Lindridge

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

The provider had initiated and implemented improvements since our last inspection. The management of risks to people’s safety had improved. There were processes to identify risks and action was taken to address these. Risks were monitored and assessments had been updated.

Shortfalls with the medicines ordering systems had been rectified and people’s medicines were stored and administered safely. There were enough staff to ensure people got the help and support they needed. People told us, “They [staff] are kind and caring.” Recruitment systems were robust and ensured the right staff were recruited to support people safely.

The provider introduced quality assurance processes to assess the quality of the care provided and to identify areas for improvement which had improved the overall quality of the service. The breaches identified at the last inspection had been met.

The service was well led and had a positive culture that was person centred, open and inclusive. Staff understood their role and responsibilities, were motivated and had confidence in the registered manager. Staff told us the registered manger was approachable and supportive.

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

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

Rating at last inspection

The last rating for this service was requires improvement (published 12 January 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

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 carried out an unannounced comprehensive inspection of this service on 5 November 2020. 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 good governance and safe care and treatment.

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 Lindridge on our website at www.cqc.org.uk.

Follow up

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

Lindridge is a residential nursing home providing personal and nursing care to 29 people aged 65 and over at the time of the inspection. The service can support up to 75 people. The home is comprised of five wings, each of which has separate adapted facilities, one of which was vacant on the day of inspection. One of the wings specialises in providing care to people living with dementia.

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

People were not always supported by a consistent, clearly visible management team. People and relatives did not know who to go to, to raise a concern or an issue. Some relatives were frustrated with the lack of communication when a person’s care needs changed.

Accidents and incidents were recorded in separate ways. There were clear systems to identify which incidents needed to be reported to CQC or the local authority. The incident details were also transferred to a dashboard to identify trends and patterns. With the absence of a manager to have oversight of analysing trends or implementing an action plan was not always completed in a timely way.

The home used agency staff frequently and they did not always know about people’s needs and risks. Relatives voiced concerns about lack of knowledge of agency staff. In addition, care plans lacked person-centred detail or guidance for agency staff to follow. Attempts had been made to have regular agency staff to prevent further risks of the spread of Covid-19.

Risk assessments in people’s care plans lacked detail. People were confident that permanent staff members knew them well. However, the lack of detail in care plans could lead to agency staff struggling to understand people’s individual risks and keeping people safe.

People told us that staff supported them with their medicines. However, medicines management systems did not always identify medicines errors.

People told us they felt safe at Lindridge and relatives told us that they felt that the home was overall safe. The pandemic had resulted in unprecedented challenges across the adult social care sector. We saw evidence of the service working to keep people safe and effectively manage the outbreak of Covid 19. Safe infection control policies and procedures were being followed.

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

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

Rating at last inspection

The last rating for this service was Good (published 22 August 2019).

Why we inspected

The inspection was prompted in part due to concerns received around safeguarding incidents, the management of the service and an outbreak of COVID-19. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 assurances that the service can respond to coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this focused report. You can see what action we have asked the provider to take at the end of this full report.

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.

The overall rating for the service has changed from Good 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 Lindridge 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 monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

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.

Lindridge is a care home providing personal and nursing care to up to 70 people with a variety of needs related to their mobility and long term medical conditions, some people at the service were living with dementia. One area of the home was dedicated to providing people with short term support to help them return to their own homes. At the time of this inspection there were 49 people living at the service.

People received care in one purpose built building across four communities. People lived on communities suited to their needs and rehabilitation goals. One area was unoccupied at the time of this inspection.

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

People told us they felt safe and our observations and findings supported this. Staff took action in response to risk and there were systems to ensure incidents and concerns were monitored and responded to. People’s medicines were managed safely with a variety of checks and audits in place to ensure good practice was sustained. The home environment was clean and people were supported by sufficient numbers of staff.

People were satisfied with the food and told us their healthcare needs were met. There had been recent refurbishment works and we saw recent improvements to the environment for people living with dementia. Staff had the right training and support for their roles, including clinical support for nursing staff. 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.

