Cedar Court Nursing Home (Dementia Unit)

Cedar Court Nursing Home (Dementia Unit) is a care home providing nursing and personal care for up to 45 people living with dementia. At the time of the inspection 37 people were living at the home. The home is in a rural location with enclosed accessible gardens. Care is divided across 2 floors and there are several communal lounges for people to spend time in.

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

Throughout the inspection we observed staff monitoring and addressing areas of risk for people. However, we found risks such a skin integrity and malnutrition were not consistently recorded in people's care records. We discussed this with the home manager and action plan was put in place to address the shortfalls promptly. We have made a recommendation about making improvements to the relevant care plans and people’s care records to ensure all documentation is accurate and up to date.

The provider's systems for monitoring the quality and safety of the service prior to our inspection were not always effective in identifying issues.

People and their relatives were mostly pleased with the care provided at the home; however, we received some concerns which we shared with the home manager following our inspection. The manager recorded the feedback and followed the home complaints policy to investigate these.

People were supported to maintain a balanced diet where this was part of their care plan, but improvements were required to make sure food and fluid intake was consistently documented. At lunch time, people were having to wait long periods of time for their meals which led to some people becoming frustrated. We spoke with the manager about our findings and they addressed it immediately by introducing staggered mealtimes.

People received their medicines as prescribed, and staff had clear information about how people liked to be supported with their medicines. Staff were knowledgeable about people's health needs and the provider had sought support from other health professionals as appropriate to support people's needs. Staffing levels were appropriate and matched the dependency tool being used to meet the needs of people at the home. Staff received training and support to enable them to effectively meet the needs of the people they supported.

The provider followed safe recruitment practices. Staff completed infection control training and followed national guidelines when supporting people to reduce the risk of the spread of infection. They were aware to report any accidents or incidents which occurred during their work.

Staff were supported in their roles through training and supervision. People had access to a range of healthcare services when needed, and staff ensured people received consistent support across different services. Staff sought consent from people when offering them assistance. 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.

Staff treated people with kindness and consideration. They respected their privacy and treated them with dignity. People were supported to make decisions about the care they received and were encouraged to maintain their independence wherever possible. The provider had a complaints policy and procedure in place which people and relatives were aware of.

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 1 January 2021).

Why we inspected

We received concerns in relation to risk management, documentation, quality of care and governance at the service. A decision was made for us to inspect and examine those risks. We undertook a comprehensive inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report. The provider took prompt and effective actions to mitigate the risks following our 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.

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

Enforcement and Recommendations

We have identified breaches in relation to good 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.

Cedar Court Nursing Home (Dementia Unit) is a residential care home providing personal and nursing care to 25 people living with dementia. The service can support up to 45 people. The home is in a rural location with enclosed accessible gardens. Care is divided across two floors and there are several communal lounges for people to spend time in.

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

People received their medicines as prescribed and the risks associated with medicines were managed effectively. People received safe care and there were effective infection control systems to keep them safe. There were enough staff available to meet people's needs safely and in a timely manner. Nursing staff were being recruited and regular agency staff were utilised in the interim. People were protected from the risk of harm and lessons were learnt when mistakes happened.

The systems in place to monitor and improve the service were effective in achieving good outcomes for people. Staff were aware of their responsibilities and were encouraged to raise concerns and report mistakes to create a learning culture. Under current restrictions the service had implemented strict infection control measures but were innovative in maintaining contact with families virtually and on site through building development.

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 requires improvement (published 12 December 2019).

Why we inspected

We received concerns in relation to infection control, staffing and risk management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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.

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

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for infection control, staffing and risk management 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.

Cedar Court Nursing Home (Dementia Unit) is a residential care home providing personal and nursing care for up to 45 people aged 65 and over. At the time of the inspection they were 37 people using the service.

