The inspection took place on 13 December 2018. The inspection was unannounced.

Ashley Down Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashley Down Nursing Home provides accommodation and support for up to 19 older people. There were 13 people living at the service at the time of our inspection. People had varying care needs. Some people were living with dementia, some people had diabetes or were recovering from a stroke, people required support with their mobility around the home, no one was able to walk around independently.

Although a manager was in post, they were not 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 our last inspection, on 20 and 21 February 2018, the service was rated as ‘requires improvement’. At this inspection, the service continues to be rated requires improvement. Since two previous ‘inadequate’ ratings, this is the second consecutive time the service has been rated requires improvement. However, improvements have been made in many areas.

At the last inspection we found breaches of Regulations 12, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to, medicines administration processes were not managed safely; robust recruitment processes were not used to make sure only suitable staff were employed; Registered nurses and staff did not receive the appropriate training to carry out their role.

The provider and registered manager sent action plans dated 27 April 2018 stating they had already made the improvements to make sure regulations 12 and 19 were met. They said they would meet regulation 18 by 18 May 2018. At this inspection, the provider and registered manager had made improvements in most areas. People’s prescribed medicines were now being managed and administered safely. Robust recruitment processes were now being followed to make sure only suitable staff were employed.

Although improvements had been made to the training of nurses and staff, there were still areas that needed to improve. The manager did not have access to staff training records and registered nurses had not completed professional development training.

Although the provider had a means of assessing people’s needs to determine the numbers of staff needed each week, staff did not always have the time available to sit and chat with people. Staff numbers at night were low, meaning there was a risk people’s needs might not be met. We have made a recommendation about this.

Although the food looked appetising and there were no complaints about food, people were not given suitable choices on the menu at meal times. Accessible formats of the menu were not available to help people to make choices. We have made a recommendation about this.

We received very positive feedback about the new manager, their knowledge and their approachability. This was their first position as a manager, having previously held the role as senior nurse at the service. The new manager had not received the support, training and access to local networks to help them to succeed in their role. We have made a recommendation about this.

Although the manager had been in post since August 2018, they had not applied to register with the Care Quality Commission. It is the provider’s legal responsibility to ensure a registered manager is in post.

Staff felt supported and confirmed they could speak with the manager at any time if they needed to. They were confident any concerns they

The inspection took place on 20 and 21 February 2018. The inspection was unannounced on the first day. We told the provider and manager when we would return to complete the inspection.

Ashley Down Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Ashley Down Nursing Home provides accommodation and support for up to 19 older people. There were 11 people using the service at the time of our inspection. Some people were unable to communicate verbally with us. People had varying needs including diabetes and Parkinson's disease and some people were living with dementia. Some people required the use of a hoist to help them to move from their bed to a chair and vice versa and others required two staff to assist them to move around. Six people were cared for in bed due to their frail health.

A registered manager was in post. The registered manager was also the registered provider. 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. A new manager was in post who had not yet registered with CQC, this manager was present throughout the inspection, providing the information we requested.

At our last inspection on 4 and 7 July 2017 we found breaches of Regulations 9, 11, 12, 17, 18, 19 and 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Five breaches had continued since the previous inspection relating to, person centred care and the lack of meaningful activity to avoid social isolation; people’s basic rights and consent to care and treatment; the management of risk in relation to individuals’ safety and the safety of staff; the management of the deployment of staff to ensure safe staffing levels and the management of effective systems to ensure the quality and safety of the service. Two further breaches were identified relating to safe recruitment practices and the display of the previous inspection ratings in a prominent place. We placed the service in special measures for the second time and initiated action against the provider. This inspection took place to check that the provider had made improvements in the areas that required improvement.

At this inspection, we found the provider had made improvements within the service, although further improvements were required and work was still in progress.

We told the provider they must not admit any new people into the home following the last inspection in July 2017. This meant the provider and the new manager were able to spend time improving the quality and safety of the service for the existing people living there.

People and their relatives told us they received care that was safe, effective, caring, responsive and well led.

