Heatherfield Care Home

Heatherfield Care Home provides accommodation, nursing and personal care to a maximum of 74 people. At the time of the inspection 67 people were receiving support in a purpose built building across 3 separate units; specialising in nursing care, younger people and dementia care.

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

Most aspects of medicines were managed safely. The management of covert medicines and some documentation was not in line with the provider’s policy. We have made a recommendation about this.

People were safe from the risk of abuse. Risks to people were assessed and regularly reviewed when people's needs changed. Some staff were not fully aware of people’s individual risk assessment details. We have made a recommendation about this. The building was well maintained, and health and safety risks were assessed.

The provider employed sufficient staff, staff were trained appropriately and recruited safely. Staff worked effectively with visiting professionals. Infection control measures were in place, and visiting was managed in line with current guidance.

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.

Care records were person centred. People were supported to eat and drink a balanced diet. Menu choices were not always presented to people living with dementia in line with best practice guidance. We have made a recommendation about this.

The management team worked in partnership with healthcare professionals to ensure people received appropriate support in a timely manner.

There was a positive culture in the service. Staff said the management team were supportive. Most relatives thought the service was managed well. Quality assurance checks were taking place, lessons had been learnt and improvements were made continuously.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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 25 January 2023).

Why we inspected

We received concerns in relation to end of life care and skin integrity. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and effective sections of this full report.

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

Recommendations

We have made recommendations in relation to menu choices, risk assessments and medicines management.

Follow up

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

Heatherfield Care Home provides accommodation, nursing and personal care to a maximum of 74 people. At the time of the inspection 67 people were receiving support across 3 separate units, specialising in nursing care, younger people and dementia care.

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

Action had been taken since our last inspection to improve. There was a system in place to manage medicines. Records showed that medicines had been administered as prescribed. There were sufficient staff deployed to meet people’s needs. Staffing levels had increased. The registered manager had identified that more staff were required due to unexpected behaviours.

Accidents and incidents were monitored to help identify if there were any trends or themes so action could be taken to reduce the risk of any reoccurrence. One health and social care professional told us, “I am always kept well informed of any safeguarding concerns, any concerns raised by family members and the manager always has a plan in place to reduce risk.”

People spoke positively about the staff and living at the home. One person told us, “I would sum it up as excellent, there are no problems at all. To me it's wonderful, the staff are good, there are no problems with the staff, they treat you well.” The provider sent us case studies to show how being at the home, with the support of staff, had led to an improvement in people’s health, independence, mobility and wellbeing. This was also confirmed by the people we spoke with. Positive feedback was received from health and social care professionals about the staff and people’s care and support. One health and social care professional told us, “They know about their patients, they invest in them and want the best for people.”

An effective quality monitoring system was now in place. Checks were carried out to monitor all aspects of the service. Action was taken if any shortfalls were identified. There was a new registered manager in place. People, relatives and health and social care professionals spoke positively about her and the improvements she had made. We heard how she encouraged and promoted a culture of learning amongst staff.

A communication system was in place. Staff explained that handovers had improved, and staff meetings were carried out. Several relatives and health and social care professionals explained that more effective communication would be appreciated.

Staff worked in partnership with other health and social care professionals to help ensure people’s needs were met. One health and social care professional told us, “They promote positive outcomes for people in relation to taking the residents out in the community…The staff are always pleasant and welcoming and seem to know the residents well.”

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 9 April 2022) and there were 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. At this inspection we found improvements had been made and the provider was no longer in breach of the regulations.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions of safe and well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of 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 Heatherfield Care Home 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.

Heatherfield Care Home provides accommodation, nursing and personal care to a maximum of 74 people. At the time of the inspection 69 people were receiving support across three separate units, specialising in nursing care, younger people and dementia care.

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

A safeguarding system was in place; however, this was not always operated effectively. Records did not always evidence what actions had been taken to ensure people were safe.

Risk was not always safely monitored and managed. The provider had systems in place to analyse and monitor accidents and incidents, complaints and safeguarding. However, these were not always followed or operated effectively to ensure risks, trends and themes were identified, recorded, reported and monitored.