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

Whilst people told us they felt safe and staff knew their responsibilities to keep people safe, we found some improvements were needed in medicines management. Records we reviewed relating to the management of as required medicines) were not consistent and did not show if pain medicines were effective for people. We found some areas of improvement were needed in infection control in the medicines room as well as monitoring the temperature of where medicines were stored.

Although 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, not all staff understood the legislation. Care plans also did not always have decision specific best interest assessments, meaning they did not look at the person's ability to make a choice around a particular part of their lives. There were systems in place that ensured people who were deprived of their liberty were done so with the appropriate legal authority

The provider had introduced a new senior management level audit system. Although we saw this had made a positive impact in driving improvements within the service. For example, improved staffing levels and the recruitment of a clinical lead, they had not always achieved improvements which had been identified. We saw examples of this with areas we identified such as the sharps bin not being labelled and clinical waste needing emptying.

During the inspection relatives spoke positively about the staff that supported their loved ones and told us they felt they were well cared for. Staff had a good understanding of the needs and preferences of the people they supported. Most of the feedback we received from relatives and healthcare professional we spoke with commented on improvements in the last few months.

People were supported by staff who had the skills and knowledge to meet their needs. Staff understood their role and were confident when performing tasks through training and support from the management team. People’s cultural and spiritual needs were supported by staff who understood their importance. Staff at the service worked together with a range of healthcare professionals to achieve positive outcomes for people.

Since 2016 onwards all organisations that provide publicly funded adult social care are legally required to follow the Accessible Information Standard (AIS). The standard was introduced to make sure people are given information in a way they can understand. There was evidence that where needed the service supported people in accordance with the AIS. People felt their concerns and complaints would be listened to. Accidents, incidents and complaints were reviewed to learn and improve the service where needed. People were supported to take part in a variety of activities which reduced their risk of social isolation.

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. (the last inspection report was published in October 2018). We found multiple breaches of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. During this inspection the provider demonstrated that improvements had been made and they are no longer in breach. However, the service remains rated requires improvement as improvements were still needed.

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection 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.

There was 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.

The service had been in special measures at their last inspection on 27 March 2018. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. After the last inspection, the provider sent us an action plan to confirm what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. Cedar Court Nursing Home (Dementia Unit) also had positive conditions on their registration since March 2017. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement so that we could monitor their progress towards their action plan. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

However, there were still improvements required to ensure that they provided people with a good service. The training and support provided to staff was not always sufficient to enable them to fulfil their role effectively. They did not always assist people to manage their behaviour when it could be harmful to themselves or others. They did not always take action to protect people or report all incidents. This meant that learning from when things went wrong was not always sufficient.

There were not always enough staff to meet people’s needs promptly. Staff were often rushed and task focussed leaving little time to comfort and reassure people. People had little interaction and no activities were provided to engage them. This impacted on people’s dignity which was not always respected. Their privacy was also not always upheld.

There were systems in place to drive quality improvement which included regular audits and feedback from people who use the service. However, some of the provider’s systems were not effective in ensuring that people were safe.

There were good relationships with other organisations and professionals; including working closely with commissioners to meet actions on improvement plans.

People were assisted to maintain good health and had regular access to healthcare professionals. Medicines were managed safely and people received them when they needed them. Mealtimes included a choice of meal and food and drink was monitored for people who were nutritionally at risk. Care plans were regularly reviewed to correspond with changing support needs and they were personalised and accessible.

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. The environment was planned to meet their needs and there was signage to help them to orientate.

Visitors were welcomed at any time. They knew the registered manager and felt confident that any concerns they raised would be resolved promptly. There were regular meetings with people and their relatives and their feedback was used to improve the home.

Staff felt well supported by the registered manager and there were regular meetings with them to ensure they were consulted and informed of changes. They understood their roles and gave kind and compassionate care to people when they had time.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

Services in special measures 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. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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

Cedar Court Nursing Home (Dementia Unit) has had positive conditions on their registration since March 2017. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement and at this inspection we saw that some further improvements had been made as the provider had reported. However, they had not completed all of the actions that were detailed and this impacted on the safety and wellbeing of people who lived at the home. Therefore, we will retain the positive conditions on the provider's registration until we are satisfied that significant improvements have been completed.

