Venn House

We found the following examples of good practice.

• The provider was following best practice guidance in terms of ensuring visitors to the home did not spread COVID-19. On arrival visitors were asked to consent to a lateral flow test (LFT) and their temperatures recorded. A booking system was also in place to monitor visitors into the home.

• The provider ensured enough stock of appropriate personal protective equipment (PPE) and there was signage to remind staff and visitors about the correct guidance for donning, doffing and disposing of PPE.

• Staff were adhering to PPE guidance and practices. There was a plentiful supply of PPE close to people’s bedrooms.

• Staff encouraged people to keep a safe distance from each other and there was additional cleaning of touch points in communal areas to mitigate the risk of cross infection.

• Staff continued to support people to access healthcare and arrangements were in place should people need to attend hospital and return to the home safely.

• Policies, procedures and risk assessments relating to COVID-19 were up to date which enabled staff to keep people safe.

Venn House is a residential care home in Lamerton, Tavistock. The service can accommodate a maximum of 25 older people across two buildings, the main house and the Coach House.

At the time of the inspection the provider was only using the Coach House which was able to accommodate a maximum of 18 people,16 people were living at the Coach House. Some people were living with dementia. Nursing care was provided by the local community nursing teams.

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

People, relative and professionals told us the service had improved.

People received person-centred care which was responsive to their specific needs and wishes. Each person had an up to date, personalised electronic care plan, which set out how their care and support needs should be met by staff.

Assessments were regularly undertaken to review people's needs and any changes in the support they required. Any needs in relation to the Equality Act 2010 were specified in care plans and if required, assessments detailed any support people required in relation to the Accessible Information Standard (AIS). The Accessible Information Standard aims to make sure that people who have a sensory loss, disability or impairment get information they can access and understand.

People had access to a wide range of group and individual activities and events they could choose to participate in, for example, music and dancing and art and crafts.

When people were nearing the end of their life, they received compassionate and supportive care by trained staff. People's end of life wishes were sensitively discussed with people and their families.

Staff were aware of people's communication methods and provided them with any support they required to communicate. This helped ensure their wishes were identified and they were enabled to make informed decisions and choices about the care and support they received.

The service had appropriate arrangements in place for dealing with people's complaints if they were unhappy with any aspect of the support provided at the home. People and their relatives said they were confident any concerns they might have about the service would be appropriately dealt with by the registered manager and provider.

People were kept safe at the home and were cared for by staff that were appropriately recruited and knew how to highlight any potential safeguarding concerns. Risks to people were clearly identified, and ongoing action taken to ensure that risks were managed well. The provider and registered manager ensured that incidents and accidents were recorded and fully investigated. The home was well kept and hygienic.

Staff were well supported through training, supervision and appraisal. Staff worked effectively together to ensure people's needs were communicated and supported them to access healthcare professionals when they needed them. Professional feedback was positive.

People’s medicines were safely managed. Staff knew how people liked to take their medicines and we observed thorough checks were in place to ensure people had received their medicines.

People enjoyed the meals available to them, were involved in menu planning and were appropriately supported with eating and drinking where required. 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 home was dementia friendly and met the needs of the people living there. Staff held “Champion” roles and kept up to date with best practice. They were a resource to the staff team. Staff could demonstrate how well they knew people.

People and their relatives were very positive about the care provided. They were listened to and involved. People were treated with privacy and dignity and supported to be as independent as possible whilst any differences or cultural needs were known and respected.

The service had a management structure in place, and quality assurance systems were effective in continuing to drive improvements across the home. Feedback about the leadership at the service was very good. The provider and registered manager knew people well. Regular feedback was sought from people and their relatives to ensure they were involved in the development of the service.

The last comprehensive inspection of this service was Requires Improvement (published July 2018). There were no breaches of regulation.

At this inspection we found improvements had continued to be made across the service and quality assurance systems embedded.

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

Why we inspected

This was a planned inspection based on the previous rating. The service was now Good.

