• Care Home
  • Care home

Mr 'C's

Overall: Good read more about inspection ratings

4-6 Matlock Terrace, St Lukes Road, Torquay, Devon, TQ2 5NY (01803) 292530

Provided and run by:
Woodland Healthcare Limited

All Inspections

25 May 2022

During an inspection looking at part of the service

About the service

Mr C’s is a residential care home providing personal care to up to maximum of 40 people. At the time of our inspection there were 26 people using the service.

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

People and their relatives told us they felt safe living at Mr ‘C’s and spoke positively about the management and the caring culture of the staff.

People were protected from the risk of abuse as staff knew the correct procedures to follow to keep people safe.

The service had infection control processes in place to reduce the risk of people contracting COVID-19. However, during the inspection we observed some staff not wearing their face mask correctly. This was immediately addressed by the manager.

Care records were person-centred and risk assessments provided written guidance for staff on how to minimise or prevent the risk of harm. Systems were in place to manage risks associated with the building and equipment. During the inspection we found missing fixtures and fittings that posed a risk to people’s safety. This was immediately rectified.

People were receiving their medicines safely and improvements had been made to medicine’s management and administration to ensure people received their medicines as prescribed for them.

People and their relatives told us there were enough staff to meet their needs. Staff were recruited safely, and recruitment checks had been completed before staff started work at the service.

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 had been asked for their opinions on the quality of the service. Staff had opportunities to discuss the service and voice their opinions. However, some staff told us they did not have formal one-to-one meetings or supervisions to discuss their performance or training needs. We made a recommendation to the provider about this.

Systems and processes were in place to monitor the service and make improvements. The providers checks and audits were effective in identifying shortfalls and action had been taken to rectify these. This ensured good governance of the service and resulted in the service improving since the last inspection.

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 13 April 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. During this inspection we also checked the service had followed their action plan and to confirm they now met legal requirements.

This report only covers our findings in relation to the Safe and Well-led key questions, which contain those requirements.

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

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mr’C’s on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

27 November 2020

During an inspection looking at part of the service

About the service

Mr ‘C’s is a residential care home providing personal care to 27 people aged 65 and over at the time of the inspection. The service can support up to 40 people. Mr ‘C’s accommodates people across four floors.

Mr ‘C’s no longer provides nursing care. Any nursing needs are met by the community nursing team. The provider and registered manager aim to remove the permission to carry out nursing tasks from their registration.

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

People told us they continued to receive care that was effective, caring and responsive to their needs. Staff were kind and considerate and people spoke fondly of them.

We found the management of people’s medicine needed further improvement. The new manager and provider had identified there were issues and were in process of addressing these, however, this meant on inspection we still found concerns.

There were enough staff to meet people’s needs. We have made a recommendation in respect of recruitment to ensure the provider follows the latest safer recruitment practice.

The service had not experienced an outbreak of Covid 19 and we were assured that the service was following the latest infection control guidance. We have recommended the provider reviews the area where staff change to maximise the ability to prevent cross contamination.

Systems of governance were not always effective. Quality monitoring systems had not highlighted or addressed shortfalls in the management of people’s medicines. Despite our findings, people and family were positive about how the service was being managed. They felt they were kept up to date and informed and could approach staff at any time to raise concerns or ask questions.

People were protected from risk and had their health needs identified and supported.

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 Good (report published 7 March 2019), however, the safe section of the report was rated Requires Improvement. There were no breaches of regulations.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mr ‘C’s on our website at www.cqc.org.uk.

Why we inspected

We received concerns in relation to staffing, people’s skin care and staff not responding to people’s care needs in a timely manner. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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

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 have found the concerns were not substantiated however, a breach was found in respect how people’s medicines were managed. Please see the safe and well-led sections of this report. Please see the action we have told the provider to take at the end of this report.

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 local authority medicine optimisation team have visited the service and are giving support to ensure medicine management is addressed.

