Derwent Lodge Nursing Home

Derwent Lodge Nursing Home provides accommodation and personal and nursing care for up to 46 people. At the time of the inspection 33 people were living in the home, some of whom were living with dementia.

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

Risks to people were not always assessed and mitigated robustly, as although risk assessments had been completed, they were not always updated when people’s needs changed. Repositioning records did not all reflect that people received support as planned and pressure relieving air mattresses were not all set at the correct setting for people. Care plans were detailed regarding people’s medical conditions, but other plans were not always updated when people’s needs changed.

Most people told us staff were very busy at times and they had to be patient and sometimes had to wait for care. Staff told us that although they were busy at times, especially mealtimes, they felt there were enough staff to meet people’s needs. Staff rotas showed staffing levels were not always maintained at the usual level the registered manager described during the inspection, although agency staff were used when possible. We made a recommendation about this.

Although a range of audits were completed to monitor the quality and safety of the service, they required further development to ensure they effectively identified all improvements required. New systems in place had led to improvements within the service, such as medication stock checks, recording of thickening agents and care plans regarding people’s medical conditions.

Medicines were managed safely; they were stored securely and administered as prescribed. There were protocols in place to guide staff when to administer medicines prescribed on an 'as required' (PRN), but these required further person-centred detail to ensure staff knew when to administer them. Medicines were administered by staff that had undertaken training and had their competency assessed.

People told us they felt safe living in Derwent Lodge Nursing Home. Procedures were in place to ensure safeguarding concerns were managed appropriately and records showed that accidents were recorded and reported, and appropriate actions were taken to ensure people's safety. Effective infection prevention and control measures were in place, and the home appeared clean and well maintained.

Referrals were made to other professionals when required for their specialist advice and support, to ensure people’s needs were met.

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 service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.

People and their relatives told us they felt the service was well managed and they were always informed of incidents and kept updated regarding any changes in their family members' well being. Staff told us they were well supported and enjoyed their jobs. Systems were in place to gather feedback from people, staff, and relatives.

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 9 May 2022). At that inspection breaches in relation to Regulations 12 and 17, regarding medicines management, risk management and the governance of the service were identified.

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 in relation to medicines management and the governance of the service and the provider was no longer in breach of Regulation 17. However, further improvements were required in relation to the assessment of risk and the provider remained in breach of Regulation 12.

This service has been in Special Measures since 1 December 2021. 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

We undertook this focused inspection to check the provider 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains requires improvement. This is based on the findings at this inspection.

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

We have found evidence that the provider needs to make improvements. Please see the Safe 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.

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

Enforcement and Recommendations

We have identified a breach in relation to the management of risk at this inspection. We also made a recommendation regarding staffing. Please see the Safe key question for further infromation.

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 from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Derwent Lodge Nursing Home provides accommodation for up to 46 people who need help with nursing or personal care. At the time of the inspection 23 people lived in the home. Most of the people living in the home required nursing care and most people lived with dementia.

People's experience of using this service

At the last inspection serious concerns were identified with regards to the management of risk, care planning, the delivery of care, the management of medicines and governance. At this inspection, we found that while some improvements had been made, further action needed to be taken to make sure the service was safe and well led.

People were not safe. At the last inspection visit, we identified concerns in relation to medicines management. The safety of medication management had improved at this inspection, but there were still a number of concerns relating to medicines that had not been properly addressed.

Information about people needs, risks and care had been reviewed. Care plans now contained much better information about people’s day to day care needs. They failed however to contain adequate details of people’s medical conditions and the clinical care they required to keep them safe and well. This was found at the last inspection but had not been acted upon.

Wound care management and the monitoring of fluid intake required improvement to ensure that people’s pressure sores were cared for properly and the risk of dehydration mitigated.

We spoke with the new manager and regional manager about these ongoing concerns and asked them to address them without further delay. They told us they would do so.

