Archived: The Berkshire Care Home

The Berkshire Care Home is a care home providing personal and nursing care for up to 58 people over two floors in one building. The service provides support to older people and younger adults. At the time of our inspection, there were 26 people using the service.

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

Staff were not always deployed in the most effective way. We observed several people were left without stimulation or engagement for extended periods. One person identified as being at risk of choking was left unsupervised in their room whilst eating their lunch. People were not always protected from a risk of harm and we found concerns about risk management and medicines. People were not always protected in the event of an evacuation. Medicines were not always managed safely. We received negative feedback about staffing levels with some people commenting at times they needed to wait to be supported.

People’s hydration was not monitored effectively. Not all staff were up to date with the provider’s mandatory training and had not received training in relation to people’s specific needs to support those people living with conditions such as Parkinson’s Disease or epilepsy. The provider had not made sufficient adaptations to the premises to meet the needs of people living with dementia.

People told us at times they felt rushed as the staff were so busy but felt that most staff were caring towards them.

We have recommended the provider reviews people’s communication needs and ensures the service supports people in order to meet the Accessible Information Standard.

Some staff were responsive to people’s needs. However, we observed several people who were in need of support were left alone for long periods and their care plans were not always individualised to identify their spiritual and cultural needs.

The service now had a registered manager who was appointed in June 2022 to support the development of the home. A new clinical lead had also been employed to support with the nursing aspects of the care provision. Although we recognised the positive changes implemented by the new management team and further improvements planned, we found the provider’s governance required further improvement. We took this into consideration when making our judgement to ensure the most proportionate regulatory response to the concerns identified. Notifications had not always been sent to CQC when required.

The provider followed safe recruitment practices.

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.

Complaints were managed effectively, and the registered manager supported people to raise concerns as needed.

Staff supported people to receive the care needed at the end of their lives and had completed end of life care training.

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 9 May 2022). The service is now rated inadequate. 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 the provider remained in breach of regulations.

This service has been in 'special measures' since 14 December 2021. Further improvements are required, as some regulations remain in breach and new breaches of regulations were identified.

Why we inspected

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

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and recommendations

We have identified breaches in relation to medicines management, risk assessments, environmental risks, nutrition and hydration, staffing, staff training, good governance, notifications not being sent to CQC when required, person centred care, dementia friendly premises and incident and accidents at this inspection.

We have made a recommendation in relation to the Accessible Information Standard.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good.

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Berkshire Care Home is a care home with nursing that provides a service for up to 58 older people, some of whom may be living with dementia. At the time of our inspection there were 31 people living at the service. The care home is located in a residential area. Accommodation is arranged over two floors. There are a number of communal lounges and a communal dining area. There is a large garden surrounding the building.

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

Changes were made to improve the safety of care people received. However, further action is required to ensure safe care is always provided. Some risks were found for night time care but the service had reacted to increase vigilance of support during these shifts. There was a dependency tool in place for determining the number of staff for shifts. Call bell audits were sporadic and analysis could occur more frequently to measure safe staff deployment. Recruitment files did not always contain all of the information required at the point of employment, however work was progressing on this. Incidents and accidents were logged, but there was some inconsistent recording and follow up. Infection prevention and control remained satisfactory. People were protected against abuse and neglect. Premises risks were assessed, however mitigation of risks was not always satisfactory.

People's needs were assessed by staff and reviewed regularly. Not all staff have completed mandatory training. Staff supported people to maintain an adequate dietary intake. Staff liaised effectively with professionals to meet people's health and wellbeing needs. The provider had not made any improvements to the premises to meet the needs of people living with dementia. Mental capacity assessments and best interest decisions were not always completed fully and effectively. Care plans did not always contain evidence of legally appointed representatives for people assessed as not having capacity. People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Some improvements to systems and processes were in place to ensure safe, compassionate, well-led care. Work on recruiting a new home manager was ongoing. Progress was being made towards compliance with the regulations in breach, but some breaches have continued at this inspection. The action plan was being used to track progress, as well as an electronic system of tasks. There is evidence of a programme of audits, completed at different intervals, however more time is required to embed the new system of audits and checks. There is evidence of meetings with people, relatives and staff. The clinical oversight by the clinical lead is well-managed and they are proactive at following up actions required by other staff members. Staff reported an improved workplace culture.

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 inadequate (published 7 January 2022) and there were nine breaches of regulations.

We served two warning notices against the provider and issued seven requirement notices. For the requirements notices, 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 the provider had complied with some regulations but remained in breach of other regulations.

