Elmhurst Residential Home

Elmhurst Residential Home is a residential care home providing accommodation and personal care to people aged 65 and over, some of whom are living with dementia. The service is registered to support up to 34 people. At the time of the inspection there was 21 people living at the home. The home is a large adapted residential house which has living space and bedrooms over two floors

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

People told us they felt safe living at Elmhurst Residential Home. Safeguarding processes were in place to help protect people from the risk of abuse.

Risks associated with people's care had been assessed and guidance was in place for staff to follow to keep people safe.

People were protected from the risks associated with the spread of infection. The service was clean and well maintained.

There were enough numbers of staff deployed to meet people's needs and ensure their safety. Appropriate recruitment procedures ensured prospective staff were suitable to work in the home.

Medicines were managed and administered safely. Staff received the required training and support and applied learning effectively in line with best practice. This meant people’s needs were safely and effectively met ensuring a good quality of life.

Staff were caring and kind and relatives confirmed this. We observed staff responding to people's needs with dignity and respect.

There were quality monitoring systems and processes in place to identify how the service was performing and where improvements were required.

We have made a recommendation to the registered manager to source and provide appropriate training and development on the provision of meaningful activities.

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 18 May 2021)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 11 March 2021. A breach of regulation 18, staffing, was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

Follow up

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

Elmhurst Residential Home is a care home providing personal care for up to 34 older people. At the time of the inspection there were 20 people living in the home. The service is an adapted building with a lift.

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

There were not always enough staff on duty to meet people's needs. The provider told us they immediately increased the staffing levels after the inspection to ensure people’s needs could be met safely and responsively in the evenings and at night.

We observed people were cared for by staff who were caring and compassionate. Relatives spoke positively about the staff team and how caring they were.

People received their medicines safely as prescribed. There were suitable systems and processes in place to manage medicines safely.

There were processes in place to prevent and control infection at the service, through regular COVID-19 testing, additional cleaning and safe visiting precautions. However, the home’s infection control policy did not give guidance about COVID-19 and we saw some staff not wearing Personal Protective Equipment (PPE) appropriately. The management team confirmed after the inspection they had addressed this concern through additional training, displaying information about how to wear PPE and checking on staff to ensure they wore their masks properly.

Safeguarding processes were in place to help safeguard people from abuse. Risks associated with people's care had been assessed and guidance was in place for staff to follow.

We made one recommendation to consult people to ensure their dietary preferences were being met.

Relatives were satisfied that people were looked after well by staff who knew their needs and preferences, however some relatives felt communication and updates could be improved.

People had care plans which detailed their needs and preferences. Staff knew people’s care needs and wishes very well.

Staff spoke very positively about the manager and the support they received. Despite the challenges posed by the COVID-19 pandemic, the manager had implemented some improvements and new processes at the service.

The management team engaged well with health and care professionals who told us they found them to be helpful and said the manager acted on their advice.

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 good (published 9 April 2019). At this inspection the rating has deteriorated to requires improvement.

Why we inspected

We received anonymous concerns in relation to staffing levels, quality of food, hygiene and poor care. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. Although we found staffing levels needed to be increased there was no evidence to justify the other concerns. The level of hygiene in the home was good and the staff team was caring and worked well together to provide good care.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe section of this full report. You can see what action we have asked the provider to take at the end of this full report.

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

We made one recommendation to consult people to ensure their dietary preferences were being met.

Enforcement

We have identified a breach in relation to staffing.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We carried out a focused inspection on 24 July 2018 to check on compliance with the warning notices. We found that overall there had been improvements but there was a continued breach of Regulation 12 (Safe care and treatment) because the provider did not provide staff with a written protocol for when to give “as and when needed” medicines and did not follow their own policy of weekly medicines audits. The home was rated 'Requires Improvement' in all five key questions.

Following the last inspection, we met with the provider to confirm what they would do and by when to improve the rating of the home to at least good.

Elmhurst Residential Home 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.

Elmhurst Residential Home is a residential home registered for up to 34 older people in one adapted building. There were 14 people living at the home at the time of the inspection. There had been an embargo on admissions to the home since March 2018 due to the local authority’s concerns about the home, so no new people had moved into the home since our last inspection.

The home 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 home is run. The registered manager was registered by CQC the week before this inspection and had been working at the home for three months.

We found that a lot of improvements had been made in the home since our last inspection and since the new manager had been in post. People were satisfied that they were receiving care that met their needs and wishes. Staff morale had improved significantly.