At this inspection, we found that sufficient improvement had not been made to the assessment used to determine the numbers of staff required to provide the level of care people needed. Staff did have the opportunity to meet with their line manager on a regular basis to discuss work related issues.

Sufficient improvement had not been made to the recruitment processes. Robust checking had not always been employed when assessing the suitability of new staff to provide care and support to people living in the service.

The evidence was not available to show that staff had received the training and updates required to carry out their role providing care and support to people. Registered nurses were not provided with the opportunities to continuously develop their skills in order to maintain and improve their professional role. New staff were

The inspection took place over two days, 04 and 06 July 2017. The inspection was unannounced.

This was a planned comprehensive inspection to follow up from the previous inspection report when we placed the service into special measures to monitor improvements made. The local authority had visited the service since the last inspection and had raised their concerns that improvements had not been made.

Ashley Down Nursing Home is registered to provide accommodation for older people who require nursing or personal care. The home could provide care and support for up to 19 people. There were 15 people living at the home at the time of this inspection. Two of these people were in hospital so 13 people were actually living in the home. People had complex health needs, including diabetes and stroke. Many people were living with dementia, some at an advanced stage requiring intense support from registered nurses and staff.

The registered provider of the service was also the 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 was not available on the first day of inspection, however they were available on the second day.

Our last inspection report of this service was published on 20 February 2017 and related to an inspection that had taken place on 22 and 24 November 2016. At the inspection in November 2016 we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 9, people’s individual needs were not adequately assessed and regular checks on people were not recorded; Regulation 11, people’s care plans did not reflect their basic rights to consent and decision making; Regulation 12, evidence was not available to show that care was provided in a safe way; Regulation 16, the correct information was not available through an up to date procedure to enable people to make a complaint; Regulation 17, effective systems were not in place to monitor the quality and safety of the service and Regulation 18, staffing levels were not based on peoples’ individually assessed needs. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, CQC had not been notified of important events that had taken place in the service.

We asked the provider to take action to meet regulations 9, 11 and 16. We also asked the provider to take action to meet Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. We took enforcement action against the provider and told them to meet Regulation 12 by 30 March 2017, Regulation 17 by 28 April 2017 and Regulation 18 by 31 January 2017.

The provider sent us a report of the actions they were taking to comply with Regulations 9, 11 and 16 and they told us they would be meeting these Regulations by 28 February 2017. They also said they would meet Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 by 28 February 2017.

At this inspection we found the provider and registered manager had made some improvements to the service and standard of care. The provider had a new complaints procedure in place and regular checks on people were now recorded. The provider had notified CQC of important events as required. The improvements related to Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. However many improvements had not been made and we found continuing breaches of regulations from the last inspection. These related to Regulation 9, 11, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Acti

We inspected Ashley Down Nursing Home on the 22 and 24 November 2016 and the inspection was unannounced. Ashley Down Nursing Home provides accommodation for up to 19 people over the age of 65 that may require nursing and personal care and support, some of whom living with dementia or a physical disability. The accommodation is provided in an older style detached house in a residential street. There is a communal lounge, dining room, kitchen, communal bathrooms and bedrooms with en-suite bathrooms. Outside there is a good size garden that people have access to. There were 16 people living in the home on the days of our inspection.

The provider was also the registered manager, who was in day to day charge of the home. 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 undertaken on the 07 January 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to staffing levels; recruitment practice, the provision of meaningful activities, management of complaints, notifying CQC of significant events and improving their quality assurance framework. The provider sent us an action plan stating they would have addressed all of these concerns by June 2016. At this inspection we found the provider had made improvements to safe recruitment practice but the provider continued to breach the regulations relating to the other areas.

Systems in place to assess the quality of the service provided were not always effective and had not consistently identified shortfalls in the provision of care and quality. Care plans were not consistently fit for purpose and lacked personal information on people’s likes, dislikes and what was important to them.

The principles of the Mental Capacity Act (MCA 2005) were not embedded into practice. Appropriate processes in regard to mental capacity assessments had not been followed for the use of potentially restrictive care practices such as bed rails and wheelchair lap belts.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS applications had been made to the local authority and had been approved. However the registered manager had continued to fail to notify CQC of the authorisations. DoLS care plans were not in place.