People told us staff were kind and caring and we observed interactions that supported this. We observed people being supported in a way that encouraged them to maintain independence or develop skills. People’s dignity and privacy were promoted by staff who provided care in a respectful and personalised manner.

People had access to a range of activities and they told us they liked the variety and had input into these. Care plans were personalised and staff had gathered important information about people’s preferences for end of life care. People knew how to complain and complaints had been responded to appropriately.

People told us they had seen improvements in leadership at the service and we found an increased number of audits and checks. We saw improvements to record keeping but identified instances where records didn’t reflect care delivery. There was a plan to improve documentation, as well as plans to improve the environment. People, relatives and staff had regular meetings and these had been used to involve them in improvements as well as to gather feedback and suggestions to improve their care.

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

Rating at last inspection: Good (Report published on 15 December 2018)

Why we inspected

This was a planned inspection based on the previous rating.

This service was selected to be part of our national review, looking at the quality of oral health care support for people living in care homes. The inspection team included a dental inspector who looked in detail at how well the service supported people with their oral health. This includes support with oral hygiene and access to dentists. We will publish our national report of our findings and recommendations in 2019.

When we completed our previous inspection on 22 May 2018 we found the provider had failed to ensure that people were receiving their medicines safely. A warning notice was issued for a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there was a lack of management oversight and governance which meant that the service had failed to sustain improvements, risks had not always been identified and managed and records were not always accurate and complete. In July 2018 the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of regulations.

We undertook this focused inspection to check that the provider had followed their plan and to confirm that they now met 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 Lindridge on our website at www.cqc.org.uk.

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. The overall rating has improved to Good.

Lindridge 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. Lindridge accommodates up to 75 people across three units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. On the day of this inspection there were 40 people living at the home.

Lindridge has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Improvements had been made in systems for managing the administration of people’s medicines. People were receiving the medicines they needed safely and systems for ordering medicines had improved so that people had access to their prescribed medicines when they needed them. This meant that the provider had met the requirements of the warning notice.

Some new systems had been introduced but not all staff were confident and familiar with the new systems. This meant that improvements were not yet fully embedded and sustained. We identified this as an area of practice that needs to improve to ensure positive changes are sustained.

Risks to people were assessed and managed effectively. Care plans provided staff with clear guidance in how to support people safely whilst respecting their freedom. Staff understood their responsibilities with regard to safeguarding people.

Environmental risks were managed and staff understood their roles in relation to infection control and hygiene. There were enough suitable staff on duty to care for people and people told us they felt safe living at the home. One person said, “It couldn’t be better.”

Systems for monitoring incidents and accidents supported staff to learn from mistakes and reduce risks of further incidents. Governance arrangements had been strengthened and improved to support management oversight at the home. There was clear leadership and staff understood their roles. Staff had developed positive links with the local community and with partner agencies.

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 service is run.

At the last inspection on 22 June 2017 we found one breach of the Regulations and some areas of practice that needed improvement. Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key question to at least good. At this inspection, on 22 and 23 May 2018, we found that there had been improvements and the previous breach had been addressed. However, we found some other areas of practice that continued to require improvement.

People were not always supported to receive their medicines when they needed them. Systems had not always ensured that there were sufficient medicines in stock to meet people’s needs. Records were not always accurate and complete. This meant that the registered manager could not be assured that people were receiving their medicines as prescribed. This was a continued breach of the regulations.

Management systems and processes were not always effective in identifying shortfalls in practice. Governance arrangements were not clear in all areas of the home. Improvements had not been sustained and embedded within practice. This was a breach of the regulations.

People told us they were happy living at Lindridge. One person said, “It’s a very pleasant atmosphere here.” Another person told us, “It’s fantastic. I feel very safe because I am so well looked after.” Risk assessments and care plans were in place to guide staff in how to support people safely. There were enough staff on duty to meet people’s needs. Staff demonstrated a clear understanding of safeguarding and whistleblowing policies. Incidents and accidents were monitored and there were robust infection control procedures in place.