There was an infection control system in place. However, records did not always evidence that staff followed government guidance in relation to COVID-19 testing. In addition, an effective system to reduce the risk of visitors spreading infection was not fully in place. We observed that staff used PPE effectively and safely.

Medicines were managed safely, however, records were not in line with the provider’s policy.

Whilst there were sufficient numbers of staff on duty; due to the impact of Brexit, COVID-19, vaccination as a condition of employment and staff leaving the sector, the use of agency staff had increased. This had affected the skill mix of staff on duty. People and relatives told us the permanent staff were skilled and knowledgeable about people's needs. However, they were not as positive about the skills of the agency staff. The provider had recruited new staff which would reduce the use of agency staff and provided additional training for agency staff.

Whilst the provider had quality monitoring and communication systems in place; these were not always operated effectively. In addition, an effective system to ensure notifiable events at the home were reported to CQC was not fully in place. This is being dealt with outside of the inspection process.

The provider sent us several case studies to show how being at the home, with the support of staff, had led to an improvement in people’s health, independence and wellbeing. They also sent us compliments which had been received from relatives. Positive feedback was received from health and social care professionals about the staff and people’s care and support.

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 17 February 2021).

Why we inspected

The inspection was prompted due to concerns received about people’s care and treatment. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating.

The local authority had placed the home into 'organisational safeguarding.' This meant the local authority was monitoring the home and supporting them to ensure the correct procedures were in place to keep people safe. The provider was cooperating with this.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

We have found evidence that the provider needs to make improvements. The overall rating for the service has changed from good to requires improvement. 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 Heatherfield Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents).

Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response in relation to Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents) is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Heatherfield Care Home provides accommodation, nursing and personal care to a maximum of 74 people. At the time of the inspection 63 people were receiving support across three separate units, specialising in nursing, younger people and dementia.

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

Medicines were generally managed well. People received their medicines in a timely manner and as prescribed. We did find some minor issues which we have made a recommendation about.

Infection control procedures, including those related to COVID-19 were appropriate and the provider planned to further review these, including training. The service was clean and tidy.

Safe staff recruitment procedures were in place. Any staffing issues were addressed by the registered manager. The provider had a training programme in place and staff support procedures.

Enough staff were on duty throughout the inspection, although we noted some shortages had been present in recent months due to COVID-19 and staff sickness. A recruitment programme was on going.

People felt safe and safeguarding procedures were followed by staff. Accidents and incidents were reported appropriately and notified to the relevant authorities.

People and their relatives reported staff to be kind and caring.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The provider had a range of quality assurance checks in place and together with the registered manager used these to monitor the service provided.

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 18 May 2018).

Why we inspected

We received concerns about staffing levels and care not being provided effectively. 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.

The overall rating for the service has remained as good. This is based on the findings at this inspection. Please see the safe and well led sections of this full report.

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

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Heatherfield Care Home is a nursing care home providing personal and nursing care to up to 74 people. There were 72 people living there at the time of this inspection, including younger people with physical disabilities, people with nursing needs and people living with dementia.

We found the following examples of good practice.

There were appropriate measures in place to prevent visitors from spreading infection. All visitors had to wear appropriate personal protective equipment (PPE), sanitise their hands, complete a track and trace form and had their temperature checked prior to entering the home.

The provider was following national guidance for anyone moving into the home and new admissions were carried out safely.

The home was divided into three distinct units with PPE stations at each crossing point which helped to prevent cross infection. People isolating in the dementia care unit had their own dedicated care and housekeeping staff who supported all their needs.

There was PPE at frequent places throughout the home and clear signage was in place regarding the correct use of PPE. Staff had received appropriate infection prevention and control training.

At the time of this visit, local restrictions on non-essential visiting were in place so alternative measures such as telephone and video calls were being used.

The premises were very clean. Additional cleaning was taking place including frequently touched surfaces such as handrails.

We were assured that this service met good infection prevention and control guidelines.