Follow up:

We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

Venn House is a care home registered to provide accommodation with personal care for a maximum of 25 people. It comprises of two buildings, the main house, and the Coach House, which is primarily for people living with dementia. 14 people lived at the service when we visited.

When we completed our previous inspection on 29 November 2017 we found concerns relating to staffing levels; risk management; medicine management; safeguarding; management of odours; adherence with the Mental Capacity Act; personalisation of care; complaints management; inadequate governance arrangements; inaccurate statement of purpose and a lack of incident reporting. At this time these topic areas were included under the key questions of safe, effective, caring, responsive and well-led. The service was rated as inadequate overall. Safe and well-led were rated as inadequate and effective, caring and responsive were rated as requires improvement. In light of our concerns, we also raised a safeguarding alert with the local authority. As a result, the service was placed in a whole home safeguarding process. A number of health and social care professionals became actively involved in the service. This included reviews of people’s care and support from the local authority Quality Assurance Improvement Team (QAIT). The provider was engaged in the process and as a result, the whole home safeguarding process was closed in April 2018. We also met with the provider to discuss the concerns and what action they were going to take. This inspection found improvements had been made.

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

The service did not have a registered manager. The previous registered manager left in January 2018. 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. However, a new manager had been appointed and was in the process of registering with the Care Quality Commission.

Staffing levels were under regular review. A dependency tool had been introduced which assessed people’s specific needs in detail, such as mobility. The tool provides practice and management guidance for people delivering and planning care and support services. It is used to provide a summary of a person’s functional needs and/or the degree of dependence/independence. As a result, it calculated the staffing levels required to meet people’s needs safely and in a timely manner. The service continued to actively recruit new members of competent staff.

Risk management was much more robust to ensure people’s safety. Risk assessments and care plans had been updated and contained more detail for staff to follow to mitigate risks.

We also had serious concerns about environmental risks relating to the security of the Coach House. As a result the patio had been made safer, including the heightening of the fence and doors leading to this area had been fitted with a better locking system. In addition, an environmental audit had been conducted in March 2018. This identified areas for improvement, such as a redecoration programme being implemented.

Medicines management had improved. Incidents and accidents were much more scrutinised and appropriate referrals made to other agencies. People felt safe and staff knew their safeguarding responsibilities. Infection control was taken seriously and no odours were evident.

We found action had been taken to improve the application of the Mental Capacity Act and staff training and support. People's legal rights were protected because staff knew how to support people if they did not have the mental capacity to make decisions for themselves.

A new training programme had been implemented and staff were receiving better support.

People’s health needs were managed well through regular contact with community health professionals.

People’s individual needs were met by the adaptation, design and decoration of the premises. A maintenance plan was in place to address identified areas of redecoration and improvement.

Action had been taken to improve the care people received. People and relatives gave mixed views about the care provided at our previous inspection. This inspection we received only positive views of the care and support provided. Staff relationships with people were caring and supportive. Staff spoke confidently about people’s specific needs and how they liked to be supported. Staff treated people with dignity and respect.

Action had been taken to improve people’s care. Staff were engaging with people meaningfully because the atmosphere was calmer which allowed for more positive interactions. The service was actively trying to recruit an activities worker to enable more activities to take place.

Although most care plans were rewritten, others were still complete but needed transferring to the new format. A further three were in the process of being updated to ensure they were accurate and personalised to people’s needs.

We found action had been taken to improve the governance, quality assurance and leadership. The management team had started to review the policies and procedures to ensure they were effective and reflected the practice at the service.

The provider had implemented quality monitoring arrangements which were ensuring the safe running of the service. Residents and family meetings had taken place to give opportunities for people and their relatives to share their views about how the service was run. The service statement of purpose had been updated. Complaints were being managed appropriately.

Notifications had been reported to CQC in accordance with the regulations.

There had been improvements at the service, although the provider and management team recognised further work was needed to embed the new quality assurance systems they had put in place.

