Cedar House

Cedar House is a nursing home for up to 42 older people. At the time of our inspection, 39 people were living at the service. The service is managed by HC-One Limited, an organisation providing care in over 300 care homes across the United Kingdom.

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

People were happy living at the service. They liked the staff and felt their needs were met.

People were safely cared for. They were given their medicines in a safe way. Risks were assessed, planned for, and mitigated.

Staff felt well supported and had the information they needed to care for people.

People’s care had been planned to reflect their needs and choices.

There were suitable systems for monitoring and improving the quality of the service, including dealing with complaints, investigating when things went wrong and learning from these incidents.

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 information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 22 February 2022).

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 25 January 2022. 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 person-centred care, safe care and treatment and good governance.

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, responsive and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. 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 Cedar House on our website at www.cqc.org.uk.

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.

Follow up

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

Cedar House is a nursing home for up to 42 older people. At the time of our inspection, 38 people were living at the service. The service is managed by HC-One Limited, an organisation providing care in over 300 care homes across the United Kingdom.

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

People did not always receive personalised care. For example, they did not always have opportunities for stimulating and personalised activities. Additionally, relatives told us people did not have showers as often as they would like.

The kitchen had not been properly cleaned presenting a health and safety risk.

Medicines management had improved, but further improvements were needed.

Systems and processes for monitoring and improving quality were not always effectively operated.

People using the service and relatives liked the staff and had good relationships with them.

Staff felt supported and happy working at the service. They had the training and information they needed, but they told us they did not have enough time to provide quality care.

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

The registered manager was experienced and qualified. Staff, people using the service and relatives felt able to speak with the registered manager and told us concerns were addressed. There had been improvements at the service including an improved culture and record keeping. The management team worked with the staff to learn when things went wrong and make improvements to the service.

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 rating at the last inspection was requires improvement (published 12 November 2020). This was a focused inspection looking at the key questions of 'is the service safe?' and 'is the service well-led?' only. The last comprehensive inspection where we looked at all key questions was in March 2020 (published 10 June 2020).

At the last two inspections, we identified breaches in relation to person-centred care, dignity and respect, need for consent, safe care and treatment and good governance. 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 in some areas, but the provider remained in breach of regulations.

This service has been in Special Measures since 10 June 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last 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. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service remains requires improvement.

We have found evidence that the provider needs to make improvements. Please see the safe, 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.

Enforcement

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

We have identified breaches in relation to person-centred care, safe care and treatment and good governance 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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Cedar House offers accommodation and personal or nursing care for up to 42 older people, some of whom are living with dementia. Accommodation is provided on the ground floor and first floor of a purpose-built building. There were 31 people using the service at the time of our inspection.

Cedar House is part of HC-One Oval Limited, a large organisation which owns over 300 care homes across the United Kingdom.

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

People’s needs were not always met. The provider sought advice from external professionals where people’s needs required this. However, staff did not always follow instructions from them or take prompt actions as advised.

Improvements have been made to the management of medicines, for example in relation to people who were given medicines covertly. However, further improvements were needed to ensure robust arrangements were in place to ensure people received their medicines safely.

Systems for monitoring the quality of the service, gathering feedback from others and making continuous improvements had improved, but had failed to identify the issues we found during our inspection.

Risks to people's health and wellbeing were assessed, and there were guidelines for staff to follow to deliver safe care to people who used the service. This included risks in relation to COVID-19.

There were systems in place to protect people from the risk of infection and cross contamination and staff had received appropriate training in this. There were good measures in place in relation to COVID-19 and staff adhered to guidelines.

There was a policy and procedure for the recording of incidents and accidents, and these were recorded and investigated appropriately. Lessons were learnt when things went wrong.

Staff were recruited safely and the provider had employed new care staff to fill all vacancies.

Staff felt supported by the management team and said they worked well together. There were regular staff meetings where all important information was shared. Issues raised were being addressed more consistently.

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 inadequate (published 11 June 2020) and there were multiple breaches of regulation. The service was placed in special measures as it was rated inadequate in the safe, caring and well-led key questions and overall. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

While some improvements have been made at this inspection, the provider was still in breach of regulations.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. During the inspection, we made the decision to widen the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

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 safe care and treatment, person-centred care and good governance 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.

