Stretton Nursing Home

Stretton Nursing Home is a residential care home providing personal and nursing care to up to 50 people. The service provides support to older people with dementia. At the time of our inspection there were 26 people using the service.

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

Medicine records and checks were not always sufficient, detailed or recorded. Risks were not always identified and mitigated. The provider had effective safeguarding systems and processes in place to keep people safe. The number of experienced and knowledgeable staff was sufficient to meet people's needs. Staff followed the infection control procedures the provider had in place. Incidents and accidents were monitored, and lessons were learned when things went wrong.

The provider’s systems and processes to provide oversight of the service delivery were still in development. The provider had improved their relationship with external professionals. A positive person-centred culture was promoted, and the manager promoted learning and development.

People’s needs and choices were assessed, and care was reviewed regularly. The staff team received regular refresher training to meet people’s needs. People were supported to eat healthily and drink fluids to maintain their health. People were supported to access healthcare services and activities to promote their wellbeing.

Care was person-centred with people's privacy, dignity and equality maintained. People were involved in their care and supported to express their views. The staff made every effort to get to know people and understand what was important to them.

Care was personalised, and people were supported to effectively communicate their needs and preferences. The provider had a complaints procedure in place to manage and respond to any complaints they may receive. People were supported to maintain relationships with their families and to engage in activities that interested them.

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

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

Rating at last inspection and update

The last rating for this service was requires improvement (Published 19 December 2019).

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

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

Stretton Nursing Home accommodates up to 50 people within a large adapted building, and specialises in

care for older people with physical disabilities and sensory impairments, who may be living with dementia.

At the time of our inspection, 36 people were living at the nursing home.

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

The provider failed to meet regulations to ensure people were safe and had their needs met. Systems to ensure people were safeguarded from abuse had not been addressed by the provider. People were at risk of harm, systems to protect people were not always followed and were ineffective at identifying and managing these risks. People did not always receive their medicines safely and the guidance for their clinical needs was not always clear for staff. There were not always sufficient staff to ensure people received the support they needed in a timely way.

The management overview needed to be improved to ensure the principles of Mental Capacity Act (2005) were complied with, and staff knowledge and understanding improved. The new manager was ensuring staff updated their skills. People were supported to access the health care they needed. People had a nutritious diet, and they enjoyed the food offered. People had their needs assessed and the environment was adapted to meet their needs.

People and their relatives said they were supported by kind and caring staff. However, the provider did not always show compassion for people by ensuring there were sufficient staff to meet people’s choices about when they received their support. Staff were kind to people, however people’s privacy was not always upheld because staff did not always follow best practice.

The new manager was updating records to provide personalised guidance for staff to ensure people received person centred care. People had access to interesting things to do. The management team were recruiting for extra staff to improve people’s well-being. People’s end of life plans needed additional information to ensure they were up to date. Complaints were investigated, and outcomes actioned.

The service was not well led. The provider continued to not have effective governance systems in place to identify shortfalls in the quality and safety of the service for the third inspection in three years. The provider’s governance systems had failed to ensure people were protected from the risk of harm, and that agreed safety measures were put in place. Systems to provide an overview of clinical governance were not effective because staff were not given time to complete checks. Actions identified were not consistently addressed, therefore there was a lack of continuous learning and improving people’s safety and outcomes.

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 16 October 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made or sustained 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 people’s safety in protecting them from avoidable harm and to the quality and governance systems in place at this inspection. We found the provider remained in breach of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

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

Stretton Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Stretton Nursing Home accommodates up to 50 people within a large adapted building, and specialises in care for older people with physical disabilities and sensory impairments who may be living with dementia. At the time of our inspection, 32 people were living at the nursing home.

The provider had a registered manager of the service. However, this person had not been involved in the day-to-day management of the service for several months. 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. During our inspection visits, we met with the home's deputy manager and the newly-appointed manager who oversaw the management of the home with the support of the provider and their organisational oversight manager.