Venn House is a care home registered to provide accommodation with personal care for a maximum of 25 people. It comprises of two buildings, the main house, and the Coach House, which is primarily for people living with dementia. 17 people lived at the service when we visited.

The service had a registered manager. 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.

At the last inspection in May 2017 the service was rated as requires improvement overall. Safe and Well led were rated requires improvement and Effective, Caring and Responsive were rated as good. Two breaches of regulations were found in Staffing and Good governance.

Following the inspection in May 2017 the Care Quality Commission (CQC) took enforcement action in relation to staffing, which required the provider to ensure sufficient numbers of staff were deployed to meet people's care needs by 14 Aug 2017. We also made a requirement that the provider must improve their system to assess, monitor and improve the quality and safety of the service. The provider sent us an action plan outlining improvements being made.

At a previous inspection in January 2016, the service was also rated as requires improvement, we found four breaches of regulations in relation to Safe care and treatment, Safeguarding, Staffing and Good governance. At an inspection in October 2013, we found two breaches of regulations in relation to the safety and suitability of premises and recruitment.

At this inspection, people remained at risk because there were insufficient numbers of staff with the right skills to safely meet people’s care and supervision needs at all times. The service had admitted five people with complex care needs since we last visited, whilst the needs of others already living at the home had also increased. Eight staff had left the home since we last visited, and were replaced with newly recruited and agency staff. This, combined with staff sickness meant a number of staff working at the service did not know people’s needs well or how to safely care for them. Contingency arrangements for obtaining assistance in an emergency were inadequate.

On 22 and 23 November 2017 we witnessed a number of incidents and near misses in the Coach House. For example, on several occasions a person at high risk of leaving the home unaccompanied was able to unlock a door unobserved and get out on a patio area when it was unsafe for them to go out alone. The previous week the person had climbed over the fence from this patio area and got outside, which put them at high risk. The actions taken to improve security in response to that incident were not sufficient to make this area safe and secure.

Another person was verbally and physically aggressive towards staff and other people living at the home which staff did not have the skills to manage. Staff had not been trained to manage challenging behaviours. People's care records lacked guidance for staff about how to manage these behaviours, which meant people and staff continued to be at risk.

On 23 November 2017, we advised the provider people were at risk because the service did not have enough staff to safely care for people and meet their needs. We identified six people at increased risk and made a safeguarding alert to the local authority safeguarding team about those people. We requested the provider take further urgent action to ensure they had sufficient numbers of suitably qualified, competent, skilled and experienced staff on duty at all times and improve security of the Coach House. We asked the provider to write to CQC by 10am on 24 November 2017 to set out urgent steps being taken to improve safety at the home.

The provider wrote to CQC on 24 November 2017 setting out immediate plans to increase staffing levels and improve safety. They also outlined immediate steps to secure the doors to the patio. The provider undertook a voluntary agreement with CQC not to admit any more people to Venn House until CQC were more confident about people’s safety.

On 24 November 2017 a local care manager also visited the service to offer support and planned further monitoring visits by health and social care professionals. On the 29 November 2017 we identified two more people at risk which we made the local authority safeguarding team and local care manager aware of. A whole service safeguarding meeting was convened. The local authority's safeguarding team, commissioners and other agencies are working together with the provider to review people’s care and keep people safe. On 28 November 2017 when we next visited the service the provider had increased staffing levels to the levels agreed. Staff said the increased staffing levels of staff had made a “massive difference” and “Things have improved.”

People were at increased risk because individual and environmental risks were not adequately managed. Risk assessments and care plans were not accurate or up to date about people’s risks and current care needs, and did not provide staff with the guidance they needed. Accidents, incidents, and near misses were under reported, which meant the level of risk at the home was not been recognised or adequately responded to. Actions taken did not sufficiently mitigate risks of verbal and physical aggression or environmental risks. Gaps in training were identified, for example, in managing challenging behaviour and in safeguarding training for some staff. We identified concerns about nutritional risks for one person and choking risks for another which were not being adequately managed. Some aspects of infection control in relation to odour were not well managed. Medicines were not managed safely, and we had concerns about the use of ‘as required’ medicines.

