Archived: Sunrise Care Home

Sunrise Care Home is a residential care home registered to provide personal care for up to 20 older people, some of whom are living with dementia. At the time of the inspection 15 people were living in the home.

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

The provider continued to fail to have sufficient systems and oversight to assess, monitor and mitigate the risks relating to the health, safety and welfare of people. The provider had not made enough improvement since the last inspection to ensure people were protected from risks associated with the safety and management of fire, water, food, substances that could be hazardous to health (COSHH), medicines and environmental risks. People living with dementia were exposed to unnecessary risks.

The provider failed to ensure staff had access to and follow current government guidelines for the prevention and control of infection. This placed people and staff at continual risk of being exposed to and acquiring infections including COVID-19.

There were not enough staff employed to meet people’s needs. The manager and care staff carried out multiple roles; there were not enough staff to provide personal care. People did not always receive their personal care as planned or have staff available to them to administer their medicines as prescribed. The provider failed to ensure staff followed national guidance when administering medicines.

The provider failed to learn from safeguarding, complaints, accident or incidents to use these experiences to improve the service.

Most staff had received training; new staff required further training and checks on their competence to ensure they were following the provider’s policies and procedures.

People were supported to maintain a balanced diet. However, not all risks had been mitigated to prevent the risk of choking.

Improvements had been made to the decoration and maintenance of the home. Flooring had been replaced in the communal areas and bedrooms and bathrooms had been refurbished. More improvements were required to create an environment which was more dementia friendly.

People’s risk assessments and care plans had been recently updated. Staff had the information they needed to mitigate the known risks. Staff received a comprehensive handover about people’s current needs.

Staff knew how to recognise the signs of abuse and who to report their concerns to. Staff had raised their concerns with the manager who raised safeguarding alerts appropriately.

Staff were skilled in taking clinical observations and referring people to medical services when people’s conditions deteriorated.

The provider was not meeting the requirements of the Accessible Information Standard. People living with dementia did not have access to information in mediums they could access.

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 Inadequate (published 20 April 2021).

Why we inspected

The inspection was prompted in part due to concerns received about the staffing levels, safety and managerial oversight demonstrated in the monthly action plans to the commission. A decision was made for us to inspect and examine those risks.

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.

At the last three inspections the provider was in breach of regulations relating to safe care and treatment and managerial oversight. We imposed conditions on their registration which required them to provide monthly action plans to show what they were doing to implement and sustain improvements.

At this inspection enough improvement had not been made and the provider was still in breach of regulations. We have identified three breaches in relation to safe care and treatment, staffing and management oversight.

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

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

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.

This service has been in Special Measures since 24 March 2021. During this inspection the provider did not demonstrate that improvements have been made. The service remains rated as inadequate overall. Therefore, this service remains in Special Measures. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Sunrise care home is a residential care home providing personal care to 17 people aged 65 and over at the time of the inspection. The service can support up to 20 people.

The home is set out across two floors with a communal lounge, dining room and conservatory. People’s rooms have en-suite facilities.

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

Medicines were not consistently managed safely. We were not reassured that people received their medicines as prescribed or that medicine stock was managed safely and effectively.

Risks to people and risks in the home environment had not consistently been identified and mitigated. The providers systems and processes had not identified all of the issues found during the inspection and lessons had not always been learned from previous inspections and local authority audits.

Infection control was not always well managed and required improvement to ensure people were well supported with personal and oral hygiene. Risks from water born infection and COVID-19 were not consistently mitigated.

People were not consistently supported to have maximum choice and control of their lives and we were not reassured staff supported them in the least restrictive way possible and in their best interests as the policies and systems in the service did not support this practice.

People had not been involved in the planning of their care but felt staff knew them well and they were happy with the care they received. People had been encouraged to join a meeting where they had shared ideas and suggestions which had been implemented.

Staff spoke highly of the manager and felt they were able to share ideas and raise concerns. A recent staff supervision for all staff had taken place. Supervisions were scheduled to take place regularly going forward.

The provider had a complaints procedure in place and the manager understood the need to be open and honest if things went wrong.

Staff were recruited safely, and checks were in place to ensure they were suitable for the role. There had been a recent increase in staff numbers for some shifts. We have recommended that staff numbers are reviewed to ensure people’s needs are met across all shifts.

People were protected from the risk of abuse. Staff had received training and knew how and where to raise concerns.

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

This service was not rated at the last inspection as we only looked at infection control measures within the service. We identified breach a of regulation during this inspection and a report was published. (published 15 January 2021).

