Lilleybrook Care Home

Lilleybrook Care Home is a care home providing accommodation to persons who require nursing or personal care, for up to 60 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 57 people using the service. People are accommodated in 1 adapted building, which has been divided into 3 households or ‘units’.

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

People and their relatives told us Lilleybrook Care Home was safe and staff responded to their needs safely. There were enough staff deployed to meet people’s needs. The management changed staffing levels depending on the occupancy of the home and people’s needs. Staff told us they had the skills, time and support they needed to meet people’s needs.

At the time of our inspection the provider was carrying out remedial fire safety works identified through a fire risk assessment. Immediately after the inspection work was carried out to ensure people were protected from risk.

People’s needs and choices had been assessed. Staff understood people’s individual risks and the support they required to maintain their health and wellbeing.

Incidents and accidents were reviewed to reduce the risk of reoccurrence. The management reviewed where accidents and incidents had occurred to identify and make improvements to the care they provided people. Staff were supported to reflect on incidents, complaints, and medicine errors to enable them to make improvements.

The provider had infection control procedures in place to protect people and prevent the spread of infection. Staff accessed personal protective equipment (PPE) and acted in accordance with government guidance. People’s visitors could visit in accordance with current guidance.

Staff supported people in the least restrictive way possible and in their best interests. Where people were living under Deprivation of Liberty Safeguards; staff understood the support they required.

People and their relatives told us there had not always been a wide range of activities, however more activities and support was now being provided. The manager and provider were aware of this concern and had recruited activity co-ordinators to start providing group and 1 to 1 activities.

The manager and provider operated effective systems to monitor the quality of care they provided to people living at Lilleybrook Care Home. There was a clear service improvement plan for the home based on the manager and provider's audits and knowledge of the service.

People, their relatives and staff spoke positively about the new management of the service and the improvements they had noticed. Staff told us they felt supported by the management team and felt they had the communication and guidance they needed.

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 25 January 2022).

Why we inspected

This inspection was prompted by a review of the information we held about this service. This included information of concern about people’s risk and the risk of choking. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lilleybrook 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.

Lilleybrook Care Home is a 'care home' registered to provide accommodation and personal care to 60 older people and people living with a diagnosis of dementia. At the time of our inspection 51 people were receiving support at the service.

People receive care in one of four units in the home. Each unit had communal spaces for people to use. There was also a secure garden which people could use.

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

At the time of our inspection the management of the service had just changed. The provider told us they would notify us of this management change.

People told us they had built good relationships with staff and we found staff were committed to provide care that met people’s needs. However, feedback received from people, relatives and staff meant that we could not be assured that everyone in the home experienced person-centred care where choices and preferences were respected.

People and their relatives had raised complaints and the provider told us these would have been investigated. However, as they were still familiarising themselves with the previous registered manager's systems at Lilleybrook there was a delay to providing requested information.

We have made a recommendation about the provider taking action to ensure management information is readily available in the absence of a registered manager.

The provider had systems in place to monitor the quality and risk in the service. However, the provider had not identified through their own monitoring systems that people were not always satisfied with their care and that records in the service were not reliable in supporting the provider’s monitoring activities.

We were somewhat assured the service was following safe and correct infection control processes. We have signposted the provider to resources to develop their approach in relation to monitoring of cleaning practices and use of PPE.

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 26 February 2020).

Why we inspected

We received concerns in relation to people’s experience of their care. As a result, we undertook a focused inspection to review the key questions of responsive 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 COVID-19 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.

We have found evidence that the provider needs to make improvement. Please see the responsive and well-led sections of this full report. We shared these improvements with the provider at inspection and they have told us they are taking action to review their systems.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lilleybrook 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to regulation 9 (Person-centred care) and Regulation 17 (good governance).

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

Follow up

We will request an action plan 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.

Lilleybrook Care Home is registered to provide accommodation and personal care to 60 older people and people living with a diagnosis of dementia. The service was working in co-ordination with the local authority, providing discharge to assess beds, with the aim of reducing pressures on local hospitals. At the time of our inspection 54 people were receiving support at the service.

