The West Gate

The Westgate is a residential care home providing personal and nursing care to 47 people at the time of the inspection. The service can support up to 50 people.

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

People and their loved ones told us they felt safe at the service and had peace of mind. We identified some shortfalls relating to the amount of information in people’s risk assessments, and one missing tablet in one person’s medicines. However, there was no impact to people of these shortfalls and the management team had already identified these as areas which required improvement. Actions plans were in place and additional training had been arranged. One recently recruited staff member had information missing from their recruitment file, this was resolved during the inspection.

People were supported by staff who were kind and compassionate to both them and their loved ones. Staff took time to get to know people well and used this knowledge to reassure them when they were distressed or confused. People’s loved ones could visit at any time and could take part in activities which were taking place. Dedicated activities staff ensured everyone had things to do, including those who stayed in their room by choice or due to their health.

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 were encouraged and supported to have a voice in planning their care and letting staff know what was important to them. People were supported to have food and drink they enjoyed and to stay healthy with the support of staff and health professionals. People had planned their end of life care.

People, relatives and staff told us their views were requested and valued by the management team. Actions were taken to address any concerns raised or to respond to complaints. Learning from this and accidents and incidents was shared. There was a focus on continual improvement at the service, which had led to an increase in nursing and staffing levels and improvements to the environment. The environment was designed to meet the needs of people living with dementia and information was available in a range of formats.

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 21 February 2019).

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.

The West Gate 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.

There were 43 people living at the service when we inspected. Many people needed support with personal care, eating, drinking safely and with mobility.

We last inspected this service in October 2017. Breaches of regulations were found. We issued requirement notices in relation to safe care and treatment, medicines management and shortfalls in keeping accurate and up to date records. We asked the provider to take action. The registered manager sent us an action plan telling us what action they would take to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements.

At this inspection, there had been improvements but more are needed.

People's care plans stated their fluid intake needed to be monitored. Staff did not effectively record the amount people drank. Some staff were recording the amounts and others were not. There was no oversight or accurate record of the amount that people drank to make sure they remained hydrated.

A risk assessment for catheter care was not completed or had not been fully captured or completed on the system. People could be at risk of not receiving care and support appropriate to their needs.

Audits and checks had not been fully effective in identifying and remedying shortfalls.

There was a registered manager in post at the time of the inspection. They had been at the service since April 2018. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. The manager was supported by a clinical lead, and team of clinical nursing staff and care staff. The manager told us there was still issues with the electronic system they were using which collated all the information about the care and support that people needed.

Before people decided to move into the service their support needs were assessed by the manager or clinical lead.

Improvements had been made to make sure people received their medicines safely and when they needed them. PRN (‘as and when’) medicines that were given covertly had the necessary risk assessments and accurate records of when creams and ointments were applied displayed on body maps.

The management and staff knew how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests Deprivation of Liberty Safeguards (DoLS) had been applied for by the manager when it was necessary.

People were supported to have a nutritious diet. Their nutritional needs were monitored and appropriate referrals were made to specialist teams such as dieticians when it was necessary.

Staff were familiar with people's life stories and were very knowledgeable about people's likes, dislikes, preferences and care needs.

We saw many positive interactions and people enjoyed talking to the staff. Throughout the inspection people were treated with dignity and kindness. People's privacy was respected and they were able to make choices about their day to day lives. When people became anxious staff took time to sit and talk with them until they became settled.

Accidents and incidents were reported and responded to.

Staff knew how to keep people safe from abuse and neglect. The registered manager referred incidents to the local safeguarding authority.

The safety of the premises was assured by regular checks on utilities and equipment. Fire safety had been addressed through training, fire drills and alarm testing. Maintenance had been carried out promptly when repairs were needed.

Staff encouraged people to eat their meals and gave assistance to those that required it.

There were enough staff on duty that had received relevant training and supervision to help them carry out their roles effectively. Staff were observed putting their training into practice in a safe way.

Staff were recruited safely.

A range of professionals were involved in people's health care.

Care plans were person-centred; they reflected people's individual preferences and gave staff an understanding of the person.