At our previous inspection in January 2018, we rated the service as 'Inadequate,' and it was therefore placed in 'special measures.' We identified eight breaches of the Regulations. These related to the provider’s failure to deploy suitable numbers of staff and fully safeguard people from abuse, the management of people’s medicines, a lack of clinical leadership and the ineffectiveness of quality assurance processes, the failure to assess and minimise risks to individuals, and the failure to fully promote people’s rights under the Mental Capacity Act. In addition, people’s care plans were not always accurate or reflective of their current needs, and they were not always protected from the risks of malnutrition or dehydration. As a result of the inspection, we imposed a condition on the provider’s registration which meant they needed to tell us, on a monthly basis, how they were monitoring the quality and safety of service provided and inform us of actions taken to bring about improvement.

At this inspection, the provider demonstrated to us that sufficient improvements had been made to the service that it was no longer rated as inadequate overall or in any of the key questions. Therefore, the service is no longer in 'special measures.' However, further improvements were still required to the safety and quality of the care people received, and the provider remained in breach of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s rights under the Mental Capacity Act were still not consistently promoted. Procedures for assessing people’s capacity and, where appropriate, making decisions on their behalf were not followed on a consistent basis. People’s medicines were not always managed safely to ensure they received these as prescribed, and that accurate and complete medicines records were maintained. People’s risk assessments did not always provide clear guidance on how to minimise the risks to individuals, including the management of long-term health conditions, and were not always read by staff. New staff were sometimes permitted to provide personal care without appropriate initial training. This included training in the home’s moving and handling procedures.

The plans for improving people’s hydration and addressing weight loss were not always clear. Screening tools for assessing people’s risk of malnutrition had not always been completed on a consistent monthly basis. The provider’s staff induction programme did not reflect the requirements of the Care Certificate. The provider lacked a clear strategy for creating a dementia-friendly environment. People’s personal information held on the premises was not always stored securely to prevent unauthorised access to this. People’s care plans were sometimes contradictory, lacking in detail or omitted key information about the individual’s current needs, and were not always read by staff. The provider’s procedures for identifying people's preferences and choices for their end-of-life care were not followed on a consistent basis.

Staffing levels enabled staff to meet people’s needs safely and without unreasonable delays. Staff received training in and understood their individual responsibilities to remain alert to and report abuse. Measures were in place to protect people, staff and visitors from the risk of infection.

People were supported to choose what they wanted to eat and drink, and received any physical assistance required to eat and drink safely and comfortably. Staff participated in a programme of training and received formal supervision and appraisal to support them in them in fulfilling their roles. Staff helped people seek professional medical advice and treatment when they were unwell.

Staff adopted a kind and compassionate approach towards their work and knew the people they supported well. People and their relatives were encouraged to express their opinions and participate in decision-making that affected them.

People’s care plans were individual to them, and had been developed with input from their relatives and relevant health and social care professionals. People’s communication needs had been assessed and recorded in their care plans. The management team understood the need assess and consider people’s protected characteristics under the Equality Act. People received support to participate in recreational activities and pursue their interests. People and their relatives were clear how to raise any concerns or complaints about the service.

Staff commented on improvements in the overall management and clinical leadership of the service, and felt valued and well supported in their work. The provider took steps to invite feedback on the service from people, their relatives and staff. People’s relatives benefitted from open communication with the management team, whom they felt able to approach at any time. Staff and management liaised with, and sought advice from, a wide range of community health and social care professionals to ensure people's individual needs were met.

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

Stretton Nursing Home is located in Hereford, Herefordshire and 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. The service provides accommodation and nursing care for up to 50 older people. On the day of our inspection, there were 41 people living at the home. This included a number of people who lived with dementia.

At our previous inspection in October 2017, we identified breaches of regulation. These were in relation to staffing, governance, protecting service users from abuse or improper treatment, and notification of incidents. The provider was asked to complete an action plan to set out how they would comply with the regulations.

At this inspection, we found the provider remained in breach of these regulations. We also identified further breaches of regulation. These were in relation to person-centred care; need for consent; safe care and treatment; and meeting nutrition and hydration needs.

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.

There was a registered manager at this home, but they had been absent from work for a period of four months. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered providers and registered managers 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.

Staffing levels had not been determined according to the assessed needs of people living at the home, which meant there were not enough staff to care for people safely. The lack of staff had an adverse effect on people's personal care needs, hydration and emotional wellbeing.

Systems and processes in place to protect people from abuse were not always followed. Action had not been taken by the provider to address failures to report alleged abuse or harm.