Heatherfield Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 74 people. The home is divided into three areas for those who have general nursing, dementia care and younger physically disabled care needs [YPD]. The provider referred to these areas as units so we have used this terminology throughout the report. There were 60 people living at the service at the time of the inspection.

At our last inspection in November 2017, we found four breaches of the Health and Social Care Act 2008. These related to safe care and treatment, staffing, receiving and acting upon complaints and good governance. We placed conditions on the provider's registration to minimise the risk of people being exposed to harm. We rated the service as requires improvement overall and inadequate in the well-led key question.

At this inspection we found that improvements had been made and they were now meeting all the regulations we inspected. Following the inspection, we agreed that the conditions placed upon the provider's registration could be removed.

A new manager was in post. They had commenced employment in January 2018 and become registered with the Care Quality Commission [CQC] in April 2018. A registered manager is a person who has registered with the 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 were safeguarding procedures in place. Staff did not raise any concerns about staff practices at the service. Safeguarding incidents were appropriately referred to the local authority and other relevant bodies.

There were sufficient staff deployed although we recommended that the provider reviews staff deployment on the young physically disabled unit because of the mixed feedback we received from people, relatives and staff from this unit. Agency staff were still used at the service. The provider tried to ensure the same agency staff were requested for consistency. Safe recruitment procedures were followed and staff had completed training in safe working practices and to meet the specific needs of people. An effective induction process was now in place which was linked to the Care Certificate. There was a supervision and appraisal system in place to help ensure staff were supported in their roles.

We checked the management of medicines. We identified several minor medicines recording issues in the nursing unit. These were addressed by our second visit to the service. Enteral feeding and medicines administration was now carried out safely. Enteral feeding refers to the delivery of a nutritionally complete feed via a tube, directly into the stomach or bowel.

Action was being taken to ensure the environment met the needs of the needs of people who used the service. New flooring was being laid and areas of interest had been added in the dementia care unit.

The maintenance of care records and charts had improved and were more detailed. They now reflected people’s needs. We identified minor shortfalls regarding enteral records which the registered manager told us would be addressed.

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 place supported this practice.

People were supported with their dietary requirements. Staff were attentive to people’s needs and provided discreet support. Portion sizes were reflective of people’s preferences and requirements. Meals appeared appetising and were served at the correct temperature.

We observed positive interactions between people and staff. Staff spoke with people respectfully and provided discreet support.

There were four activities coordinators employed, although one activities coordinator was on leave. There was an activities programme in place.

Most people, relatives and staff told us that improvements had been made. Less positive feedback was received from some people, a relative and several staff on the YPD unit. This related to staff deployment, activities and meals. Due to the mixed feedback we received, we recommended that the provider reviews the culture, involvement and person-centred approach on the YPD unit.

A complaints procedure was in place. Complaints were documented and action taken. Feedback systems were in place to obtain people and their representatives' views.

The management structure had been strengthened. The registered manager was supported by a deputy manager. New team leader posts had been introduced on each of the units to oversee the care and support provided. The head of compliance and a compliance officer oversaw the operational management of the service. Strategic oversight was provided by the head of care and the director who were both actively involved in the service and visited regularly.

New monitoring and communication systems had been introduced. These were in the process of being embedded into practice.

The service has a history of non-compliance with the regulations. Improvements which had been made at previous inspections were not always maintained. In addition, there had been a number of different managers at the service since 2013. Action was therefore required to ensure that the improvements made at this inspection were maintained and sustained.

Following our inspection, the provider sent us an action plan which stated what action they were going to take to improve.

Heatherfield Care Home provides accommodation and care for up to 74 people. The home is divided into three units for those who have general nursing, dementia care and younger physically disabled needs. Accommodation is spread over two floors. There were 68 people living at the home at the time of the inspection.

A manager was in post. She had commenced employment in May 2017 and applied to register with the Care Quality Commission as 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.

Prior to the inspection, we received information of concern regarding staffing levels, the maintenance of records and certain aspects of people’s care. We brought forward our planned inspection in order to check the concerns raised.