7 January 2019

During a routine inspection

Mr ‘C’s is a ‘care home’, operated by Woodland Healthcare Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Mr ‘C’s is currently registered to provide accommodation for people requiring both nursing and personal care. However, during 2018 the service began making changes and has ceased providing nursing care for a trial period. People who needed nursing care left the service and so the service no longer had registered nurses working at the service at the time of the inspection. Any nursing needs people may develop were met by the community nursing teams. At the time of the inspection 28 people were living at the service, some on a permanent basis, others were there for short stay respite care, or intermediate care between a period of hospital care and returning home.,

People living at Mr ‘C’s were mainly older people, most living with physical health conditions associated with older age, or mental ill health. Some people had limited care needs but were awaiting changes to their accommodation or needing support during the ill health of their carer. The service accommodates up to 40 people in one adapted building, set over four floors, but we were told they were not intending to take over 29 people at the present time.

At the last inspection in August 2017, Mr ‘C’s was rated as requires improvement overall and in the key questions of safe and well led. Key questions for effective, caring and responsive were rated as good.

On this inspection we have rated the service as good overall, but with requires improvement in the key question of safe. This was because we identified some areas of concern about the medicines systems in use and the management of urinary catheters. Between the inspection visits the service changed the way they managed medicines. We have recommended they arrange for an early audit of the new systems to ensure they meet safe standards and good practice. We also saw the service had taken immediate action in the meantime to reduce risks.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Since the last inspection the service’s management structure had been strengthened by the appointment of two managers at the service - one looking at the management of the environment and the other looking at people’s care. People living at the service and staff were clear about who was ‘in charge’, and told us they were approachable and supportive.

Systems were being operated to assess, monitor and improve the quality and safety of the services provided, and mitigate the risks to people from their care or the environment. Assessments including those provided through the trusted assessor scheme or intermediate care professionals identified risks to people and how they could be reduced. For example, from skin damage, long term health conditions or choking. Staff were aware of the principles of safeguarding people from abuse and how to report concerns about people’s well-being.

Mr ‘C’s was continuing to develop the services and care provided. Some people stayed at the service for only 24 hours, while others were there for longer periods of intermediate care following a hospital admission. Advice on good practice was sought and visiting professionals including those from the intermediate care team told us the service communicated with them well, and followed their advice to support people’s needs. We heard examples of where people had improved and returned home following a supported stay at the service.

People were supported by sufficient numbers of staff on duty to meet their needs. A full recruitment process was in place which ensured staff were recruited safely. This included the taking up of disclosure and barring service (police) checks, previous employment references, and assessments of risk where some information was not available.

People were supported by staff whose training needs were assessed both individually and as a group. Where there were shortfalls in learning or skills due to staff changes, action plans were in place to ensure learning needs were met.

People’s rights with regard to the Mental Capacity Act 2005 and under equality legislation were respected. Staff had received training in the Mental Capacity Act 2005 and applications had been made under the Deprivation of Liberty Safeguards (DoLS) where appropriate to deprive people of their liberty, although none had yet been authorised due to delays at the local authority.

Systems were in place for the management of complaints, including seeking external reviews of improvements needed, and people’s views on the service were sought through a series of questionnaires. We have made a recommendation about improving the quality of the questionnaires in use and providing additional information on the complaints form. Mr ‘C’s management team learned from incidents and accidents, which were analysed and audited to see if a repetition could be avoided; actions were taken where identified.

Activities were provided each day. Visitors were welcome to visit at any time and have a continuing involvement in their relations care if they wished.

3 August 2017

During a routine inspection

Mr C’s is a nursing home in the centre of Torquay. It is registered to provide accommodation and personal care for up to 40 people, who may be older or have nursing needs. On the first day of inspection there were 23 people living at the service and on the second day there were 22 people living there. The provider has made a decision not to admit people who are living with high dementia care needs. The statement of purpose for the service indicates that while people living with dementia can be accommodated they will only be admitted where their physical needs are predominant. There is a registered nurse on duty at the service each day from 8am to 8pm. From 8pm to 8am one registered nurse covers three services in the area which are also owned by the provider.

There was a registered manager employed at the service. 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 was last inspected in November 2016 when it was rated overall as Inadequate. This was because we found improvements were needed in all the key questions. Improvements were needed to the way the quality of the service provided was monitored, the maintenance of the environment, staffing levels, risk assessments and staff recruitment. Improvements were also needed to ensure people received person-centred care and were treated with dignity. As the service was rated as Inadequate at the inspection in November 2016 it was 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. During this inspection in August 2017 the service demonstrated to us that improvements had 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. The overall rating for the service is now ‘Requires improvement’.

