- Independent mental health service
Broomhill
All Inspections
During an assessment of the hospital overall
19, 20, 21 and 25 July 2023
During a routine inspection
The Chief Inspector of Hospitals is placing St Mathews Broomhill Hospital into special measures. Services placed in special measures will be inspected again within six months. If sufficient improvements have not been made such that there remains a rating of inadequate overall or for any key question or core service, we will act in line with our enforcement procedures to begin the process of preventing the operator from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve. The service will 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, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
Our rating of this location went down. We rated it as inadequate because:
- The provider had not ensured they had effective governance structures and processes to provide oversight and assurance of all aspects of service delivery to be able to identify and improve practice in a timely manner and sustain that improvement. Examples included patients’ identifiable information was not always kept securely. There was no effective monitoring to ensure patients received debriefs after incidents of violence or aggression from other patients. Such incidents were not recorded in a timely manner to allow for effective monitoring. There was little oversight to ensure that all patients received a comprehensive assessment and treatment plan in a timely manner, managers had not realised that some care planning information was cut and pasted between records, leading to recording errors. Managers were not monitoring the quality of the food served on the wards. Managers were not effectively monitoring the mandatory training compliance for all staff. A lack of governance oversight regarding mandatory training and sustainable action plans had been cited in previous inspection reports and enforcement action we had taken. This related to all wards in the hospital wide issue.
- The provider did not provide an environment which was safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff could not observe patients in all parts of the hospital and there were reports of staff sleeping while on observation duties. We saw multiple blind spots throughout the wards in the long stay rehabilitation, which were not mitigated by mirrors or individual risk assessments. Numerous ligature points were identified on the ligature risk assessment, however the mitigation identified did not address the identified risk. This was reported on in previous inspection reports.
- Staff failed to ensure that all corridors were kept clear of hazards to enable safe exit from ward areas in the case of emergency and that patients had access to call alarms.
- The provider had failed to address maintenance issues and repairs in a timely way, leaving areas of risk for some patients. Staff had not ensured that all necessary repair works to improve the quality of the environment were completed within reasonable timescales and that high-risk requests were resolved on the same day. Not all ward areas were clean, and some wards had ripped, dirty, or broken furniture and fittings.
- Staff had not fully risk assessed all patient activities on the ward including potential risks relating to other patients. We saw electrical equipment placed on the floor in patient areas and staff had not fully risk assessed this issue. We found plastic bags in a drawer on one ward.
- Staff were not adhering to the hospital’s policy and procedure when bed rails were used.
- The service did not work to a recognised model of mental health rehabilitation, to meet patients’ needs. Staff were not routinely offering patients regular access to activities that promoted rehabilitation such as employment and education opportunities. This had been cited in previous inspection reports.
- Staff did not always adhere to the hospital’s infection prevention and control policy. Examples include food hygiene and storage of food. Lack of cleaning in areas where patients ate their food. Bedrooms that had not been cleaned before admission. Staff who were not bare below the elbows and wearing jewellery. Staff did not ensure that the traps used to manage the current mouse infestation on Manor ward were not placed in patient areas.
- Staff had not always followed best practice after administration of rapid tranquillisation regarding the monitoring and recording of physical observations. This had been cited in previous reports.
- Staff did not always ensure that patient medication was prescribed within British National Formulary limits and where this was needed, they were not recording a clear rationale for doing so and there was no evidence that second opinion was always sought. Staff had not ensured that all patients could give consent to treatment by medication.
- Staff had not always followed National Institute for Health and Care Excellence guidelines when undertaking enhanced patient observations. This was an area of concern in February and September 2020. Staff had not always used the correct techniques when restraining patients. Staff did not always have access to de-escalation facilities.
- Staff had not always routinely checked cleaned or calibrated medical equipment. Staff had not regularly checked the emergency grab bags and defibrillators, and emergency equipment was accessible in a timely manner.