A range of activities were on offer with specific sessions and groups designed for people the service supported. Staff encouraged people to be involved and feel included in their environment.

Complaints had been documented and recorded. People and relatives said they knew how to complain if necessary and that the registered manager was approachable.

People's confidentiality was respected and their records were stored securely.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. CQC check that appropriate action had been taken. The manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service where a rating has been given. This is so that people, visitors and those seeking information about the service can be informed of our judgments. We found the provider had conspicuously displayed their rating at the service and on their website.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 39 people living at the service when we inspected.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff.

We last inspected this service in October 2016. Breaches of regulations were found. We issued requirement notices in relation to safe care and treatment, medicines management and shortfalls in keeping accurate and up to date records. We asked the provider to take action. The registered manager sent us an action plan telling us what action they would take to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found improvements had been made but there were continued breaches of the regulations.

Since the last inspection the registered manager had left the service. There was no registered manager working at the service at the time of this visit. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 and associated Regulations about how the service is run. There was a manager in post who had applied to register with the CQC and was awaiting their fit person’s interview. The manager was supported by a nurse manager, and team of clinical nursing staff and care staff.

The manager told us there was still issues with the electronic computerised system they were using which collated all the information about the care and support that people needed. Information about people had been transferred to the electronic system including care plans and risk assessments. However the system was not formulating all the information needed to make sure there was an accurate account and guidance of the care and support people needed. The manager and other staff had highlighted their concerns to the provider about the electronic system and they were working together to improve its efficiency. In the meantime some records were not accurate.

Risks had been identified and assessed for people's health and welfare but full guidance to make sure all staff knew what action to take to keep people safe and manage risks was not always available. Staff knew people well and were able to explain what action they would take to make sure risks to people were mitigated. However, when new staff were working or when agency staff were covering there was a risk of people not receiving the interventions they needed to keep them as safe as possible.

Before people decided to move into the service their support needs were assessed by the manager or nurse manager to make sure they would be able to offer them the care that they needed. The care and support needs of each person were different and each person’s care plan was personal to them. The care plans were written to inform staff about how people preferred to be supported and cared for.

Improvements had been made to make sure people received their medicines safely and when they needed them, however there were areas that needed further improvement. These areas included ‘as and when’ medicines that were given covertly and keeping accurate records of when creams and ointments were applied.

Staff understood how to keep people safe and protect them from the risk of abuse. They were aware of how to recognise and report safeguarding concerns both within the service and to outside agencies such as the local authority safeguarding team. Staff were confident to whistle-blow to the manager if they had any concerns, and

were confident that appropriate action would then be taken.

The management and staff knew how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests Deprivation of Liberty Safeguards (DoLS) had been applied for by the manager when it was necessary.

People were supported to have a nutritious diet. Their nutritional needs were monitored and appropriate referrals were made to specialist teams such as dieticians when it was necessary. The staff were effective in monitoring people's health needs and sought professional advice when it was required. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

Staff were familiar with people's life stories and were very knowledgeable about people's likes, dislikes, preferences and care needs. They approached people using a calm, friendly manner which people responded to positively. Staff understood people's specific needs and had good relationships with them. Most of the time people were settled, happy and contented. Throughout the inspection people were treated with dignity and kindness. People's privacy was respected and they were able to make choices about their day to day lives. When people became anxious staff took time to sit and talk with them until they became settled. People were encouraged and supported to join in with activities.

People's confidentiality was respected and their records were stored securely.

The complaints procedure was available and accessible. People, relatives and staff knew how to complain and the majority felt confident their complaints would be listened to and acted on. People had opportunities to provide feedback about the service provided both informally and formally.

There were enough staff to meet people's needs and staff had received appropriate training and support to help them carry out their roles effectively. Recruitment processes had been followed to ensure staff were suitable for their role. All staff had received regular one to one meetings with a senior member of the staff team. The registered nurses practises were monitored and they also received clinical supervision from the management team.

Staff had completed induction training when they started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people’s needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people’s care and lives.

There were regular health and safety checks of the environment to make sure everything was in good working order. Emergency plans were in place so if an emergency happened, like a fire, the staff knew what to do. There were regular fire drills at the service so that people knew how to leave the building safely. People's personal evacuation emergency plans (PEEPS) had been reviewed and updated to explain what individual support people needed to leave the building safely.