Staff received the training and support they needed to be effective in their roles. Assessments were in place to identify people’s needs and choices. Staff understood their responsibilities with regard to gaining consent from people for their care and support. Staff ensured that people had access to the health care services they needed. People were supported to have enough to eat and drink and risks associated with nutrition and hydration were managed effectively. People spoke highly of the food and drink on offer, one person said, “It’s very good, it’s tasty and hot.”

People and their relatives spoke highly of the caring nature of the staff. Their comments included, “The staff a very kind and gentle with me,” and, “We are blessed to have kind staff here.” Staff supported people to remain as independent as possible. People were treated with dignity and their views were respected. People and their families were involved in making decisions about the care provided. One person told us, “I’m very satisfied that I was able to discuss my care plan.” Staff maintained people’s confidentiality and supported people’s privacy.

Staff knew people well and people told us their care was person-centred. One person said, “My care has been tailored for me.” There was a range of planned activities available to people every day and people spoke highly of the events that were organised. People told us they had enough to do and that they could choose how they spent their time. One person said, “Nobody puts any pressure on you, the staff are wonderful.” People knew how to complain and any concerns were recorded, together with the provider’s response and the resolution that was offered. Care plans included people’s needs and wishes for end of life care. One relative described a positive experience and spoke highly of the care their relative had received at the end of their life.

People, their relatives and staff all described being included with developments at the home. There were regular meetings with people and their relatives as well as regular staff meetings. Records showed how people’s ideas were encouraged, acknowledged and incorporated into the planning process. One person said, “I made a suggestion, and it was implemented.” Staff spoke positively about how people and relatives were included in the recruitment process for new staff.

Staff had made connections within the local community and described positive working relationships with other agencies. The provider had development plans in place and used feedback mechanisms and quality assurance monitoring to drive improvements at the home.

We found two breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 service is run. The registered manager had been absent from the home since January 2017 and the home was being managed by the deputy manager who was present throughout the inspection.

At the last inspection on 30 March 2016 there was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was due to concerns about the proper and safe management of medicines. At this inspection on 22 June 2017 the provider had made improvements and had addressed the previous breach of regulation.

Some risks to people were not being consistently managed. Some people had enteral feeding tubes and risks associated with maintaining the feeding tubes were not being managed. This is an area of practice that requires improvement. We brought this to the attention of the deputy manager and immediate steps were taken to address this issue.

Some people were receiving their medicines covertly but records did not always show that this decision had been taken in line with the Mental Capacity Act 2005. This is an area of practice that needs improvement.

There were systems and processes in place to monitor quality but not all systems were working effectively. This meant that some shortfalls had not been identified and acted upon and some records were not complete and accurate. This is an area of practice that needs to improve.

People and their relatives told us that they were happy with the care provided at Lindridge and they felt safe. One person said, “I’m a happy bunny, of course there are ups and downs but I like it mainly, it’s my home.” A relative told us, “When I leave here, I don’t worry.” There were enough staff to keep people safe and recruitment processes were robust. Risks to people had been assessed and plans were in place to guide staff in how to keep people safe. Incidents and accidents were monitored and analysed to reduce risks of further similar events. Staff supported people to access health and care services when they needed them. One person told us, “If ever I’m ill, like in January I was ill, they got me down to the hospital and they responded quickly.”

Staff received training and support and were confident in their roles. Communication was good and staff had a firm understanding of their responsibilities. The environment of the home had been adapted and designed to meet people’s individual needs. A number of dementia friendly features had been added to help people to orientate themselves and to reduce anxiety. People who had mobility needs were able to move around the building and access the garden independently.

People had developed positive relationships with staff and spoke highly of their caring nature. One person said, “The staff are lovely, really respectful, patient and caring.” Staff knew people well and encouraged them to make decisions about their care and support. One staff member said, “We try and support people to remain in charge of their care as much as possible.” People were treated with respect and staff maintained their privacy and dignity.