People receive care in one of four units in the home. Each unit had communal spaces for people to use. There was also a secure garden which people could use.

We found the following examples of good practice.

¿ The provider and registered manager had set up a visiting ‘pod’ in accordance with recognised safe visiting guidance. Additionally, alternative ways, including the use of technology, had supported people’s ability to remain in contact with their relatives.

¿ Where necessary, people’s relatives were supported to visit the home to promote people’s health and wellbeing where concerns have been identified. Alongside of the support provided by the home’s GP, relatives were added to the routine testing programme to enable them to support their loved ones.

¿ Admission to the home was completed in line with COVID-19 guidance. People were only admitted following a negative COVID-19 test result and supported to self-isolate for up to 14 days following admission to reduce the risk of introducing infection.

¿ People’s health and wellbeing was monitored. People were observed for symptoms of COVID-19 and other potential infections. Healthcare professionals had continued to provide clinical support to people when this was required. This included assisting people with COVID-19 vaccinations.

¿ Action had been taken to reduce the risk of infection spreading which had included the correct use of personal protective equipment (PPE). Staff had received training and support in relation to infection control and COVID-19. The managers observed staff practice ensuring they were following the correct use of PPE.

¿ The registered manager and provider had clear plans in relation to the isolation of people affected by COVID-19 and the cohorting of staff to reduce the spread of infection.

¿ People and staff were tested in line with national guidance for care homes.

¿ As part of full infection control measures laundry and waste arrangements had been correctly implemented to reduce the spread of infection.

¿ Cleaning schedules had been enhanced and were followed by housekeeping staff and care staff. This included the additional cleaning of frequently touched surfaces to reduce the risk of infection spreading.

¿ The provider’s policy for managing COVID-19 and related infection prevention and control procedures had been reviewed and kept up to date. COVID-19 guidance was also kept up to date for staff reference.

¿ People were being supported with activities and engagements which met their wellbeing needs, whilst promoting social distancing. People on one unit enjoyed singing and engaging with staff. The registered manager and staff spoke positively about maintaining people’s wellbeing needs during the COVID-19 pandemic.

The Grange Care Centre (Cheltenham) is a residential care home which provides personal and nursing care to 60 older people and people living with dementia. At the time of the inspection 58 people were receiving care. The Grange Care Centre (Cheltenham) is located in Leckhampton, a suburb of Cheltenham. The home is set across four units. The home is set in well presented gardens which people could access. There was a range of communal areas that people and their relatives could use.

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

The registered manager and provider had carried out a number of improvements at The Grange Care Centre (Cheltenham). This included a range of recruitment, which had improved people’s continuity of care. Management, activity and care staff were building strong links with the local community including healthcare professionals which helped to improve people’s wellbeing. The registered manager was instilling a positive caring culture in the home which was welcomed by people, their relatives and staff.

The registered manager and provider had clear and robust systems to assess, monitor and improve the quality of care people received. Systems helped to improve the service and drive positive changes.

People, their relatives and healthcare professionals felt The Grange Care Centre was a safe place. People received appropriate care and treatment, based on current guidance and best practice. People’s risks were known by care and nursing staff. Care and nursing staff were fully aware of their responsibilities to raise concerns and the registered manager and provider ensured lessons were learnt from any incidents or accidents.

Staff were well trained and had the skills to meet people’s needs. Staff had access to support, reflective practice and the professional development they needed. People received effective care and treatment. The service worked alongside a range of healthcare professionals to ensure people’s health and wellbeing were maintained.

People told us care and nursing staff were kind, caring and compassionate. Staff were attentive to people’s needs and knew how to promote their wellbeing. Staff had assisted people with their needs and supported people to return to their own homes following a short period of respite.

People received care which was personalised to their needs. Where people’s needs changed, or their health deteriorated, nursing and care staff took appropriate and effective action to ensure their health and wellbeing. People enjoyed an engaging and varied life at The Grange Care Centre. People and their relative’s spoke positively about the activities in the home as well as the one to one engagement they received.