The service did not have a policy on the Mental Capacity Act to support staff practice. People were not supported to have maximum choice and control of their lives. Staff had not carried out mental capacity assessments or documented best interest decisions in relation to the widespread use of pressure mats for monitoring people’s movements. Low staffing levels meant staff could not always support people in the least restrictive way possible. The provider had not acted in accordance with the conditions of a person's Deprivation of Liberty authorisation.

People did not always receive personalised care that met their needs. People’s care records lacked detail about how to meet people’s individual care needs, and several were out of date. There were gaps in people’s food and drink records so it wasn’t clear whether they had enough to eat and drink some days. Some complaints had not been dealt with to the satisfaction of the complainant, and complaint information did not provide details of other agencies they could contact.

The registered manager and provider demonstrated a poor understanding of risk management, governance and quality assurance. They did not recognise the impact of low staffing levels on increased risks and the quality of people’s care. Staff did not feel valued and described a culture of fear at the service. They said feedback about low staffing levels and risk were not being listened or responded to.

The quality monitoring systems in use failed to identify poor standards of care or take effective action to make required improvements. Systems and processes were inadequate to assess, monitor and improve the quality and safety of the service provided. The service lacked some key policies, other policies, procedures. Individual risk assessments were of poor quality, so did not support staff in their practice. The systems for managing environmental risks were confusing and ineffective.

Some safeguarding incidents which had occurred at the home had not been notified to the local authority safeguarding team or the CQC. A notification is information about important events which the service is required to send us by law.

Health and social care professionals such as GPs, community and mental health nurses regularly visited the home to meet people’s healthcare needs. Staff relationships with people were caring and supportive of people’s independence. People praised the quality of the food and choices. Meals were freshly cooked and looked appetising. Furniture and décor in The Coach House reflected evidence based practice about best types of environment for people living with dementia.

We found ten breaches of regulations at this inspection. Breaches of regulations were identified at Venn House for the fourth successive inspection. We have rated the Safe and Well led domains as inadequate, and the Effective, Caring and Responsive domains as requires improvement. The previous warning notice served about staffing which was due to be complied with by 14 August 2017 had not been met.

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,

Venn House is registered to provide accommodation and personal care to a maximum of 25 people. It is not a nursing home. The accommodation consists of two buildings: the main house, which is an old building and a new purpose-built Coach House. This had been designed for people living with dementia and incorporated several aspects which research has shown created a dementia friendly environment, such as large and tactile signage. When the inspection began there were nine people living in the main house and six people in the Coach House.

The service was last inspected on 5, 8, and 20 January 2016 when it was rated as Requires Improvement overall. At that inspection, we found four breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to monitoring the quality and safety of the service, staffing arrangements and the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. The provider had developed an action plan to ensure improvements were made and sustained. We found that improvements had been made at this inspection to most of those areas, but some concerns remained about risk assessment of staffing levels and of the premises.

A registered manager was 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.

Previously, we identified concerns about levels of staffing at night. Although staffing levels had been improved for the night shift by increasing the numbers of staff on duty from two to three, levels on the day shift were a source of concern. This applied particularly to the afternoons and early evenings when there was just one person on duty in The Coach House with no other support in the building.

Risk assessments and audits of premises and equipment were in place, but those relating to premises were not always fully implemented or reviewed in a timely way. A full premises and equipment review took place after the inspection.

People living at the service and people visiting, including healthcare professionals, all made positive comments about the staff and the buildings. For example, one said, “I like it. It’s cosy, homely and clean. The atmosphere is very nice, it feels very relaxed. Staff are always very helpful and friendly.” People said they felt safe living at the home.

Staff were able to describe signs of potential abuse and knew how to report concerns. A robust recruitment process ensured that only appropriate staff were employed. Medicines were administered safely.

