Archived: Swinton Hall Nursing Home Limited

When we carried out a comprehensive inspection of Swinton Hall Nursing Home on 05 and 06 April 2017 we found the service was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Good governance, and Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Safe care and treatment.

We then carried out a focussed inspection on 07 June 2017 and a pharmacist who is a medicines inspector with CQC visited the home to see if the necessary improvements had been made to ensure that people were protected from the risks associated with the safe handling of medicines. At that inspection we found continuing concerns regarding medicines management and the service was still in breach of this regulation.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve. At this comprehensive inspection on 06 and 07 December 2017 we found medicines were still not being administered safely.

During this inspection, we also found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regard to receiving and acting on complaints, good governance, staffing, fit and proper persons employed. We are currently considering our enforcement options in relation to these breaches.

Swinton Hall 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.

Swinton Hall Nursing Home is a privately owned nursing home and is within easy access to the cities of Salford and Manchester. The home is registered to provide accommodation with personal and nursing care for up to 62 people across two units. The home has a 15 bed continuing care unit to support people with complex nursing needs. At the time of the inspection there were 42 people using the service with 11 people residing in the continuing care unit, 18 people in the ground floor and upstairs nursing units and 13 people occupying residential beds.

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 2008 and associated Regulations about how the service is run.

Medicines were not always handled or administered safely. Effective systems for the safe administration and storage of drink thickeners were not in place, which placed people at risk of harm. Records regarding the administration of moisturising or barrier creams were not always completed and this meant people’s skin might not be cared for properly. Although medicines had been audited, these had failed to identify the continuing issues we found during the inspection regarding the unsafe management of medicines.

The provider had a process of staff recruitment in place but this was not consistently followed for every staff member. One staff member had been recently recruited but did not have a specific job role identified and references supplied were insufficient. The manager also confirmed this staff member had also not received any formal period of induction.

A staff vacancy of ‘unit lead’ in the main nursing unit of the home had not been replaced and attempts at recruiting to this role had been unsuccessful. The registered manager was unclear why this had happened, and how to ensure that it did not happen again. As a result the registered manager was engaged in clinical nursing activities which detracted from their ability to undertake the registered manager role.

The home had a management and staffing structure but not all job roles had been filled. This meant there was a lack of appropriately skilled staff deployed which resulted in the registered manager being unable to ensure effective oversight and governance, due to being involved in clinical tasks.

Building cleaning schedules were in place and the premises were clean and tidy and there were no malodours. Staff wore appropriate personal protective equipment (PPE) such as gloves and aprons as required.

The provider had failed to submit statutory notifications to CQC regarding applications/decisions for when a person was deprived of their liberty (DoL). Information received from a best interest assessor during the inspection indicated DoLS applications were not submitted in a timely way and information in applications submitted was poor.

People we spoke with and their visiting relatives agreed that staff were kind and compassionate and thought staff treated them with respect. However we observed people were left alone in the communal lounges on many occasions and this was particularly apparent when staff were engaged in supporting other people.

Some people’s needs and care plans had been reviewed and updated but this was not consistent. This meant we could not be confident their needs and the risks associated with them had been identified and managed. It was not always possible to determine how often people needed support to change position as this was not detailed on all people’s turning charts.

There was no clear identification of people with end of life care needs which meant they may not be supported in ways that reflected their current medical condition and personal preferences. This could result in insufficient care being provided which could undermine people’s dignity and preferred choices.

The manager acknowledged the home had received complaints but these had not been recorded properly and therefore we could not determine the nature and number of any complaints received since February 2017 and if these had been responded to correctly.

The home has been rated as requires improvement since 2015 and the provider had failed to improve the overall rating of the home from 'requires improvement' over time. The expectation would be that following the previous 'requires improvement' rating, the provider would have ensured the quality of care received had improved and attained a rating of either 'good' or 'outstanding' at this inspection. This had not been the case, as we found the quality of service provided to people living at the home was not continuously improving over time.

We identified significant shortfalls in the care provided to people at the home. This was linked to ineffective governance arrangements and leadership both by the provider, and through the management arrangements in place at the home. Audits were not up to date and day-to-day clinical and operational leadership of staff was inadequate. The provider had failed to provide sufficient oversight to recognise and respond to emerging issues identified at this inspection.

Shortly after the date of the inspection the provider contacted us to inform us they had taken the decision to close the home. Following this we attended a meeting with the provider, the clinical commissioning group (CCG) and local authority commissioners to identify the next course of actions and expectations of the service regarding the closure process. It was agreed a high level action plan would be drawn up by the provider to mitigate the risks identified at the inspection during the closure process.