At the last inspection, the systems in place to monitor quality and safety were not robust and managerial oversight of the service and people’s care was poor. At this inspection, a new manager was in post and we saw that action had been taken by them to improve the systems in place, but these improvements had not been fully embedded and further improvements were required.

The new manager had only been in post eight weeks at the time of this inspection, but we found they had had a positive impact on the service so far. Managerial oversight had improved, action had been taken to address any shortfalls in staff practice and the support people received, and feedback from people living in the home and their relatives about the difference the new manager had made was positive.

The provider had a system in place to determine safe staffing levels. However, some people and staff felt that at times more staff were needed on duty. We fed this back to the manager to review.

The home was clean and well-maintained. There was a staff and resident COVID-19 testing programme in place and appropriate safety measures in place for visitors and new admissions to the service. Some of the government's guidance in respect of assessing risks to the workforce and the taking of people’s temperatures twice daily during an outbreak had not been followed as recommended. We asked the manager to review the guidance in relation to this.

People and their relatives told us they felt the service had improved since the new manager had been in post and that they felt more involved with the service and the care provided.

Rating at last inspection

The last rating for this service was inadequate (published 01 December 2021).

Why we inspected

At the last inspection, the provider was found to be in breach of regulations 12 (Safe care and treatment) and 17 (Good Governance). CQC placed conditions on the provider’s registration in relation to these concerns, which restricted admissions to the service and required them to take specified action in respect of medicines.

We undertook this inspection to follow up on the action we had previously told the provider to take and to check whether the provider was now compliant with the Health and Social Care Regulations in the domains of Safe and Well-led.

During this inspection, we looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to 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.

At this inspection, we found that the provider had made some improvements to the service, but further improvements were still required. This service remained in continued breach of regulations 12 and 17. However, improvements made in relation to Regulation 17 and the management of the service has resulted in the overall rating for this service changing to requires improvement, at this inspection. The conditions on the provider’s registration have also been removed.

For more details, please see the full report which is on the CQC 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.

At this inspection we found breaches of regulations 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to the failure to ensure people received safe care and treatment and a failure to ensure the service was always governed and managed adequately.

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

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

Special Measures

At the last inspection, the service, due to its rating of inadequate, was placed in special measures. At this inspection, the overall rating for this service had changed to ‘Requires Improvement’. The service however, will remain in ‘special measures due to its inadequate rating in the ‘Safe’ domain. 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.

Derwent Lodge Nursing Home provides accommodation for up to 46 people who need help with nursing or personal care. At the time of the inspection 39 people lived in the home. The majority of the people living in the home required nursing care and most people lived with dementia.

People's experience of using this service

At this inspection, we identified serious concerns with the management of risk, care planning, the delivery of care, the management of medicines and governance.

Medication management was unsafe. People did not always receive their medicines as prescribed and medicines were not always administered in a safe way. This placed people at serious risk of avoidable harm.

Environmental risks within the home had not been addressed. For example, first floor windows were not secure, some people’s pressure mattresses were not set correctly; some bed rails were unsafe and as a result posed a risk of entrapment and multiple fire doors within the home were faulty. These environmental risks placed people at serious risk of injury or harm.

Staff did not always have clear and accurate information on people’s needs or, sufficient guidance on the support they needed to keep them safe and well. This placed people at risk of inappropriate or unsafe care and meant good outcomes for people were not always promoted.

The systems in place to monitor quality and safety were not robust. Managerial oversight by the manager and the provider was not effective. Staff practice in the delivery of care did not always adhere to best practice guidance or the provider’s own policies and procedures. This meant staff practice was not always consistent or safe.

During the inspection, CQC asked the provider to submit an urgent and immediate action plan for improvement, as the concerns about people’s safety were high risk. The provider and manager responded swiftly and a programme of improvements was commenced without delay. However, it should not have taken a CQC inspection to identify and act on these risks.

There were enough staff on duty to meet people’s needs and staff were recruited safely. Infection control standards were maintained, and the risk of COVID-19 managed appropriately.

Accident and incidents and safeguarding events were reported and monitored. Learning from these incidents was shared with the staff team to prevent similar incidences from occurring in the future.