At our last inspection we recommended that staff receive additional training in safeguarding adults at risk and review how clinical staff work effectively with health and social care professionals. At this inspection we found the service made progress towards the prior recommendations.

This service has been in ‘special measures’ since 14 December 2021. During this inspection the provider demonstrated that some improvements have been made. Further improvements are required, as some regulations remain in breach.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 5 October 2021, 6 October 2021 and 12 October 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the safety of people, the effective of care and ensure the service was well-led.

We undertook this focused inspection to check they had followed their action plan and to confirm whether they now met legal requirements. This report only covers our findings in relation to the key questions Safe, Effective 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 inadequate to requires improvement. 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 The Berkshire Care Home on our website at www.cqc.org.uk.

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

We have found evidence that the provider needs to make further improvements.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified continued breaches in relation to Regulation 11, Regulation 15, Regulation 18, Regulation 19 and a new breach of Regulation 12.

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 from 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 continue to monitor information we receive about the service, which will help inform when we next inspect. We will also continue to meet with the provider to discuss their progress towards achieving compliance with the regulations.

The overall rating for this service is requires improvement. However, the service will remain in 'special measures'. We do this when services have been rated as inadequate in any key question over two consecutive inspections. The inadequate rating does not need to be in the same question at each of these inspections to remain in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant further improvements.

If the provider has not made enough further improvements within this timeframe, and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated further improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Berkshire Care Home is a care home with nursing that provides a service for up to 58 older people, some of whom may be living with dementia. At the time of our inspection there were 40 people living at the service. The Care Quality Commission (CQC) regulates both the premises and the care provided.

The care home is located in a residential area. Accommodation is arranged over two floors. There are a number of communal lounges and a communal dining area. There is a large garden surrounding the building.

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

Leadership, management and governance systems were poor and did not demonstrate the service was well led, people were safe, or their care and support needs were being consistently met. Systems in place to oversee the service and ensure compliance with the fundamental standards were not always effective. They did not enable the registered manager and provider to identify when their legal responsibilities were not being met. The health, safety and welfare of people using the service, and others, were not always managed effectively and required records were not always kept or available.

Risks to people were not effectively assessed and mitigated. Staff were not deployed effectively to provide person-centred care. Medicines were not managed safely. People were placed at risk of harm due to a lack of information for staff about how to manage people’s medicines. Incidents and accidents were not analysed to prevent recurrences and keep people safe. Recruitment practices were not sufficient or robust enough to ensure suitable staff were employed.

Assessments of people’s care and support needs were not sufficiently detailed to enable staff to provide safe, effective care. Care plans did not contain adequate information for staff to help them manage people’s health conditions. Staff did not always work effectively with professionals from outside agencies to promote people’s health and wellbeing.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People’s dignity and independence were not valued and promoted. People were left unattended for long periods of time and had to wait extended periods to receive support from staff. People were not supported to maintain their independence.

People were not involved in planning their care and support. There was a lack of evidence to show people, their family members, professionals and people’s legally appointed representatives had been involved in making decisions about their care and support.

The provider had failed to notify the local authority safeguarding teams promptly when notifiable safety incidents occurred. The provider had not maintained a complete and accurate record of complaints and investigations into complaints.

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

Rating at last inspection

The last rating for this service was good (published 07 April 2019).

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to a formal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about nursing care, the management of specific health conditions and unsafe medicines management. This inspection examined those risks.

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

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from good to inadequate. 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 The Berkshire Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

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

We have identified breaches in relation to safe care and treatment and good governance. We have served warning notices on the provider.

We have also identified breaches in relation to person centred care, dignity and respect, need for consent, premises and equipment, receiving and acting on complaints, staffing and fit and proper persons. We issued requirement notices and asked the provider to send us a report that says what actions they are going to take.

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

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as

inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice:

Residents were supported by staff to have contact with their family and friends via telephone and internet when they could not see them face to face. The home facilitated garden and window visits which helped to minimise the risk of infection. Visitors accessed the home via an outside area. Visitors were asked a series of screening questions and took a lateral flow test which needed to be negative before seeing their relative. Visitors had their temperature taken and were asked to wear personal protective equipment (PPE) including face masks and aprons.

Plans were in place to isolate people if required, to minimise the risk of COVID-19 transmission, such as new residents admitted from the community. One-to-one care, activities and high levels of support were provided to those people required to isolate within their rooms.

Staff had received training on how to keep people safe during the COVID-19 pandemic and staff and residents were regularly tested for COVID-19. The building was clean and free from clutter.