People, relatives, visiting professionals and staff felt the management of the service had greatly improved. They said the manager and management team were approachable and supportive and that they listened and took action when they needed to. The manager had full oversight and scrutiny of the service. They knew what was going well and the areas that needed improvement. The manager had sought feedback from people, staff and others involved with the service. Their opinions had been captured, and analysed to promote and drive improvements within the service. Informal feedback from people, their relatives and healthcare professionals was encouraged and acted on whenever possible.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. CQC check that appropriate action had been taken. The manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service where a rating has been given. This is so that people, visitors and those seeking information about the service can be informed of our judgments. We found the provider had conspicuously displayed their rating at the service and on their website.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There is a lift to the first and second floors. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 34 people living at the service when we inspected.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff.

We last inspected this service in April 2016. We found significant shortfalls and the service was rated inadequate and placed into special measures. The provider had not ensured that care and treatment was being provided in a safe way. People were not receiving appropriate care and treatment to meet their health care needs. Staff had not ensured the proper and safe management of medicines. Care plans lacked detail and at times were contradictory. Care plans were not consistently updated when people's needs changed. People's assessed needs were not always regularly reviewed and properly assessed before they moved into the service. Staff were not suitably competent and skilled to manage risks to people safely. People were not protected from abuse, harm and improper treatment. Staff had not received appropriate support, training, professional development and supervision, as was necessary to enable them to carry out the duties they were employed to perform. The provider had not ensured that the systems and processes that were in operation to assess, monitor and improve the quality and safety of the service were consistently applied. The provider failed to maintain accurate and complete records in respect of each person.

We took enforcement action and required the provider to make improvements. This service had been placed in special measures. 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. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that improvements had been made in many areas. There were still areas were improvements were required.

The service had a newly appointed registered manager who was available on the days of the inspection. 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 registered manager was supported by a clinical lead whom had recently been appointed.

The provider had recently installed a new computer system where all people’s information was being transferred to. Staff said that the system would be effective when it was ‘up and running’ properly but they were having a few initial problems with how the information was stored and generated. They were sorting these out but at the time of the inspection some records on the system were inaccurate and not consistent. The registered manager said that progress was slower than they hoped because of these initial ‘teething’ problems.

People’s records relating to the care and support they needed were not always accurate or completed. The registered manager and staff team were aware of this and were working to make sure all records were updated and in place. This was a work in progress.

Risks to people had been identified and recorded but guidance was not always in place to make sure risks were kept to a minimum. Staff knew people well and were able to explain what action they would take to make sure risks to people were mitigated. Regular environmental safety checks were completed to make sure ‘The Hockeredge’ was a safe place to live and work.

Each person had a care plan that was designed to inform staff about how people preferred to be supported and cared for, but there were some issues with the new electronic system. Some information in the care plans was not accurately recorded and was contradictory. The registered manager and staff were aware of this and said that the new computer system was generating inaccurate information. Despite the reduced effectiveness of the care plan, staff were able to tell us how they cared for and supported people consistently. People, their relatives and specialists who visited the service confirmed that people were getting the care and support that they needed.

Improvements had been made in managing people’s medicines and errors had been significantly reduced. However there were still shortfalls in how some medicines were recorded.

People were protected from the risk of abuse. Staff had received safeguarding training. They were aware of how to recognise and report safeguarding concerns. There was one occasion when an incident that was a safeguarding issue had not been reported to the local authority safeguarding team. The registered manager said that this was an oversight on their behalf and had they reported all other incidents. All other safeguarding concerns had been reported. Staff knew about whistle blowing and were confident they could raise any concerns with the registered manager, provider or outside agencies if needed.

People were supported effectively with their health care needs. Staff had taken the necessary action when people's health deteriorated. People were getting the care, support and treatment they needed when they needed it. Staff recognised signs and symptoms of ill health and doctors and other professionals were contacted. Staff acted appropriately and in a timely way to make sure people were safe and getting the care and treatment that they needed.