There were continued shortfalls and omissions with regards to the management of medicines. We identified concerns with the care and treatment of people who required enteral feeding. Enteral feeding refers to the delivery of a nutritionally complete feed via a tube, directly into the stomach or bowel.

A high number of agency staff were used. At the time of the inspection, we found there were insufficient suitably qualified, competent, skilled and experienced staff employed.

Staff were knowledgeable about safeguarding and told us they would report any concerns. There were three ongoing safeguarding investigations. Two of these were being investigated by the police. We will monitor the outcome of these safeguarding investigations and action taken by the provider.

The local authority had placed the service into organisational safeguarding. This meant that the local authority was monitoring the whole home.

There was a lack of evidence to demonstrate that safeguarding incidents were monitored and lessons to be learned considered to help identify any changes in practice to ensure continuous improvement.

The training matrix had gaps against certain training courses. Some people, relatives and staff raised concerns about the communication and skills of agency workers. Records of the clinical skills and competencies were not available for most of the agency nurses. There was no evidence of clinical supervision.

We checked the design and décor of the service. There were extensive accessible gardens which had won a number of awards. The service had its own hydrotherapy pool. There was an additional charge if people wished to use this facility. The service also had a cinema room, hairdressing salon and kitchen areas where people could make hot drinks and prepare snacks. However, we found that not all aspects of the environment met best practice guidance relating to supportive environments for people living with dementia. We recommended that the design and decoration of the premises is based on current best practice in relation to the specialist needs of people living at the service.

Some people’s care records had omissions. This meant it was not clear whether care and treatment had been provided.

A complaints procedure was in place. We found however, that not all complaints were recorded or dealt with in line with the provider’s complaints procedure.

An activities programme was in place. Some people and relatives told us that more activities would be appreciated. We recommended that access to and the variety of activities available is kept under review in light of the feedback we received.

We observed positive interactions between staff and people. Staff spoke with people respectfully and provided discreet support.

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.

We found shortfalls in many areas of the service including the management of medicines, training, the care and treatment for those who required enteral feeding and dealing with complaints. In addition, records relating to people, staff and the management of the service were not always accurate, complete or securely maintained.

Since 2013, we found the provider was breaching one or more regulations at five of our six inspections. This meant that systems were not fully in place to ensure compliance with the regulations and good outcomes for people.

Following our inspection, the head of compliance sent us an action plan and further information detailing the actions they had taken/planned to take to address the shortfalls we identified.

We found four breaches of the Health and Social Care Act 2008. These related to safe care and treatment, staffing, receiving and acting on complaints and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The last comprehensive inspection of this service was carried out in February 2015. At that time the service was in breach of Regulation 12 HSCA (RA) Regulations 2014 Safe Care and Treatment. We followed up on this breach at a focussed inspection in August 2015 and saw the breach had been met, however that inspection found the service in breach of Regulation 17 HSCA (RA) Regulations 2014 Good Governance.

During this inspection we found that whilst some actions had been taken to improve the quality and monitoring systems, shortfalls in care remained. The provider’s system had not identified the shortfalls which we found during our inspection.

A registered manager was 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.

Risks related to the receipt of care had not been mitigated. Two people at risk of developing pressure damage were using pressure relieving mattresses which were set incorrectly for their body weight. Nursing staff were unable to tell us when the settings were last checked as there was no formal process for monitoring this equipment.

Risks related to covert medicines had not been assessed. Records were not kept to note where medicines administered via a patch on people's skin had been applied, putting people at risk of discomfort.

People and relatives told us they thought one area of the home was understaffed. The registered manager advised staffing was determined by an assessment of people's needs. We saw from rotas that staffing numbers in the home had met the assessed number. During our inspection the atmosphere was unhurried and people were responded to quickly.

Robust recruitment procedures had been followed to ensure checks the suitability of potential employees had properly considered.

Steps had been taken to mitigate the risk of infection.