However, the quality assurance systems had failed to identify the issues in relation to the recording of some care provided, the disruptive noise of the call bell panel and the temperature some medicines were stored at.

There were details of some activities available to people on the noticeboard in the hallway. These included crafts, bingo and outside entertainment. Pet therapy also visited the service with animals for people to hold and people told us they enjoyed these visits. An activities organiser was employed by the service, but were on leave during the inspection. The registered manager told us care staff provided activities while the activities organiser was away. There were some activities detailed on people’s daily notes and these included spending time with people in their rooms.

People’s care plans contained details of how their personal care needs were to be met and were reviewed regularly. However, they did not always record the safe care and treatment given. People’s medicines were managed safely. However, the provider could not be assured some medicines were stored at a safe temperature.

People’s needs were met in a safe and timely way, because there were enough staff on duty to ensure this. Since the inspection in November 2016 an extra staff member had been employed to cover the periods of breakfast and supper. This enabled care staff more time to meet people’s needs during these busy times. Previous issues with call bells not being answered quickly had been addressed and there had been no further issues raised with the registered manager or CQC. There was a daily check of the call bells to ensure they were working correctly. However, we heard the noise from the main call bell panel was intrusive and loud and interrupted conversation at meal times.

People lived in a comfortable environment that was suitable for their needs. Since the inspection in November 2016 the provider had made a decision not to admit anyone with dementia as their primary diagnosis. This meant improvements necessary to make the environment suitable for people living with dementia were no longer needed. Issues with not all rooms having hot water had been rectified. Daily checks were made to ensure this remained the case.

People were supported to receive a healthy balanced diet and plenty of fluids. People were complimentary about the food provided and told us "There's plenty of food" and "It’s always tasty and hot." People had good support from medical and other healthcare services. We spoke with two visiting healthcare professionals who both told us they were happy with the care people received.

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. Throughout the inspection we heard staff offering people choices. We heard one staff member ask a person "What would you like to wear today?" People were also asked what they wanted to do and what they wanted to eat or drink. Staff told us that if people could not tell them what they wanted to eat, they would show them the food so the person could indicate their preference.

People received care from staff who were trained and knowledgeable in how to support them. Staff had received training in a range of subjects including medicine administration, first aid and moving and transferring to help meet people’s needs. They had also received training in caring for people with specific health care needs. There was an effective system in place to ensure staff were putting their learning into action and remained competent to do their job. Staff records showed they received regular supervision and yearly appraisals. There were robust recruitment procedures in place to ensure staff who may be unsuitable to work with people needing help with their care were not employed. People were protected from the risk of abuse. Staff had received training in how to recognise and report any suspicions that abuse was occurring.

People and their visitors told us staff were very good and caring and all the interactions we saw between people and staff were positive. One person told us “They are all lovely. Of course I have my favourites, but all are nice really.” Another told us “It’s fantastic here.” One visitor told us the staff were “All kind, all good, very hard working.” Another told us “Everybody is very friendly, they all seem to care for him [relative].” Staff treated people with dignity, respect and kindness. When addressing people staff used people’s preferred names and appropriate language. When staff discussed people’s care needs with us they did so in a respectful and compassionate way. People and their relatives were supported to be involved in planning and reviewing their care.

People and their visitors told us staff were responsive to people’s needs. Comments included "People are always coming in to see how I am,” One relative told us they and the service took care to ensure their relative was well dressed and groomed as this had been something that had been very important to them before they became ill.

People living at the service knew the registered manager well and we saw positive interactions between them. Staff told us they were well supported by the registered manager and spoke highly of them. One staff member told us "I love working here, training and support has been very good." Another told us they liked working at the service because it was “A rewarding job – when you leave you feel you have done something worthwhile.” Staff felt the philosophy of the service was to ensure “All care was given to everyone”.

We have made recommendations in relation to the recording of some care given, the temperature some medicines are stored at and the call bell panel.

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

16 November 2016

During a routine inspection

Mr ‘C’s is a nursing home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. It is registered to provide accommodation and personal care to up to 40 people who may have needs related to dementia. The home also provides nursing care. There is a nurse on duty during the day, and at night one nurse covers three homes owned by this provider.