People were complementary about the food and drink at the home and told us they had plenty to eat and drink. Individual preferences and needs were catered for and risks associated with eating and drinking were identified and managed.

People received personalised care that was responsive to their needs. A relative described how staff supported their relation who was living with dementia. They said, “Staff managed her agitation very well, they got to know her, and knew how to help her to calm down.” People told us that they enjoyed a wide range of activities provided at the home. People were able to follow their interests and were supported to remain occupied and stimulated. Staff had time to spend with people and supported them to maintain relationships that were important to them.

People and their relatives knew how to make a complaint and felt comfortable to do so. Feedback was encouraged and people were confident that any issues raised were taken seriously. One relative told us, “If I have a concern they respond instantaneously.” People, relatives and staff members spoke positively about the deputy manager and described them as easy to talk to and committed to improving the service. Regular quality monitoring systems were used to drive improvements. There was a clear management structure and leadership was evident throughout the home. The deputy manager maintained a clear overview of the service and was knowledgeable about the people living at the home and their needs.

We found one breach of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

The home has 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.

Not all medication practices ensured that medicines were managed safely. Medicines that required refrigeration were not always stored within the required temperature range and there was a recording omission in the MAR chart for one person. Pain assessment charts held for each person stated the pain relieving medicines they had been prescribed. Some entries on these did not state a minimal interval between doses, or a maximum daily dose. These instructions are needed to ensure the safe administration of medicines.

We checked whether staff were working within the principles of the MCA and whether conditions or authorisations to deprive a person of their liberty were being met. None of the staff members that we spoke with could tell us about the implications of DoLS for the people they were supporting. We identified this as an area of practice that needs to improve. Staff were able to demonstrate a good understanding of the MCA including the nature and types of consents, people’s right to take risks and the necessity to act in people’s best interests when required. However they were not consistent in their approach to undertaking Best Interest decisions.

People were not always consistently supported and monitored where nutritional risks had been identified. One person had been assessed by a Speech and Language Therapist (SALT) due to difficulties with swallowing however staff were not aware of the identified risks for this person or the SALT guidance regarding positioning, monitoring and advice stating that the person should be supervised when eating. This meant that identified risks associated with eating and drinking were not being appropriately managed.

People told us they felt safe living at Lindridge, one person said, “I feel secure here, the staff know how to care for me and the other people here.” Risks to individuals were identified and managed including environmental risks and risks of infection. Staff were knowledgeable about the correct procedures to follow should they suspect abuse and there were robust recruitment procedures in place to ensure that staff were suitable and safe to work in the care sector. People told us that there were enough staff on duty to care for them, one person said “Staff are still busy but they make time, I have never felt rushed by anyone.” Throughout the inspection we observed that staff were spending time with people, providing care but also just chatting and keeping people company. Staff rotas showed that staffing levels were maintained and we saw evidence that recruitment to vacant posts was in progress.

People told us that they felt well cared for, that staff were kind and their views were valued, saying “They do treat me with respect and maintain my dignity, they shut the door and pull the curtains before attending to me.” Throughout the inspection we saw positive interactions between staff and people with many examples of staff demonstrating that they knew people well and treated them with kindness and compassion. People were offered choices around food and told us that they enjoyed their meals, we saw that meal times were a social occasion and that staff were supportive and attentive to people both in the dining areas and those choosing to eat in their own rooms.

People were supported to maintain their health and to have access to healthcare services. People told us that staff were proactive in seeking help and advice from health care professionals when they needed to and records confirmed this. One person said, “I think it is excellent here, the best care I have had in my life.” People and relatives told us that there was a focus on individual needs and that they were included in the review process. Care records were well personalised and detailed and we saw that there were effective systems in place to support staff communication regarding any changes in people’s needs. People were supported to follow their interests and there was a varied activity programme available arranged by two activities co-ordinators.