- Staff had not always ensured that patients were protected from harm and safeguarded. Incidents included patient on patient assaults, sexual vulnerability and staff not managing known allergies. Managers had not managed the numbers of assaults and altercations between patients. Patients told us they did not always feel safe on the wards or received debriefs from staff following any incidents. Adequate safeguarding of patients was an area of concern in February 2021.
- Staff did not always treat patients with compassion and kindness, dignity, and respect. Staff did not always respect their privacy and dignity and did not always understand the individual needs of patients. We heard of several occasions when staff had been speaking to one another in front of the patients, in a language other than English. Staff did always knock on bedroom doors before entering. Staff who had made hurtful, racist, and derogatory remarks to patients. Dignity and respect issues been cited in previous inspection reports and enforcement activity.
- There were limited rooms for use as quiet areas on some wards. Wards had limited space for patients to meet visitors in private.
- Staff had not always made sure that patients were fully involved in the development and ongoing monitoring of their care plans, some patients told us they did not have copies of their care plans and there was no evidence in the care plan records that copies were routinely given to patients.
However:
- The ward teams included or had access to, the full range of specialists needed to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team. This was an improvement on previous inspection findings.
- Staff had developed care plans informed by a comprehensive assessment. This was an improvement on previous inspection findings.
- Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983.
11 January 2023
During an inspection looking at part of the service
Our rating of this service stayed the same. We rated it as requires improvement because:
• Managers did not ensure safe environments for patients and staff. They had not identified a blind spot on Spencer Ward and all ligature points on Manor Ward. Staff were unable to access the emergency bag quickly on Spencer Ward as it was in a locked cupboard that was difficult to open.
• Managers did not ensure that staff had access to accurate and up to date ligature risk assessments. We saw an out of date ligature risk assessment in the office and risk assessments were inconsistent in relation to door hinges and door closure risks.
• Staff were not completing personalised care plans for all patients. Staff were copying and pasting information between care plans resulting in wrong names and genders. There was also inaccurate or missing information in care plans for section 17 leave.
However:
• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff provided a range of treatments suitable to the needs of the patients cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service worked to a recognised model of mental health rehabilitation.
• The service provided a range of activities for patients to engage in.
• There was positive feedback from staff about induction, leadership and support.
• Overall, the service had a positive culture and were keen to improve.
19, 20 and 21 October 2021
During an inspection looking at part of the service
This was a follow up inspection in response to enforcement action we had taken. We looked at specific key lines of enquiry in safe, caring and well led. We looked at sufficient evidence in these areas to rerate. The rating in these domains has improved from inadequate to requires improvement. Therefore, the hospital has now moved out of special measures.
Our rating of this service improved. We rated it as requires improvement because:
- Ligature risk assessments in two wards were not accessible to staff. Some ligature risks did not have full mitigation documented to manage the risk. The installation of closed circuit television had not been included as mitigation on any risk assessments.
- The service did not evidence that some medical equipment had been serviced and service stickers were not in place on some equipment to show it had been tested.
- On the rehabilitation service, emergency equipment had not been checked. The provider had not ensured that spare oxygen cylinders were available.
- Three patient beds on a rehabilitation ward, did not have duvet covers on their beds.
- In both services, there was no evidence that patients and their families had been involved in incident investigations.
- Not all staff had been respectful and caring towards patients.
- Staff on the rehabilitation ward had not always responded appropriately to patients’ gender issues.
- In both services, patients had not been fully involved in the development of their care plans and care plans were not written from the patients' perspective.
- Not all staff across the hospital knew and understood the provider’s vision and values.
- The provider had introduced new governance processes with a number of committees and meetings. However, there was a lack of clarity about what areas were covered in each meeting which meant there was a risk of topics being repeatedly discussed or different approaches being advised.
However:
- We noted improvements in safe, caring and well led domains since our last inspection.
- All wards were clean, well equipped, well furnished, well maintained and fit for purpose.
- The service generally had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm. Agency staff were block booked to ensure patients had consistent care.