People were referred to and received support from a range of other health and social care professionals in respect of their needs. Relatives told us that the staff team engaged with them well and the manager was approachable.

Staff were observed to be kind and caring. Relatives told us they felt their loved one were happy at the home and with the staff team that supported them.

Rating at last inspection

The last rating for this service was good (published 25 December 2020).

Why we inspected

This focused inspection was prompted by a serious incident relating to environmental safety that occurred at the service. This raised concerns about the safety and management of the service overall. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

For more details, please see the full report which is on the CQC 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.

At this inspection we found breaches of regulations 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to the failure to ensure people received safe care and treatment and a failure to ensure the service was governed and managed adequately.

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

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service has been placed 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.

Derwent Lodge Nursing Home is a ‘care home’ providing accommodation, nursing and personal care for up to 46 younger and older adults. At the time of the inspection 26 people were living at the home.

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

We continued to identify some areas requiring improvement in relation to risk assessment and safety monitoring processes. We have made a recommendation regarding this.

Medication administration was safe. New electronic medication administration recording procedures were still in the process of being embedded. Staff had received the appropriate training and audits were being regularly completed.

Staff received safeguarding training and understood the importance of keeping people safe. Staff knew how to raise any concerns and were familiar with reporting procedures they needed to follow. The registered manager had systems in place to review and monitor safeguarding incidents, including learning from any incidents.

Staff were familiar with level of support people required and relatives told us that they believed safe care was provided to their loved ones.

There were enough staff at the home. Staffing levels were effectively monitored and safe recruitment processes were in place. Relatives confirmed that they had developed positive relationships with the staff team who worked at the home.

Infection prevention and control (IPC) arrangements and processes were safely embedded at the home. The registered manager ensured that all staff were familiar with COVID-19 policies and the importance of complying with the measures that had been implemented.

The staff team and relatives we spoke with during the inspection all expressed that they had been well informed during the COVID-19 pandemic and that lines of communication had been well established.

Governance systems and processes were in place to monitor, assess and improve the quality and safety of care people received. Audits and checks were completed as a measure of reviewing the provision of care being delivered.

Rating at last inspection and update:

The last rating for this service was ‘good’ (report published November 2019).

Why we inspected

We carried out an unannounced focused inspection to review the ‘safe’ and ‘well-led’ domains.

Our report is only based on the findings in those areas at this inspection. We did not look at all the five key questions during a focused inspection. We found evidence that the provider needs to make improvements. Please see the ‘safe’ section of this report. 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.

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

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.

Derwent Lodge Nursing Home is a two-storey purpose-built building that is located on the Wirral, Merseyside. Derwent Lodge is registered to provide personal and nursing care for to up to 46 people. At the time of our inspection there were 34 people living at the home.

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

The registered manager told us that staffing levels had been a concern but was able to demonstrate how this was being managed. We recommend that this area of care continues to be monitored.

We received mixed feedback about the variety of activities that were arranged for people at Derwent Lodge. An activities co-ordinator helped to arrange different activities, but it was clear that people would benefit from more stimulating and interesting activities. We have made a recommendation regarding this.

People received a safe level of care; risks were well managed, and staff were familiar with people’s support needs and how their support needed to be provided. Environmental risk assessment tools were in place, although we discussed with the registered manager how some areas needed to be strengthened.

Safeguarding and whistleblowing procedures were safely in place. People were protected from avoidable harm and abuse. Staff received the appropriate safeguarding training and understood the importance of protecting people who lived at Derwent Lodge.

Safe recruitment procedures were in place. Pre-employment checks were carried out and people received a safe level of care by staff who had been appropriately recruited.

Staff received regular supervision and told us they felt supported by the registered manager. Staff also received support with a variety of different training, learning and development opportunities.

Medication procedures and policies were complied with. People received support with their medication by staff who had been appropriately trained and regularly had their competency levels checked.

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 registered provider had an up to date complaints procedure in place. Complaints were responded to and managed in accordance with the complaint policy and procedure.