The overall rating for this service is ‘requires improvement’. However, as the service is rated inadequate in the caring key question from the last inspection, we continue to place the service in 'special measures'. We do this when services have been rated as inadequate in any key question over two consecutive comprehensive inspections. The inadequate rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and we will re-inspect within six 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.

Cedar House offers accommodation and personal or nursing care for up to 42 older people, some of whom are living with dementia. Accommodation is provided on the ground and first floor of a purpose-built building. There were 32 people using the service at the time of our inspection, two of whom were in hospital.

Cedar House is part of HC-One Oval Limited, a large organisation which owns over 300 care homes across the United Kingdom.

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

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

Risk assessments and support plans were in place to help staff to deliver safe care to people. However, staff did not always follow these and we witnessed unsafe practices which put people at risk of avoidable harm.

People received their medicines as prescribed. However, staff did not follow the provider’s medicines policy in relation to medicines to be given ‘as required’, and medicines which were given covertly.

People were not always protected from the risk of infection and cross contamination. On the day of our inspection, there was a malodour which persisted throughout the day. Staff did not always follow the provider’s health and safety and fire policy and procedures and there were significant safety risks identified during our inspection.

People were not treated in a kind and dignified manner all the time. The staff worked in a task-focussed manner and did not always meet people’s needs or consult them in relation to what they wanted to do. Staff were not always aware of their needs. People’s communication needs were not always met.

The provider’s quality monitoring systems were inadequate as, although they had identified many of the shortfalls we found during our inspection several months ago, we found the service failed to demonstrate they were providing care and support that was safe, caring, effective or responsive. This put people at risk of harm.

There were few activities taking place on the day of our inspection, and the activities on offer did not meet people’s needs. The environment and the activities had not been developed to meet the needs of people living with dementia.

People’s nutritional needs were not always met and mealtime was not always a positive experience for people who used the service.

Care plans were developed from the initial assessments and contained enough information for staff to know how to meet people’s needs. However, staff did not always support people in line with their care plans.

Staff received training and had a basic knowledge of the principles of the MCA. However, they did not always consult people or give them choice. They did not always use the least restrictive options when supporting people.

The provider had recruited more staff to help ensure there were sufficient staff to meet people's needs.

Incidents and accidents were recorded and there were systems in place to learn from these to prevent the risk of reoccurrence.

People’s healthcare needs were recorded and met.

Staff received regular supervision and an annual appraisal. New staff received an induction and relevant training to help ensure they could provide effective care.

The service worked with other health and social care professionals who spoke well of them.

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 10 April 2019) and there were 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 enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safe care and treatment, need for consent, person-centred care, dignity and respect and good governance at this inspection.

We made a recommendation in relation to the environment.

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.

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.

Special Measures

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.

• Cedar House offers accommodation and personal or nursing care for up to 42 older people, some of whom are living with the experience of dementia. The accommodation is provided on the ground and first floor of a purpose-built building. There were 40 people using the service at the time of our inspection.

• Cedar House is part of HC-One Oval Limited, a large organisation which owns over 300 care homes across the United Kingdom.

People’s experience of using the service:

• We found that, although there were processes for auditing and monitoring the quality and safety of services people received, these had failed to identify the issues we had found in a timely manner so the provider could make the necessary improvements.

• Although some improvements had been made, some people stated there were not always enough permanent staff on duty, especially at weekends and during school holidays to provide continuity of care. The staff rota indicated all shifts were covered, although many by agency staff.

• People who required the use of hoists to mobilise did not have their own allocated slings. This meant there was a risk of cross contamination. There was a malodour in the downstairs unit which persisted throughout the day of our inspection.

• People who used the service did not always get the support they needed to eat, in line with their care plans. Therefore there was a risk some people did not receive enough food and drink to meet their nutritional needs.

• There were times when staff did not meet people’s needs in a person-centred way and were focused on the task they were required to complete. Some supported people without speaking with them or explaining what they were doing.

• The provider had processes for the recording and investigation of incidents and accidents. However, not all included actions taken to prevent reoccurrence and the lessons learned.

• People were supported by staff who were suitably trained, supervised and appraised

• There was evidence that people were offered a range of activities and an activity plan was displayed. The provider employed an activity officer who was planning to improve the provision of activities for people who used the service.