- Staff stored, managed and audit medications effectively.
- Mandatory training compliance for permanent and agency staff had improved.
- Staff assessed and managed risks to patients and themselves well.
- Staff understood how to protect patients from abuse. Staff had received training on how to recognise and report abuse and they knew how to apply it. A freedom to speak guarding had been appointed and staff knew how to raise issues.
- Executive directors had the skills, knowledge and experience to perform their roles.
- New governance systems and processes were in place to improve accountability and monitor performance of the service.
- Senior managers had made significant steps to change the closed culture identified at previous inspections. Staff morale, team working and communication from ward to board and board to ward had improved. Poor performance of staff was managed effectively.
12, 18 and 25 February 2021
During an inspection looking at part of the service
This was an unannounced focused inspection, undertaken in response to concerns the care Quality Commission (CQC) had received in relation to two allegations of staff to patient assaults. The first report related to an allegation that a patient had been physically assaulted by a nurse on an acute ward. The second report related to an allegation that a patient had been assaulted by a member of staff on two separate occasions on a rehabilitation ward.
During the inspection, we looked at specific key lines of enquiry. Therefore, we have reported on the following domains:
- Safe
- Caring
We did not re-rate Broomhill as we did not inspect all aspects of the safe and caring domains.
- The service did not always have enough nursing staff, who knew the patients. The provider was using high levels of agency staff. In January 2021, the provider reported that agency staff had been used to cover 56% of all shifts. However, 33% of agency staff had been blocked booked.
- Staff did not fully understand how to protect staff from abuse or how to report it. The provider had not followed national guidance in the levels of safeguarding training provided. Staff were unable to apply training received into practice. The provider had not updated the risk register to reflect current concerns relating to safeguarding.
- Staff had not always managed risks to patients well. Patients had not always been protected from verbal and physical abuse from staff. Staff had not always ensured that patient care plans had been updated to reflect current patient risks.
- The service had not always managed patient safety incidents well, once reported. We viewed a total of 192 provider incidents from 01 January to 01 February 2021. Managers had not closed most of these within the agreed time frame. Of the 192 incidents, 181 (94%) were overdue for review and relevant action/s by managers.
- Staff had not always ensured that physical health observations were recorded after administration of rapid tranquillisation. The provider had not ensured that emergency medication had been prescribed before administration under the Mental Health Act.
- The provider had not ensured that staff on one ward had easy access to technology for them to maintain high quality clinical records on one ward.
- The provider had not ensured that all staff were up to date with their mandatory training in respect of the prevention and management of violence and aggression, basic life support and manual handling.
- Staff had not always treated patients with kindness and compassion. We were given an example where staff were mimicking and copying a patient behind their back. Patients and staff told us that they had heard staff talking in languages other than English in front of patients.
- Staff had not always involved patients in care planning and risk planning.
However:
- All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff followed infection control policy, including handwashing. Staff and visitors had their temperature recorded on entry to the building. The provider had ensured that staff had access to personal protective equipment (PPE).
- Staff completed risk assessments for each patient on admission, using a recognised tool and updated risk assessment after incidents.
02 and 10 September 2020
During an inspection looking at part of the service
Broomhill offers mental health care, support and treatment to men and women. The hospital has acute wards, and long stay / rehabilitation wards. During our inspection we found some concerns relating to medicines management; infection prevention and control; observation documentation and recording, and the privacy and dignity of some patients. We also saw two isolated incidents whereby staff had spoken to patients in an unacceptable way. We found that:
- Staff did not always adhere to the provider's policy when undertaking patient observations. We examined records for eight patients who were on enhanced observations. We found gaps in seven of the eight records. We also found that there were inconsistencies in some records. This meant that we could not be assured that patient observations had been carried out in accordance with their identified risks and care plans.
