Halton View Care Home

Halton View Care Home provides accommodation for persons who require personal care. The home provides support to older people including those living with dementia and can accommodate up to 64 people. The ground floor provides accommodation for people who require general residential care, and the first floor accommodates people who are living with dementia. At the time of our inspection there were 45 people living at the home.

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

Systems in place to protect people from harm and learn lessons when things went wrong were not always effectively used and therefore failed protect people from abuse or improper treatment. This exposed people living at the home to a risk of harm.

People were exposed to a risk of harm as their care needs and associated risks had not been routinely assessed, reviewed, monitored, or mitigated. Medicines were not managed safely.

Staff were not always deployed effectively to ensure people's safety or that their needs were met in a timely way.

Ineffective governance and quality assurance measures meant that people were exposed to unnecessary risk. Monitoring systems failed to identify and address shortfalls found during this and the previous inspection. This was in relation to risk and medicines management, accurate care planning and recording, governance and the oversight and deployment of staff. Furthermore, improvements were needed to cleaning regimes throughout the service.

People were supported by staff who knew them well and it was evident that positive relationships had been formed.

The newly recruited manager was aware of their role and was in the process of developing an action plan to make positive changes to the service provided for people.

We could not be assured that 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; or that the policies and systems in the service supported this practice. At the time of this inspection the newly recruited manager was carrying out a full review of Deprivation of Liberty Safeguards (DoLS) and best interest decisions that were in place for people using 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 and update

The last rating for this service was requires improvement (published 11 October 2023).

At this inspection we found the provider remained in breach of regulations.

Why we inspected

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

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 has changed from requires improvement to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive, and well-led sections of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to medicines management, management of risk, the environment, safeguarding and management oversight. We have made a recommendation in relation to staffing.

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

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.

Halton View Care Home provides accommodation for persons who require personal care. The home provides support to older people including those living with dementia and can accommodate up to 64 people. The ground floor provides accommodation for people who require general residential care and the first floor accommodates people who are living with dementia. At the time of our inspection there were 52 people living at the home.

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

There were ineffective processes in place to protect people from abuse or improper treatment. This exposed people living at the home to a risk of harm. Safety related themes and trends were not analysed reliably or robustly and there was little evidence of learning from events or action taken to improve safety.

People were exposed to a risk of harm as their care needs and associated risks had not been routinely assessed, monitored and mitigated and medicines were not managed safely.

Ineffective governance and quality assurance measures meant that people were exposed to unnecessary risk. Monitoring systems failed to identify all shortfalls found during the inspection in relation to risk management and mitigation, accident and incident analysis and governance.

The provider failed to share information with external organisations and professionals. For example, reportable incidents were not shared with the safeguarding authority and multiple statutory notifications were not submitted to the CQC.

There were enough staff to meet people's needs. However, staff were not always deployed effectively to ensure people's safety. We made a recommendation about this.

We saw that complaints were investigated and responded to. However, information was not always made available to a complainant about what further action they could take if they were not satisfied with how the provider responded to their complaint. We made a recommendation about this.

Staff followed good infection control practices and used personal protective equipment (PPE) to help prevent the spread of healthcare related infections. We observed friends and relatives visiting their loved ones during the inspection.

Staff supported people to stay in contact with those important to them. Relatives told us that staff had gone above and beyond to ensure contact was maintained with their loved ones throughout the COVID-19 pandemic. People and relatives provided many positive examples of how the home supported them in a person-centred way and described how they achieved good outcomes as a result.

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.

There were systems in place to obtain feedback from people, their relatives, staff and other stakeholders about the running of the service. The feedback was used to identify improvements. People were encouraged to be involved in the running of 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

The last rating for this service was good (published 23 September 2020).

Why we inspected

We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process.

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.

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 has changed from good to requires improvement based on the findings of this inspection.

The provider has been receptive to the concerns and taken immediate action to reduce the risk to people living at the home.

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 Halton View Care Home 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 and will take further action if needed.

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse and governance at this inspection.

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

Follow up

We will 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.

Halton View Care Home can accommodate 64 people. 28 are designated general residential on the ground floor of the building and 36 are for people living with dementia accommodated on the first floor.