Mental Capacity Act 2005 (MCA) assessments had been carried out using the MCA principles. Deprivation of Liberty Safeguarding applications had been made to deprive people of their liberties lawfully, for their own safety. Those who were not subject to a deprivation of liberty safeguard were able to go out and return as and when they liked.

Medicines were being managed safely. People were receiving medicines as prescribed and this was recorded on their Medicine Administration Record (MAR). Weekly medicines audits were being carried out and these were effective. One person was given medicines covertly and this was not documented or checked properly. This was the third inspection where this concern was raised. The provider was not following their own policy on covert medicines. The registered manager began to address this immediately after the inspection.

Staff told us they were very happy with the new registered manager and felt very supported. They received regular supervision and competence assessments. Staff training had improved since the last inspection to ensure staff had the necessary knowledge and skills.

Care plans were in place and the registered manager advised us that they were in the process of introducing an improved care plan format. People living in the home told us they were happy with their care and found the staff to be kind and caring. Staff encouraged people to be as independent as they wanted. One example of this was staff assisting a person to bake their own gluten free cakes which they had really enjoyed. People said staff treated them with respect. We saw positive interactions between all staff and people living in the home.

People were given choices of food and drinks and individual preferences were well catered for. Since the last inspection the service had started cooking some foods which met people’s cultural preferences. Food intake was being monitored well for people with specific health concerns.

No complaints had been made since the last inspection. People and their relatives told us they had no concerns with the home other than some said they would like more activities. The range of activities had improved since the last inspection.

People were supported to maintain their health and to attend appointments with healthcare professionals. Staff called the GP promptly when a person was unwell and worked well with healthcare professionals.

Quality assurance systems were in place. The registered manager carried out daily, weekly and monthly checks of the home. People living in the home, their relatives and staff all praised the new registered manager for improving standards in the home and being very supportive. One staff member said the new registered manager had "raised the bar." Record keeping was well organised and records were stored securely.

We made one recommendation which was to review the mealtime experience.

We inspected the service against three of the five questions we ask about services: is the service well led, is the service safe and is the service effective? This is because the service was not meeting some legal requirements in those areas. This report only covers our findings in relation to those requirements. No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Elmhurst Residential Home on our website at www.cqc.org.uk.

Elmhurst Residential Home 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.

Elmhurst Residential Home is registered to provide care for up to 34 older people. There were 17 people living in the home at the time of this inspection. The provider informed us that the local authority had placed an embargo on the service which meant no new people would be moving in until the legal requirements had been complied with.

There was no registered manager in place at the time of this inspection. The registered manager had recently left. 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 time of this inspection one of the joint owners of the home (referred to as “the provider”) was managing the home and a manager from their other registered care home was assisting.

At the last inspection we found six breaches of legal requirements. One breach of legal requirement was about safe care and treatment. Two people’s care plans did not contain adequate information for staff about their diagnosed medical conditions. One person was not receiving safe care despite the provider knowing they had a medical condition which posed risks to their health and wellbeing. Some medicines were not being given as prescribed. The second breach was due to not meeting some people’s nutrition and hydration needs. The third was about insufficient oversight of the care by the provider. We served three warning notices on the provider requiring them to make the necessary improvements by 10 June 2018.

The other three breaches of regulations were about staffing and staff supervision, failing to notify us of serious incidents and lack of appropriate person-centred activities. At this inspection we found that the provider still had no written dependency tool to enable them to work out staffing requirements. Despite this, staffing levels were adequate for the people in the home at the time of the inspection with the exception of early mornings. We have recommended that the provider, in the absence of a system, reviews staffing levels by consulting with people in the home and staff working there. Supervision of staff was improving since the last inspection. The provider had notified us of serious incidents since the last inspection as required. We did not look closely at activities during this inspection so could not confirm whether people felt the activities had improved to meet their needs. This will be addressed at the next inspection.

Although we did not look at whether the service is caring at this inspection, we did note that staff interacted with people in a caring way and a relative, three professionals and people living in the home told us that the staff were very caring.

There was one continued breach of legal requirement as some concerns about medicines had not been addressed despite a warning notice being served. One was an administrative error where a person’s medicine was given but not recorded and the other was a failure of the provider to ensure staff had written protocols to follow for medicines given “as and when require” so that staff knew in what circumstances to give the medicines. You can see what action we told the provider to take at the back of the full version of the report.

Elmhurst Residential Home is a residential home for up to 34 people with dementia. There were 19 people in the home at the time of the inspection.

The home had a registered manager. 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 home is run.