- The registered nurses on both wards we spoke with, who were agency and had administered medications, did not know the process for the recording of medicines disposal. Registered nurses did not always adhere to the provider's policy in relation to the administration of controlled medicines. This meant that medicines could be unaccounted for, or disposed of incorrectly.
- Managers had not ensured that beds and bedding were clean and well maintained. We saw bed bases and mattresses which were not clean. We found sheets, pillowcases, pillows and a duvet which were either dirty, or not fit for purpose and required replacing. We found several mattresses which were too long for the divan bases.
- Staff were not always kind and respectful towards patients. During an incident of restraint, we saw one staff member shouting at a patient. During a separate incident, we heard a nurse say to a patient that if they did not stop being destructive, they would be taken to their room and be given an injection. The provider took action to investigate the poor behaviour of staff in the two incidents seen on CCTV.
- Staff did not always maintain the privacy and dignity of some patients. We observed the privacy and dignity of some patients who were having their medicines administered had been compromised. Some staff continued to speak to one another in languages that patients did not understand, despite this being highlighted as a concern during inspections in February and July 2020.
- Managers did not have robust processes in place to ensure they had clear oversight of the quality of care being delivered to patients day to day. On all the inspections we have carried out since February 2020 we found aspects of poor care that the provider had not identified. Whilst the provider made the required improvements when we told them to they had failed to identify these themselves and therefore had not acted to ensure care was always safe and of a high standard.
- The culture between staff and managers was not open. Some staff and patients felt unable to raise complaints directly to senior managers. Complaints about poor staff behaviour and practice were made directly to CQC and not via the managers of the service. We raised issues about culture at our inspections in February and July and the provider took steps to address them. Staff and patients continued to share their experiences with the CQC directly, despite the provider having internal processes in place.
However,
- Registered nurses undertook regular checks of the stock of controlled medicines, and medicines liable for misuse.
- Staff planned observation allocations at the commencement of each shift and rotated staff regularly.
- We observed some caring and respectful interactions between staff and patients. During two incidents seen on CCTV, other staff involved in the incidents, were observed to use de-escalation skills and positive interactions when patients were distressed.
- Some patients spoke positively about their care and treatment.
22 and 27 July 2020
During an inspection looking at part of the service
During our inspection, several concerns relating to the prevention and management of infection control were identified. The provider was subsequently issued with a Section 31 letter of intent. This letter required the urgent submission of an action plan, setting out how the provider had already addressed each of the concerns identified, or how they intended to address them immediately and ensure that the concerns are addressed on an ongoing basis. The provider has subsequently produced an action plan, which will be monitored via provider engagement meeting with inspectors.
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Managers had not ensured that personal protective equipment was always available to staff.
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Some staff did not comply with infection prevention and control requirements.
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Staff had not ensured that physical health equipment was cleaned after use on each patient.
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Managers had not ensured that risk assessments had been undertaken for staff from black and ethnic minority backgrounds, in respect of Covid-19.
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One patient and nine staff reported that they had recently heard staff talking in foreign languages in front of patients.
- Most staff did not know and understand the provider’s vision and values and how they were applied in the work of their team
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Managers had not ensured that systems and process were in place to ensure that complaints were responded to effectively, and that patients had received a written response regarding the outcome of their complaint
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Staff had not ensured that handovers were structured, and there was limited information shared in relation to patient presentation, needs and risk
However;
- The ward environments were safe and clean. The wards had enough nurses who knew the ward and patients. Most staff had received training on how to recognise and report abuse and had applied this knowledge in practice.
- Most staff had the necessary skills and knowledge to provide high quality care. Staff received supervision and appraisal and had access to mandatory training.
- Managers had ensured that poor staff performance was dealt with robustly, and that staff were given support to improve.
- Staff treated patients with compassion and kindness and respected their privacy and dignity. Patients knew how to make a complaint and were comfortable doing so. The service treated concerns and complaints seriously, investigated them and protected patients from discrimination.
- Leaders were visible in the service. Staff felt respected, supported and available. Staff felt able to raise concerns without discrimination.