There were 46 people being supported at the time of the inspection.

People’s experience of using this service:

During this inspection we looked at the infection control and prevention measures the provider has in place in response to the coronavirus pandemic. We found people were reassured by the homes approach which was based on good practice guidelines and updated policy from Public Health.

We received positive feedback about the skills, experience and abilities of the staff from people who received support and their relatives. Staffing levels were appropriately managed and there was good continuity of care for people. Staff knew and understood peoples care needs.

We confirmed that all staff received the necessary training and were provided with training, learning and development opportunities. This was an improvement from the last inspection.

The home had undergone improvements to the overall environment since the last inspection. This included improvements to the design, furnishings and décor of the unit for people living with dementia. This unit was homely and there were aspects of the design which were aimed at assisting people’s orientation and feelings of wellbeing. This was an improvement from the last inspection.

We made a recommendation to access an appropriate good practice audit tool to assess and develop the environment further.

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.

People received good ongoing support for their health care needs and supporting care notes helped confirm this.

People were receiving support form a range of in-house activities so there was ongoing positive interaction which enhanced people’s wellbeing and meant that their needs, choice and preference for social activity was being met. This was an improvement since our last inspection.

Since the last inspection a new registered manager had been appointed. The overall management of the home was settled. The feedback we received from people living in the home and their relatives, professional visitors and commissioners was positive regarding the management and culture of the home and the improvements made. This had been consistent over a period of time.

Rating at last inspection:

The last rating for this service was requires improvement (published 27 March 2019) and there were multiple breaches of regulation. 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 coronavirus and other infection outbreaks effectively.

At the last inspection there were breaches identified in relation to the provision of activities for people, the living environment for people living with dementia, staff training and the overall management of the home.

In planning the inspection, we took account of the current risk factors associated with Covid19 in the community and the need to spend as little time on site as possible. As a result, we undertook a focused inspection to review the key questions of Effective and Well led only.

We also looked at the outstanding breach to provide activities for people and have reported on this under ‘responsive’ but did not look at the other key questions in this domain.

We reviewed the information we held about the service. No areas of concern were identified in the other key question. We therefore did not inspect the caring domain.

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 requires improvement to Good. This is based on the findings at this inspection.

Follow up:

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

Halton View Care Home is a purpose-built residential care home providing personal care and accommodation for 64 older people. At the time of the inspection 49 people resided in the home.

People’s experience of using this service:

People were positive about living at Halton View Care Home and were complimentary about the staff who cared for them.

There were sufficient staff to meet people’s needs. Staffing levels had improved since our last visit and there was less dependency on agency staff. Which meant that people were supported by staff known to them.

Relatives told us that they were satisfied with the care their loved ones received.

Care and support was not always tailored to each person's needs and preferences, specifically around activities.

Appropriate recruitment checks were carried out to ensure staff were suitable to work in the care environment.

Improvements were evident that medicines were managed better in the home.

Risks were identified and managed to minimise harm.

Staff had not received regular training and improvement was needed to ensure that staff were working in line with current guidance and best practice.

The home complied with the principals of Mental Capacity Act 2005 (MCA), measures were in place to ensure consent to care and treatment.

People were satisfied with the food available. Menus offered choice on a daily basis.

People were well cared for by staff who treated them with respect and dignity. People were supported by staff who knew them well.

Systems were in place for people to raise complaints and concerns. People told us they knew how and to whom they should complain.

Overall we received positive comments to the recent changes in the management structure at the home from residents, staff and relatives.

More information is in the full report.

Rating at last inspection:

Requires Improvement (report published 24 May 2018) This is the second time the service has been rated Requires Improvement.

Why we inspected:

This inspection was brought forward due to information of risk or concern. The rating remains requires improvement.

Follow up:

We will continue to monitor any intelligence we receive about the service until we return to visit in accordance with our inspection schedule. If any concerning information is received we may inspect sooner.