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.

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 15 January 2019) and we identified two 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 that improvements had been embedded and sustained.

Why we inspected

This was a planned inspection based on the previous rating of “Requires Improvement”. At this inspection we found that the service had improved and was now rated as “Good”.

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.

We last inspected the home on 6 and 8 November 2017. At the November 2017 inspection we rated the service as “Requires Improvement”. We found the provider was not meeting all of the requirements of the regulations at that time. People did not always receive care personalised care and were not always protected from the risk of infection. Care staff did not always have the training and formal support they required and the registered manager and provider did not have effective systems to monitor the quality of service they provided.

At this inspection, we found improvements had been made to the safety of the service and the provider’s quality assurance systems had effectively address some shortfalls. However, sufficient progress had not been made in relation to staff training and support and people’s person centred care. The provider was aware of these concerns and had a plan in place to improve the quality of care people received.

At this inspection, we found similar concerns in relation to staff training and support and in relation to people’s person-centred care. The provider was aware of these concerns and had a plan in place to improve the quality of care people received.

A registered manager was not in position at the service. The deputy manager and clinical lead were providing day to day management at the home, with the support of the provider until the new manager was in post. A new manager was in the process of being recruited by the provider. 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.

People did not always receive person centred care or meaningful engagement from care and nursing staff. Some care staff did not always ensure people received care which was tailored to their individual needs and preferences. People’s life histories and interests did not always inform their care plans and the activities they would enjoy.

People, their relatives and staff felt staffing had improved at the Grange Care Centre. There was a high level of agency usage which staff and people’s relatives felt impacted on some person centred care. The provider was taking action to address staffing concerns by carrying out recruitment. Care and nursing staff felt they were supported by the clinical lead and deputy manager. However, care staff informed us they did not always receive effective supervision and did not have the training they needed to meet people’s needs.

People were care for in a clean, safe and well-maintained home. The provider and manager carried out effective checks to ensure the service was appropriate for people’s needs. The provider had plans to refurbish the home in 2019. Nursing and care staff followed recognised infection control procedures.

People were protected from the risks associated with their care. Care and nursing staff knew how to assist people with their needs and ensure their health was maintained. People’s prescribed medicines were managed well.

Staff understood their responsibilities to protect people from harm and to report any safeguarding concerns. Staff provided people with choice and worked to protect and maintain their legal rights.

People had access to a good variety of food and drink. Care and nursing staff treated people with dignity and ensured they had their nutritional support and their prescribed medicines. Catering and care staff were aware of and met people’s individual dietary needs.

People’s relatives felt their concerns and views were listened to and acted upon due to changes within the management team. The provider and manager were aware of this and were making opportunities to effectively engage with people’s relatives.

The provider had systems in place to drive the quality of care people received. There was an action plan in place to drive these improvements. An interim management team was in place with a focus of ensuring the service was safe before a new manager started at the home in 2019. Time and consistency was required to ensure the provider’s action plan was completed, improvements were effectively sustained and embedded.

We found two repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have not escalated these actions as we had identified improvements at this inspection from the last full inspection in November 2017. You can see some of the action we told the provider to take at the back of the full version of this report.

We last inspected the home on 14 and 15 May 2017. This was a focused inspection which was prompted in part by the HM Coroner Gloucestershire issuing a Regulation 28 to the provider which required them to address some matters of concern as a result of the death of a person. We also followed up on a requirement notice from our October 2016 inspection in relation to the management of medicines. At the May 2017 inspection we rated the service as “Requires Improvement”. We found the provider was not meeting all of the requirements of the regulations at that time and we issued a warning notice against the provider and the registered manager in relation to Regulation 12. People’s risks were not always effectively addressed and acted upon to ensure their health and wellbeing. At our November 2017 inspection we found improvements had been made to ensure people’s needs were assessed and acted upon, however the service was not meeting the requirements of all relevant regulations.