Salford adult social care and Salford CCG made direct contact with all the people living at Swinton Hall and their families to identify wishes and needs and help find alternative suitable care home places. This took place in close co-operation with the owners of Swinton Hall to ensure the service continued whilst ensuring a smooth and safe transition for all the people living there. CQC also worked together with Salford local authority regarding the situation, in line with the joint national guidance on care home closures.

We undertook a focused inspection to check that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Swinton Hall Nursing Home Limited on our website at www.cqc.org.uk.

We found continuing concerns about the safe handling of medicines for all 11 people whose records we viewed and there had been no significant improvement in the handling of medicines since the date of the last comprehensive inspection.

These issues meant the service remained in breach of Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, in respect of the safe management of medicines. You can see what action we told the provider to take at the back of the full version of this report.

After our inspection we issued a Possible Urgent Enforcement Action – Section 31 of the Health and Social Care Act 2008 urgent letter asking the provider how they would ensure that people’s health would be protected and we required an action plan to be produced within 24 hours. The provider produced an action plan and we held discussions with the manager and provider regarding the plan.

The manager of the home explained in detail exactly how the plan would be implemented, which included less use of agency staff because two new nurses and a clinical lead had been appointed and had started their induction in the home since the date of the last inspection. The plan also included new systems and processes being put in place to check medicines were given correctly; these systems had not previously been in place.

We were assured by the provider that they took the management of medicines very seriously and that they would work hard to make sure people were safe and protected against the risk of poor medicines management.

We also had assurances from NHS Salford Clinical Commissioning Group (CCG) that it was the intention of NHS Salford CCG to encourage and promote partnership working with Swinton Hall to support any improvements they are required to make.

As a result of the action plans submitted to the Commission and the assurances from the CCG no further enforcement action will be taken at this time in order to allow the necessary improvements to be made.

At the previous focussed inspection improvements were required to ensure medicines were managed safely and this was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, with regards to safe care and treatment.

At this comprehensive inspection we found the service to be in continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, with regards to the safe management of medicines. We also found the service in breach of Regulation 17 (2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance, because the service had failed to effectively assess, monitor and improve the quality and safety of the services provided. We are currently considering our enforcement options in relation to these breaches.

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 2008 and associated Regulations about how the service is run.

People who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise risk.

We observed good interactions between staff and people who used the service during the day. People felt staff were kind and considerate.

Recruitment of staff was robust and there were sufficient staff to attend to people’s needs.

The service undertook a range of audits of the service to ensure different aspects of the service were meeting the required standards. However, at this inspection we found audits of the safe management of medicines had not recognised or identified the issues we found at this inspection.

People’s nutrition and hydration needs were met appropriately and they were given choices with regard to food and drinks. Staff responded and supported people with dementia care needs appropriately.

People and relatives told us they were involved in making decisions about their care and were listened to by the service.

We saw people being treated with kindness and respect and when support was provided, such as supporting people eating their lunch time meal.

People were involved in developing their care plan and sensitive information was being handled carefully. We saw that people were involved in group activities and other individual activities that took place during our visit.

The service followed the Six Steps programme in end of life care and were supported by relevant community professionals.

There was a service user guide and statement of purpose in place. There was a business continuity plan in place that identified actions to be taken in the event of an unforeseen event.

The service worked alongside other professionals and agencies in order to meet people’s care requirements where required.

There was a complaints policy and procedure in place which had contact numbers for CQC and the local authority and a copy was available in the entrance to the home.

Swinton Hall Nursing Home is a privately owned nursing home close to the A580, East Lancashire Road and is within easy access to the cities of Salford and Manchester. The home is registered to provide accommodation with personal and nursing care for up to 62 people across two units. The home comprises of a 15 bed continuing care unit to support people with complex nursing needs and a nursing unit.

There was no registered manager in place at the time of our inspection, however a manager had been appointed and was in the process of applying to register with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

As part of this focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the reports from our last comprehensive and focused inspections, by selecting the 'all reports' link for Swinton Hall Nursing Home on our website at www.cqc.org.uk.

We found limited improvements had been made had been made since our last inspection, however people were still not protected against the risk of unsafe medicine handling. We looked at medicines and records about medicines for 14 people and found there were concerns about the safe handling of medicines for all 14 people.

The systems for ordering medicines were poor and people did not have their medication delivered in a timely manner. Four people ran out of some of their medication, because it did not arrive in time for the start of the new medication cycle. One person had to wait four days for their eye infection to be treated, because the medication did not arrive when expected and nurses failed to chase the missing medication up. We also found that nurses failed to act or follow up on other health care professionals’ advice regarding medication, which placed people’s health at risk of harm.