The risk of social isolation had not been addressed or mitigated. People had no access to stimulation or meaningful activities. Insufficient staffing levels and deployment of staff meant staff had no time to provide activities or one to one chats with people. A visiting relative told us, “ I have no complaint apart from the fact there is little to do but I understand they are recruiting; you’d think they would think of something in the meantime though, it doesn’t take much to start a sing-along for example. I guess they are too busy to do that, they have so much to do.”

The management of continence required improvement. Large gaps in documentation reflected that people could go up to seven hours without support to meet their continence needs. Staff told us they received essential training that equipped them with the skills to meet people’s individual care needs. The provider had failed to identify that training had not been provided on the safe and effective management of diabetes, epilepsy and pressure care. We have identified this as an area of practice that needs improvement and have made a recommendation about reviewing the formal provision of training based on best practice guidelines and people’s individual care needs.

The risk of skin breakdown for people had been assessed, however, where people received care on an air mattress, documentatio

The inspection was carried out on the 7 January 2016 and was unannounced.

Ashley Down Nursing Home provides accommodation for up to 19 people over the age of 65 that may require nursing and personal care and support, some of which may have dementia or a physical disability. The accommodation is provided in a older style detached house in a residential street. There is a communal lounge, dining room, kitchen, communal bathrooms and bedrooms with ensuite bathrooms. Outside there is a good size garden that people have access to. There were 16 people living in the home when we inspected.

At our previous inspection on 15 and 16 December 2014 we made reference to a number of areas for improvement. The fitting of a stair gate was still required. The assessments to make sure that the use of bed rails did not restrict people’s freedom unlawfully were still in progress. Essential training such as end of life care had not yet been provided for all care staff. Regular one to one supervision for all staff and annual appraisals had not yet been provided. Plans to improve the format of all information for people in a larger and pictorial format had not been implemented. Activities did not meet peoples needs and preferences. Improvements to the management systems and the actions that had been taken as a result were not yet embedded into the practices at the service.

At this inspection, we found that some improvements had not been made since the last inspection. However, some of the areas for improvement had not taken place.

The registered provider was also the registered manager, who was in day to day charge of the home. 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 told us they felt safe in the home. Relatives also told us they thought their relatives were safe and care was provided appropriately.

Recruitment practices were not always robust and we found one person working in the home without a Disclosure and Baring Service check. Nursing staff had checks carried out on the professional registration with the Nursing and Midwifery Council (NMC) but the registered manager had not implemented suitable checks to monitor when these were due for renewal.

People and relatives told us they didn’t feel there was enough staff deployed to meet their needs. Staffing levels had not been increased despite a recorded increase in dependency levels.

Staff were receiving supervision but not in line with the provider’s policy. Some staff told us that the manager was approachable and that they felt supported. Other staff said that they didn’t feel listened to. We made a recommendation about this.

Staff had completed training in the Mental Capacity Act 2005 but there was no evidence that this training had been embedded in every day practice of caring for people. Staff had not received training in Deprivation of Liberty Safeguards (DoLS). We have made a recommendation about this.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS applications had been made to the local authority and had been approved. However the registered manager has failed to notify CQC of the authorisations.

The environment of the home had not been adapted to make it more suitable for people living with dementia. We have made a recommendation about this.

The registered manager frequently worked care shifts and not supernumerary therefore did not have the time to complete their role and responsibilities as the manager.

The home had systems in place to audit and monitor the quality of the service. However, these were not robust and did not demonstrate that improvements had taken place as a result.

The provider had put into place new policies and procedures but they had not established that some of them were not fit for purpose. Some policies could not be practically implemented and the registered manager was unaware of the content and details of other policies which conflicted with practice.

There were no meaningful activities taking place in the home. People told us that there was nothing to do and no one to talk to. There was a lack of stimulation and people were at risk of social isolation.

People had opportunities to feedback about their care and support. However ‘Resident’s survey’s’ showed that specific requests had not been responded to.