Halton View Care Home is a purpose-built residential care home providing personal care and accommodation for 64 older people. It is a two storey building comprising of 64 single bedrooms located within three separate units, all having en-suite toilet and shower facilities. There is a range of communal spaces including lounges, dining and sitting areas. Toilet and bathroom facilities are dispersed throughout the building.

At the time of the inspection there were 62 people living at Halton View. The accommodation was split into a residential unit on the ground floor and male and mixed units accommodating people living with dementia on the first floor. There were twenty eight people living in the residential unit, 23 living in the mixed unit and 13 living in the male unit.

The service did not have a registered manager in post. 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. Previous registered managers had not completed the process of de-registration however were no longer employed by the service. A new home manager had recently been appointed but had yet to begin their application to become the next registered manager.

We identified three breaches of relevant legislation, in respect of safe care and treatment, staffing and governance.

Overall people and relatives we spoke with were positive about the care and support they received at Halton View and spoke favourably about the staff. We observed many caring interactions although we saw one member of staff supporting a person whilst using their mobile phone. This was brought to the attention of the regional manager who advised they would address this with the staff member concerned.

We found that sufficient numbers of staff had not been deployed by the registered provider, particularly in one area of the home. This impacted upon the care that people received and the level of supervision and monitoring of support needs that staff were able to achieve. Although a dependency tool was used to determine staffing needs, we saw that this did not take into account the level of supervision that was needed and therefore, we queried the accuracy of the outcome.

We found shortfalls in the safe management of medicines. We saw that there were occasions when stocks had been allowed to run out or staff could not locate them, which meant that people did not receive their medicines as prescribed.

Although the home was visibly clean and tidy some areas were malodourous. This had improved on the final day of inspection but remained an issue. The service was working with the local infection prevention and control team to manage this issue who made a recommendation to install impermeable flooring had been made.

We saw that staff did not always follow guidance given by external professionals and risk assessments to mitigate risks, for example for a person who was at risk of choking.

The registered provider followed safe recruitment procedures to ensure that people employed were suitable to work with adults at risk of harm or abuse. Staff had received training and demonstrated an understanding of their responsibilities with regard to reporting abuse and whistle-blowing.

Arrangements were in place for checking the environment at Halton View to ensure it was a safe place for people to live. We spot checked safety certificates and found these were up to date.

People, visitors and staff felt that staff had received the training needed to deliver care that was effective. Communication, staff supervision, appraisal and meetings had improved since the appointment of the new manager.

We saw that the provider was working within the principles and requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People were complimentary about the nutritious food which was available.

The provider had plans to improve the environment within Halton View with new furniture already having been purchased and further plans to improve soft furnishings and flooring. The hairdressing salon had been refurbished and café area improved.

Details of advocacy services were available for people who did not have family or friends to support them.

People told us that they were able to make choices such as what to eat and where to eat their meals. However, we identified that some restrictive practice had taken place with the removal of seating from the corridor of one unit.

Improvement was needed with regard to person centred care planning including involvement of the people living at Halton View and their representatives where appropriate. The manager had identified this as an area for improvement and had already begun measures to achieve the necessary improvement.

There had been a lack of meaningful activities following the departure of the activity co-ordinator. On the final day of inspection we saw that a new co-ordinator had been appointed.

There was a policy for monitoring and responding to complaints. People we spoke with were aware of how to make a complaint and who to speak with if they needed to.

The provider used a suite of audits to assess and monitor the quality of the service. However, we found that these were not sufficiently robust to have identified all of the concerns noted during this inspection.

During the inspection we found the manager and regional manager to be approachable and responsive to feedback. The manager’s enthusiasm and drive to improve the service was evident. They had identified key challenges and on the last day of inspection we saw that some improvement was evident.

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

There was no registered manager at the time of our inspection. The service employed a manager who had applied for registration 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.

Halton View Care Home is a purpose-built residential care home providing personal care and accommodation for 64 people. At the time of our inspection there were 63 people living at the home. It is a two-storey property comprising of 64 single bedrooms located within four separate units, all having en-suite toilet and shower facilities. There is a range of communal spaces including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff.

We last inspected Halton View in January 2016 and rated the service ‘good’ in all domains and ‘good’ overall.