People were cared for by experienced, trained staff who treated them with kindness, compassion and care. Regular training and supervision was provided to ensure staff remained competent. People their relatives and health care professionals spoke highly about the care provided by staff. One person said, “I have experienced the highest quality care here… I couldn’t speak too highly of their thoughtfulness and care”. Healthcare professionals confirmed that referrals were made to them in a timely and effective manner.

People’s legal rights were being upheld. Decision-making was in line with the principles of the Mental Capacity Act and the least restrictive option was used when someone was being deprived of their liberty.

The standard of food at the service was high with a wide variety of healthy choices. There was a brand-new purpose built kitchen within the new dementia wing, which provided food to both sites. People confirmed that they enjoyed the food.

Assessment and care planning was person centred. People confirmed that they were always offered choices regarding their care and treatment. There was a new activities coordinator with a programme in place five days a week. People participated in a range of different activities according to the individual preferences. Family and friends were able to visit at any time and said they felt very welcome.

There was a complaints procedure available to people which was well publicised.

An effective culture change had been implemented by the new registered manager. The service now aspired to a set of values which included openness, accountability and improvement of the quality of care. Quality assurance systems were now integrated and embedded to monitor quality and safety at the service. However, the quality assurance system had not identified some issues of concern which we found.

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

Venn House is registered to provide accommodation and personal care to a maximum of 25 people. It is not a nursing home. The accommodation is over two buildings, the Coach House and the main house, on the one site. There were 12 people in the main house and six people in the Coach House when the inspection began.

The service is required to have a registered manager. 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. Venn House has a registered manager but they have not been in day to day control of the service since August 2015. They have not yet removed their name from the register.

People were not benefitting from a stable management of the home because it had been managed by three consecutive managers in the last five months. The last ended their employment during the inspection. People said they were not sure who was running the home. However, a new manager was due to start on 22 January 2016.

There were no embedded systems to monitor the quality and safety of the service. This meant risk was not always identified and managed so people were protected.

Staffing arrangements did not always ensure people were safe and there had been an increasing number of falls at the home. Although steps had been taken to mitigate risks to individuals, and staffing numbers had increased, this had not fully protected people. Risk assessments were not always reviewed. New risks had not been assessed taking into account the vulnerability of individual people, such as moving to the new Coach House. Prior to moving to the new Coach House people were living in premises not safe for their use, including damp. The new Coach House provided a home for people with dementia based on research into suitable dementia friendly environments.

People's legal rights were not always upheld because they were not free to leave the home and were under constant supervision. Some applications to deprive people of their liberty had been requested for their safety and welfare, in line with the Mental Capacity Act and deprivation of liberty safeguards. Decision making arrangements were in place where needed, in line with the principles of the Mental Capacity Act.

Staff did not receive regular supervision or appraisal of their work and so training needs and support might not be identified. Staff training had lapsed but was being reorganised and updated.

People received their medicines as prescribed and when needed but records were not always completed and audit of medicine use not always available. We have made a recommendation about the management of some medicines.

People's needs were assessed and their care planned with them or a family member. Staff knew people's needs well and provided person centred care when they were able. People had interests which they followed, such as reading and quizzes an some activities were provided, but with people's increased frailty some had only limited company, when staff had time. We have made a recommendation about activities to prevent isolation.

Staff were kind, friendly and treated people with respect and dignity. They showed great concerned for people's welfare. People said of the staff, “Wonderful”; “The carers are very nice” and “They’ve made me feel very welcome.” Community health care professionals said the staff contact them in a timely manner for advice and to provide health care to people.

People liked the food which they described as, “Very good; enough quantity and variety”. People had choices, assistance where required and meal times were friendly and sociable occasions.

Staff recruitment protected people from staff who might not be suitable to work with vulnerable adults. The staff knew how to protect people from abuse and harm.

There was a complaints procedure should people wish to complain. There had been no recorded complaints at the service.