There were risk assessments in place that were personalised to people’s needs and updated as their needs changed. However, there was little evidence that people had been involved in the drawing up or review of their care plans.

There was a complaints policy in place. However, one person was still waiting to receive support with the issues they had raised.

The security of the home had been improved as well as the surrounding perimeter of the garden.

There was a safeguarding policy in place that made reference to the local authority’s policy. Staff had received training in safeguarding and were able to describe what they would do in the event of any safeguarding issues occurring. Staff knew about the whistle blowing policy, why and how to use it.

People had personal evacuation plans and staff had received fire training and knew how to support people to evacuate the building in an emergency.

People were supported to receive their medicines on time by qualified and competent staff. Medicines were managed and stored appropriately.

People were encouraged to maintain a healthy diet. The kitchen was well stocked and people told us they enjoyed the food. People had access to drinks and snacks throughout the day.

People were supported to access health services and their health care needs were being met.

People told us that staff were caring and we observed staff engaging with people in a kind and compassionate way. Relatives were able to visit their relatives when they wanted to. Care plans were individualised and people’s likes and dislikes had been recorded. Staff knew people well and treated them with respect and dignity. People and staff records were kept confidentially and could only be accessed by those authorised to do so.People’s rooms had been personalised and some people had their own furniture.

There was a service user guide, but this was not available in other formats that might me more suitable for people’s needs.

There were ‘residents meetings’ held which all people were encouraged to attend.People had been consulted about recent redecoration works and chosen colours. People told us they thought the home was well led.

We found 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 this report.

The inspection team was made up of two inspectors. We set out to answer 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, discussions with people using the service, their relatives, the staff supporting them and looking at records.

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

Is the service safe?

We found that people were not always safe due to poor security at the home. This was because one of the fire doors at the side of the building was broken and it was possible to access the home. We also saw that a side door in the living room was open during our visit of 22 April 2014 and it was possible for people to walk in and out of the home. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring appropriate measures are taken in relation to the security of the premises.

We reviewed the arrangements in place in case of fire and found that evacuation plans were not in place or known to staff. We asked staff if they were aware of personal emergency evacuation plans that would include information about how to safely evacuate people living at the home. They did not know if plans were in place. This meant that people may be at risk of harm in the event of a fire.

Is the service caring?

People we spoke with were positive about the support given to them by members of the staff team. We saw that staff were attentive and caring. However, we observed that people sometimes had to wait for their needs to be met as staff were busy providing support for other people. We have asked the provider to tell us what improvements they will make in relation to ensuring that there are sufficient numbers of suitably qualified, skilled and experienced staff.

Is the service effective?

We found that people’s needs had been assessed before they moved into the home and detailed care plans had been developed that included information about medical needs and particular risks that had been identified. However, people we spoke with told us they were not involved in their care planning. Two relatives told us they had not been asked for their views concerning what should be included in the care plan for their family member. We were told there was no service user guide in place or information that was given to people when they moved into the home. This meant that people had not been consulted and their views had not been taken into account concerning how they wanted their care delivered. We have asked the provider to tell us what improvements they will make to ensure people are involved in their care.

Is the service responsive?

We saw that although there was a file kept concerning complaints people had made there was no indication concerning whether or not complaints had been investigated or the response given by the provider. People we spoke with did not know about a complaints system and we did not see any information displayed in the home. Staff we spoke with were not aware of any information that had been given to people concerning how to raise concerns. They were also unaware that the home kept a log of complaints. We have asked the provider to tell us what improvements they will make to ensure people are aware of the complaints procedure at the home and records are kept concerning the outcome of complaints.

Is the service well led?

We were not able to see any evidence that quality control audits or other systems were in place to assess the quality of the service. People told us they were not asked for their views concerning the care they received. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, and the improvements they will make in relation to ensuring the people are aware of the complaints procedure in order to raise concerns.

We carried out this inspection to follow up on concerns identified during our inspection of 01 October 2013. We found that some steps had been taken to address the concerns which had been raised. However, we identified a number of ongoing concerns such as the security of the premises. This meant that people's safety was not protected and the provider was not learning from incidents.