We received some information of concern from the Local Authority with regards to a serious incident at the home where a person fell and passed away a short time later in hospital. The feedback we received from the Local Authority and our own requests for information indicated that we would need to go and inspect to ensure other people living at the home were not at risk. We wanted to examine what strategies were in place to monitor and supervise people who were at risk of falling to ensure that other people living at the home were kept safe. We also wanted to check whether the staff numbers were sufficient to support people and whether staff had received the necessary induction to enable them to fulfil their roles effectively.

This inspection was 'focused' in response to concerns in that we only looked at two domains; Safe and Well-led. The domains ‘Effective’, 'Caring' and 'Responsive' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for 'Halton View Care Home’ on our website at www.cqc.org.uk.

During this inspection we found that the service was meeting the needs of people and was keeping people safe from harm specifically in relation to falls prevention although record keeping did not always reflect this. The service had taken positive steps to improve their risk management practices following the above serious incident.

On this inspection, we saw that many people living at Halton View were mobile with the assistance of an aid and therefore we considered that they were more susceptible to accidental falls. We found that the service had taken appropriate measures to mitigate this risk as far as possible and that people who were in danger of falling had the necessary risk assessments in place. However, we found that records were not always accurate and meant that the level of risk was not always captured correctly. We have made a recommendation about this.

People we spoke with told us they felt safe living at Halton View. People told us and our observations confirmed, that there were sufficient numbers of staff on duty to meet people's needs.

We saw evidence of good quality assurance procedures which had been developed to meet the needs of the service. The service was able to evidence a series of robust audits carried out by the area manager to monitor and improve standards in the home.

The manager had notified the Care Quality Commission (CQC) of events and incidents that occurred within the home in accordance with our statutory requirements.

Halton View Care Home is a purpose-built residential care home providing personal care and accommodation for 64 older people. It is a two-storey property comprising of 64 single bedrooms

located within three separate units, all having en-suite toilet and shower facilities. There is a range of communal space's including: lounges; dining rooms and sitting areas. Toilet and bathroom facilities are dispersed throughout the building. There is a car park provided for visitors and staff.

The home was divided into three units. The ground floor unit accommodated 28 people. The upper unit had two separate units; a male only unit which was equipped to accommodate 13 people and a further unit which accommodated up to 23 people who were living with dementia. At the time of the inspection there were 61 people using the service.

There is a registered manager at Halton View. 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.

We saw that care records contained care plans and assessments pertaining to health and well-being, these were individualised depending on need.

People were actively supported to access the community. The home arranged for people to be involved with community activities as part of their daily living skills.

Staff understood the Mental Capacity Act 2005 (MCA) regarding people who lacked capacity to make a decision. They also understood the Deprivation of Liberty Safeguards (DoLS) to make sure people were not restricted unnecessarily.

We saw that staff supported people and we saw caring interventions. Staff told us that they observed people’s body language and facial expressions to support their communication.

Staff told us that management was approachable and would listen to the concerns of staff and take necessary action if required.

One visiting heath care professional told us that staff contacted them when they had any concerns about people’s health. They said that staff took notice of any advice given and acted on it with immediate effect.

Recruitment practices were thorough, appropriate and safe. Rigorous pre- employment checks ensured that only suitable people were employed. Staff training was up to date and staff received supervision and appraisals.

Relatives told us that their family members had the correct level of well trained staff supporting them. We reviewed the most recent staffing rotas. There were sufficient staff on duty to meet the assessed needs of the people who currently lived in the home.

We saw that the service assessed peoples’ nutritional needs and had developed a varied menu. People told us that the food was good, not too fancy- but very tasty.

The registered manager had robust systems in place to monitor the quality of the staff and the services provided.

During the inspection we spoke with the registered manager, twelve staff, seven relatives and a health care professional. We also spoke with fifteen of the people who used the service and encouraged each individual to communicate using their preferred method of communication. We observed people using a system called a Short Observational Framework of Inspection (SOFI). This process helps us gather information where people using services cannot verbally communicate with us.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service safe?