A registered manager was in position 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.

People were not always protected from the risk of infection. Care staff did not act in accordance with national best practice guidance regarding the control of infection. People’s equipment was not always effectively cleans and maintained.

People did not always benefit from activities and stimulation which was appropriate to their needs or abilities. The service and its managers are task focused. They do not encourage or support staff to provide care and support in a compassionate and supportive way. Care staff did not always ensure people received suitable stimulation and engagement, including at mealtimes. People’s life histories and interests did not always inform their care plans and the activities they would enjoy.

People told us they were safe living at the home and enjoyed the meals they received. Care and nursing staff treated people with dignity and ensured they had their nutritional support and their prescribed medicines. Catering and care staff were aware of and met people’s individual dietary needs.

There were enough staff deployed to ensure people’s needs were being met, however concerns had been raised about leadership at weekends. However care staff did not always have the training and support they required to meet people’s needs. Staff did not always feel they had the communication they needed to ensure people’s day to day needs were being met. The registered manager was taking immediate action in relation to these concerns.

Care staff were aware of people’s health and wellbeing needs. Care staff treated people with dignity and responded when there were any concerns with their wellbeing. People and their relatives felt their concerns and views were listened to and acted upon. Relatives told us they were informed of changes and felt the registered manager was responsive and approachable.

The registered manager did not always have effective systems to monitor the quality of service provided at The Grange Care Centre while systems were in place to ensure people’s care plans were current there was not always effective systems in place around the care people received in the home. Concerns identified at this inspection had not previously been identified. The service has a history of “requires improvement” ratings through three previous inspections.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see some of the action we told the provider to take at the back of the full version of this report. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations have been concluded.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 14 and 15 May 2017 to check that they had followed their plan and to confirm that they now met legal requirements. At this inspection, we also followed up on concerns raised following a HM Coroner’s inquest in March 2017 and whistle blowing concerns we received in relation to staffing levels within The Grange Care Centre (Cheltenham). This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Grange Care Centre (Cheltenham)’ on our website at www.cqc.org.uk’

The Grange Care Centre (Cheltenham) provides residential and nursing care for up to 60 older people. 58 people were using the service at the time of our inspection. Many of the people living at the home were living with dementia. This was an unannounced inspection.

The home has 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 and associated Regulations about how the service is run.

At our focused inspection on the 14 and 15 May 2017, we found that the provider had followed their plan and the legal requirements in relation to the management of medicines had been met.

People mostly received their medicines as prescribed. Where mistakes in the administration of people’s medicines had occurred, nursing and care staff took immediate action to ensure people were safe. The service maintained a clear record of people’s prescribed medicine stocks, and following our last inspection had reduced the amount of individual boxed medicines and sought advice from healthcare professionals. People’s prescribed medicines were stored securely.

In relation to concerns raised following the HM Coroner’s inquest we found people’s care needs were not always recorded effectively. Records relating to people’s healthcare needs, such as food and fluid and repositioning charts were not always consistently completed. Care plans did not always provide care staff with clear details on how to assist people with their healthcare needs.

There was enough staff deployed to meet people’s needs in the main however we raised concerns regarding levels of staffing at certain specific times with the registered manager and provider. We were informed of the immediate action that was being taken to address these concerns. We recommended the provider review their staffing levels against the dependency of people living at The Grange Care Centre (Cheltenham).

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

We last inspected the home in January 2016 and found the provider was not always meeting the regulations. We found people did not always receive their medicines as prescribed, were not always protected from the risks of infection and their care plans did not contain necessary information about their care. Staff did not always have the training and support they needed to meet people’s needs and the provider did not have effective systems to monitor and improve the quality of service people received. Following our inspection in January 2016, the provider issued us a plan of the actions they would take to meet these breaches in regulation. At this inspection we found some appropriate action had been taken but other actions were still work in progress. One breach had been repeated from our last inspection.