During observations in the dementia care unit over lunchtime, we found there were not enough staff to support the people with the highest level of need so they had to wait a considerable amount of time before staff could support them to eat. There was not enough room in the dining room to accommodate people comfortably.

People in the dementia care unit were not offered a choice of meal, and steps had not been taken to ensure that choices could be provided in a way which would meet people's needs.

Care Quality Commission (CQC) is required by law to monitor the operations of the Mental Capacity Act 2005 (MCA), and to report on what we find. MCA is a law that protects and supports people who do not have the ability to make their own decisions and to ensure decisions are made in their ‘best interests’.

Where decisions had been made on people’s behalf, records showed capacity had been assessed and best interests process followed. The provider had sought authorisation to deprive people of their liberty where it was considered they would not be able to keep themselves safe if they left the home alone.

The provider had identified a set of training modules for all staff to undertake. We saw this training was monitored to ensure staff stayed up to date with any refresher training required. We have made a recommendation about staff training on the complex needs of some people using the service.

New staff inductions included policies and procedures, shadowing experienced staff and undertaking training. Staff received regular supervisions sessions, an annual appraisal and opportunities to develop their skills and knowledge.

The home was purpose built, and had been designed to meet the needs of the people who used it. Steps had been taken to aid people's orientation on the dementia care unit, but the manager advised us further improvements were planned in this unit to ensure it met best practice for people with dementia conditions.

People and relatives told us the staff were warm and friendly. We observed staff were considerate of people’s privacy and dignity.

Processes were in place to ensure that people were supported in compassionate way, by appropriately trained staff, at the end of their lives.

Assessments of people’s needs and the care plans which described how they should be cared for did not always contain accurate information and some were out of date, which put people at risk of receiving inappropriate care.

The home employed four activities coordinators but some people and relatives told us that there was not enough for people to do.

The provider did not have a robust system to monitor the quality of the service provided. Whilst a scheduled of audits were carried out regularly they had not addressed the shortfalls which our inspection highlighted.

We found two breaches of the Health and Social Care Act 2008. These related to safe care and treatment and good governance.

The provider had not sent us notifications which are a legal requirement of their registration. This was a repeated breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We will continue to work with the provider to monitor and improve service. You can see further action we have asked the provider to take at the back of the full version of this report.

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

Relationships between people and staff were clearly good. Relatives told us and we saw in practice staff treated people with respect and helped them to remain as independent as possible.

We found people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans. Relatives we spoke to were positive about the care and support people received. One relative said, 'They understand all my mam's needs. Her care and support is very good and she is well looked after.' Another relative told us, 'She gets good care here, without a doubt. She's happy, she is well looked after, the care is spot on and that's good enough for me.'

We found that there were suitable numbers of skilled, trained and experienced staff. One relative commented, 'The staff all seem confident and competent in what they are doing.' Another relative told us, "They were having staffing problems, but recently there has been a definite improvement and I've seen an increase in staff."

The service had a complaints procedure that detailed the process to be followed in the event of a complaint. This indicated complaints should be documented, investigated and responded to within a set timescale. People and relatives told us that they felt able to raise any concerns or comments about the service.

We spoke with seven people and 16 relatives to find out their opinions of the care and treatment at the service. One person told us, 'The care and support is good when I can get it.' One relative said, 'I'm glad she's here, she's well looked after.' Another relative told us, 'The lack of staff impacts on people's care and treatment. They can't tend to their needs properly.' One person told us, "There's always a high turnover of staff."

We were unable to speak to all of the people who used the service because of the nature of their condition. We spoke with staff and observed their practices to determine how care and support was delivered.

We found that people's care, support and treatment were not always properly assessed and their care was not always planned and delivered in a way which met people's individual needs.

People, relatives and staff told us and we found that suitable numbers of skilled and qualified staff were not always on duty. We spoke with seven people, 16 relatives and 10 members of staff. Six people, 14 relatives and nine members of staff told us they felt that more staff on duty would be appreciated.

The service did not have an effective complaints recording system available. Complaints people made were not always documented or responded to appropriately, in line with the providers own complaints policy.