The home had Infection Prevention Control ‘champions’ that engaged with staff and monitored areas such as the donning and doffing of PPE and hand washing.

Additional cleaning of all areas and weekly auditing of infection prevention processes were carried out. The service had good supplies of PPE which were readily available throughout the service.

Staff supported people's emotional and social wellbeing. Activities had been planned within the home to positively support people through a period of extreme change to their routines.

The Berkshire Care Home is a care home with nursing that provides a service for up to 58 older people, some of whom may be living with dementia. The accommodation is arranged over two floors. At the time of our inspection there were 45 people living at the service. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

People’s experience of using this service:

People felt safe living at the service. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately. There were appropriate recruitment processes in place. Relatives felt their family members were kept safe. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People told us staff were available when they needed them and staff knew how they liked things done most of the time. The registered manager reviewed and improved staffing numbers to ensure enough qualified and knowledgeable staff were available to meet people's needs at all times.

People and their families told us they were happy with their care and had seen a lot of improvements. People confirmed staff respected their privacy and dignity. The registered manager was working with the staff team to ensure caring and kind support was consistent.

We reviewed information held regarding Deprivation of Liberty Safeguards to ensure people's liberty was not restricted in an unlawful way and people's rights and freedom were protected. The management team told us they reviewed people to ensure no one was deprived of their liberty unlawfully. The deputy manager took appropriate action to ensure appropriate applications were made where necessary.

We observed people were treated with care and kindness. People and their families were involved in the planning of their care. The service carried out risk assessments and had drawn up care plans to ensure people's safety and wellbeing. Staff recognised and responded to changes in risks to people who use the service. These changes were reported to the senior person to ensure a timely response and appropriate action was taken.

There were contingency plans in place to respond to emergencies. The premises and equipment were cleaned and well maintained. The dedicated staff team followed procedures and practice to control the spread of infection and keep the service clean.

People had sufficient to eat and drink to meet their nutrition and hydration needs. Hot and cold drinks and snacks were available between meals. People had their healthcare needs identified and were able to access healthcare professionals such as their GP. The service worked well with other health and social care professionals to provide effective care for people. People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately.

Staff training records indicated which training was considered mandatory by the provider. The registered manager had planned and booked training to ensure staff had appropriate knowledge to support people. Staff said they felt supported to do their job and could ask for help when needed.

The registered manager held residents and relatives' meetings followed by staff meetings to ensure consistency in action to be taken. The staff team had handovers and flash meetings to discuss matters with the team.

People were able to engage in meaningful activities, spend time with their visitors or, if they chose, be by themselves. Their choices were always respected. We observed people were offered different activities and were encouraged to join in.

We have made a recommendation about seeking guidance from a reputable source to ensure principles of the Accessible Information Standard are met.

Staff felt the management was open with them and communicated what was happening at the service and with the people living there. People felt the service was managed well and that they could approach management and staff with any concerns.

The management team had reviewed, assessed and monitored the quality of care with the help of staff and other members of the company. They encouraged feedback from people and families, which they used to make improvements to the service. The provider was taking steps proactively to ensure people were protected against the risks of receiving unsafe and inappropriate care and treatment.

Further information is in the detailed findings in the full report.

Rating at last inspection:

At the last inspection which took place on 27, 28 and 29 November 2017 the service was rated Good in the domains of caring and responsive. The service was rated Requires Improvement in the domains of safe, effective and well-led. Overall the service was rated Requires Improvement.

Why we inspected:

This was a planned comprehensive inspection based on the rating at the last inspection.

Follow up:

We will follow up on issues that we identified by asking the registered manager to send us evidence of how and when the issues will be resolved. We will monitor all intelligence received about the service to inform the assessment of the risk profile of the service and to ensure the next inspection is scheduled accordingly.

The Berkshire Care Home is a care home with nursing that provides a service for up to 58 older people, some of whom may be living with dementia. The accommodation is arranged over two floors. At the time of our inspection there were 44 people living at the service. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a registered manager as required. However, the newly appointed home manager was in the process of applying to register with CQC. A registered manager is a person who has registered with the 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.

At the last inspection the service was rated Requires Improvement. At this inspection we found the service remained Requires Improvement.

People told us they felt safe living at the service. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately. There were appropriate recruitment processes in place. All necessary safety checks were completed to ensure prospective staff members were suitable before they were appointed to post. Relatives felt their family members were kept safe.

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

We reviewed information held regarding Deprivation of Liberty Safeguards (DoLS) to ensure people's liberty was not restricted in an unlawful way and people's rights and freedom were protected. The management team told us they reviewed people to ensure no one was deprived of their liberty unlawfully. The deputy manager took appropriate action to ensure appropriate applications were made where necessary.