Policies and procedures had been developed by the registered provider to provide guidance for staff on how to safeguard the care and welfare of the people using the service. This included guidance on the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). We were informed that a small number of people using the service had been assessed as lacking capacity to make decisions although no applications had needed to be submitted to ensure that people's rights were protected. Training records highlighted that the majority of staff had completed Mental Capacity Act training. They had also been provided with Deprivation of Liberty Safeguards training. This has been a useful way to increase staff knowledge and understanding of these issues. Examination of records and discussion with staff confirmed staff had been provided with lots of training and support to enable them to provide safe needs led care.

Is the service effective?

Feedback received from people using the service was generally positive and confirmed people were happy with the standard of care provided. Comments included: "Staff ask us what we want and take notice of our comments"; "I am very happy here, it's almost as good as my home and I know exactly what my care involves". We spoke with several relatives of people who lived at Halton View and they told us that they had been involved in the assessment process and had been able to influence, via discussion and sharing of information, how people received their care and support. Three people told us they had visited four care homes before making the decision to "choose Halton View". They told us that they had been given lots of information about the home; the staff and services provided and felt the home had "a very nice atmosphere".

Is the service caring?

We spoke with fifteen people who lived in Halton View and asked them what they thought about the staff and services provided. Comments were positive and included; "Staff are wonderful and treat us well"; "Staff make me feel very much at home here" and "The care and support we get is second to none". We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. People looked clean and well cared for. We saw care staff interacted well with people, were warm, supportive and sat and talked with people, when possible.

Members of the staff team spoken with demonstrated a clear understanding of people's care needs and their role and responsibility to maintain their safety. People we spoke with during our inspection told us that communication with staff at the home was "very good" and the care and treatment for people living at Halton View was carried out promptly and efficiently. We observed staff providing care and support to people in a caring and dignified manner.

Is the service responsive?

Staff meetings were held on a regular basis and staff were encouraged to speak their mind about any issues or areas of concern.

Each care plan we looked at was reviewed every month and provided people or their relatives with the opportunity to make comments or suggest changes about how their care was provided. This showed us the provider consulted with people at regular intervals to ensure the service was responsive to any concerns or changing needs.

Is the service well- led?

We noted that a number of audits were carried out on a regular basis. We looked at the audits file and saw that they included checks on cleaning, infection control, fire safety, water temperature and wheelchair safety and were being carried out on a regular basis, issues had been recorded that were then addressed and actioned.

We noted good interactions between staff during the inspection and were told that the manager was very good and led by mutual consent. The provider informed us that they had worked hard to establish a well-managed service and although it had taken some time the home now had a very good reputation. Feedback from local contracts and commissioning officers confirmed this and they also made positive comments about the robust management of the service.

to alWe saw that all of the people living at the service were clean and well presented.

There were no malodours, bedrooms were decorated with each individuals personal effects and the furnishings and decor were to a good standard. The paved garden areas provided areas of shade and colourful flower displays that people who lived at the service helped to look after.

We spoke with people who lived at the service, family members and staff. Most people that we spoke with were positive about the provider, the care provided and the staff. Comments from the people we spoke to included, ''The staff are very good and they fit in with my relatives routines and wishes'' and ''The staff have supported me through a family bereavement and are very understanding.'' We saw that staff interacted well and supported people living at the service with dignity and that they interacted well with visitors and each other.

Two people living at the service told us that it was often noisy during the night. We passed this comment to the provider who told us that they would look into the matter.

Staff members told us they received training and support low them to provide a good quality of care for the people living at the service.

People living at the service and their relatives made overall positive comments. They used words to describe the service such as:

'Its top class, they can't do enough for you';' It's really very good"; " We visited this and other homes which were also very good, but this one had the edge as its closer for us all' and 'My relative really loves it here and joins in the activities'. One relative was very complementary of the activities officer.

The service had developed areas within the environment to support people with dementia. They had introduced specialised picture signs as a way of advising people regarding daily services like activities and were facilities are, such as were toilets and bathrooms were located. These tools for communication help people with dementia to be orientated and reminded about their surroundings and living space.

We had also contacted the local authority contracts and monitoring team for Halton Social services before we visited the service. They shared a detailed report from their recent reviews of the service.