• Care plans were comprehensive and detailed. They contained all the necessary information about the person and how they wanted their care provided.

• Risk assessments were in place. These identified the risks that people faced and included guidelines for staff to follow to help ensure people were safe from harm.

• People’s healthcare needs were met because staff took appropriate action when concerns were identified.

• Medicines were safely managed. There were systems for ordering, administering and monitoring medicines. Staff received training in the administration of medicines and had their competencies checked.

• People’s end of life wishes were recorded in their care plans. These included their religious and cultural needs and where they wanted to receive care when they reached the end of their life.

• Recruitment checks were carried out before staff started working for the service and included checks to ensure staff had the relevant previous experience and qualifications.

• The environment was comfortable and homely and suited to the individual needs of people, such as people living with the experience of dementia.

• The provider acted in accordance with the Mental Capacity Act 2005 (MCA). Where people lacked the capacity to make particular decisions about their care, their mental capacity was assessed. Where necessary, people were being deprived of their liberty lawfully.

• Rating at last inspection: At the last inspection on 15 and 16 January 2018 the service was rated requires improvement in the key questions of ‘safe’, ‘caring’, ‘responsive’ and ‘well led’ and overall. Previously to this, we also rated the service requires improvement for two consecutive years. During this inspection we found the service had not made the required improvements and remained requires improvement.

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

• Improvement action we have told the provider to take: We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to meeting nutritional and hydration needs and good governance. You can see what action we have asked the provider to take at the end of the full report.

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 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

Cedar House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Cedar House accommodates up to 42 people living with mental health support needs and dementia in a purpose-built building. There are two separate units, over two floors and each unit has two lounges and a dining room. At the time of the inspection there were 40 people using the service.

At out last inspection in September 2017 we rated the service as Requires Improvement and found a breach of Regulation 9 because the care provided did not always reflect the needs or preferences of people using the service. At this inspection, we found some improvements had been made in relation to the recording of personal care which met the wishes of the person and daily fluid intake.

At the time of the inspection there a registered manager in post and the provider had appointed a deputy manager since the last inspection. 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 using the service and staff felt that at times there were not enough staff to provide the level of support people required. There were times during the day when people were left unsupervised and without appropriate support as staff were supporting people in other parts of the unit.

People felt staff were kind and caring but, at times, were focused on the care tasks they needed to complete which meant they were not always able to identify if a person required support or reassurance.

The provider had a range of quality assurance processes to monitor the service and identify areas for improvement but some of these were not effective.

There was a range of activities provided and people were supported to be involved with both one to one and group activities.

The provider had processes in place to help keep people safe and protect them from abuse. People told us they felt safe when they received care.

A robust recruitment process was used to identify if new staff were suitable to provide care for the people using the service. Staff completed a range of training and regular supervision with annual appraisals to support them to provide care in an appropriate and safe way.

Incidents and accidents were recorded and reviewed to identify if there were any trends and actions required to prevent reoccurrence.

Medicines were managed and administered safely and people received their medicines as prescribed.

A detailed assessment of a person’s support needs was completed before they moved into Cedar House to ensure their care requirements could be met.

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

People had a choice of food every day and their dietary needs had been identified and were met.

People told us they were happy with the care they received, they were treated with dignity and respect and they were supported to maintain their independence.

Care plans included information for staff in relation to the person’s religious and cultural needs as well as their preferences for how they wanted their care provided.

Records were completed to identify incidents of behaviour which required additional support but the information was not used to inform future practice to ensure staff understood ways to appropriately support people.

An audit of care plans had identified areas where information was not consistent for example what type of equipment should be used when helping a person move. Action was being taken to resolve the issue.

Staff felt supported by the registered manager and said that the service was well-led. People and relatives could provide feedback on the care provided which was used to identify areas for improvement and they felt the service was well-led.

We found breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were breaches of Regulation 17 (Good governance) and Regulation 18 (staffing). You can see what action we told the provider to take at the back of the full version of the report.

At the inspection in September 2017 we found the provider and registered manager had taken action and made improvements in most of the areas where we had concerns. However, further work was needed to make sure the service met all of the fundamental standards.