The last rating for this service was requires improvement. (published 2 October 2020). This service has been rated requires improvement for the last three consecutive rated inspections. The service remains rated requires improvement.

The provider completed an action plan after the last rated inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We undertook this focused inspection to check whether the Warning Notice we previously served in relation to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met on a specific concern we had about infection control. We also checked they had followed their action plan from the last rated inspection and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sunrise 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 the safety and management of the service at this inspection.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

Sunrise Care Home is a residential care service registered to provide personal care for up to 20 people. On the day of our inspection, the service was supporting 14 people. Some people using the service, were living with dementia.

The home is set out across two floors with a communal lounge, dining room and conservatory. People’s rooms have en-suite facilities.

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

Infection control was not always well managed. We found that clinical waste disposal procedures did not consistently follow government guidance. Cleaning records were not always completed to evidence good cleaning practices were taking place.

Staff putting on and taking off (donning and doffing) of PPE whilst supporting people who were isolating did not follow current government guidance. Systems and processes to prevent visitors from catching and spreading infection needed improvement. Individualised risks to people living in the service had not been assessed and mitigated.

We found the following examples of good practice.

Staff had access to personal protective equipment (PPE) and hand sanitizer was available throughout the service.

Staff had received training in infection control and competency checks had been completed to ensure staff understood the importance of good hand hygiene and the appropriate use of PPE.

Staff and people received regular COVID 19 testing.

Staff supported people to maintain contact with their family and friends by telephone and via window visits.

The provider followed government guidance on the admission of people into the home. New admissions were tested for COVID19 test and were isolated for a period of 14 days to mitigate the risk of transmission.

Staff supported people to social distance in communal areas. Staff had a good understanding of signs and symptoms to monitor regarding COVID 19 and people were monitored daily for a raised temperature.

The provider supported staff by providing access to online courses to help them manage their wellbeing.

Risks to staff had been assessed. The provider had audited staff files and spoke with staff to ensure any conditions or associated risks were considered.

Further information is in the detailed findings below.

Rating at last inspection

The last rating for this service was requires improvement (published 2 October 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted due to concerns received about infection control. A decision was made for us to carry out an infection control inspection and examine those risks.

We have found evidence that the provider needs to make improvements.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Sunrise 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 infection control at this inspection.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection program. If we receive any concerning information we may inspect sooner.

Risks to people had not consistently been mitigated. We identified concerns around fire safety and infection control. Peoples individual risk assessments were not reviewed regularly to ensure the information was current and relevant in mitigating risk.

The provider and management team had not consistently maintained effective oversight of the safety and quality of the service and lessons had not consistently been learnt when things went wrong.

Medicine records were not consistently completed to ensure people received their medicines as prescribed. Medicines were stored safely and were administered safely by senior members of staff.

Some improvements were required to the recruitment process to ensure staff were recruited in line with current legislative requirement. Criminal record and barring checks were completed. There were enough staff available to meet people’s needs and people and their relatives spoke positively of the staff and management team.

Staff knew people well and demonstrated a person-centred approach to care that supported choice and decision making but relatives did not consistently feel involved in the planning of care.

Improvements were required in record keeping for people to ensure oversight of people’s health and to allow for early recognition of a decline of health. There was evidence of partnership working with professionals to support people’s healthcare needs.

The home was not consistently clean and was visually unkempt. Further refurbishments were required to ensure a homely environment.

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; however, the policies and systems in the service did not support this practice. Deprivation of liberty safeguards had not consistently been applied for. Mental capacity assessments were not completed and best interest decisions were not recorded.

People were protected from the risk of abuse. People and their relatives knew how to raise concerns or make a complaint if needed.

PPE (personal protective equipment) was readily available, and staff used this appropriately.

People, staff and relatives spoke highly of the provider management team. Staff told us they felt well supported.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 19 February 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about infection control and people’s safety. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

During the inspection the provider took action to mitigate some of the risks, further improvements were needed to ensure risks all were mitigated.

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 the safety and managerial oversight of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan 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.

Sunrise Care Home is a residential care service that was registered to provide personal care for up to 20 people. On the day of our inspection, the service was supporting 14 people. Some people using the service, were living with dementia.

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

No registered manager was in post during the focused inspection at Sunrise Care Home, but the provider and deputy manager were working closely together to manage the service until an appropriate registered manager could be recruited.

The provider was open and transparent throughout the inspection. Whilst some improvements had been made, these need time to become embedded and sustained so they become part of normal practice.