People did not always receive their medicines in accordance with updated instructions from the prescriber. Medicines were not always signed for, which made it difficult to tell whether prescribed creams or liquid medicine had been administered correctly.

Risk assessments were not in place for specific health conditions and infection control. The lack of clear guidance about how to keep people safe placed people at risk of harm

Decisions made on behalf of people who lacked capacity were not always the least restrictive, nor had they been made in accordance with the Mental Capacity Act.

People did not always have enough to drink, even when they expressed symptoms of dehydration. Staff did not always have time to spend with people to encourage them to eat, which placed people at risk of malnutrition.

Staff did not receive sufficient training and supervision to enable them to be effective in their roles. New staff did not have a structured induction before caring for people.

Due to the time constraints staff were under, people were sometimes placed in undignified situations and did not have their personal and continence care needs met in a timely way. People's choices about how they wanted to be cared for were not always taken into account. Staff were unable to spend quality time with people.

People's call bells did not always work, nor were they always kept within people's reach. This meant people could not always alert staff, when needed. People's requests for help were not always responded to.

People's care plans were not reflective of their current healthcare and wellbeing needs, and they sometimes contained incorrect information which then affected the care and treatment people received.

Key information about the service, such as service user guides and complaints procedures, were not in accessible formats for people with physical impairments and disabilities.

There was a lack of clinical and general management of the home, which affected the quality and safety of care provided. Quality assurance measures were not effective in identifying risks to people's health and wellbeing, nor in identifying shortfalls in the service. Where care records were completed, these were not audited or reviewed.

Morale was low amongst the staff team, and they did not feel valued in their roles. Staff consistently expressed concern about unsafe working practices within the home and the pressures they were under.

The provider told us they recognised significant improvements were needed to the quality and safety of care people received, and that they were committed to working in partnership with other agencies to achieve this. During and immediately after our inspection, the provider sought advice from another local provider and asked them to support them in a mentoring capacity. This arrangement is now in place. The provider also implemented the urgent recommendations from the Local Authority and the Clinical Commissioning Group, who are working closely with the provider to bring about improvements. The provider told us that an acting manager was due to start working at the home on 29 January 2018; they are now in post. The provider has implemented a stop on further admissions to the home along with a formal placement stop by Commissioners until improvements are made.

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.

Stretton Nursing Home provides accommodation, nursing and personal care for up to 50 people. At the time of our inspection, there were 42 people living at the home.

A registered manager was in post at the time of our 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.

The registered manager had been away from the service for a number of weeks at the time of our inspection visit. In their absence, we met with the managing director of the service. The nurses and senior staff team had overseen the day-to-day management of the service, during the registered manager's absence, with the support of the managing director.

Staff did not always fully understand, or fulfil, their individual responsibilities to protect people from abuse. The provider had, at times, been unable to maintain planned staffing levels over recent months, particularly on weekends. People’s rights under the Mental Capacity Act 2005 were not always fully promoted. The provider lacked a clear overview of the status of people’s DoLS authorisations and conditions on these were not always reviewed and complied with. Staff were not always invited to regular one-to-one meetings with senior staff or management, in accordance with the provider’s supervision policy. Staff did not have the time with people to provide personalised care that was responsive to people's needs. The management, leadership and line management structure of the service was not as effective as it needed to be. The provider had not always notified us of safeguarding issues involving people who lived at the home in a timely manner. The records maintained in relation to people’s care and support were not always accurate or complete. The provider’s quality assurance had not enabled them to identify and address significant shortfalls in the quality of the care and support provided.

The risks associated with people’s care and support needs had been assessed, recorded and plans put in place to manage these. People’s medicines were handled and administered in accordance with good practice guidelines by registered nurses.

Staff received an induction and ongoing training to help them fulfil their duties and meet people’s individual needs. People had enough to eat and drink, and any associated risks were assessed, recorded and managed. When people were unwell, they were supported to access professional medical advice and treatment.

Staff took a caring approach towards their work, and knew the people they supported well. People’s views about their care and support were welcomed and listened to. People were treated with dignity and respect.

People’s friends and relatives contributed to the assessment and planning of their care. People’s care files included details of their preferences and what was important to them. People had support to participate in one-to-one and group activities. People and their relatives understood how to raise concerns and complaints about the service, and felt comfortable doing so.