Staff told us they were well supported and that opportunities for training and development were good. There was a clear management structure and staff told us that the registered manager was approachable and accessible. Morale was good and staff told us that they enjoyed their work, comments included “I love it here. This is the best job in the world,” and “I’ve worked here a long time, I wouldn’t stay if I didn’t like it, it’s a happy home.”

The adaptation, design and decoration of the home took into account the needs of the people living there. The home had been designed to accommodate people who used wheelchairs and a lift provided access to the upper and lower floors. People told us that they were able to access communal areas with ease, one person who used an electronic wheelchair told us “I can get around easily, I go out in the garden too, in the front they have raised beds which is good for people in wheelchairs.” We saw that consideration had been given to the needs of people who were living with dementia for example, a wall- mounted screen had been adapted to give the appearance of a television from the 1950’s and the images it displayed were also of that era, staff said this was designed to stimulate pleasant memories for people.

People told us that they would feel comfortable in raising any issues or complaints with staff or with the registered manager. There was a system in place for managing complaints and that the registered manager was proactive in seeking feedback from people and their relatives.

There were effective monitoring systems in place to check the quality of the service and the registered manager used this information to drive improvements in the service. Staff had developed good links within the local community and with health and social care services. Staff described a fair and open culture where they were able to raise issues and be supported. People, relatives and staff spoke highly of the registered manager and senior staff and told us that the home was well led, their comments included “The home is run pretty well” and “This is a well- managed home.”

We found one breach 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,

Below is a summary of what we found. The summary describes what people using the service, their relatives, visitors and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw care plans that reflected issues identified in the assessment. These were sufficiently detailed to allow nursing and care staff to deliver safe and responsive care. A care worker said, 'The care plans are drawn up by the nursing staff and allow us to work confidently with that person.'

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

People were cared for in a clean, hygienic environment. The service had systems in place designed to assess the risk of, and to prevent, detect and control the spread of infection.

During our unannounced visit, we observed there were sufficient care staff to meet people's needs. We checked the rotas and saw that staffing levels were well maintained.

Is the service effective?

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We saw that people or their representatives had been involved in their care assessments and reviews.

People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. One person who used the service told us, 'The staff here take care of all our needs. We are well looked after.' Staff had received training to meet the needs of the people receiving care.

Is the service caring?

People were supported by committed and attentive staff. We saw that care staff were patient and empathetic when supporting people. The relative of one person told us, 'I cannot fault the care given to [My relative] at Lindridge. They couldn't be in better hands. The kindness and efficiency of the care givers is amazing.'

Is the service responsive?

People's needs were continually assessed. Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and treatment had been provided in accordance with people's wishes. One person told us, 'I really can't fault the care. [My relative] wouldn't be here if I didn't think he was well looked after. When [my relative] moved in they made so many changes to suit his needs. They chopped and changed the location of his bed, provided a special mattress.'

Is the service well-led?

Staff had a good understanding of the ethos of Lindridge and its commitment to providing personalised individual care. Quality assurance processes were in place to support this. People told us they were asked for their feedback on the service they received and they confirmed they had felt listened to. Systems were in place to help the service develop and learn.

People told us they felt happy and safe in the home. Everyone remarked on the kindness of the staff. We were told that people felt confident that any concerns were always quickly addressed. One person told us 'the staff are "Kindness itself, nothing is too much trouble.'

People told us that staff understood their needs and provided appropriate care and support. We were told that staff were responsive when people asked for assistance and quickly dealt with any issues. We found that the home enabled people to lead fulfilling lives by listening and supporting people to reach their potential. One person told us "I have a brilliant quality of life - it couldn't be better."

We found care was recorded appropriately, with potential risks to people's safety monitored, assessed and updated in a timely manner. We saw that the home provided high quality training and support to staff which was reflected by the people who used the service and their relatives praising the knowledge and expertise of the staff in caring for them. We found there were robust systems in place to continuously monitor the quality of serve offered.