We found that people who needed to have their medicines given by means of a special feeding tube were placed at risk because their medicines were not given safely.

We found as at the last inspections, that the information to guide nurses and care staff on how to apply creams and thicken fluids or give medicines prescribed as 'when required' were either missing or provided limited guidance.

We found the records about the administration of medicines and creams were still inaccurate or not in place and still could not be relied upon to demonstrate people were given their medicines safely.

We found the records about the stock of medicines in the home were still inaccurate. This meant that audits and checks could not be done to ensure that medicines had been given as prescribed.

People who were prescribed insulin must have their blood sugars monitored. We saw there was very clear guidance about what to do if one person’s blood sugar levels fell outside their safe range. However, we saw that the nurses failed to follow this guidance which placed people at risk of harm.

As at the previous inspection we saw the storage of medicines was not safe. We found that creams were still not stored safely because they were not locked up in people’s bedrooms.

We saw there was out of date medication in the fridge.

We found that no improvements had been made in the storage of waste medication it was still stored in open containers on the floor of the medication room, which is against national guidance.

This was a breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the service had not protected people against the risks associated with the unsafe management of medication.

CQC are currently considering their enforcement options in respect of these continuing concerns.

Swinton Hall Nursing Home is a privately owned nursing home close to the A580, East Lancashire Road and is within easy access to the cities of Salford and Manchester. The home is registered to provide accommodation with personal and nursing care for up to 62 people across three units. The home comprises of a 15 bed continuing care unit to support people with complex nursing needs and a nursing unit.

There was no registered manager in place at the time of our inspection, however a manager had been appointed and was in the process of applying to register with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

As part of this focused inspection we checked to see that improvements had been implemented by the service in order to meet legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Swinton Hall Nursing Home on our website at www.cqc.org.uk.

At the last inspection visit on 06 January 2016, we found that medicines were not handled safely. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the service had not protected people against the risks associated with the safe management of medication. We told the provider they must take action to improve the safe handling of medicines.

We found records still could not be relied on to demonstrate that people had received their medication safely and in line with their prescription.

We also looked at the records relating to the application of prescribed creams. We found the information recorded to guide staff as to which creams to apply were incomplete. We found that the information did not include all their prescribed creams. The records showed creams were not applied as prescribed.

We saw that the records about the quantities of mediation held in the home for each person were inaccurate. We found more medication was in stock that had been recorded as being available. This meant audits and checks could not be done to show that medicines had been given as prescribed.

We found one person was not given their prescribed medication for almost four days, because there was none available. Another person’s tube of gel to replace their saliva had been almost all used up, but none had been ordered to maintain a continuity of supply. If medicines are unavailable people’s health maybe placed at risk.

We found that medicines were not administered safely. We saw one person did not have one of their heart medicines for 18 days, even though it was in stock and available for administration. We also found when we compared the stock of tablets with the records of administration, that it had not been administered as many times as it had been signed for. The same person was prescribed some tablets to be taken each night. However, despite the fact they had been signed as given on ten out of 17 nights, the box was sealed and none had been given.

Medicines were not administered in accordance with the manufacturers’ directions regarding food. We saw that medicines, which must be given before meals were given at the same time as medicines which need to be given with food. If medicines are given at the wrong times with regard to food they may not work properly and people will not receive the full benefit of their medication, which places their health at risk.

This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the service had not protected people against the risks associated with the safe management of medication. CQC are currently considering there enforcement action in respect of these concerns.

Prior to this visit we received information of concern regarding staffing levels relating to qualified nurses and an over reliance of agency nurses. We looked at how the service ensured there were sufficient numbers of staff on duty to meet people’s needs and keep them safe. We looked at rotas and spoke to staff on duty about whether they had any concerns about staffing levels. We found there were sufficient numbers of staff on duty during the day and night to support people who used the service.

During our last inspection we found that the provider failed to provide care and treatment that met individual needs and reflected personal preferences. This related to providing opportunities for people to take part in activities they enjoyed, which met their personal preferences. This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person centred care

During this inspection we found that the service was able to demonstrate that they were now meeting the requirements of regulations. We found that the service had installed a sensory therapy suite. This provided opportunities for people living with different stages of dementia to be stimulated and engage in activities, either as a group or individually with the activities coordinator. People engaged in recreational pass times such as card making and craft work. We saw people making use of this facility during our visit.

The activities coordinator told us they were fully supported by the management team, who ensued the role was a dedicated position. We found that were people chose not to involve themselves in group events, they had the option of one to one stimulation with the activity coordinator. Records were maintained of what activities and engagement people participated in.