This inspection took place on 16, 17 and 21 November 2016 and was unannounced. During the first two days of the inspection there were 19 people living at the home and on the third day of the inspection there were 18 people living at the home. The home is spread over five floors with the dining room, kitchen and lounges on the ground floor and people’s bedrooms on the first to fourth floors. People with the highest level of nursing care needs had bedrooms on the first floor, where the nurse’s base was situated. People who were more independent, with residential care needs were furthest away, on the fourth floor. At the time of the inspection, there were eight people requiring nursing care and eleven people requiring residential care living at the service. Twelve people needed the help of two care staff to assist with their mobility. Two people were living with dementia type illnesses.

The service was first inspected in August 2014, when we identified the provider was not meeting the regulations in respect of records. We carried out a ratings inspection in August 2015 when the home was rated as Requires Improvement. The provider was not meeting the regulations in respect of ensuring people received safe care and treatment, staffing levels and record keeping. The provider sent us an action plan that confirmed improvements would be completed by December 2015. At this inspection we found sufficient action had not been taken in relation to the concerns identified at the previous inspection. We also identified new areas of concern.

We have found people were not always receiving a safe, effective, caring, responsive or well-led service.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was responsible for two nursing homes owned by the company and had a quality monitoring function for a third home, one day per week. This meant they only spent two days a week at Mr ‘C’s, sometimes split into half days. The lack of a consistent manager presence had impacted on the safety and quality of care and led to people and their relatives losing confidence in the overall management approach.

The layout of the building presented challenges for staffing. There were not always enough staff on duty at all times to ensure people received the care, support and observation they needed. At night there were two care staff on duty to cover the home. A registered nurse covered Mr ‘C’s and two other nursing homes in the group overnight. They were not always present at Mr ‘C’s. Although the registered manager told us they had assessed staffing levels, the consistency of concerns raised indicated people did not always receive assistance at the times they needed it.

Staffing levels meant staff were not always able to provide care in a way that ensured people’s dignity was protected. For example, on the second day of our inspection when we arrived we found one person downstairs walking by the reception area who was naked from the waist down. There were no care staff on the ground floor at this time.

Complaints about some aspects of care were repeatedly raised by people living at the service and their relatives. These included the varying availability of hot water in parts of the home and call bells not being answered in a timely way. Although the service had a system in place for responding to complaints, we found the service had not investigated these concerns sufficiently to fully understand the issues or put them right. For example, we found the call bell system had not been working reliably since the home opened in May 2014. There was no hot water on the second day of our inspection on one floor of the home. Both these issues were resolved by the registered manager. However, they had not been resolved when people had complained. Some people were unhappy with the way their complaints had been responded to they had asked the local care Trust for support.

Risk assessments and care plans were in place for each person. Although risks to people had been identified, the steps to be taken to deals with those risks were not always clear. Care plans did not always give enough detail to staff to be able to manage those risks. Whilst there was a lot of information available within care plans, the important information could be difficult to find. Sometimes care plans used highly medicalised language which was unlikely to be accessible for people, their relatives or care staff and could restrict involvement in planning of care.

Some areas of risk were not identified, assessed or managed. For example, bed rails were widely in use in the home to prevent people falling from bed. There were no risk assessments in place regarding their use. Some bed rails did not have protective soft coverings to reduce the risk of entrapment or injury. There were no specific risk assessments in place regarding risks for people who could not call for help. One person’s care plan said they should be checked every hour, but there was no system for ensuring that they had been checked on regularly, and the rationale for these decisions had not been recorded, as they should be. Where one person was at risk of pressure sores, there were no records to evidence they were repositioned in line with their care plan.

Body maps were used to show where people had broken or sore areas of skin. These were cluttered and unclear and this made it difficult to track the progress of people’s wounds. One person’s body map said they had a grade two pressure sore, but there was no evidence of any guidance for staff regarding treatment of this. Lack of clear recording increased the risk that care may not be provided in a safe way.

Management of topical creams was unsafe. Nurses were signing to say these had been applied. However, nurses were assuming they had been applied by someone else. This placed people at risk of creams not being applied correctly and skin becoming sore and breaking down, or medical conditions not being treated effectively. The registered manager took actions to address this.

The environment was not suitably adapted to meet the needs of some people who were living with dementia. For example, signage was not in place to help people orientate themselves and patterns on the floor coverings on the ground floor were confusing and unsuitable. We have made a recommendation in relation to this to the provider.