Cedar House is a purpose built home providing accommodation, nursing and personal care for up to 42 people with mental health and/or dementia care needs. The home is situated within a residential area of the London Borough of Hillingdon. At the time of our visit there were 42 people using the service.

The provider appointed a new manager in November 2016 and they registered with the Care Quality Commission (CQC) in February 2017. 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.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider assessed people’s care and support needs and developed person-centred care plans to meet these. However, staff did not always record accurately the care and support people received and staff did not always follow care plans that had been agreed with people and that met their preferences. We also made a recommendation that the registered manager should review the deployment of staff to make sure people had the care, support and supervision they needed at all times.

The provider had systems in place to keep people safe and staff understood and followed these. There were usually enough staff to meet people’s needs but the provider needed to review the way they deployed staff to make sure they were available at all times. The provider carried out checks on new staff to make sure they were suitable to work with people using the service.

The provider carried out regular monitoring visits to the service and developed an action plan to address issues they identified. In addition, the registered manager and staff carried out regular checks on quality in the service and identified improvements they needed to make. However, the checks and audits the provider carried out did not always identify areas where they needed to make improvements.

The provider assessed people’s healthcare needs and gave staff guidance on how to meet these. People received the medicines they needed safely.

The provider carried out checks on health and safety in the home and took action when they identified areas they needed to address.

Staff had the training and support they needed to care for and support people using the service. The provider, manager, nurses and care staff had a good understanding of their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The provider did not deprive people of their liberty unlawfully.

People told us they enjoyed the food provided in the service.

People using the service and their relatives told us the staff who looked after them were kind and caring. We saw staff were kind, caring and gentle with the people they supported. We saw they allowed people time to make decisions and offered them choices. People using the service told us that staff respected their privacy.

People told us they had access to and enjoyed the activities provided in the service.

People using the service and their relatives knew how to raise concerns and they told us they were confident the provider would take these seriously.

The provider sought the views of people using the service and others on the care and support people received.

The provider had appointed a qualified and experienced manager who was registered with the Care Quality Commission. Staff told us they found the manager and senior staff in the service supportive.

You can see what action we told the provider to take at the back of the full version of the report.

Cedar House is a purpose built home providing accommodation for up to 42 people with mental health and/or dementia care needs. The home is situated within a residential area of the London Borough of Hillingdon. At the time of our visit there were 38 people using the service.

We previously inspected Cedar House on 10 and 11 April 2014 and the provider had met all the regulations that were inspected.

At the time of the inspection there was a registered manager in place. 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 using the service were put at risk as standards of cleanliness were not maintained in relation to equipment and communal bathrooms

There were not always enough staff to meet people’s care needs appropriately and safely.

Care workers and nurses were sometimes busy which resulted in them not appropriately supporting people’s emotional and social needs as they were focused on tasks.

Care plans were not written in a way that identified each person’s wishes as to how they wanted their care provided. Daily records were focused on the tasks completed and not the person receiving the support.

The records relating to care of people using the service did not provide an accurate and complete picture of their support needs.

The provider had a range of audits in place but checks in relation to records of care and care plans did not identify issues noted during the inspection.

Activities were organised at the home but some of these were not meaningful for people and when the activities coordinator was unavailable there were limited activities organised. We have made a recommendation to the provider in relation to this.

People told us they felt safe when they received support and the provider had policies and procedures in place to deal with any concerns that were raised about the care provided.

The provider had processes in place for the recording and investigation of incidents and accidents. A range of risk assessments were in place in the care plan folders in relation to the care being provided.

The provider had an effective recruitment process in place. There was a policy and procedure in place for the administration of medicines.

The provider had policies, procedures and training in relation to the Mental Capacity Act 2005 and care workers were aware of the importance of supporting people to make choices.

Care workers and nurses had received training identified by the provider as mandatory to ensure they were providing appropriate and effective care for people using the service. Also care workers and nurses had regular supervision with their manager and received an annual appraisal.

We found breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to infection control, staffing levels, care plans, records and monitoring the quality of the service provided. You can see what action we told the provider to take at the back of the full version of this report.

The inspection was carried out by an inspector over two days. They helped answer our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe and well cared for.

The home was clean and tidy and people were able to personalise their rooms.