People and their relatives and friends were satisfied with the overall management of the service.

We found breaches of Regulations of the Health and Social Care 2008 (Regulated Activities) Regulations 2014 and a breach of the Care Quality Commission (Registration) Regulation 2009. You can see what action we told the provider to take at the back of the full version of the report.

Stretton Nursing Home provides accommodation, nursing and personal care for up to 50 people. At the time of our inspection there were 42 people living at the home.

There was a registered manager in post. 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 and associated regulations about how the service is run.

People were kept safe by staff that knew how to recognise and report any concerns about people's safety. Staff understood people's needs and about risks and how to keep people safe. There were enough staff on duty to make sure that people got the right support at the right time. The provider completed checks to ensure staff were suitable and safe to work at the home.

People were positive about the support and care that they received. People were treated with dignity and respect and staff were kind and caring in their approach with people. People's care and support was centred on their individual needs.

People had their health needs responded to effectively. People were supported to access doctors and other health professionals when required. People were supported to have their medicines when needed. Medicines were stored and administered appropriately.

People were asked and gave staff permission before any care or support was given. Time was taken to make sure that people could make choices and decisions about the care and support they received.

People were supported by staff that had the skills and knowledge to understand and meet their health needs. Staff had access to on-going training and support to meet people's specific health and wellbeing needs. Staff felt that they were able to contact the registered manager at any time if they needed support or guidance.

People and their relatives found the staff and management approachable, willing to listen to their views and opinions. People knew how to complain and who to complain to.

Audits and checks were completed regularly to ensure that good standards were maintained. There were established links with organisations relevant to the care and support provided.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found.

Is the service safe?

The people who lived in the home and their relatives we talked with were pleased with the care provided. They felt that their views were respected and listened to.

People told us they felt safe. We saw that people were free to go about their daily routine. One person told us, 'The staff are brilliant'. Another person said, 'It's very nice here'.

Staff understood about the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and how they would be put this into practice. No DoLs applications had been submitted.

Is the service effective?

People told us that they were happy with the care they received. They told us that the manager and the staff had asked them what their needs were and how they would like them met. A relative said, 'Mum is well looked after.' One person said, 'They talk to me about what I want.'

One person said, 'They look after me very well.' Care records confirmed people's needs and preferences had been recorded and care and support had been provided in accordance with their wishes.

People and their relatives were involved in the assessment of their needs. One person said, 'They talk to me about what I want'.

People and their relatives told us they were happy to discuss their personal preferences with staff. They said that staff obtained help for them if they were unwell. This meant people were supported to keep in good health, have access to health care services and received ongoing support.

Is the service caring?

The people we talked with told us they felt that their wishes were respected and they were helped to live their lives as they wished. Staff took the time to find out about people's past. Staff we talked with knew people's needs well and how they wished to be cared for. This meant that staff cared about the person as an individual and showed concerned about their well-being.

People and their relatives were encouraged to make their views known about their care. People that we talked with told us that they found the registered manager and the staff easy to approach about any issues they had. This meant that people were listened to and they felt that their views mattered.

Is the service responsive?

People had been assessed before they moved into the home so that arrangements could be made to meet their needs.

People and their relatives told us they talked with the staff about what was important to them. They talked about the activities they took part in and how they liked their meals prepared. They told us that staff had changed their care packages as a result.

Is the service well led?

One of the individuals identified as registered manager at this home no longer works there. They have yet to apply to deregister with us. The management and staff demonstrated values that included involvement, compassion, dignity, respect and independence. Staff we spoke with showed they understood those values as they discussed their role and responsibilities in their work. This meant the service promoted an open culture that was centred on the individual and empowered them to take control of their life as much as they were able.

The provider had systems in place to assess and monitor the home so that potential improvements in meeting people's care needs could be identified and put into place.

People were cared for in an environment that was safe, clean and hygienic. The provider had appropriate arrangements in place to manage people's medicines.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People told us that they were happy with the care that had been delivered and their needs had been met. It was clear from our observations and from speaking with staff that they had a good understanding of the people's care and support needs and that they knew them well. One relative told us, "They know her needs and are very good at dealing with things'.