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

People did not always receive their medicines as prescribed. We discussed this concern with the registered manager who took immediate action. People’s care plans were not always current and accurate. The registered manager had a clear plan in place to ensure all people’s care plans and risk assessments were reviewed and updated.

People and their relatives were positive about the home, the staff and management. People told us they were safe and looked after well in the home. Staff managed the risks of people’s care and understood their responsibilities to protect people from harm.

People benefitted from activities and person centred care. There was a friendly, pleasant and lively atmosphere within the home. People also enjoyed the time they spent with each other and staff and carrying out activities. People were offered choices about their day. People and relatives told us they felt listened to and able to raise concerns or suggestions.

People had access to plenty of food and drink and received a diet which met their needs. Staff ensured their on-going healthcare needs were met.

People were cared for by staff who had access to the training they needed to meet people’s needs. The registered manager had a clear plan for staff to have the training they needed and to professionally develop. All staff felt supported by the registered manager and provider.

Staff were supported by a committed registered manager. There were enough staff with appropriate skills deployed to meet the needs of people living at the service and support them with activities. Staff spoke positively about the home and the registered manager.

People and their relatives spoke positively about the management of the service. The registered manager ensured people, their relatives and external healthcare professionals’ views were listened to and acted upon. The registered manager and provider had systems to assess, monitor and improve the quality of service people received at The Grange Care Centre (Cheltenham).

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

We last inspected in May 2015 and found the provider was meeting all of the requirements of the regulations at that time.

There was not a registered manager in post on the day of our inspection. The previous registered manager had left in July 2015. A new manager had been appointed in November 2015 and they were in the process of applying to become the 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.

People did not always receive their medicines as prescribed. Care staff did not always keep an accurate record of when people had received their medicines. People were not always protected from the risks of the spread of infectious diseases as some people had to share some pieces of equipment.

Staff told us they felt supported; however staff did not have access to supervision and training to enable them to be confident in their role. There were enough staff to meet people’s needs, however they were not always suitably deployed round the home to meet people’s needs.

The home’s manager was implementing new activity plans which included specific activities for people living with dementia. Care staff spent time with people and talked with them about things which were important to them, however there was not always structured activities available to them.

People’s care plans were not always current and accurate. The provider was aware of this concern and was in the process of reviewing and updating people’s care and risk assessments.

The provider had not ensured that systems were in place and regularly undertaken to sufficiently assess, monitor and continually improve the quality and safety of the services provided. The manager had identified concerns regarding the quality and the management of the home and had implemented an action plan. They had a clear goal to improve the service and provide good quality dementia care to people living in the home. Staff were aware of this goal, and people and their relatives spoke positively about the new manager.

People felt safe and were cared for by caring, compassionate and supportive staff. Care staff supported people to celebrate important events in their lives, such as anniversaries and birthdays. Relatives spoke positively about the impact staff had on their and their love ones lives. Care staff treated people with dignity and respect when they assisted them with personal care and mobility. Care staff offered people choice, and ensured people were treated compassionately.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report. We have also made a recommendation regarding staffing within the home.

This inspection was carried out by one inspector and a pharmacy inspector. During the inspection we spoke with the manager, one qualified nurse, two care staff and the maintenance person. We spoke briefly with three of the 25 people who were in residence. We looked at three people's care files, the medicine administration records and records in respect of audits completed. We used the information we collected during this inspection, to answer the five questions. Is the service safe, effective, caring, responsive and well-led?

Is the service safe?

Each person needed to be supported with their medicines. The clinical lead nurse had taken the responsibility for ordering medicines and this had eliminated supplies running out. People's medicines were administered at the times they were due. Appropriate records were kept of medicines administered and these were regularly audited. Medicines were stored safely and there were suitable arrangements in place for the storage of controlled drugs. Any creams and ointments were applied as prescribed.

Where people needed to have bed rails to maintain their safety in bed, risk assessments had been completed and written consent was obtained from either the person or their relative.

Is the service effective ?