Following the last inspection, we met with the provider 18 July 2017 to confirm what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. At this inspection we found that some improvements had been made, however further improvements were required and we also had additional concerns in some areas.

Cedar Court Nursing Home (Dementia Unit) is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care is provided in one building with an accessible, secure garden. Some of the people are cared for in a male only environment on the first floor, called Bretby View. There are two communal areas on this floor and a further two communal areas on the ground floor. The home provides accommodation and nursing care for up to 50 people who are living with dementia. There were 36 people living at the service when we visited; including 14 men were living in Bretby View.

There had not been a registered manager in post for over one year. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a recently appointed manager who was in the process of completing their registration with us.

We found that risk was not managed sufficiently to ensure that people were kept safe. This was an issue at our three previous inspections. Medicines were not always managed and administered to ensure that people had them as prescribed. Systems had been introduced to protect people’s skin from pressure wounds but these were not always followed or clearly documented. When people were losing weight the provider did not always respond adequately to maintain the person’s wellbeing. Records which were in place to support the care people received so that staff understood what they needed to do were not always up to date or clear.

Staff had an understanding of how to recognise and report any suspected abuse. Concerns were investigated in partnership with safeguarding authorities when needed. However, the provider did not always learn from when things went wrong to ensure that action was taken to avoid it happening again.

At the previous inspection we found that the provider ensured that there were enough staff deployed but because a lot of them were from an agency they did not always know people well enough to meet their needs. At this inspection we found that care staff were more consistent and this had helped to establish caring relationships and an understanding of how to support people when they were distressed. However, there were still difficulties in recruiting and retaining nurses and this impacted on the communication with partner organisations to ensure that people’s healthcare needs were met. It also meant that at times there was not sufficient oversight of daily records to ensure that action was taken to keep people safe and well.

Quality improvement systems had been embedded and audits were regularly completed. However, they did not always lead to action being taken to improve the quality of the service. At the previous three inspections we found that the Mental Capacity Act 2005 (MCA) was not fully embedded and we found that this was still the case at this inspection. Capacity assessments did not include people who were legal representatives in decision making. They had also not completed capacity assessments for some important decisions. Some people had safeguards in place which staff did not understand or comply with.

People did not always have enough stimulation and engagement in activities. Their dignity was not always upheld and respected.

Complaints were responded to in a timely and open fashion in line with the provider’s procedure. There was a record of the outcome and the provider ensured that people were happy with it.

Staff had positive relationships with people. Families were welcomed to visit and felt that there was more effort from the provider to hear their feedback through meetings and surveys.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

The overall rating for this service is ‘Requires improvement’ and the service remains in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures 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.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

After the last inspection on 24 January 2017 we put positive conditions on the provider’s registration with us. This meant that they were required to report to us what improvements they had made every two weeks. The provider complied with this requirement and at this inspection we saw that some improvements had been made as the provider had reported. However, they had not completed all of the actions that were detailed in their improvement plan and this impacted on the safety and wellbeing of people who lived at the home. Therefore, we will retain the positive conditions on the provider’s registration until we are satisfied that significant improvements have been completed.

The home did not have a registered manager in place; however, they did have a manager who was in the process of applying for their 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.

We found that risk was not managed sufficiently to ensure that people were kept safe. This was an issue at the two previous inspections. People were not always supported to move safely and the plans in place to protect people’s skin were not always followed to be effective. In the provider’s action plan they had addressed staff understanding of managing behaviour which could be challenging. They had also reviewed risk around peoples eating and drinking. However, the improvements did not address all risk management.

At the previous inspection we found that the provider ensured that there were enough staff deployed but because a lot of them were from an agency they did not always know people well enough to meet their needs. Although this had improved because there were more permanent staff it was still a concern around the leadership team and for nurses. It meant that there was not always sufficient senior staff to support staff or the manager. It also meant that improvements were not progressed quickly because they were all dependent on the manager completing them. Quality improvement systems were not fully embedded and actions from audits were not all completed.

