Prema Court

Prema Court is a residential care home providing personal and nursing care to 29 people with mental health needs at the time of the inspection. The service can support up to 44 people.

Prema Court comprises of two buildings, Brook House and Clifton House. Each person has their own bedroom, with shared lounge and bathroom facilities. Small kitchens are available in each building for people to use as well as a central kitchen and dining room. At the time of our inspection Brook House was being re-furbished, so all the people living at Prema Court were living in Clifton House.

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

A recovery model was being embedded at Prema Court to support people with their mental health. Nurses and care support staff were engaged with people to involve them in their care and support and work towards achievable goals and aspirations.

People’s care and support needs were assessed. Care plans and risk assessments were regularly reviewed and were up to date. Action was being taken to reduce the risk of people leaving Prema Court unaccompanied when they should have staff support. All incidents were recorded and reviewed to identify actions to reduce further occurrences.

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

People received their medicines as prescribed, with the service now using paper-based medicines administration records. The service worked closely with the GP surgery and pharmacist. There were enough staff on duty to meet people’s needs, Staff were safely recruited.

A quality assurance system was in place, with regular audits being completed and action plans written for any shortfalls identified. The area manager had oversight of the service through an electronic recording system and monthly audits.

Infection control procedures were in place and staff used PPE effectively. Additional cleaning had been introduced during the COVID-19 pandemic. A visitors pod had been built to enable relatives to visit safely.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 13 June 2019) and there were four breaches of 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 regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 30 April 2019. Four 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, person-centred care, good governance and the notification of incidents to the CQC. We had also received concerns in relation to the management of risks, including people leaving Prema Court unaccompanied when they should have staff support, people not returning to the home after going out and the management of behaviours.

As a result, we undertook this focused inspection to review the concerns, 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, responsive and well-led which contain those requirements.

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.

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.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection. We found no evidence during this inspection that people were at risk of harm from the concerns that had been raised with us. Please see the safe, responsive and well-led sections of this full report. Action had been taken to reduce the risk of people leaving the home unaccompanied or not returning to the home after going out.

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

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.

Prema Court is a 'care home' that provides both residential and nursing care. The service can provide care for up to 44 people in two buildings called Clifton House and Brook House. There were 33 people with mental health needs who used the service at the time of our visit.

At the last inspection we rated the service as inadequate and was placed in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection this service demonstrated to us that improvements had been made and is no longer rated inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

People's experience of using this service:

Although we found sufficient staff on duty, it was not always evident staff were deployed to meet the needs of the service to support the providers recovery model. We recommended staffing numbers be revisited. Furthermore, we noted the service was reliant on agency nursing staff at the service. The provider was actively looking to recruit new nursing staff, with one new nurse due to start at the service.

Although some aspects of the medicines systems had improved, we found further work was needed to ensure people received their medicines safely.

At our last inspection we found that Prema Court was not supporting people to become independent; this was partially due to there being no distinctive recovery model of care used at the service. At this inspection we found limited progress had been made.

People could choose how to spend their time and to access the community independently if they wished. However, during our inspection we noted that there was a lack of activities for people to engage with within the service.

Staff understood how people consented to the care they provided and encouraged people to make decisions about their lives. Care plans reflected that care was being delivered within the framework of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards had been applied for when necessary.

The management and staff understood their obligations under the Mental Health Act 1983 and worked within these legislative frameworks. Staff had received training in mental health awareness and were fully informed of any changes at team meetings to ensure they continued to provide care within the law.

We found the meal time experiences on Brook House and Clifton House varied. We found elements of the mealtime experience had improved particularly on Clifton, but further work was needed to improve the mealtime experience on Brook House. We have made a recommendation the provider develops and monitors this area further.

Staff regularly reviewed people's health. Staff responded to changes in people's needs by making appropriate referrals to their GP or other healthcare professionals. However, for two people we found their medical appointments were not always recorded by staff, which meant we could not be satisfied people were always supported with their medical appointments.

Risks associated with people's care had been comprehensively assessed and plans of care were in place for the staff team to follow.