Elmhurst Residential Home 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 home was extended in 2017 from 14 people to accommodate up to 34 people. There were suitable facilities for people using wheelchairs including assisted baths, wet room and a lift.

There was a failure to provide safe care to some people as there was insufficient information about two people's medical conditions and some people were not being given their medicines safely as prescribed. The food was fresh and well presented but some people who were at risk of poor nutrition were not receiving enough support with and monitoring of their nutrition.

The governance of the home (by the registered manager and the provider) was not effective as they did not find and act on the concerns we found and some confidential information was not stored securely. They had also not notified us of events they are required to tell us about by law.

Relatives said they felt welcome and were generally positive about the service although some said they would like to see more interaction and activity. They said any concerns were listened to and acted on. Staff received training but did not receive regular supervision where they could discuss their work. Staff were happy working in the home.

There were risk assessments in place to help keep people safe in the home but some were not up to date. Staff knew how to recognise signs of abuse and how to respond.

Although staffing had increased since the last inspection there was no systematic way of assessing how many staff were needed on duty to meet people's needs as the provider did not use a dependency tool.

The registered manager, provider and staff were kind and caring and formed good knowledge of people's individual needs. Some care plans were of a good standard and reflected people's needs and wishes about their care. Others, especially for people who had stayed temporarily in the home, did not contain enough information for staff to provide good person centred care meeting all their needs. Some plans had not been reviewed regularly to ensure they were up to date.

People had good support with seeing the GP and other healthcare professionals when required. The standard of cleanliness throughout the home was very good.

There were six breaches of legal requirements found at this inspection. Two were continued breaches from the previous inspection as the provider had not improved the quality of activities and had not developed a system for assessing people's needs in order to ensure enough staff were available on duty. The other breaches were about safe care and treatment, meeting nutritional needs, failure to report significant events and ineffective governance.

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

Elmhurst Residential Home is a residential home for up to 34 people with dementia. There were 12 people staying there at the time of the inspection. At our last inspection on 28 June 2016 the home accommodated up to 14 people. Following our last inspection, the provider submitted an application to extend their registration to accommodate up to 34 people. The registration was granted on 29 June 2017.

The home had a registered manager. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.

The provider submitted an action plan following the breaches identified at the last inspection. The action plan detailed how breaches would be addressed and included a system would be put in place to calculate staffing levels contingent with people’s dependency needs. The breach relating to staffing levels had not been addressed in full. Staff told us that there was still not enough staff to support people. Systems were still not in place to calculate staffing levels contingent with people’s dependency levels.

Activities were not taking place on a regular basis. Most people told us that activities were not taking place and records did not detail if people were taking part in regular activities.

Risks associated with people’s care had been identified and assessed that provided information to staff on how to mitigate risks to keep people safe.

Regular fire and evacuation tests had been completed. There were evacuation mats in place to evacuate people in the event of an emergency. Staff had been trained in fire safety and were able to tell us how to evacuate people safely.

Quality monitoring systems were in place. Questionnaires had been sent to people, relatives and professionals. Action had been taken following feedback.

Quality assurance systems were in place. The registered manager carried out daily, weekly and monthly checks of the home.

Mental Capacity Act 2005 (MCA) assessments had been carried out using the MCA principles. Deprivation of Liberty Safeguarding applications had been made to deprive people of their liberties lawfully, for their own safety. Staff were able to tell us about the principles of the Act.

People told us they felt safe. Staff knew how to keep people safe. They knew how to recognise abuse and who to report to and understood how to whistle blow. Whistleblowing is when someone who works for an employer raises a concern which harms, or creates a risk of harm, to people who use the home.

Recruitment and selection procedures were in place. Checks had been undertaken to ensure staff were suitable for the role.

Medicines were being managed safely. People were receiving medicines as prescribed and this was recorded on their Medicine Administration Record (MAR). PRN medicines, which is as needed medicines such as paracetamol, were given when needed. Weekly medicines audits were being carried out.

Staff told us they were supported and the registered manager was approachable and supportive. Recent supervisions had been carried out. However, two staff had not received their annual appraisal.

Staff had received training to enable them to perform their role effectively. Staff had received induction when starting employment.

Care plans were informative and person centred. Staff told us that the care plans helped them to provide person centred care.

The previous CQC inspection rating had been displayed at the home.

People were given choices during meal times and their needs and preferences were taken into account. Food was being monitored for people with specific health concerns to ensure they had a healthy balanced diet.

No complaints had been made since the last inspection. Staff were aware of how to manage complaints. People and relatives told us they had no concerns with the home.