We found four breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

On the day of our inspection there were 19 people living at Venn House. The summary is based on conversations with 10 people using the service, the registered manager, four staff supporting them, observation and records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People had confidence in staff's ability and felt safe receiving care from them, one person saying "They're very skilled". Risks to people's health and welfare were managed through detailed care planning, supervised and competent staff. Recruitment arrangements protected people. Environmental risks had been assessed and minimised. Events at the home, such as falls, were monitored and acted upon.

Is the service caring?

People were treated with dignity and respect; their care was unhurried. People's opinion was sought and taken into account. There was a relaxed, homely atmosphere with smiles and humour between staff and people using the service.

Is the service effective?

People spoke highly of the care they received with comments including "You ring your bell and somebody comes" and "Very, very good". People were involved in planning their care and their needs were monitored and reviewed when required. People received care based on their individual needs and wishes and risks were managed without undue effect on their day to day life.

Is the service responsive?

People's opinion was sought in several ways. Where a person wanted changes in their room those changes were made. When a person had a fall new equipment was provided for their benefit. Where external health care advice was needed for an individual this was promptly arranged. The service responded to finding by CQC at the previous inspection and made immediate changes.

Is the service well led?

The provider and registered manager worked together to ensure the standards they expected were maintained. Staff were very positive about the home's management one saying "(The registered manager) is always available and listens'. The registered manager was seen to lead by example. They ensured staff received the support they required to provide a good service.

We saw, met or spoke with most of the people living at the home. We had meaningful conversations with eight of the people. We spoke with one relative and one visiting GP. We spoke with seven members of staff and the registered manager.

The home had a welcoming, friendly and open atmosphere. People told us they liked the home very much and felt safe. Comments included 'you haven't got anything to worry about here', 'I feel safe' and 'we are extremely fortunate where we live'.

Each person had a plan of care to meet their individual needs. Care staff knew each person need's well and how to meet them. People were treated in a kind, respectful and friendly way.

People we spoke with were very complimentary about the staff and the home. Comments included 'it's an awfully good place', 'it couldn't be better' and 'wouldn't swap this place for anything'. We observed that staff provided care and support in a kind, respectful and friendly manner. Staff we spoke with understood the needs and wishes of the people they cared for. People told us that staff always asked for their consent before carrying out any care or treatment. Comments included 'it's fantastic here', 'the staff are lovely', 'the girls have good manners' and 'if I ring my bell someone comes!". Not all of the staff employed at the home had undergone the necessary recruitment checks before starting work.

People were consulted and chose the activities they wanted in the home.

People were very complimentary of the food and comments included 'they always give me good meals', 'food is very good' and 'we have very good cooks'. They told us that they could have an alternative if they did not like their main meal. People were asked for their choices of food when they first came to live at the home.

The home was a listed building and retained many of its original features. People were very complimentary of their rooms and comments included 'I like my room', 'it's always clean and there is no smell' and 'it's (the room) wonderful'. Rooms were individual and varied in layout. Due to the type of building, people were not always safe due to environmental risks not being assessed and managed in the home.

The manager had an open door policy. People living at the home, relatives and care staff told us that they would have no hesitation in discussing any issues or concerns with the manager and felt the home had an open and inclusive atmosphere.

People told us. 'They know me and I know them'; 'Staff are very, very good. All of them' and 'The level of care that Xxx receives is exemplary'.

We found that people were offered choice and consulted about their care. No care was delivered that people had not agreed or consented to. People's rights and dignity were upheld.

A district nurse described the care as 'very good'. We saw that detailed records were available to inform care workers about people's needs and how they were to be met. We saw from people's records and talking to them that their needs were met.

Staff were aware of how to safeguard people from abuse and there was good information for them to refer to. Medicines were handled in people's best interest and safety. Individual risk to people was well managed. However, general risks within the home, such as stairwells and equipment use, had not been assessed to ensure that any risk was understood and managed.

The arrangements for listening to people's views and managing the home effectively ensured people's welfare was fully promoted.