People were offered a choice of food and drink which they enjoyed. The food looked appetising. Staff encouraged and supported people to eat a healthy and nutritious diet.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. People had DoLS in place and staff had up to date knowledge on the Mental Capacity Act 2005 (MCA) and DoLS. They supported people to make their own choices when possible and best interest meetings had been held

Staff encouraged people to be involved and feel included in the day to day routines of the service. People were offered varied activities and participated in social activities of their choice. Staff knew people and their support needs well. Staff were discreet and sensitive when supporting people with their personal care needs. Staff were caring, kind and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff.

There were enough staff to meet people's needs and they had received appropriate training and supervision to help them carry out their roles effectively. Recruitment processes had been followed to ensure staff were suitable for their role. All staff had received regular one to one meetings with a senior member of the staff team. The registered nurses practises were monitored and they also received clinical supervision from an external clinical professional.

Staff had completed induction training when they started to work at the service. Staff were supported during their induction, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people’s needs. There were staff meetings, so staff could discuss any issues and share new ideas with their colleagues, to improve people’s care and lives.

The provider had a complaints policy and process. Complaints were managed effectively and responded to appropriately, in a timely manner and in line with the policy. People and their relatives told us they would speak with the registered manager or staff if they had a concern and they would be listened to.

The registered manager had taken appropriate steps to ensure they had oversight and scrutiny to monitor and support the service. The registered manager led the staff team and promoted a positive culture which was transparent, inclusive and open. The registered manager had vision and ideas to improve the service, which had a positive impact on people, staff and the quality of service provided. Staff were clear about their roles and were positive about the registered manager. Staff were proud of the improvements that had been achieved. Audits and checks were in place and had been effective in identifying shortfalls or areas for improvement. The registered manager had sought formal and informal feedback from people, relatives, staff and other stakeholders. The analysis of this feedback was used to improve the service.

As this service is no longer rated as inadequate, it will be taken out of special measures. Although we acknowledge that this is an improving service, there are still areas which need to be addressed to ensure people's health, safety and well-being is protected. We identified a number of continued breaches of Regulations. We will continue to monitor The Hockeredge to check that improvements continue and are sustained.

The service provides accommodation with nursing and personal care for up to 50 people, some of whom may be living with mental health and dementia related conditions. Bedrooms are on the ground and first floor and are all single occupancy. There is a lift to the first and second floors. There are communal lounges, a dining room and activity areas on the ground floor. There is a garden to the rear of the property. There were 42 people living at the service when we inspected.

We last inspected this service in July 2015. At this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. We issued two warning notices in relation to good governance and safe care and treatment. We issued requirement notices relating to person centred care, staffing, safeguarding service users from improper care and treatment and the need for consent. We asked the provider to take action and the provider sent us an action plan.

The provider had not completed all the actions they told us they would make. In particular, they had not met the requirements of the warning notices we issued following our last inspection. As a result, they were continuing to breach regulations relating to fundamental standards of care.

There was no registered manager when we visited as required by regulations. The last registered manager left the position in March 2014. 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 an acting manager in post who was in the process of applying to become the registered manager. The acting manager was supported by two clinical managers who were registered nurses.

People had suffered avoidable harm and pain. The nursing staff had not acted appropriately or in a timely way to make sure people were safe and getting the care and treatment that they needed. Nursing staff had not taken appropriate action when people’s health deteriorated.

People were at risk of neglect and were at risk of receiving improper treatment. Risks to people were not being well managed and reduced. People’s weight loss, pressure areas, diabetes and catheter care were not managed consistently. Medicines were not always available for people when they needed them.

People were not supported effectively with their health care needs. There had been delays in accessing health care specialists when they were needed. When people needed to see a doctor because their health was deteriorating the staff did not always recognise signs and symptoms of ill health and doctors or other professionals were not always contacted.

Recruitment processes were in place to check that staff were of good character. Information had been requested about staff’s employment history, including gaps in employment. There were enough staff on duty to meet people’s needs. Staff had not received all the training they needed to meet the needs of people. Staff did not receive the supervision and support they needed to carry out their roles effectively.