Not all staff had received all the training that was needed to meet people's needs. This meant the provider could not demonstrate that the staff employed to work at the home had the skills and experience needed to support the people living there.

Is the service caring?

People were supported by kind, compassionate and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People told us they were able to do things at their own pace and were not rushed. What we saw confirmed this. One person's relatives told us, 'This is the best place she could have been".

Is the service responsive?

People's needs had been assessed before they moved into the home. People told us they regularly talked with the staff about what was important to them. Records confirmed people's preferences, interests, wishes and needs had been recorded. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Is the service well led?

A new manager had recently been appointed and registered with us. They had made improvements in a number of areas. Staff told us they were very supportive of the new manager and were confident that the improvements would continue. One person said, 'It's nice to see changes happening, not just talked about'.

We identified further improvements as being necessary. There was no structured reviewing process carried out by the provider to ensure that any necessary changes were identified.

We carried out this inspection because we needed to check if the home had made the necessary improvements to the way medicines were managed. We found that the improvements had not been made. We also found other areas of concern.

People told us that they were happy with the care and support they received at the home. We saw that staff were kind and caring towards people.

Staff lacked knowledge and understanding about their legal responsibilities when people became unable to make informed decisions for themselves. Staff had not received training to support them when working with people living with dementia.

Some care plans did not provide a consistent or accurate record of people's needs and how they should be met. There was no effective system for monitoring care records to ensure that people received the support that they needed.

The management arrangements for the home did not provide sufficient time for the interim manager to carry out their management duties. There was no evidence available of a planned approach to monitoring the quality of the service.

We carried out this inspection so that we could check whether the provider had made the required improvements to ensure that medicines were managed safely. We also had information that people's care needs had not always been fully met.

We found that people's care needs had been assessed and plans had been put into place to manage their needs. People told us that the care at the home was, "very good indeed" and, "as good as you'd get anywhere".

There was evidence that measures to prevent infection were not effective. We found that people might have been put at risk because staff were not following good practice about disposal of potentially infected waste.

We found that the improvements to the management of medicines had not been made. Staff were not ensuring that the risks associated with medicines were managed safely.

We found that medicines were not being stored safely. There was no way of checking whether or not people had received their medicines as prescribed. Medicines were not being disposed of appropriately. There was no evidence that staff had been trained or assessed as competent to give medicines.

We spent time in the lounges, to see how staff supported people. We also visited people in their bedrooms. We spoke with people living at the home and relatives. We also spoke with staff and checked care records.

People were very positive about the home. One relative described the staff as, "extremely understanding". Another relative told us how pleased they were with the care their family member was receiving, saying, "I can't fault the care here".

We saw that staff were attentive to people's needs. Staff were making sure that people had regular drinks.

Some people were at risk of pressure damage to the skin. We saw that people were being supported to change position regularly, and were using appropriate pressure relieving equipment.

Although staff were providing some social activities for people, we found that these were not all appropriate for the people living at the home.

Some people had been prescribed creams and ointments for skin conditions. Records of when and where these creams had been applied were inconsistent and incomplete. This meant that it was not possible to know if people had received them as prescribed. Some other aspects of the management of medicines were not safe.

We found that the home had made improvements to the way they supported people who were at risk of pressure damage to the skin. However, we found that people were not being given sufficient fluids to drink. This put them at risk of dehydration and other health problems.

The home was providing a wider range of social and leisure activities for people to take part in. One person said, 'at least it's not quite as boring as it was'. The registered manager acknowledged that there was still work to be done in this area.

We saw that staff were kind and caring in their approach to people. We saw some staff talking between themselves about people, without involving the person in the conversation. Records showed that staff made sure that people were as involved as they could be in planning and reviewing their care.

Visitors told us that they were always made welcome at the home. People who were able to tell us about their experience said that they were generally happy with the care and support provided. Records showed that people received a good standard of care which met their physical needs.

People told us that they felt safe at the home. They said that they knew they could speak to the manager if they had any concerns. Staff knew how to report any concerns about possible neglect or abuse.

There were effective recruitment and selection processes in place. We saw that appropriate checks were undertaken before staff began work.

People were made aware of the complaints system. We saw that each person had a copy of the complaints procedure in their bedroom. People told us that they would feel comfortable raising any concerns with the manager.