People told us that they were well cared for and in a kind manner. Staff knew the people they were supporting well and understood their care needs. People were treated with dignity and respect and involved in planning and making decisions about their care.

The provider had a procedure for managing any complaints. Information was not on display in an easy read format to help people with additional learning needs.

The registered manager was aware of their regulatory responsibilities. The registered manager notified CQC of events and incidents that occurred in the home in accordance with statutory requirements. However, we found one incident had not been report to CQC or the local safeguarding authority in a timely manner.

There were a number of quality audits at the service; these included medicines, care records, infection control and health and safety. Actions were identified following the audits completed. We saw plans were in place to improve the care records and refurbishment of the premises. However, we found limited progress to implement a recovery model, as this had not progressed since our last inspection. Improvements in the level of activities varied and aspects of recording keeping was inconsistent. Furthermore, we still identified persistent medicines issues that had not been resolved by the management team.

Rating at last inspection:

The service was last inspected on the 4 and 5 October 2018 (report published 13 November 2018) when the overall rating for the service was ‘Inadequate’ and the service was therefore in ‘special measures’ and kept under review. At this inspection we found the registered provider had addressed a number of shortfalls effectively, which meant the service was no longer in special measures. However, we still noted further improvements were required.

Following our last inspection, we took enforcement action against the registered provider and manager. This included serving a Notice of Proposal (NoP) to cancel the registration of the service. The provider put forward representations to the Commission (CQC) in respect of the NoP to cancel the registration of the service and the decision taken by CQC was to withdraw the NoP to cancel the registration of Prema Court. A Notice of Decision (NoD) was served against the previous registered manager, which meant their registration was cancelled.

Why we inspected:

This was a planned, comprehensive inspection based on the rating at the last inspection.

Enforcement:

Full information about CQC's regulatory response to the more serious concerns found in

inspections and appeals 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 re-inspection programme. If any concerning information is received we may inspect sooner.

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

Prema Court is a ‘care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Prema Court is owned and operated by Deepdene Care Limited and is registered with CQC to accommodate up to 44 people. At the time of this inspection, 33 people were living at the service with enduring mental health needs.

Accommodation is arranged over two units; Clifton House and Brook House, which were formally registered as a hospital. In April 2017 the provider made changes to their registration and service delivery, as Clifton House incorporated Brook House Hospital as part of their registration. This location is now called Prema Court. Brook House is a specialist unit within Prema Court providing nursing care and rehabilitation support for up to 12 adults experiencing high and complex mental health needs.

Our last inspection of Clifton House took place on 11 and 12 July 2016, when we rated the service good, with the well-led domain rated requires improvement.

At this inspection we identified seven breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We have made three recommendations.

You can see what action we told the provider to take at the back of the full report. We are currently considering our options in relation to enforcement in response to some of the breaches of regulations identified. We will update the section at the back of the inspection report once any enforcement work has concluded.

The service had a registered manager who had been in post for over seven years. 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. The registered manager was also supported by a deputy manager.

The premises were not maintained to a safe standard. During our tour of the premises we found the fire exit in the dining room was open, which led to an unsecure garden area, this potentially compromised people’s safety. A small number of people were under restrictions and were not free to leave the home independently, however the fire exit leading to an unsecure garden meant the provider could not assure people’s safety.

We noted some areas of the home that would benefit with being refurbished or re-decorated. The décor around the home appeared tired; the paintwork was scuffed and the carpets in high traffic areas of the lounge and downstairs corridor were showing signs of wear and discoloration. We discussed this with the registered manager who acknowledged our observations, but did not provide assurances that the home would be refurbished going forward.

The management of medicine was not always safe which put people at risk. The records about the stock and administration of medicines were kept electronically. When audits were done using these records they did not evidence that medicines were always administered as prescribed or could be properly accounted for.

Staff were not always working within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Information about people's care was not always being communicated effectively between staff.

The home did not comply with either the Mental Health Act 1983. We found there was an inconsistent approach detailing people’s Community Treatment Orders (CTO’s). We found several CTO’s that had expired and the provider had not been proactive at making sure these orders were still relevant.