11 to 14 February 2020
During a routine inspection
Our rating of this service went down. We rated it as inadequate because:
- Staff did not give sufficient attention to safeguarding patients and had not recognised and responded appropriately to abuse or discriminatory practice. Staff did not fully understand how to protect patients from abuse or work well with other agencies to do so. Staff had received training on how to recognise and report abuse, however staff were not fully aware of how to apply it.
- Patients did not feel cared for. Some patients reported staff as rude, impatient, judgmental, dismissive, and mocking. We found that some patients basic needs had not been met. Patients told us that night staff had been observed sleeping, and staff frequently spoke to one another in a language other than English.
- Staff had not assessed and managed risks to patients well. Staff had not fully completed patients risk assessments. Opportunities to prevent or minimise harm were missed. Staff had not updated assessments and risk management plans following incidents.
- Senior managers of the service admitted several acutely unwell patients directly to the rehabilitation wards. Clinical had not been routinely involved in the decision to admit patients, and on occasions had received very short notice of admissions. The provider had not ensured that staff had been prepared or adequately trained to care for all new patients.
- The provider had not updated its scope of registration and its operational policy in line with the changes to the service with regards to admitting acutely unwell patients.
- Patients received care from staff who did not have all the necessary skills, knowledge and experience to enable them to deliver quality care to the current patient group.
- Wards were unsafe. Staff were unaware of ligature points, blind spots and associated risks. Not all staff had access to emergency alarms. Staff did not adhere to the providers policy when undertaking enhanced patient observations. Not all staff had received training or were not competent in accessing key clinical information.
- Staff had failed to comply with the Mental Health Act Code of Practice in respect of explaining rights to patients in a timely manner. Staff were administering medication to three patients illegally and capacity assessments were not in place for five patients.
- We found issues of concern around staff failing to obtain and record consent to treatment in line with the Act. Staff had not assessed and recorded capacity clearly for all patients who might have impaired mental capacity.
- Managers had not ensured that improvement notices identified from the Care Quality Commission inspection in December 2017 had been actioned and embedded into practice.
However:
- The service had enough nursing and medical staff who knew the patients. Staff had received the providers mandatory training and were up to date with this. Staff could adjust staffing levels when required.
4 to 6 and 21 December 2017
During a routine inspection
We rated Broomhill as good because:
- Patients reported feeling safe on the wards.
- Six of the seven wards were clean, tidy, and well maintained.
- Staff demonstrated the provider’s visions and values in their behaviours.
- We observed staff to be passionate and motivated to meet the patients’ care needs.
- Staff demonstrated a good understanding of patients’ individual needs, including care plans, levels of observations and risks.
- Staff completed assessments for all patients following admission.
- The Mental Health Act administrators had good oversight of the service and provided support to the wards.
- Shift to shift handovers were taking place daily.
- Senior managers had good oversight of the wards and clinical governance. There was a robust process in place to drive up standards and compliance.
- Staff consistently reported that managers were supportive and would listen to concerns.
- Staff morale was good and teams were striving to provide good care and treatment to patients. Managers were responsive in making improvements.
However:
- The management of medication, specifically stock control was not robust across all wards. Not all medical equipment was in date or checked regularly.
- Ligature risk assessments did not cover the hospital communal areas. The ward assessments were not robust.
- Not all staff had personal alarms and there were areas across all wards where there was no immediate access to an alarm point.
- The service employed four health care assistants that were under the age of 18 and legally a child. There were no additional risk assessments, support, or supervision in place for these staff.
- Overall, compliance with mandatory training was poor at 51% between April and November 2017. Not all staff received regular supervision and compliance for appraisal was low.
- Capacity assessments were present but not always detailed; they did not document rational for decision making.
- Care plans were not always holistic or recovery focused. They did not routinely capture the patient’s views or identify strengths.
- Some staff did not receive feedback from investigations or were aware of lessons learnt across the service.