People were supported to maintain good health and appropriate referrals to other healthcare professionals were made.

People were encouraged to be independent and their privacy and dignity was respected.

We found breaches of regulation related to staffing and activities. You can see what action we have asked the provider to take at the back of the full version of this report.

We undertook this unannounced focused inspection on 7 November 2016 to check that the provider had complied with the conditions. At this inspection, we looked at aspects of the key question 'Is the service safe?’ This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Elmhurst Residential Home’' on our website at www.cqc.org.uk.

Elmhurst Residential Home provides accommodation and support with personal care for up to 14 people. At the time of our visit, 10 people lived there who needed support with personal care.

The home did not have a registered manager. There was an acting manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 provider told us that a manager had been recruited and will commence employment once pre-employment checks have been completed.

During our focused inspection we found the provider had made improvements with fire safety. Risk assessment and personal evacuation emergency plans (PEEPs) had been completed. Staff had been trained on fire safety and knew what to do in the event of an emergency evacuation. Fire safety audits and fire risk assessments were being completed to ensure the risk of fire was minimised and follow up action was recorded. Fire safety equipment had been installed and staff were aware on how to use the equipment. A risk assessment had been completed for a person that may exhibit behaviour that may be a fire risk.

The home had complied with the urgent conditions we had imposed. Although improvements had been made, we have not changed the service’s rating from 'Requires Improvement' as there were other issues within this key question that we identified at the last comprehensive inspection that need to be addressed.

Elmhurst Residential home is a residential home for up to 14 adults with dementia. There were thirteen people staying there at the time of the inspection.

The home did not have a registered manager in place during our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 home had a manager in place and the provider told us that the manager is in their probationary period and will apply for registration when their probation finishes.

The report for the last inspection carried out on 16 November 2016 had been published on the CQC website on 11 January 2016. The CQC inspection rating had not been displayed at the home. An action plan which is required from the provider, detailing how the breaches identified at the last inspection would be met, had not been sent to the CQC.

Three people lacked mobility and lived on the upper floors. There were no risk assessments or plans to evacuate the people in the event of a fire. Most staff had not received training in fire safety and staff were not aware on how to evacuate people that lacked in mobility living in the upper floors. We found a person was high risk of causing fire; risk assessment had not been completed to mitigate this risk. Fire evacuation equipment had not been installed to evacuate people in the event of a fire.

We found improvements had been made with identifying and assessing risks to people. Assessment had been made specific to some people’s circumstances and health conditions. Moving and handling assessments had been completed. However, we still found that some risk assessments had not identified all the risks or been completed in full.

Systems were not in place to calculate staffing levels contingent with people’s dependency levels.

Improvements had not been made in assessing people’s capacity to make decisions on a particular area. MCA assessment had not been carried out for four people out of the seven care plans we looked at. Where it was judged a person lacked capacity, we did not find evidence that showed health and social professionals and family members had been consulted to make a best interest decision. Staff still had not received MCA and Deprivation of Liberty Safeguarding (DoLS) training.

DoLS application had been made to deprive people of their liberty lawfully in order to ensure people’s safety.

We made a recommendation at the last inspection to make the home and environment suitable for people living with dementia. There was a lack of progress as there was no directional signage around the home and no names of people or their photo’s to show which person was occupying a room especially for people that had dementia.

Some improvements had been made with supervisions. Appraisals were carried out with staff but this did not cover training, objectives and development needs. Only one staff supervision had taken place since the last inspection.

Not all of the staff working at the home had received the training they needed to do their jobs effectively. Staff had received induction when starting employment.

Care plans were inconsistent and were not always completed in full.

Quality assurance had been implemented to allow the service to demonstrate effectively the safety and quality of the home. However, the provider’s quality assurance had not identified the shortfalls we found during our inspection.

People were given choices during meal times and their needs and preferences were taken into account. Nutritional assessments were in place for people, which included the type of food people liked. Food was being monitored for people with specific health concerns to ensure they had a healthy balanced diet. Fluid intake charts were not in place for two people with specific health concerns.

No complaints had been made since the last inspection. Staff were aware on how to manage complaints. People and relatives had no concerns with the service.

People told us they felt safe. Staff knew how to keep people safe. They knew how to recognise abuse and who to report to and understood how to whistle blow. Whistleblowing is when someone who works for an employer raises a concern which harms, or creates a risk of harm, to people who use the service.

Recruitment and selection procedures were in place. Checks had been undertaken to ensure staff were suitable for the role.