The provider had a complaints policy and process. Complaints were not always managed effectively to make sure they were responded to appropriately, in a timely manner and in line with the policy. People and their relatives told us they would speak with the acting manager or staff if they had a concern and they would be listened to.

The provider had not taken appropriate steps to ensure they had oversight and scrutiny to monitor and support the service. There was a lack of continuity in the management of the service, which had impacted on people, staff and the quality of service provided.

Care staff were clear about their role and responsibilities but the clinical management by the registered nurses was not effective. The clinical competency and accountability of nurses was not assessed and monitored and registered nurses had not consistently completed the tasks they were accountable for.

A range of policies and procedures were available to guide staff on carrying out their roles safely and effectively. Staff knew where to access the information they needed; however, these policies were not consistently followed. People were at risk because systems for monitoring the quality of care provided were not effective. Records were not suitably detailed, or accurately maintained.

People could not be sure that when they were at the end of their life they would receive the care and support that they needed. People’s care and nursing needs were not always met. People’s care had not been planned or updated when there were changes in their needs.

The acting manager and some of the staff understood the requirements of the Deprivation of Liberty Safeguards. There were procedures in place in relation to the Mental Capacity Act 2005.

People were offered a choice of food and drink which they enjoyed. The food looked appetising. Staff encouraged and supported people to eat a healthy and nutritious diet. People were treated with dignity and respect. Staff were discreet and sensitive when supporting people with their personal care needs and protected their dignity.

People had some opportunities to take part in activities. Relatives told us they were able to visit when they wanted to and there were no restrictions.

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

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

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 Hockeredge but has not yet deregistered with CQC. The provider has put an acting manager in place who is in the process of applying to be registered.

We looked at people's plans of care, staffing records and quality assurance processes. We set out to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

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

Is the service safe?

People were treated with respect and dignity by the staff who focused on positive risk assessment to support people to maintain their independence. For example, risk assessments were focused on what people could do and managing risks as far as was possible, rather than focusing on limiting peoples abilities because of the level of risk. People told us they felt safe and we observed that staff demonstrated that they understood how to protect people's rights and safeguard the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people who used the service and helped the service to continually improve.

We found that the service was safe, clean and hygienic. Equipment was well maintained and the service was going through a renovation programme to ensure that the environment continued to meet people's needs safely.

People's care needs and the qualifications, skills and experience of the staff were taken into account when making decisions about staffing numbers required to the meet the needs of people who used the service.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People who used the service and their relatives said that they had been involved in the planning of their care and that the care plans reflected their current needs.

People's needs were taken into account with signage and the layout of the service, enabling people to move around freely and safely. The premises were undergoing renovations and were in the process of being adapted to continue to meet the needs of the people using the service.

Is the service caring?

People were supported by kind and attentive staff. We used the Short Observational Framework for Inspection (SOFI 2). SOFI 2 is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed that care workers showed patience and gave encouragement when supporting people. People commented, that staff were courteous One person told us 'On the whole it is very nice here. The atmosphere is friendly and one of acceptance. The staff are very good.'

We found that people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People regularly completed a range of activities of their choice both in and outside of the service. We found that surveys were regularly sent to people who used the service, relatives and professionals. We saw that the feedback the service received was acted upon.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home. This helped to ensure that the quality of service was maintained.

We saw a lunch service and were shown the Food Safety and Nutrition leaflets which included the corporate policy, sample menus, training schedules and a 'must tool'. This tool showed the five step screening plan to enable identification of malnutrition concerns. It was used as an audit tool as well as part of the daily care planning process.We looked at staff planning and support with a training framework. We also talked through the complaints process looking at the policy, the complaints folder and reached an understanding of the process.

People told us that they felt safe and well looked after. People looked relaxed, comfortable and at ease with each other and staff. One staff member told us, "I have been given the skills and experience to keep people safe."

We observed that staff were respectful and caring to people who used the service and spent time talking to them. People were encouraged to make choices for themselves including what and where they ate their meals.

The service had participated in a recent dementia care improvement project and had changed the ways in which they worked in accordance with published research and guidance.

Staff we spoke with were committed to working in a person centred way and had knowledge and understanding of people's needs and knew their routines and how they liked to be supported.