Although staff had received training in relation to the Mental Capacity Act (MCA), this learning was not being applied. Capacity assessments were not decision specific or individualised for each person. Capacity assessments and best interest’s decisions were not completed where they should have been. For example, in relation to the use of a lap safety belt or bed rails.

Applications for Deprivation of Liberty Safeguards (DoLS) had not been made for everyone who legally required this safeguard. This meant people’s human rights were not fully protected.

The premises were not free from offensive odours. Odours of urine were noted at different places and different points of the inspection, in some bedrooms and communal areas. We have made a recommendation in relation to this to the provider. Where one person was living with dementia and had difficulty getting to the toilet in time, there was no care plan in relation to managing their continence.

At the last inspection we found that there was a low level of social activity in the home and concerns about people being socially isolated. At this inspection we found improvement had been made in this area. A new activities organiser had been appointed and was working individually with people. There were more organised activities available for those who could take part. However, some people’s choices were restricted because they could not leave their bedrooms.

Staff understood the principle that people should be supported to make their own choices and decisions about their care wherever possible. We heard staff asked people for consent before delivering care and offered people choice to support decision making.

People were supported to maintain their health through good nutrition. People told us they liked the food and were able to make choices about what they had to eat. One person said “The food is alright, no complaints there”. Another said “The food is good and there’s a choice.” Pictures of different meals were available to assist those who had communication difficulties. Every morning the chef spoke with people individually about their food preferences for the day. Some people had specific dietary needs. The chef had been trained to cater for those needs.

People spoke highly of the care they received from staff. Comments included, “The staff have always been very good to me”. Asked if the staff seemed caring, one person said, “Yes, they do. Very kind. I just don’t think there is enough of them. They laugh, joke and are very kind.” Another person said staff were always “Smiley and happy” and there was a good atmosphere in the home. We observed staff caring for people during the inspection. Staff addressed people with their preferred name. We saw that staff were cheerful and positive when talking with people, and treated them with respect. People responded

19 and 25 August 2015

During a routine inspection

Mr ‘C’s is registered to provide nursing care and support to 40 people who may have dementia care needs.

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

This inspection took place on 19 and 25 August 2015 and was unannounced. There were 24 people living in the home at the time of the inspection. People had a range of needs with fourteen people requiring residential care and ten people requiring nursing care. Some people were independent, other people were being nursed in bed, and five people were living with dementia.

The service was last inspected on 20 August 2014 where we identified the provider was not meeting the regulations in relation to records. The provider sent us an action plan and confirmed in July 2015 they had completed the required actions to meet the regulations. At this inspection, we found sufficient action had not been taken in relation to the concerns identified at the previous inspection.

Prior to this inspection, we received safeguarding concerns from the local authority. Concerns included a lack of monitoring of blood sugar levels for people with diabetes, weight loss, skin care, records in place for monitoring people’s health and wellbeing not being completed, and referrals to healthcare professionals not being made in a timely way.

Shortfalls in the assessment, planning and delivery of care and treatment meant people may not always be kept safe. There was no system for ensuring that people at risk had been checked on regularly. People’s fluid intake was not recorded in a way that ensured people were having enough to drink and could place people at risk of dehydration. Weights were not being monitored and recorded in a way that addressed the risk of people losing weight. Where people were at risk of pressure sores, there were no records to evidence they were repositioned in line with their care plan. Records relating to pressure sores were unclear. One person’s diabetes was not well managed. We have made safeguarding alerts to the local authority about these concerns.

Prior to the inspection, a visiting healthcare professional raised concerns about staffing levels. The building layout is over four floors with long corridors. When a staff member needed assistance they said it could take some time to find another staff member, which meant people had to wait. People, relatives, healthcare professionals, and staff told us there were not enough staff at times. One person said the staff did not always assist them to the toilet in time. We observed staff were very busy during our inspection. Although the registered manager had carried out an assessment of staffing in April 2015, there had been some changes and they said this needed to be reviewed.

People’s needs had been assessed and care plans were reviewed monthly and updated when their needs changed. Where updates had been added, these were not always clear and dated which meant it was difficult to follow. This meant people’s care plans did not always accurately reflect people’s needs. The registered manager told us they had recently introduced a new care plan format.

