The inspection was carried out by one inspector to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.
If you want to see the evidence that supports our summary please read the full report.
Is the service safe?
People told us they felt safe and secure.
The provider and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Although no DoLS applications had been made, staff were able to describe the circumstances when an application should be made and knew how to submit one.
People's care plans were person centred and detailed how the person wanted their needs to be met. Risk assessments identified risks associated with personal and specific health related issues, and recorded guidance for staff to minimise those risks. However, people whose fluids were being monitored were at risk of dehydration because staff could not be sure that the records for the purpose of assessment were accurate. The provider had taken immediate steps to ensure this area of non-compliance was resolved immediately.
Medicines were prescribed and given to people appropriately and were kept safely.
We inspected the staff rotas which showed that there were sufficient staff on duty to meet people's needs throughout the day. However, we had found there was not enough staff to support people at mealtimes. The provider took immediate action to be compliant so that people received a consistent and safe level of support.
We saw that the home was clean and well maintained. All the people we spoke to told us that this was always the case. Equipment was well maintained and regularly serviced and all health and safety records were up to date. These checks meant that people were not placed at unnecessary risk
Procedures for dealing with emergencies were in place and staff were able to describe these to us.
Is the service effective?
People were involved in their care planning and knew what actions would be taken to support them.
People we spoke with who lived in the home told us: 'there's always something to do' such as 'coach trips and quiz nights'. One-to-one activities were provided for people who remained in their room due to ill health or choice.
People's preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. People's individual interests were identified and used to enhance people's lifestyle.
Is the service caring?
People we spoke with who lived in the home told us they were supported by kind and patient staff. We saw that care staff interacted positively with people who used the service. We saw that they were sensitive to people's moods and needs and mostly approached them in a respectful and appropriate manner.
We told the provider that staff had not been respectful to a person's calls for assistance in the dining room. The provider had taken immediate action to improve staffing levels at meal times. This meant that staff were less hurried and were able to respond and respect people's wishes at all times.
People we spoke with who lived in the home told us staff were considerate and kind. They told us: 'staff are marvellous' and 'staff are good, they try hard without exception'.
Is the service responsive?
People completed a range of activities in and outside the service regularly. Each person had an individual weekly activities plan, which met their current needs.
The home had made changes and improvements as a result of ideas and discussions with people who live in the home and their relatives.
People knew how to make a complaint if they were unhappy. People told us they knew who to complain to and that the manager and staff were approachable. The home recorded four complaints during the last 12 months and these were investigated.
Is the service well-led?
The service had a robust quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was being maintained or improved.
Staff told us that they had the support of a manager and could get assistance from senior managers, as necessary. We saw that the home had a stable staff group who had worked in the home for a number of years. However there had been some recent staff and management changes with the home. Staff told us that they worked well as a team and were provided with guidance and support in line with the provider's policies and procedures.
People we spoke with who lived in the home, their relatives and staff told us that some changes had taken place following the resignation of the registered manager and deputy manager. The reason for their resignation was unrelated. They told us that although the new manager was very approachable they also missed the previous manager and their style of management. The new manager told us that they would be submitting an application to the commission to become the registered manager of the home.
In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register.