People were supported to maintain good health and appropriate referrals to other healthcare professionals were made.

We observed caring and friendly interactions between management, staff and people. People who used the service spoke positively of staff and management. There was an activities programme in place.

People were encouraged to be independent. People were able to go to their rooms and move freely around the house.

We identified breaches of regulations relating to consent, risk management, staffing, person centred care, supervision, training and displaying CQC performance rating. You can see what action we have asked the provider to take at the back of the full version of this report.

Following our 17 October 2013 inspection the provider sent us an action plan setting out how they had addressed these matters. At this inspection we saw that risks to people from the extension building works had been assessed and controlled and we saw that care planning, staffing and management records had been updated.

People using the service were positive. We spoke with five of the fourteen people using the service and observed how staff provided care and interacted with people. Comments from people included, 'it's nice here', 'staff look after me' and 'I like it here.' We saw that there were warm relations between staff and people using the service. We witnessed friendly conversations between them and we saw staff working in a calm, respectful manner. Staff told us that the service was running smoothly. 'It's going OK,' one staff member told us.

We looked around the premises with the acting manager and we saw that the building works meant that there was a restriction on storage space and that equipment such as wheelchairs had to be stored in bathrooms. However, we were told that this was a temporary matter as the building work was expected to be completed later in 2014.

At this inspection we saw that one additional staff member was at work for the afternoon and evening shift. There were three staff in total on duty. We spoke with staff and were told that there was an extra staff member on duty in the afternoon / evening each day. The staffing rota confirmed this.

We spoke with four people using the service. They told us there were happy with the service. One person said, 'all in all, it's pretty good here.'

We saw that there were positive relations between staff and people using the service. We saw staff working with people in a professional and friendly manner and we noted that staff knew people well and were able to tell us about people's needs and how they provided care.

People using the service were positive. They told us the service was good. One person said,' it's very good, the staff are very friendly and they help me.' A second person described staff as, 'pretty good.' We observed staff working with people kindly and calmly. We spoke with a visiting relative who told us that, 'it's absolutely fine, staff are nice people and communication with us is good.'

We spoke with the majority of staff on duty. They told us they felt supported and that they discussed arising matters together as a team. However, staff told us that they would benefit from having extra staff in the afternoon / evening shift.

We found that improvements to the staff recruitment process had been made and we were shown records of staff supervision. However, despite the provider's action plan stating that additional staff would be placed on the afternoon shift, we found that there had been no change to the staffing numbers since our inspection of 26 April 2013. Since that inspection there had been an increase in people's needs. There continues to be insufficient staff to meet the needs of people using the service, particularly in the afternoon / evening shift.

The provider was building an extension to the care home. We saw that this presented risks to the people using the service, staff and visitors. A risk assessment to identify and control risks had not been carried out. We identified that there were gaps in the provider's record keeping arrangements. This meant that people using the service were not being adequately protected from risks of unsafe or inappropriate care.

Staff were positive. They referred to good teamwork, a nice atmosphere and the personal rewards of doing a good job for people. The manager provided leadership and was a good role model for staff. People using the service were respected and care arrangements well organised. We were shown evidence that a range of quality checks and health and safety audits had been carried out.

However, we identified areas of non-compliance relating to staffing. An assessment of people's needs had not been carried out to calculate the staffing level needed and care provision relied a great deal on daily input from the manager. There was a gap in the staff recruitment records, staff had not received recent training in the Mental Capacity Act 2005 (MCA) and new staff needed safeguarding adults and manual handling training. All these factors meant that people using the service may be at risk because there were not enough qualified, skilled and experienced staff to meet people's needs.

People who use the service told us that staff were kind and respected their privacy. They confirmed that staff treated them with care, respect and dignity. One person commented 'I couldn't be happier. It's a wonderful place.' Another person said, 'I like it here. You can be yourself.'

People told us they had good access to health care professionals such as doctors, district nurses, dentists and chiropodists.

We observed that the way staff were supporting people in the home had a positive effect on their well being. Staff we interviewed had a good understanding of the needs of the people they supported.

People who use the service told us that they felt safe at the home. They said they had no concerns or complaints about their care but would speak with their relatives, the person in charge or the staff if they needed to.

People told us they were satisfied with the support they received to take their medication. One person we spoke with told us, 'they tell you what it's for.' They told us that the staff were, 'kind' and included them in decisions about their care. In general people said they thought there were enough staff on duty to support them properly.

People confirmed that the management and staff often asked them for their views about the quality of care they received. One person commented, 'It's all good here.'