- Regular ward team meetings were not taking place and attendance at the service wide staff meeting was low.
22 to 24 March 2016
During an inspection looking at part of the service
We rated Broomhill as requires improvement because:
- The service had several ligature risks, many of them in bedrooms and bathrooms. Staff had not conducted a ligature risk assessment to assist in mitigating these risks.
- The clinic had a defibrillator, however no emergency drugs or oxygen cylinders were available.
- All medication apart from Clozaril came from a local pharmacy. Prescribing was undertaken by the local general practitioner (GP) and not the responsible clinician.
- There was no evidence of learning from incidents or complaints being fed back to the staff.
- Despite having a structured activity programme, staff did not provide any psychological therapies to benefit the patient group.
- Staff did not use any recognised outcome tools to measure patient progress.
- Staff audited Mental Health Act compliance. No other clinical audits were undertaken.
- Three T3 forms (certificates of second opinion) did not have the correct hospital address on them.
- We interviewed four patients who all stated they had copies of their care plans but only two stated they were involved in developing them.
- Of the entire staffing at Broomhill only 66% had received an appraisal, whilst supervision records showed only 44% of staff had received supervision in August/ September 2015.
- Only 66% of staff had completed all the mandatory training.
- Only one qualified staff member worked at weekends at night. This raised concerns about patient safety if there was an incident and staff working long hours without a break.
- The service did not have a risk register, meaning the management team did not robustly manage potential risks to the service.
However:
- Staff undertook patient risk assessments upon admission and recorded these in their notes. Weekly ward round notes show that risk assessments were updated regularly.
- Staff read patients their rights every three months and the mental health act administrator recorded this. Mental Health Act section papers were appropriately stored and in date.
- Staff treated patients with kindness and respect. We saw that staff understood individual needs and were aware of patients’ preferences.
- Patients were able to choose their own diet to meet their needs either by going out shopping or accessing the menu at Broomhill.
- Staff were aware of the senior managers who visited the unit regularly, and staff spoke highly of the manager at Broomhill.
8 August 2013
During a routine inspection
Patients also told us that they were generally satisfied and involved with the care, treatment and support they received from staff. They said that there were plenty of activities to do. For example this included doing group activities such as gardening, baking, keep fit, board games, anger management, read papers, and go out in the community. One person told us 'I do my own laundry and clean my room' and 'I also cook once or twice a week' and they told us that they enjoyed this. Another person told us that they looked after the chickens, collected the egg and helped sale them. They told us that they enjoyed doing this activity.
All the patients also told us that they knew how to make a complaint if they were not happy with the quality of service received. They told us that they were encouraged to express their views at their monthly 'community' meetings and felt they were listened to by staff. The patients also told us that most of the staff were nice and had been on training courses to look after them. They also said that they were given support to learn new skills to become more independent.
6 September 2012
During a routine inspection
One person told us 'I do like it here' this was because they said that the views of the countryside were lovely and relaxing. They also told us that the staff spoke to them in a kind manner and 'treats me with respect'. Another person said 'I do my own laundry and dry it'. They told us that they had a family and 'two staff take me to visit my family' and they enjoyed this.
All the people we spoke with told us that the place was well decorated, and clean. One person told us 'I have a nice large room with a double bed and I have my own toilet and shower room' and they were happy with this. They told us that they helped look after the chickens and watered the plants. All the people told us that the food was 'very nice' and they had three choices of meals. One person told us 'the vegetarian food is not bad and I don't eat meat'.
People we spoke with told us that they were involved in planning their care. They told us that they knew about care plans because the care staff talked to them about this. They said they were given information about how to make a complaint if they were not happy with the service. One person told us that they spoke to the advocacy service and they told us that this information was displayed on the notice board.
Some people told us that the qualified nurses explained and gave them information about their rights. This was so they understood their responsibilities of living at the service. Most people told us that the staff were kind and respected their privacy and dignity. They said the staff knocked on their doors before they entered their rooms.