were in place to manage medicines. People were satisfied with this aspect of their care. One person who had Parkinson's disease told us, 'I get my tablets on time.' Her symptoms were controlled well because her medication was administered on time. A relative of another person commented, 'The staff make sure what medicines she needs are taken.'

The provider had taken steps to provide care in an environment that was suitably designed and adequately maintained. The building provided good access throughout for people with physical disabilities. We also noted that the first floor had been decorated with consideration of the needs of people with dementia. For instance, bedroom doors were painted in different colours and had identifying objects or photos to help people locate their rooms. People who used the service commented, 'My room is small but it's comfortable. I brought some of my own furniture' and 'It's small but it's enough for my needs. I brought my own settee and television.'

Is the service responsive?

We observed that staff provided personalised care and support and they respected people's wishes and their agreed plan of care. People and their families were encouraged to be involved in making decisions about their care and treatment. A relative told us, 'The manager came to meet my mam and the family and the doctor and went through all mam's care notes. There's been some tweaking of her care plan since then regarding medication.' This showed that the staff responded to people's needs as they changed.

We found the premises were maintained and repairs carried out promptly. Visitors told us, 'He (the maintenance person) is always working at something' and 'He is good. He sorts everything out; like if the television isn't working.'

Relatives told us the management and staff were open and friendly and they felt confident about raising any issues or concerns with them. A relative commented, 'If I had any complaints, I would tell the girls and things would happen.' Another told us, 'Anything medical, I speak to the nurses. I know I can speak to them and the manager is always available. She would listen. She is very amenable.'

Is the service caring?

We saw that people were treated with dignity and respect by staff, who were friendly and considerate. They were attentive to people and spent time talking with them to reassure and occupy them. There was a pleasant, welcoming atmosphere in the lounges where people spent time. People who used the service told us they were well cared for. One commented, 'They don't boss us around. They treat us all alike. There's no favourites. If they can help you, they help you.'

We spoke with three relatives who were all impressed with the quality of care. Their comments included, 'The staff are always helpful and generally caring' and 'Staff are very caring.'

Is the service well led?

The service had been managed by the same person for over seven years which helped provide consistency. Staff felt supported by her and people we spoke with felt the service was managed effectively. A relative told us, 'Things are up to scratch.'

There were effective quality assurance systems in place. Audits were carried out to check people were cared for appropriately, for instance in respect of their physical wellbeing and nutritional status. Medication systems were audited to ensure staff were following safe practice. Audits of the premises were carried out to make sure people were cared for in a safe environment.

We found that although regular maintenance was carried out, some areas of the home were unsafe and unsuitable for the regulated activity. These were communal bathroom and shower areas.

Staff members were seen to interact well with people and knew them by their first name. There was a choice in what people wanted to do and the privacy and dignity of residents was respected as we observed care interventions being carried out. Staff spoke to people in a pleasant and respectful manner.

People had been individually assessed to see if they could make their own decisions. Care records had enough information so staff would be able to know how to support each person in the right way.

We found that the provider was not maintaining some parts of the home in good physical repair and condition that facilitates the prevention and control of infection.

We saw on the day of our visit, there were sufficient qualified, skilled and experienced staff to meet people's needs.

There were systems for auditing and monitoring the service. For example audits, meetings with people using the service and their families and with staff. Surveys were also carried out. The records of these processes were up to date and gave the manager and staff members the information they needed to run the home effectively.