At the time of the inspection there were 40 people living at the home. Due to their health conditions and complex needs not all of the people were able to share their views about the service they received. We spoke with the manager, 11 people who lived at the home, seven visitors and six care staff.We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;
Is the service safe?
Is the service effective?
Is the service caring?
Is the service responsive?
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 who used the service, their relatives, 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?
Care records contained risk assessments and instructions on how these risks should be managed. For example, there was consideration of the risks associated with skin integrity, nutrition, preventing falls and infection control/prevention.
Systems were in place to ensure that management and staff learnt from events such as accidents, complaints, concerns and investigations. This reduced the risks to people and helped the service continually improve.
The CQC monitors the application of the Mental Capacity Act 2005 and operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. DoLS is a legal process used to ensure that no one has their freedom restricted without good cause or proper assessment. There was a policy in place related to people's mental capacity and the deprivation of liberty safeguards. There was evidence to show that mental capacity assessments and deprivation of liberty checklists had been completed.
Personal evacuation plans were in place in case of an emergency and the home had a business contingency plan, which contained emergency telephone numbers and guidelines for staff to follow.
We saw that checks on electrical and gas systems, fire-fighting equipment and water systems had been undertaken and were also being monitored. There was a system in place to ensure that maintenance was carried out at the home.
Is the service effective?
The staff we spoke with were able to describe the individual needs of the people they cared for and how these needs were met. They said the care plans contained sufficient information to help them meet individual needs. We saw people's health and care needs were assessed and the care plans provided staff with information about how each person's care needs should be met. The service worked well with other agencies and prompt referrals were made to health care professionals, which helped ensure people's health care needs were addressed.
People and their relatives told us that the care was very good and staff looked after them well. Comments included, "I am so glad I chose this place for my Mum. She looks better and sounds better since she came in. The staff are so friendly and helpful."
People's privacy and dignity was respected and surveys and meetings were held to ensure dignity was respected and assess if any improvements could be made. One relative had commented, "Staff treat her as a respected individual and are conscious of her needs which they handle with dignity."
Is the service caring?
We spoke with 11 people who used the service and their comments included, "Everything is tip top" and "I really like it here. The staff are lovely and really help us in lots of ways. I am treated well."
We spoke with six relatives who were visiting the home. They told us they felt their relatives were very well looked after. Their comments included, "I looked around at other homes before I chose this one. I am so pleased with my choice. I cannot find fault. The staff are friendly and the manager is so approachable. This is the best I have seen and my Mum really likes it" and "My daughter chose this home for my sister. It is absolutely fine. In fact it is great. There are no problems. The staff respond to any needs. They are lovely and so good."
We observed the interactions between staff and the people they cared for. We saw staff interacted well with people and were attentive and sensitive to their individual needs.
Is the service responsive?
There was a complaints procedure displayed in the home and each person was provided with a copy of this. A complaints book was maintained to record any complaints received in the home and the outcome of the investigation.
We saw prompt referrals were made to health care professionals, when required, and appropriate training was provided for the staff to help meet individual needs.
Is the service well-led?
The manager of the home was registered with the Commission and there were systems in place to monitor the quality of the service people received. People were asked their opinion of the service and meetings were held regularly to discuss day to day issues in
the home.
The manager and a quality assurance manager carried out regular audits which included areas such as medications, infection control, health and safety, safeguarding and care records.
The people who lived in the home, their visitors and the staff told us the manager was very approachable if they had any concerns or suggestions. Comments included, "I would definitely tell them if I wasn't happy but everything is fine" and "If I want to know anything or have any small problem, I just speak to one of the staff."
Surveys were issued to gain people's opinion of the service. The manager acted on the comments made to improve the service. For example, a suggestion had been made to improve the garden and this was being done. The analysis of the surveys was displayed in the home.
You can see our judgements on the front page of this report.