Care plans were not always detailed and lacked guidance around people's diagnosis. The service had not ensured people’s care plan reviews were clearly signed by the person to confirm their involvement. Action to fully meet the accessible information standard were not always in place to provide assurances people's communication needs would be met.

There was a robust recruitment processes, safe levels of staff that were always maintained, and staff protected people from the risk of abuse. There was a business continuity plan in place for staff to follow in the event of an emergency.

We received mixed views on the food and found the dining experience could be improved. People were supported to maintain their health and had access to health care professionals.

People told us staff were caring. We found that staff had a good understanding of people’s likes and preferences. However, we observed staff not always taking the opportunity to interact outside of providing support with a task.

Everyone we spoke with was happy with the activities and events provided.

Before people moved in to the service a full assessment of their needs took place. However, we found the provider did not complete this process for one person.

Complaints were recorded and responded to. People were supported with their health needs and had access to a range of health care professionals.

There was a lack of systems to monitor and improve the quality of the service. We found governance systems were incomplete and not sufficiently robust to ensure best practice was followed and compliance with regulations.

The overall rating for this service is 'Inadequate' and has been placed into 'special measures.'

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not, enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

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

Clifton House provides care and accommodation for up to 32 people with enduring mental health needs. At the time of our inspection there were 28 people living in the home. People were supported in one building over three floors. All 32 bedrooms were single occupancy and 11 had an en-suite toilet. Each floor had one or two communal bathrooms, a shared lounge and shared kitchen facilities. A sheltered smoking area was provided in the garden.

Our last inspection took place on 05, 06, 07 and 25 January 2016. At that time we rated the service as inadequate overall and for safe, responsive and well led. We rated the effective domain as requires improvement and caring was rated as good. As the previous inspection in January 2016 had rated the service as inadequate overall, we placed the service into ‘Special Measures’ because it was inadequate in three of the five domains.

At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall and good in caring, with no inadequate domains. This meant the service could come out of special measures.

We could not improve the rating from requires improvement because the provider needs to demonstrate that it can sustain improvements and consistently good practice over time. We will check this during our next planned comprehensive inspection.

The service had a registered manager who had been in post for over five years. 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.

At the last inspection in January 2016 we found that support workers had not received the right training to ensure they provided care and treatment safely. This included training on how to manage people who may present behaviours which challenge. At this inspection we found all staff had received key mandatory training in areas such as safety and breakaway.

At the last inspection in January 2016 we found the registered manager had not reported all incidents to CQC as is required by the regulations. At this inspection we found systems had been developed to ensure incidents were reported to CQC in a timely manner.

At the last inspection in January 2016 a gas cooker was in use for nearly three months after it had been deemed unsafe to use by a gas engineer. The premises were not clean and various items of equipment and facilities, such as a washing machine and the lift, were out of use and had been for some time. At this inspection we found the kitchen had been upgraded in terms of cookers, ventilation and gas safety equipment and had been certified as fully compliant. Robust cleaning schedules had been introduced and we found all areas of the home clean and tidy.

At the last inspection in January 2016 support workers did not receive regular supervision and appraisal. Records showed that more than half of the regular support workers had not had supervision in 2015. At this inspection we found the provider had developed a new system ensuring staff received regular supervisions and appraisals.

At the last inspection in January 2016 we found that Clifton House was not supporting people to become independent; this was partially due to a lack of staff. We also found that care plans did not include people's goals and aspirations. At this inspection we found evidence that this had improved and people living at the home confirmed this. We also found that people’s care plans were person centred and people benefited from the services provided by the recovery team.

At the last inspection in January 2016 we found the home did not comply with either the Mental Health Act 1983 or Mental Capacity Act 2005. Staff knowledge of both sets of legislation was mixed and documentation showed that people were not being assessed or supported properly. At this inspection we found improvements had been made. The staff we spoke with had a good understanding of the Mental Health Act 1983 and Mental Capacity Act 2005 and were aware of which people living at the home had restrictions in place. We also noted that care plans had been developed to ensure people under any restrictions were being assessed and supported in line with their care plan.