Swinton Hall Nursing Home is a privately owned nursing home close to the A580, East Lancashire Road and is within easy access to the cities of Salford and Manchester. The home is registered to provide accommodation with personal and nursing care for up to 62 people across three units. The home comprises of a nursing unit, a 15 bed continuing care unit to support people with complex nursing needs, the terminally ill and physically disabled. The home also has a dedicated 18 bed unit providing accommodation for people living with dementia, otherwise known as the Snowdrop Unit.

There was no registered manager in place at the time of our inspection, though a temporary manager was present on the day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

At the last comprehensive inspection carried out in February 2015, we identified concerns in relation to the recruitment of fit and proper persons and the risks associated with the proper use and maintenance of equipment. Following a further focused inspection carried out in May 2015, we found that the service was then meeting the requirements of regulations in respect these matters. As part of this visit we checked to see whether the improvements made had been sustained by the service.

During this inspection 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.

As part of the inspection we checked to see how the service managed and administered medication safely. We looked at a sample of 20 medication administration records (MAR), which recorded when and by whom medicines were administered to people who used the service. We found that records supporting and evidencing the safe administration of medicines were not always complete and accurate. We found a number of signature omissions in these records.

In records we looked at relating to the administration of prescribed creams we found repeated gaps and omissions. This meant the service could not demonstrate that the medication had been administered in line with people’s prescription.

In the nursing unit we found fridge temperatures for two fridges had not always been recorded and found repeated omissions for the month of December 2015. If medicines are not stored at the correct temperature they may be not be safe to use.

This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment, because the service had not protected people against the risks associated with the safe management of medication.

During our last inspection we made a recommendation regarding people being given opportunities to take part in activities they enjoyed and met their personal preferences. During this inspection we observed an activity session taking place in the Nursing Unit dining room, with the stand-in activities co-ordinator and two residents sitting at a table colouring in a craft book. The staff member was chatting amiably with the people whilst helping them. We did not witness any other activities to stimulate people taking place during our visit.

We discussed with the Registered Mental Health Nurse (RMN) in the Snowdrop Unit about the availability of dementia appropriate activities within the unit. We were told that the activities co-ordinator was on long term sick leave. In the meantime, another member of staff, from the nursing unit upstairs, had visited the unit on a number of occasions to assist with activities. However, that individual was also currently off with sickness. The RMN told us that they did not know the timetable for any planned activities for people who used the service.

Behaviours by people with dementia need to be seen by staff as expressions of how the individuals are experiencing the world around them so that staff can attempt to meet those needs by appropriate care and activity. We found no record of any activity needs documented in any care plans we looked at.

This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person centred care, because the service failed to provide care and treatment that met individual needs and reflected personal preferences.

People we spoke with told us they felt safe and were satisfied with the quality of care they or their loved ones received at Swinton Hall Nursing Home.

We found people were protected against the risks of abuse, because the home had appropriate recruitment procedures in place. We saw that appropriate checks were carried out before staff began work at the home to ensure they were fit to work with vulnerable adults.

As part of the inspection, we looked at how the service ensured there were sufficient numbers of staff on duty to meet people’s needs and keep them safe. We found there were sufficient numbers of staff on duty during the day to support people who used the service. We spoke to both staff and people who used the service and their relatives, who on the whole, did not raise any concerns about staffing levels throughout the home.

We looked at a sample of 15 care files to understand how the service managed risk. We found the service undertook a comprehensive range of risk assessments to ensure people remained safe.

The service had a dedicated training coordinator with training facilities on site. We spoke to the training coordinator who explained the induction programme all new staff received, which included attaining a mandatory ‘Level 2 Certificate’ in preparing to work in adult social care. This certificate

provided a foundation and 20 credits towards a Level 2 Qualification Credit Framework (QCF), which all staff were required to undertake after their probationary period and induction.

All staff we spoke with confirmed they received regular supervision, which we verified by looking at supervision records. Supervisions and appraisals enabled managers to assess the development needs of their staff and to address training and personal needs in a timely manner.

We found that while most staff had received training in the MCA and DoLS, some nurses we spoke with on the Snowdrop Unit were unaware of the process of requesting DoLS assessments and their purpose. Care staff we spoke with were able to explain the principals of the legislation to us.

Through our inspection, we saw staff seeking consent from people before undertaking any tasks such as delivering personal care or support with eating. Staff took their time to explain to people what they wanted to do, which demonstrated a very kind and caring culture.

We have made a further recommendation about dementia friendly environments.