The medicines prescribed to people using the service were stored in a secure appropriate manner. The home used a computerised hand held system to record when medicines were taken by people using the service. We saw that the majority of records were correct but we did find that for one person there were more tablets for one medicine in stock than stated on the record system. We saw that the majority of creams and ointments that had a limited use once opened had the date of first use written on the packaging to ensure they were disposed of appropriately.

Systems were in place to make sure that staff reported any incidents and the manager reviewed and investigated any issues. Processes were in place for the manager and staff to learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The home had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Is the service effective?

People's health and care needs were assessed and they and/or their relatives were involved in the writing of the care plans which included any specialist dietary, mobility and equipment needs. The care plans, dependency assessments and risk assessments were regularly reviewed and were up to date to ensure people received appropriate care and support.

Is the service caring?

People were supported by kind, attentive staff who treated with respect and dignity. We saw they were supportive and encouraged people to be actively involved in their daily tasks and care. One person said, "The staff are really nice and never rush you". A visitor told us "The staff are superb with my friend and they give them time and encouragement".

Visitors confirmed they were able to see people in private and were able to visit throughout the day.

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

Is the service responsive?

People took part in a range of activities in and outside the service regularly. The home had its own adapted minibus, which helped to keep people involved with their local community. The activities were based upon people's interests and were responsive to individual needs.

The service had a complaints policy and procedure. The two complaints we looked at had been responded to and resolved. The relatives and visitors we spoke with were aware of how to raise any concerns but all said they would not need to make any complaints. One person said "I am really happy with the care here and would never have to make a complaint".

Is the service well-led?

The service had a quality assurance system in place. Records seen by us showed that any identified issues were addressed promptly. As a result the quality of the service was continuingly improving.

An annual survey was sent out to people using the service and their relatives and the results were used to identify any areas for improvement.

Regular audits of the care plans and risk assessments were carried out and any identified actions had a completion date. This helped to ensure that people received a good quality service at all times.

People using the service and their relatives confirmed that overall they were happy with the care being provided.

At our last inspection we identified shortfalls in the reviewing of care plan records and asked the provider to make improvements. At this inspection we found the majority of care plans were up to date and had been reviewed monthly. Action was taken to update one at the time of inspection and staff were aware of the change in the person's needs.

During the inspection some staff expressed concern about staff shortages on some occasions. The registered manager reported that recruitment was taking place to fill vacancies that had arisen and agency staff had been used to cover shifts, so people's needs could be met.

We identified shortfalls in the reporting of some identified injuries and with some of the wound care review records we viewed and have asked the provider to make improvements.

People said they were being cared for at the home. They told us they got up and went to bed when they wanted to and staff were available to help them. People confirmed they got a choice of meals and the food was 'good'. One person said they enjoyed certain styles of music and staff understood this and provided it for them.

Comments we received from people using the service included 'I like it here, I get on with people very well' and about the staff, 'pretty good really.' A visitor expressed some concerns regarding the staffing levels at times and with their consent this was fed back to the manager, who said staffing levels were monitored in line with people's needs.

Staff said they received training and updates on a regular basis and supervision was also now taking place more regularly, so they could discuss any issues and their professional development.

Systems were in place for quality assurance and work was ongoing to gain the opinions of people using the service and their representatives, with surveys being planned once more people were living at the home.

We saw that nurses were very patient and reassuring and talked to people and explained the medicines that they were giving even when the person could not communicate. Two people were asked if they were in pain and we saw that pain relief was given appropriately and one person said that they did not need any medicines at that particular time.

People told us they were "fine" and confirmed they were being well cared for at the home. Visitors expressed their satisfaction with the care their relatives were receiving. Comments included "the staff are wonderful", "I could not fault the staff, they are very caring" and "over the moon......I cannot praise the staff highly enough". Visitors said they were confident to raise a complaint and could speak with the staff or the management about any concerns. Visitors felt there had been improvements made in the home and were pleased with the redecoration and refurbishment that was taking place.

People were given choices and time was taken to find out their interests so activities to include these could be planned. Following the last inspection improvements had been made in the updating and personalising of the care records. People were receiving their medications as prescribed, however improvements in the monitoring of medications were required. Redecoration and refurbishment was taking place to improve the environment. Staff recruitment processes were being adhered to. A complaints procedure was in place and was being followed.