At the last inspection we found effective systems for regularly assessing and monitoring the quality of service people received was lacking. At this inspection we found this had significantly improved.

Medicines were ordered, stored, administered and disposed of safely.

People using the service had access to a range of individualised and group activities and a choice of wholesome and nutritious meals.

Records showed that people also had access to GPs, chiropodists and other health care professionals (subject to individual need).

We found that there were enough support workers on duty to help people meet their basic needs, alongside the input from the recovery team to support people in their recovery or rehabilitation.

A process was in place for managing complaints and the home's complaints procedure was displayed so that people had access to this information. People and their relatives told us they would raise any concerns with the manager.

Clifton House provides care and accommodation for up to 32 people with enduring mental health needs. At the time of our inspection there were 26 people living in the home. People were supported in one building over three floors. Nine people lived on the ground floor, eight people lived on the first floor and seven people lived on the second floor. All 32 bedrooms were single occupancy and 11 had an ensuite toilet. Each floor had one or two communal bathrooms, a shared lounge and shared kitchen facilities. There was a lift to all floors; however, it was out of order during our inspection. A sheltered smoking area was provided in the garden.

Clifton House had a registered manager. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

Our last inspection took place on 30 September 2014. At that time the service was not meeting all the legal requirements. During this inspection we checked to see if improvements had been made.

At this inspection we found that support workers had not received the right training to ensure they provided care and treatment safely. This included training on how to manage people who may present behaviours which challenge.

The registered manager had not reported all incidents to CQC as is required by the regulations. A representative of the provider said that the home would review and improve their notification procedure.

A gas cooker was in use nearly three months after it had been deemed unsafe to use by a gas engineer. The premises were not clean and various items of equipment and facilities, such as a washing machine and the lift, were out of use and had been for some time.

Support workers did not receive regular supervision. Records showed that more than half of the regular support workers had not had supervision in 2015.

At our last inspection we found that Clifton House was not supporting people to become independent; this was partially due to a lack of staff. We also found that care plans did not include people’s goals and aspirations. At this inspection we could find no documented evidence that this had improved and people living at the home said it had not. We also found that people did not have support plans for all of their identified needs, for example, learning disabilities or continence issues.

The home did not comply with either the Mental Health Act 1983 or Mental Capacity Act 2005. Staff knowledge of both sets of legislation was mixed and documentation showed that people were not being assessed or supported properly.

At the last inspection we found effective systems for regularly assessing and monitoring the quality of service people received was lacking. At this inspection we found this had not improved.

The registered manager was focused on supporting the people and lacked oversight of the home. He acknowledged this during the inspection and made a commitment to improving his overall management of the home.

We found breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Most aspects of medicines management were done well at the home; however, we found people’s topical creams and lotions had not been dated upon opening so there was a risk expired medicines could be used. We recommended that the home reviews and improves current practice in line with nationally available good practice.

We found that there were enough support workers on duty to help people meet their basic needs, but not enough to support their recovery or rehabilitation.

Staff meetings were not held regularly and were not well attended. Meetings that had been held in 2015 had focused on staff issues rather than the people and their care.

People told us they felt safe. Most staff had received safeguarding training, could describe the different types of abuse and said they would report any concerns. The registered manager made sure all the necessary checks were done on new staff before they were employed at the home.

People’s feedback on the food served at the home was mixed. The cook knew people’s likes and dislikes and undertook surveys so that the menu could be changed according to people’s feedback.

Support staff helped people to book appointments and accompanied them when they needed it. We saw from records that had access to GPs, podiatrists, dentists, social workers and mental health specialists.

People and their relatives told us that the care staff were caring. Support staff we spoke with could tell us details about people’s personal histories and their likes and dislikes. We saw warm and caring interactions between support workers and people during our inspection, as well as humorous banter on both sides.

People had access to advocacy services if they needed them. The registered manager told us that the home would provide end of life care when needed and had previously spoken to one person about their wishes in this regard.