We found that individual nutritional needs were assessed and planned for by the home. We saw evidence that nutritional and eating needs had been assessed and catered for by the service. We observed the lunch time experience in the nursing and Snowdrop Units and noted a pleasant, calm and amiable atmosphere that was generated by the manner in which care staff interacted with people.

We found staff treated people who used the service with kindness and compassion in their day to day interaction.

Throughout our inspection we observed that staff treated people with dignity and respected their privacy. Staff appeared unflustered if people demonstrated anxiety. At all times they appeared patient and enthusiastic in their work.

The home was also a member of ‘Care Aware Advocacy Service,’ which was a ‘one stop shop’ for people and families to seek independent advice and support.

The home was part of the Six Steps End of Life Care programme. This programme is intended to enable people to have a comfortable, dignified and pain free death.

There was a complaints policy and procedure in place. This clearly explained the process people could follow if they were unhappy with aspects of their care.

We found that the service routinely listened to people to address any concerns or complaints. We looked at customer satisfaction survey questionnaires for 2015 and the analysed results. On the whole people were very complimentary about the quality of services delivered.

We found the service undertook a comprehensive range of audits and checks to monitor the quality of services provided. However, we questioned the effectiveness of some audits such as medication in light of the concerns we identified. The last medication audit undertaken was dated July 2015. A number of audits were also not being consistently applied.

We looked at minutes from staff meetings and staff questionnaires that had been completed. Where issues were raised, there was no evidence to demonstrate how the service had responded to these issues.

The home had policies and procedures in place, which covered all aspects of the service. The policies and procedures included; safeguarding, whistleblowing, consent, medication and supervision.

During our visit we spoke to eight people who used the service, eight relatives and friends and three visiting health and social care professionals. We also spoke to ten members of staff during our visit.

Our inspection team was made up of an inspector who addressed our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

We found people were treated with respect and dignity by staff. People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. One person who used the service told us; 'It is very pleasant. I do feel safe here.' A visiting health and social care professional said 'I do feel people are safe here. I have no concerns about staffing levels certainly during the day.'

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. We looked at supervision records and minutes from staff meetings which detailed good practice and learning that had been shared with staff. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. The service had been recently involved in the submission of one application. Relevant staff had been trained to understand when an application should be made, and in how to submit one. We found that further training had been arranged for staff by the training coordinator.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore people were not put at any unnecessary risk. The home required redecoration in some areas and we were told that a rolling programme of improvements was being undertaken.

The registered manager sets staff rotas and took people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were always met.

Recruitment practice was safe and thorough. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

It was not always clear that people's health and care needs were assessed with them, and that they or their representatives had been involved in writing their plans of nursing care.

Specialist dietary, mobility and equipment needs had been identified in nursing plans where required.

Visitors confirmed that they were able to see people in private and that visiting times were flexible. Staff were always welcoming and friendly.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People commented, 'Everybody is so good to me and expect nothing in return.' 'There is always enough staff, they are all very helpful. No concerns what so ever.' 'They are very informative, X has improved since coming here from hospital.' 'Seem to be very comfortable here and staff attend to all his needs.' 'Food is very good and cleanliness is very good.'

People who used the service, their relatives and friends completed a satisfaction survey. Where shortfalls or concerns were raised these were addressed.

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

Is the service responsive?

People completed a range of activities in and outside the service regularly. The service employed an activities coordinator.

People knew how to make a complaint if they were unhappy. The service had procedures in place to deal with complaints.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service continuingly improved.

Staff told us they were clear about their roles and responsibilities within the home.

We walked around the building and saw that it was well maintained, clean and tidy. We saw that some bedroom doors were held open with wooden wedges. We spoke with the manager and one of the directors and advised them to take advice from the local fire officer with regards to a more appropriate method of holding doors open.

We saw that staff attended meetings and received on-going supervision from senior staff. Staff we spoke with told us they felt well supported by the manager, deputy manager and the directors.

Residents and relatives meetings were organised and minutes kept. Audits were carried out in relation to infection control, care plans and falls.

Three people who we spoke with told us 'It's brilliant', 'I like living here' and 'It's absolutely wonderful'. Another person who used the service told us 'I always get my medication on time', 'This is important to me'.

Two relatives to told us 'Other people recommended that we considered this home and we haven't been disappointed', 'Nothing is ever too much for the staff', 'They are caring people and they show it'.

On the day of the inspection we found that people who used the service had been cared for in a respectful and dignified way and that their care an welfare needs had been met. We spoke with people who used the service, relatives and staff in order to gain feedback about the service, all of which was positive.