At the previous two inspections we found that the Mental Capacity Act 2005 (MCA) was not fully embedded and we found that this was still the case at this inspection. Capacity assessments were out of date and some DoLS had also expired without the provider re-applying for them. Best interest decisions were not always completed when required.

Similarly, care plans were not always up to date or regularly reviewed for people to ensure that staff had relevant information to assist them to support people. This had been an issue at the previous two inspections. The manager had devised a new care plan and those that had been reviewed were detailed. However, the progress in completing this was slow and over half of the people at the home still did not have an up to date plan.

We found that the provider did not always respond to complaints in a timely and open fashion in line with their procedure.

Some improvements were evident at this inspection. Staff now had an understanding of how to recognise and report safeguarding concerns. The provider had reviewed systems in line with safeguarding recommendations. Medicines were administered at the correct time to ensure that people received them as required. Records were maintained and management systems had been introduced.

Staff had positive relationships with people and respected their privacy and dignity. People were encouraged to participate in activities and important relationships with friends and relatives were encouraged. People and their relatives were communicated with so that their feedback could contribute to the development of the service.

Staff supported people to see healthcare professionals regularly to maintain good health. Mealtimes were well planned to ensure that people received the support they needed, including specialist diets.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Services in special measures 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. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The service had did not 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 provider had recently employed a new manager. They had been in a temporary clinical lead role for three months and had been moved to the permanent managers post for less than one week when we undertook the inspection.

At our last inspection we saw that the systems in place to monitor and improve the quality of the care provided to people were not effective. We asked the provider to set an action plan to make improvements across the home so that people received support which protected them from harm. They returned the plan in the specified time but it was not detailed enough and we received an amended plan on request afterwards. At this inspection we saw that the provider had not made significant improvement in meeting the actions on the plan and that the systems in place to manage the service were not effective. The provider had also not notified us of all of the events that they should to meet their registration.

Risks to people's health and wellbeing were not managed to keep them safe from harm. When people behaved in a way that could cause them or others harm this risk was not always assessed. Clear guidance was not in place for staff to help people to manage this behaviour. When other risks were assessed the actions to reduce these were not always followed. People did not always receive their medicines as prescribed and the systems in place to manage the risks associated with them were not always followed.

When harm had occurred to people the circumstances around the incidents were not always thoroughly investigated or reported to the local authority to safeguard people from potential abuse. Staff did not always have the skills and experience to support people effectively to protect them from harm. They did not all receive the training and support they needed to do this. This meant that at times people were not treated with dignity and respect.

Some people had legally approved restrictions to protect them when they didn't have the capacity to make their own decisions. Some decisions had not been reviewed to ensure they were made in people’s best interests. Some staff were not aware of these safeguards or what the restrictions were and therefore may not support them as defined.

Care was not always provided to meet people's preferences. Staff were not always aware of people's changing needs and records were not always amended to reflect the changes and ensure that the care was correct. Staff did not always have the experience and knowledge to support people effectively. People were not always supported to have enough to eat and drink and food was not always prepared to meet individual people’s needs. They did not always have their healthcare needs met. There were not always communication systems in place to enable people to make choices. People’s dignity was not always respected and they were sometimes supported in a manner which was not caring.

People were provided with meaningful activities and these were provided on an individual level as well as bigger events.

The provider had a complaints procedure in place and relatives told us that they knew how to complain. We saw that complaints were investigated in line with the procedure.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The home had a registered manager in place. 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.

Medicines and the risks associated with them were not effectively managed to keep people free from harm. When some people were given covert medicines a capacity assessment had not been completed and there was no record how this decision had been made in the person’s best interest. Some medicines were not securely stored and the stock of some medicine did not match the records. There were not always clear instructions to staff how to administer medicines and some recording lacked detail.