People told us staff were available when they needed them and staff knew how they liked things done most of the time. The manager reviewed and improved staffing numbers to ensure enough qualified and knowledgeable staff were available to meet people's needs at all times. Most of the staff were knowledgeable and focused on following the best practice to make sure people were supported appropriately. We observed people were treated with care and kindness. People and their families were involved in the planning of their care.

The service carried out risk assessments and had drawn up care plans to ensure people's safety and wellbeing. Staff recognised and responded to changes in risks to people who use the service. These changes were reported to the senior person to ensure a timely response and appropriate action was taken. People received support that was individualised to their personal preferences and needs most of the time. Some records were not always informative enough to ensure people's support needs were followed.

There were contingency plans in place to respond to emergencies. The premises and equipment were cleaned and well maintained. The dedicated staff team followed procedures and practice to control the spread of infection and keep the service clean. However, some maintenance checks were not always up to date. Some equipment and personal items were stored under the stairs. The premises and adaptations were not always dementia friendly. We made a recommendation to review guidance on making the environment more ‘dementia friendly’.

People were given a nutritious and balanced diet. Hot and cold drinks and snacks were available between meals. People had sufficient to eat and drink to meet their nutrition and hydration needs. Support from staff at meal times was much improved with a more relaxed atmosphere. People had their healthcare needs identified and were able to access healthcare professionals such as their GP. Staff knew how to access specialist professional help when needed. The service worked well with other health and social care professionals to provide effective care for people.

Staff training records indicated which training was considered mandatory by the provider. Not all staff were up to date with their training. The manager had planned and booked training to ensure staff had appropriate knowledge to support people. Staff said they felt supported to do their job and could ask for help when needed. The manager had put a new plan in place for staff supervisions and appraisals to ensure consistent support. The manager also planned residents and relatives meetings followed by staff meetings to ensure consistency in action to be taken. Staff felt the handovers and flash meetings were good opportunities to discuss matters with the team.

People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately. We found one minor error, which was rectified immediately and records were accurate.

People and relatives told us a mixture of good and not so good things about the service they received. Our observations confirmed the descriptions people and relatives had given us. There were a few occasions were staff did not always consider the needs of the people. However, we saw care was provided with kindness and compassion most of the time. People and their families told us in general they were happy with their care and had seen a lot of improvements. The manager was working with the staff team to ensure caring and kind support was consistent.

People were able to engage in meaningful activities, spend time with their visitors or if they chose be by themselves. Their choices were always respected. We observed people were offered different activities and were encouraged to join in. Activities planning and involvement was much improved to protect people against the risk of isolation. Most of the interactions observed between staff and people living at the service were respectful and friendly. People confirmed staff respected their privacy and dignity.

People felt staff were happy working at the service and had a good relationship with them, each other and the management. Staff told us the management was open with them and communicated what was happening at the service and with the people living there. People felt the service was managed well and that they could approach management and staff with any concerns.

The management team had reviewed, assessed and monitored the quality of care with the help of staff and other members of the company. They encouraged feedback from people and families, which they used to make improvements to the service. Throughout our inspection we observed the service had changed the way it was operating for the better. The provider was taking steps more proactively to ensure people were protected against the risks of receiving unsafe and inappropriate care and treatment.

Further information is in the detailed findings in the full report.

We last inspected the service in 17, 19, 23, 25 February and 01 March 2016 due to concerns raised about the safety of the people who use the service and the poor management of the service. We conducted a comprehensive inspection of this service and found four breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. The service was rated ‘inadequate’ and placed into ‘special measures’. When a service is rated as inadequate and placed in ‘special measures’, we will inspect again within six months. We took civil enforcement to ensure people’s safety and ensure improvement occurred at the service. We served one warning notice to the provider following the inspection. A warning notice gives a date the service must be compliant by and we inspect again to check that compliance against the content is achieved within the timescale. The provider was required to be compliant with the warning notices by 1 August 2016. The purpose of this inspection was to check what improvements were made and whether the ‘special measures’ framework continues or can be removed. We found the service was compliant with the content of the warning notices.

When we report on issues found at the previous inspection during February and March 2016, we will refer to it as ‘the previous inspection’.

The Berkshire Care Home is a care home with nursing that provides a service for up to 58 older people, some of whom may be living with dementia. The accommodation is arranged over two floors. At the time of our inspection there were 33 people living at the service. One person was at the hospital at the time of our inspection.