People we spoke with were unable to tell us about what it was like to live in The Grange but said 'The staff help me in the mornings to get up and dressed' and 'The staff know what they are doing'. Other people were not able to answer our questions because of their mental or physical frailty.

Is the service caring?

People received the care and support they need because of good assessment and care planning procedures. Those files we looked at had been completed in detail and provided specific information about they needed and wanted to be looked after.

Is the service responsive?

People received care, treatment and support that was personalised to their individual needs and took account of their needs, choices and preferences.

Is the service well-led?

A programme of regular checks and audits had been introduced and the provider was kept informed about how the service was running. Arrangements to ensure infection control and prevention measures were adhered to still need to be embedded as part of the on-going improvements for the service.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

The inspection was completed by two inspectors and a pharmacy inspector. Due to the complex needs of some of the people who used the service we were not able to ask them for their views on the care and support they received. We spoke with three people in detail and three relatives. We also spoke with seven members of staff. This is a summary of what we found.

Is the service safe?

We found risk management plans were now in place. These identified hazards and noted how to reduce and minimise these. At the last inspection we were concerned about the use of restraint for some people as this was not recorded. We found staff were no longer using restraint and diversional therapy was being used instead. This was now all recorded in people's care records.

People were not put at unnecessary risk and were offered choices remaining in control of decisions about their care and support where able or their representatives were involved on their behalf.

Safeguarding procedures were now in place and some staff had completed training in the safeguarding of adults. Staff understood how to make sure people were safe and protected from abuse.

Deprivation of Liberty Safeguards makes sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom. The safeguards should ensure that a care home only deprives someone of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them. Some staff had attended training in this area and the process they need to follow to make applications. This meant that people were safeguarded against inappropriate restrictions on their liberty and ensured they were safe.

At the inspection in February 2014 we found concerns with how people's medication was being managed. At this inspection we found some improvements but more work was needed to make sure people received their medication in a safe manner. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the management of people's medication.

Is the service effective?

One person told us their care varied each day depending which staff were on duty and another person told us it was ok. One relative told us: 'you wouldn't get better care anywhere else and the staff were excellent.' Two other relatives said they had some concerns about the care of their relative.

Care records had improved since the last inspection and now were based on the person's assessment of need. They also reflected their wishes and preferences about how they wanted to be supported. Two relatives told us they had been involved in the care planning process on behalf of their relative.

Monitoring of people who were assessed as being nutritionally at risk had improved and a new system had been implemented that included informing the kitchen and the person's GP.

Is the service caring?

We observed staff treating people respectfully, with kindness, patience and gave encouragement when supporting them. People were also offered choices about the way their care was delivered. A relative said: "the staff are excellent.'

People's preferences, interests and diverse needs had been recorded. Because of this care and support was provided in accordance with people's wishes.

Is the service responsive?

A complaints system was in place but staff told us there were no specific forms to document complaints when the new manager was not at the service. We found that all complaints had not been logged in the complaints file. One relative told us their complaint had not been investigated or the outcome reported back to them. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation obtaining the views of people or those acting on their behalf.

Is the service well led?

A new manager had started at the service since our inspection in February 2014. Two relatives told us they had: 'no faith in the management of the service.' Another relative told us that: "if they had any complaints or concerns they had confidence that the management of the service would address these.'

Changes had been made to the quality assurance system since our inspection in February 2014. We found improvements were still needed to their auditing system and we asked the provider to tell us what they are going to do to meet the requirements of the law in relation to their quality assurance system.

The service worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision and service development.

We found care plans and risk assessments were not detailed about people's individual needs and they lacked clear guidance for staff to follow. Where people had health needs that required monitoring this had not always happened.

Safe and appropriate arrangements for the management of people's medicines were not in place.

We found the provider did not have a system in place to protect people from abuse. We found several incidents where people had been at risk of abuse but local protocols for reporting this to the appropriate authorities had not been followed. The provider had a system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others. But it was not effective in meeting their actions and timescales.

At the time of our inspection the provider did not have a registered manager in post.