People’s social and emotional needs had not been fully assessed and care plans had not been developed to ensure people’s needs were met. Some people spent most or all of the day in their bedroom. There was no evidence that activities or engagement had been designed to address issues such as preventing isolation. One person said “I have tried going downstairs but I found it depressing as they all seem to go to sleep or outside to smoke”. People living with dementia did not benefit from individual activity plans to ensure they had meaningful activities to promote their wellbeing. Staff told us the activities co-ordinator was in the home and provided activities every Saturday from 1.00pm to 5.00pm. The Provider Information Return said the provider was looking to link care planning and the activities provided.

People spoke highly of the care they received. They said “Everything is good here… the staff are lovely and so patient” and “I love it and if I didn’t I’d go somewhere else.’ Staff talked about the people in their care affectionately. They demonstrated they knew the people they supported. People were clean, looked well cared for and well dressed. People were supported to make choices about the clothes they wore. One relative told us staff always made sure their husband’s clothes were colour co-ordinated which was important to them.

People enjoyed the food in the home. One person said “There’s a very good chef…we get two choices daily…I’ve enjoyed all the meals here…he’s very nice to talk to, he comes and has a chat with me”. The chef had been trained to cater for people with specific dietary needs.

There were systems in place to assess, monitor, and improve the quality and safety of care. The director visited the service every two to three weeks. The registered manager had identified records were still not being completed accurately and was taking action to make improvements.

There was an open and supportive culture. People were comfortable when speaking with the registered manager and smiled at them. One person commented “They are so efficient”. A visiting healthcare professional said they found the registered manager acted professionally, was genuine, listened to them, and cared about people. Staff found the registered manager to be very approachable. Comments included “They’re brilliant, a good manager” and “I can approach the manager whenever I want to”. However, two relatives told us they were not happy with the registered manager’s attitude and response to their comments and concerns. We discussed this with the registered manager who was disappointed to hear that people felt this way. They told us they would follow this up by speaking with everyone involved in the home.

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

20 August 2014

During a routine inspection

One adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

We had received some concerns prior to our inspection relating to the care of people living at Mr C's. We found no evidence to support this concern.

Is the service safe?

Records showed that people's needs and risks had been identified and planned for. A range of risk assessments had been completed including those for pressure areas, nutrition and moving and handling. We saw that some good directions had been given to staff on how people's needs should be met. For example, we saw clear instructions on how one person should be assisted to eat.

However, we saw that some of the information contained in records was contradictory and could leave people at risk of receiving inappropriate care. For example, we saw that a support plan relating to pressure area care stated the person should have the dressing changed weekly, but records showed the dressing being changed every three days. A compliance action has been set for this and the provider must tell us how they plan to improve.

We saw that people were protected from the risk of abuse because reasonable steps had been taken to identify the possibility of abuse and to prevent abuse. For example, there were policies and procedures in place for staff to follow if they suspected abuse had occurred. People appeared relaxed and comfortable in their interactions with staff. When we asked people if they felt safe at the home they told us 'Yes'.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One person told us 'Staff are very good, they look after me very well' Staff had received training to meet the needs of the people living at the home.

There were arrangements in place to deal with foreseeable emergencies. For example, the files we looked at contained Personal Emergency Evacuation Plans (PEEPS). This meant that staff had access to the information they would need if an evacuation of the premises was needed.

Is the service caring?

People were supported by kind and attentive staff. We saw and heard positive interactions between staff and people who lived at the home. Any directions that were given to people were done so in a sensitive and discreet manner. During our visit we heard staff speaking with people in a respectful and caring way. We saw staff interacting with the people they supported and providing opportunities for people to talk with them. We also saw that staff were friendly and patient in their approach.

Is the service responsive?

People living at the home and their representatives had been asked for their views on the quality of care provided. Responses included 'Impressed with your attitude and dedication", and 'Couldn't ask for better care for X'. One questionnaire had asked for name badges for staff. We saw that some had been purchased, but the manager did not like them and had ordered a different type.

Is the service well-led?

Prior to this inspection we found that the Registered Manager had been de-registered. They had applied to de-register from another home, but had also been de-registered from Mr C's. They were unaware of this and we are looking to rectify the matter.

The home was registered in October 2013, but did not start to admit people until June 2014. All the staff working at the home had been employed since June 2014 and had received an induction prior to people being admitted. They told us they felt the manager supported them well. One staff member told us that they felt the manager had taken care to ensure all staff worked well together and 'complemented each other'.