The service did not have a registered manager as required. However, the home manager was in the process of applying to the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

During this inspection the home manager was on leave. The clinical lead, the deputy manager and the regional manager assisted us with the inspection carried out over the three days.

People told us they felt safe living at the home. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse. They felt confident issues would be addressed appropriately. There were appropriate recruitment processes in place. All necessary safety checks were completed to ensure prospective staff members were suitable before they were appointed to post.

Relatives felt their family members were kept safe. Staff followed the principles of the Mental Capacity Act 2005 (MCA) when supporting people who lacked capacity to make decisions. People's rights to make their own decisions, where possible, were protected and staff were aware of their responsibilities to ensure those rights were promoted. People were treated with care and kindness. People and their families were involved in the planning of their care. We reviewed information held regarding Deprivation of Liberty Safeguards (DoLS) to ensure people's liberty was not restricted in an unlawful way and people's rights and freedom were protected. The management team told us applications had been made for some people. However, they were not sure if all the people living in the service had been reviewed to ensure no one was deprived of their liberty unlawfully. Once this had been identified, swift action was taken to ensure appropriate applications were made where necessary.

People told us staff were available most of the time when they needed them and staff knew how they liked things done. The service ensured there were enough qualified and knowledgeable staff to meet people’s needs at all times. However, on a few occasions we observed some staff did not recognise people’s needs. The management team were aware the permanent staff team was not full and had to rely on agency staff’s support. They tried to ensure regular agency staff would be used to maintain consistency in the service with people feeling more reassured. Most of the staff were knowledgeable and focused on following the best practice at the service making sure people were supported appropriately.

Risk assessments and care plans were carried out to ensure people’s safety and wellbeing. Staff recognised and responded to changes in risks to people who use the service. These changes were reported to the senior person to ensure a timely response and appropriate action was taken. However, some records were not always clear as to whether the action was taken and changes to people's care and treatment needs were recorded. People received support that was individualised to their personal preferences and needs. Their needs were monitored but care plans were not always reviewed at regular intervals.

There were contingency plans in place to respond to emergencies. The premises and equipment were cleaned and well maintained. Procedures and practice to control the spread of infection were much improved. However, some maintenance checks were not always up to date.

People were given a nutritious and balanced diet. Hot and cold drinks and snacks were available between meals. People had sufficient to eat and drink to meet their nutrition and hydration needs, however, support from staff at meal times was sometimes inconsistent. People had their healthcare needs identified and were able to access healthcare professionals such as their GP. Staff knew how to access specialist professional help when needed.

Staff training records indicated which training was considered mandatory by the provider. Not all staff were up to date with their training. The home manager had planned and booked training to ensure staff had appropriate knowledge to support people. Staff said they felt supported to do their job and could ask for help when needed. A supervision plan was in place and one to one meetings or group supervisions were carried out. The team meetings were not always held regularly and some staff felt it would be good to have those. However, most staff felt the handovers and flash meetings were good opportunities to discuss matters with the team.

People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately. We found some gaps in medicine records, however this was rectified and plans were in place to ensure records were checked regularly and were accurate. People and relatives told us a mixture of good and not so good things about the service they received. Our observations and the records we looked at confirmed the descriptions people and relatives had given us. There were some occasions were staff did not always understand the needs of the people. However, we saw care was provided with kindness and compassion most of the time. People and their families told us in general they were happy with their care and had seen a lot of improvements recently.

People were able to engage in meaningful activities or spend time with their visitors or by themselves. Their choices were always respected. We observed people were offered different activities and were encouraged to join in. However, we observed some people were not always motivated to get involved in activities or offered the opportunity to spend some quality time with staff. Thus people were not always protected against the risk of isolation. Most of the interactions observed between staff and people living at the service were respectful and friendly. People confirmed staff respected their privacy and dignity.

People felt staff were much happier working at the service and had a good relationship with them, each other and the management. Staff told us the management was open with them and communicated what was happening at the service and with the people living there. People told us they felt the service was managed well and that they could approach management and staff with any concerns. Everyone was pleased to know the service management had settled which had a positive impact on the way the service operated. People, relatives and staff were very pleased with the new home manager and felt they could approach and speak to them.

The management team had reviewed and changed the way they assessed and monitored the quality of care with the help of staff and other members of the company. They encouraged feedback from people and families, which they used to make improvements to the service. Throughout our inspection we observed the service had changed the way it was operating for the better. There was a clear management structure in the service leading the staff team. The provider was taking steps to ensure people were protected against the risks of receiving unsafe and inappropriate care and treatment.