People received person-centred care that was tailored around individual support needs. Care records contained a good level of person-centred information, this enabled staff to provide care and support that was centred around people’s likes, wishes and preferences.

A variety of effective quality assurance systems were in place to monitor the provision of care people received. Areas of improvement we identified during day one of the inspection were immediately responded to and measures were implemented to further monitor the quality and safety of care provided.

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 29 April 2019). We identified multiple breaches of regulation in relation to consent, safe care and treatment, governance systems and recruitment. The provider completed an action plan after the last inspection to show what improvements they would make and by when. 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.

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.

Derwent Lodge Nursing Home is a care home registered to provided personal and nursing care to up to 46 people. At the time of our inspection there were 34 people living at the home.

People’s experience of using this service:

People told us they felt safe living at the home. However, medicines were not administered, stored or recorded safely and in line with the relevant national guidance and best practice. The safety and security of the premises of the home was not maintained. Staff were not always safely recruited by the home and we received consistent feedback from people living at the home and their relatives that there was not enough staff and they sometimes waited long periods of time for assistance.

The home did not always act in line with principles of The Mental Capacity Act 2005. This meant there was risk inappropriate decisions could be made on a person’s behalf if they lacked capacity to make the decision for themselves.

People were supported to have enough to eat and drink and the feedback about the food and drink at the home was generally positive.

The atmosphere and appearance of the home was comfortable, homely and clean but additional environmental adaptations could be made to better support people living with dementia.

People and their relatives gave us positive feedback about the staff at the home. Staff respected people’s privacy and treated them with dignity and respect.

People’s care plans were informative, regularly reviewed and reflected their needs.

People and their relatives told us they felt comfortable raising any concerns if necessary and we saw that complaints were managed appropriately by the manager.

There was a positive and caring culture at the home led by the manager and we saw some examples of good leadership and governance. However, the home did not have robust and effective systems in place to monitor, assess and improve the safety and quality of service being provided. This was also the second consecutive time we have rated the service as requires improvement.

During this inspection we identified continued breaches of Regulations 11, 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was also an additional breach of Regulation 19.

Rating at last inspection:

At the last inspection the service was rated requires improvement (13 February 2018).

During the last inspection we found breaches of Regulations 11, 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

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

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

Derwent Lodge 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. Derwent Lodge accommodates up to 46 people in a purpose-built building and there were 37 people living there when we visited.

The service is required to have 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. The home had a registered manager.

During our inspection we found breaches of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people had not always received their medication as prescribed; the requirements of the Mental Capacity Act 2005 were not fully met to ensure that people who lacked capacity to make decisions received the protection they required; the provider had not implemented effective systems to monitor the quality of the service provided.

All of the people we spoke with believed the home was safe and said they were happy living at Derwent Lodge. There were enough staff to meet people’s needs. Regular checks of services and equipment were carried out by the home’s maintenance person and utilities and equipment were checked and serviced as required by external contractors. A log of accidents and incidents was maintained and showed that appropriate action had been taken when accidents occurred. Staff received annual training about safeguarding and the manager had reported safeguarding incidents as required.

People were generally satisfied with their meals and special dietary needs were identified and catered for. People received the support they needed to eat their meal. The care notes we looked at contained malnutrition risk assessments that were updated monthly. We saw evidence that people at risk were referred to a dietician. Staff received regular training and supervision, however the Care Certificate had not been implemented for new staff. A number of people were being looked after in bed and equipment had been provided to meet their needs. Improvements were needed to some parts of the building, including two shower rooms that were out of use awaiting repair.

People who lived at the home told us that staff treated them with respect and respected their choices and independence. Relatives we spoke with were very happy with the care their loved ones received. They could visit at any time and we observed that they were comfortable to speak with the manager and the nurses.