Other risks had not been effectively assessed, monitored or actioned to reduce them. We saw that there were hazards in the environment which could cause people harm. Some of the care that we observed was not in line with the recommended support agreed and put people at risk of harm.

The quality assurance processes in place were not always effective because they did not highlight the risks that we observed. We saw that audits were infrequent and that an action plan had not been put in place to check that improvements had been made. Also, when relatives of the people who used the service completed surveys and suggested where improvements could be considered this did not lead to action.

We saw that there was an inconsistent approach to assessment of a person’s capacity to consent to care. Some assessments were in place, but other important decisions were not supported by a capacity assessment or a best interest decision. The principles of the Deprivation of Liberty Safeguards had been applied within the home to protect people’s human rights.

We saw that there were enough staff to meet people’s needs safely. However, they were allocated to different communal areas during the day and this meant that it was difficult to respond to people on a personal level or spend time supporting people to pursue their interests or activities. Some of the environment did not have signs or decoration to support people living with dementia.

When staff did interact with people it was in a caring, considerate way. They were skilled and had received training and line management support to assist them to be effective in their job. We saw that people had their privacy and dignity respected. They were aware of how to protect people from abuse and knew how to report any concerns. Recruitment procedures had been followed to ensure that staff were safe to work with people.

People were supported to maintain a balanced diet and care was given to ensure that meals were prepared to meet people’s assessed need. People were monitored and referrals were made to relevant healthcare professionals when needed to ensure they maintained good health.

People knew who the registered manager was and stated that they were readily available and supportive. Staff told us that they were supported through regular supervision and appraisal. Systems were in place to receive feedback on people’s experiences.

We spoke with two relatives and asked them about their view of the care received. They told us 'Staff are very friendly here and always have a word and a smile when I come to visit. I can't fault what I have seen here, attentive staff ready to assist and spend time talking with X.' Both relatives told us they were kept informed about any changes.

The service provided people with a choice of suitable and nutritious food and drink. However, it was not always evident that staff were offering everyone a choice. People's dining experience depended on where they ate their meals, as we observed the lunch time to be disorganised in some area, and lacking in support for people who needed prompting to eat.

Systems were in place to ensure that people received their medication as prescribed.

Systems were in place to ensure that appropriate checks were undertaken before staff began work.

Both relatives told us they were very happy with the care and support provided. We saw staff were attentive to people's needs. We watched staff sit and speak with people in the lounge areas, and engage them in activities. We saw staff assist people to maintain a well groomed appearance. People were assisted to wear tabards to protect their clothes when eating. Staff politely and discreetly asked people if they could wipe their hands and face once they had finished their meal or drink.

We saw registered nurses had sought advice and guidance from health care professionals when people had or were at risk of losing weight. Care plans had been updated to reflect the guidance provided. People were provided with calorie dense meals, snacks and food supplements as required. Systems were in place to ensure care records were up to date and accurate.

We saw that although improvements had been made regarding medication, people were not always receiving their medication as prescribed. Any shortfall in registered nurses' practice had been identified and was being dealt with appropriately.

We saw that staff training was up to date, and sufficient numbers of registered nursing staff hours were being provided.

We saw that people and their relatives had been asked their views about the service through quality assurance questionnaires. We saw the information provided had been analysed and collated into a report. Areas for improvement were identified and proposed action included in the report.

We saw that a number of audits had been introduced. Medication records were checked to ensure that medication was written up correctly and given as prescribed. We saw an improvement over recent months, although a further check of medication in boxes was being introduced to make sure all medication was given as prescribed.

We saw care plans were audited on a regular basis. The audits identified areas within the care records that needed to be actioned. We saw a section for input from people who used the service and their relatives was included in the care plan audit.

We looked at the duty rota which showed the registered manager had protected supernumerary time, and she was not used as the second nurse on duty. We saw systems were in place to record when requests were made to agencies to cover shifts, but not when agencies could not cover shifts.