We have made a recommendation about the submission of CQC notifications.

People told us they received safe care. Staff we spoke with understood safeguarding procedures and were trained in this area.

The provider had improved their systems to ensure people were protected from avoidable harm. Risk assessments were in place to manage risks within people’s lives, and staff understood how to follow them and provide safe care to people.

The provider had undertaken a programme of refurbishment to modernise the facilities for people being cared for at Sunrise Care Home. Improvements had been made to the infection control of the service.

The service was clean, tidy and well maintained, and people confirmed that staff followed infection control and food hygiene procedures effectively. The management team had an overview and cleaning schedules were in place.

Staff recruitment procedures ensured that appropriate pre-employment checks were carried out.

Medicines were stored and administered safely.

Staffing support matched the level of assessed needs within the service during our inspection, and people we spoke with said that staffing levels were sufficient.

The management team continued to work in partnership with outside agencies to improve people’s support when required. Audits of the service were in place and were detailed. Any issues found were addressed promptly.

Staff felt supported by the deputy manager and responsible person. Staff had received formal supervisions, to ensure they were supported.

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 23 October 2019) and there were multiple 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 and the provider was no longer in breach of regulations. However, we would need to see a consistent level of sustained good care before changing the rating.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 7 and 8 August 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve Safe care and treatment, Good governance, Premises and equipment and Receiving and acting on complaints.

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 Safe and Well-Led which contain those requirements.

The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same, 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 Sunrise Care Home on our website at www.cqc.org.uk.

Enforcement

Since the last inspection we recognised that the provider had failed to notify CQC of the departure of the registered manager, the provider had also failed to display their rating on the provider’s website. These were breaches of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

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

The provider did not have robust systems in place to ensure people were protected from avoidable harm. Risks to people's health and safety were not always assessed and managed. Investigations into incidents and accidents were not always analysed to learn lessons and prevent future occurrences.

Some people, relatives and staff raised concerns that the service needed some redecoration. We found the service was undergoing a programme of refurbishment. The environment was not always kept clean and was not dementia friendly. The providers complaints procedure was not clear and there was no evidence to demonstrate how the provider appropriately deals with complaints.

Arrangements were in place for the safe administration of medicines, however the medicine management system was not always safe. End of life care was provided in close consultation with specialist agencies; people were supported to access to a range of local healthcare services. Relatives were complimentary about the quality of care provided by the staff.

There were suitable numbers of staff, who were recruited safely and in line with current legislation. Staff were undertaking mandatory training, staff told us they had enough training to meet people's needs. Consent to care was sought and recorded. Daily activities were organised which some people enjoyed. However further action was needed to ensure people were not at risk of isolation and lacked meaningful engagement.

Initial assessments were undertaken which reflected choices and needs. The person receiving support, was supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff felt supported by the acting manager and seniors, however formal supervisions and staff appraisals were not consistently taking place to ensure staff were supported. The service had established links in the local community and worked in partnership with key organisations including local authorities and other agencies to improve the service for people. Staff at the service worked with health and social care professionals to ensure good outcomes for people.

No registered manager was in post, but an acting manager had been at the service since January 2019. The acting manager was open and transparent throughout the inspection. Whilst some improvements had been made, these need time to become embedded and sustained so they become part of normal practice. There was a failure to meet the regulations.

Rating at last inspection: The last rating for this service was Good (published 4 March 2017).

Why we inspected: This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

During the inspection the provider made some improvements that were effective to mitigate some of the risks identified and improvements are still ongoing.

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

Enforcement

We have identified breaches in relation safety, complaints and governance.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

At the last inspection, the service was rated ‘Good’; at this inspection we found that the service remained ‘Good’.

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

People were kept safe by sufficient numbers of conscientious staff that knew their job. They had the skills and training they needed to care for older people with a range of predominantly age related needs, such as dementia and physical frailty. Staff were compassionate and kind as well as knowledgeable about people’s individual needs. Staff were supported through regular supervision and undertook training which helped them to understand the needs of the people they were supporting.

People were safeguarded from harm and poor practice by care staff that knew what action they needed to take if they suspected this was happening. There were appropriate staff recruitment procedures in place to protect people from receiving care from staff that were unsuited to the job.

People’s care needs had been assessed prior to admission and they each had an agreed care plan. Their care plans had been reviewed; reflected each person’s needs, and provided staff with the information they needed to be mindful of and act upon when caring for people. Care plans informed staff of people’s needs, their likes and dislikes and preferences. Risks were assessed and acted upon to minimise the likelihood of accidents. People were, however, supported in the least restrictive way. They were encouraged and enabled to do things for themselves and make choices in keeping with their capabilities so that they retained a sense of independence. People’s individual preferences for the way they liked to receive their care and support were respected.