We looked at the care files for three people. These showed that people’s care and support needs were assessed before they went to live at the home to ensure that the service would be able to meet the person's individual needs. The care plans contained basic relevant information including nutritional assessments and eating and drinking care plans, falls risk assessments and moving and handling plans, personal hygiene care plans and sleep care plans. These had been updated monthly. There was a weekly programme of varied social activities. People we spoke with said they would be happy to approach the manager with any complaints. The complaints procedure displayed advised people who they could contact with any complaints. We saw that the manager had kept detailed records of complaints that she had received and the records showed that complaints had been investigated and addressed.

We saw evidence of regular staff meetings which were well attended. The minutes of the staff meetings showed that staff felt able to express their views. There was also a staff questionnaire twice a year. Questionnaires had been sent out to people who lived at the home and their families. We saw some completed satisfaction questionnaires from 2017 and these contained some very positive comments about the care provided.

During 2017 there was no quality audit plan and we found that auditing tools had been implemented irregularly so did not provide a record of progress within the service.

Is the service safe?

Records we looked at showed that the correct procedures had been followed to ensure that new staff were safe and suitable to work with vulnerable older people.

Is the service effective?

Records we looked at showed that people were cared for by staff who were trained and supported to deliver care and treatment safely and to an appropriate standard.

Is the service safe?

The premises had been adequately maintained to provide a suitable home for people to live in. Effective recruitment procedures had not always been followed when employing new staff to check that they were of good character. Records showed that staff received regular training, supervision and appraisal to ensure that they knew how to work safely.

Is the service effective?

People told us that they were happy with the care and their needs were met. Staff had a good understanding of people's care and support needs. A person who lived at the home said: 'I'm fine. They look after you well, they are all very good.' And another person told us: 'The help here is very good.'

Is the service caring?

Staff were kind and patient to the people who lived at the home and we observed positive interaction between staff, visitors and people who lived at the home. A relative told us: 'They are angels. They could not look after my mother any better if she was their own mother.'

Is the service responsive?

People's needs were assessed before they moved into the home. Care plans recorded people's personal preferences and interests, and care was provided in accordance with people's wishes. People were asked to give their views of the service.

Is the service well led?

The manager was an experienced registered nurse and was registered with CQC. A deputy manager had recently been appointed and there were four senior care staff. An operations manager provided support in all areas of the service.

We saw people's needs were assessed and regularly reviewed. Care records were personalised, contained information about a person's individual needs and preferences and promoted the person's independence where possible.

We reviewed the safeguarding arrangements at the home. We saw staff had received appropriate training in safeguarding and were knowledgeable about types of abuse and who to report concerns to.

We found staff treated people kindly and supported them at their own pace. We saw during lunchtime however that the number of staff on duty was insufficient to meet people's needs. People and staff said at times there were not enough staff on duty.

We saw staff had received appropriate training to care for people but they had not had an appraisal or received adequate supervision. This meant staff had not received appropriate support in respect of their job role.

People/relatives we spoke with said they had no complaints but they would know how to make a complaint if they needed to do so. We saw the provider had the complaints policy displayed in the home and that the manager had responded appropriately to any complaints made.

We carried out this inspection on the 12 September 2012 to check the compliance actions had been met. We found significant improvements in the systems for the storage, ordering, administering, safekeeping, reviewing and disposing of medicines. However we still had some minor concerns as not all the nurses were following the correct procedures.

We spoke with three people who use the service and two relatives. Three people who used the service told us they were given choices in what they wanted to do and this included what time they liked to be woken up in the morning. The relatives we spoke with said they had never had any concerns or issues about the care provided and we saw evidence to show people were included in their care planning process. One person told us they 'couldn't fault anything about the home' another said, 'The care my mother receives is fantastic.'

All the people we spoke with said they felt safe at the home and we witnessed call bells being answered promptly throughout the duration of our visit.

We saw evidence to show there were robust recruitment processes in place and staff received induction training to provide them with the necessary skills to care for people. The manager had only been in post for six weeks but all staff we spoke with felt supported by her and told us that they could go to her if they had any concerns. We saw evidence that quality assurance processes were being developed to maintain the quality of care people received.