The complaints procedure was displayed in the home although no people or their relatives said they had ever made a formal complaint. People, their relatives and staff told us they liked the registered manager and found him both approachable and supportive. Relatives were happy with the way the home communicated with them.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary, please read the full report.

This is a summary of what we found:

Is the service safe?

People who used the service and relative told us they felt safe at the home. People made comments such as, "Yes I feel safe" and "The staff keep an eye on everyone". The four people we spoke to told us they felt respected by the staff at all times.

We spoke with three staff, two told us that they felt the staffing levels were insufficient to meet people's needs. Staff told us that they often had to attend to emergencies or support people with behaviour that challenged the service. Staff told us they were required to diffuse situations which required them to give people one to one attention. This lead to one less person on the floor for some time and being under staffed, putting people who used the service and staff at risk.

Is the service effective?

We saw the service was not adequately effective in supporting the people to develop goals and work towards their future. When reviewing peoples' independence it was found there was insufficient evidence to show the provider was encouraging and working with people to assist them in gaining life skills and making them more independent.

Is the service caring?

Clifton House operated a key worker system that allowed people to build positive relationships with their key workers who provided them with one to one sessions. The provider may like to note, the four people we spoke with who used the service all told us they felt they needed more one to one sessions and activities to do during the day. They all said they were very happy with the staff and treatment provided. The people we spoke to told us the staff we 'Very good' and 'Great.'

Is the service responsive?

We saw that the manager conducted monthly 'residents meetings' to discuss the menu and trips out. We saw that people were all happy with the menu on the previous monthly meeting. The four people we spoke to said the food was 'Very good' and 'Excellent'. We saw that trips had been suggested previously and these trips had been undertaken. Although the provider might like to note, people told us there were not enough activities. People had not made suggestions to improve the service during this meeting. The provider did however offer them a private and confidential way of leaving suggestions which was through a suggestion box near the entrance.

We saw that a care plan audit had been undertaken through an action plan which informed staff that they had to be more vigilant about signing entries made into the care files. There was no template for the audit so it was unclear what had been reviewed when the audit was undertaken. The manager told us they completed a medication audit however this was a stock check. We saw all stock was accounted for.

Is the service well-led?

The manager lead a monthly staff meeting in which they discussed any ongoing issues with any people who used the service, trips out, any incidences, root cause analysis and improvements for next time. The minutes of the meeting were too vague to see what staff had suggested as trips and any improvements. We were unable to determine if the manager responded to staff suggestions.

We asked people who lived at the home and staff about the manager and their ability to deal with concerns. They all felt the manager dealt with any issues very promptly and everyone we spoke with gave positive comments about their management style and personality for example, "He is always available" and "Good manager".

People living at Clifton House told us: 'It is welcoming and caring, they (staff) prompt and encourage you.' 'It is not my choice to be here, but while I am it is OK, I have seen my care plan and staff listen to me.' 'Staff support me in the community as I struggle to walk.' 'As part of my plan for independence I am supported to cook my own meals.' 'I have more motivation here than when I was living in my own house, I was isolated.' 'I have a more positive attitude here, you see other people who live here going out and participating in the community. I have a very positive relationship with staff and other residents.'

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. In the three care plans we sampled consent was clearly documented, we noted that people had signed a consent form.

Staff received appropriate professional development, and had support to gain a Diploma in Health and Social care. We noted that eight staff were enrolled on the level three diploma and one member of staff enrolled on the Level five.

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on

We found that care plans were incomplete in relation to recording signed consent and nutritional risk assessments and records of staff training and supervisions were not available during the inspection. Three members of staff told us that they had not received regular supervisions and appraisal or training in care planning.

Complaints and incident recording systems were robust and complaints and incidents occurring in the home had been managed appropriately.

Staff told us that minimum staffing levels had not always been maintained when support staff were absent due to sickness. Staff commented that this had a negative impact on meeting people's social needs, particularly if they needed an escort to access community activities. However, the provider confirmed that their minimum staffing levels had been maintained at all times.

We found that robust systems were in place to ensure that people using the service received their medicines exactly as prescribed by their doctors.