People’s medicines were appropriately and safely managed. Medicines were securely stored and there were suitable arrangements in place for their timely administration. People’s healthcare needs were met in a timely way and they received treatment from other community based healthcare professionals when this was necessary.

People that needed support with eating and drinking received the help they required. They were provided with varied diet and enjoyed mealtime portions of food that suited their appetite and nutritional needs. Appropriate guidance from healthcare professionals qualified to advise on diet was sought and acted upon when required.

People, and where appropriate, their representatives or significant others were assured that if they were dissatisfied with the quality of the service they would be listened to and that appropriate remedial action would be taken to try to resolve matters to their satisfaction.

The quality of the service provided at the home was monitored by the manager on a day-to-day basis as well as over time using the quality assurance systems in place.

Sunrise Care Home accommodates and cares for up to 20 older persons with a range of mainly age related dependencies, including people with dementia care needs.

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

People benefited from being cared for by sufficient numbers of experienced staff that had received the training they needed to do their job safely. Staff knew what was expected of them when caring for older people, including those with dementia care needs, and they carried out their duties effectively and with compassion.

People’s care needs had been assessed prior to admission and they each had an agreed care plan. Their care plans were regularly reviewed, reflected their individual needs, and provided staff with the information and guidance they needed to do their job. People’s individual preferences for the way they liked to receive their care and support were respected. People were enabled to do things for themselves by staff that were attentive to each person’s individual needs and understood their capabilities.

People had enough to eat and drink and received the care they needed. People’s individual nutritional needs were assessed, monitored and met with appropriate guidance from healthcare professionals that was acted upon when required. People who needed support with eating and drinking received the help they required.

People’s healthcare needs were met and they received treatment from other community based healthcare professionals when this was necessary. People’s medicines were appropriately and safely managed. Medicines were securely stored and there were suitable arrangements in place for their timely administration.

People were safeguarded from abuse and poor practice by care staff that knew what action they needed to take if they suspected this was happening. There were appropriate staff recruitment procedures in place to protect people from receiving care from staff that were unsuited to the job.

People, and where appropriate, their representatives or significant others were assured that if they were dissatisfied with the quality of the service they would be listened to and that appropriate remedial action would be taken to try to resolve matters to their satisfaction.

The provider wrote to us and told us that they would be compliant by 04 November 2013 and have all the outstanding work to ensure the details in the warning notice had been complied with.

We visited with a specialist pharmacy inspector to ensure the provider had made improvements to the medication system. He found that the provider had complied with the warning notice and noted improvements to the storage, administration and risk assessments around medicines and judged the provider had improved the arrangements for the safe use and management of medicines.

We also noted improvements in the way that care plans and risk assessments were compiled. These were better detailed and had supplementary information which backed up and confirmed what staff needed to know when caring for people.

We also looked at the changes around quality assurance (QA) and how these had been implemented since our last visit. The provider had commenced using updated versions of a number of different forms used in the monitoring process. These are now used more effectively to monitor accidents and incidents, and inform planning for risks in caring for people.

Care plans and risk assessments had been updated but still require more work to enable staff to use these as a working document. Staff also need to look at the consistency of record keeping as we saw a number of discrepancies in the files we looked at.

We also looked at quality assurance and how this had been used to monitor the progress and changes since our last visit. We found that although the provider has introduced new QA initiatives these have been unsuccessful. This was due to the introduction of the forms being poorly thought through, lacked back up knowledge and operational know how.

We found there had been improvements in the recording of people's nutritional needs, meal choices, and the environment in and around the home and staffing.

When asked about the catering another person said 'the food is awful, you get a lot of sprouts' and 'I would like to see some homemade soup and stew on the menu', another person said 'it's (the food) mundane, lots of oven chips' and 'the pork today was nice, they give you too much'. Another person stated 'there are sandwiches most days for tea, a bacon sandwich would be a welcome change'.

We asked people about their care plan. No one we spoke with had seen or been involved in compiling or reviewing their care plan. We observed staff talking with and assisting people throughout the day, this was done with the peoples' privacy and dignity in mind.

We looked at how care planning and risk assessments are completed and noted improvements are required in both these areas. We noted improvements are also needed to the fabric and upkeep of the building and staffing numbers.

We also looked at how medicines are managed and noted that improvements are also needed to this area.