During our inspection of 01 October 2013 we identified that many records relating to the management of the home could not be located promptly when required as the provider was away and many of the records were kept in their office. They wrote to us on 18 December 2013 and stated that all records apart from staff files were kept in the nurse’s office. However, during our inspection of 22 April 2014 we found that a number of records could not be located promptly as the provider unavailable.

On 27 January 2014 we served a fixed penalty notice to Ashley Down Nursing Home Limited for failing to have a registered manager in place at Ashley Down Nursing Home. A fine of £4,000 was paid.

At the time of our inspection on 22 April 2014 the home did not have a registered manager in post but the provider had indicated that they wished to undertake this role in the future.

“At the time of our inspection the provider did not have a registered manager in post.”

We looked at care plans and found that these contained information staff would need to know to be able to support a person’s needs. There were assessments undertaken on admission and the care plans had been developed and drawn up with the individual, where possible, and their family had been consulted on aspects of the care plan.

We saw that people who used wheelchairs or who needed support to get to the dining room were left in the dining room for 45 minutes after they had finished their meals. We heard people calling for staff to take them out of the dining area and when we entered the room people were complaining about being left for so long and asking for our assistance to get staff to come. One person said, “We wait too long in the dining room” This meant that the registered person was not respecting people’s dignity.

We talked with people who used the service or their relatives, one person said “staff treat me with respect, I get on very well with staff” another said “I like my room and the staff are lovely”.

We found that the registered person was not following procedures required under the Mental Capacity Act 2005 about how to make decisions for the person when there was a lack of capacity.

We talked with people who used the service or their relatives. Two people told us that there was a smell of urine in the home; one person told us that staff are often cleaning the carpets.

People told us that the food was nice and that the staff were pleasant.

We found that there were no procedures in place, available or known to staff to deal with foreseeable emergencies.

We found that the registered person was not making suitable arrangements to ensure that people who used the service were safeguarded from abuse.

We found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

We talked with people who used the service or their relatives and we were told by three people that there were not always enough staff at the home. One person told us that they do not always get two staff to carry out manual handling operations when this is a requirement in their care plan.

We found that records were not accessible and that we could not check to see if the registered person was managing the delivery of the regulated activity safely.

We carried out this visit in response to concerns which were sent to us from an anonymous source. We also informed Social Services of these concerns.

The visit was carried out by two Inspectors. During the course of the day we met or talked with all of the people who were living in the home. Some people had difficulty with communication due to their nursing needs; but other people were able to converse clearly with us.

The Director was present throughout our visit. He was acting as manager while recruiting for a new manager; and has been referred to as “the manager” in this report for ease of reading.

We also talked with the five staff members who were on duty in the morning; and briefly met other staff who came on duty during the afternoon.

We received mostly positive comments from people living in the home, and their relatives. Comments included:

“We had a lovely Christmas, and Christmas party.”

“I have no complaints; the staff are very nice.”

“It is very nice here. The staff are very good. The meals are good – the food is lovely. I would like more things to do sometimes. We have a new activities lady and there are more things to do than we used to have.”

“The staff are always helpful.”

“I would like more flexibility about the times I get up and go to bed.”

“I like my room, it is very comfortable.”

"The carers are lovely and such good girls"

"I am treated very well."

"They really care about us here."

Comments from relatives included:

“I am very happy with the way that X is looked after.”

“My relative seems happy here, and I am always made welcome when I visit.”

People living in the home said that staff asked them for their choices about day to day events, such as if they wanted a bath or a shower, and if they wanted it in the morning or evening. They also asked them if they wanted to stay in their own rooms, or go to the lounge or elsewhere. They confirmed that they had a choice of food for all meals.

We talked with ten people living in the home. People’s comments included:

“The girls are very nice and all work very hard”.

“We have activities in the afternoons and I look forward to those.”

“It’s ok here, they all look after me very well”.

“I don’t get outside as much as I would like to”.

“We mostly sit and chat together in the mornings and watch TV, and sometimes we run out of things to say”.

“I go out in a wheelchair taxi for a meal sometimes with a friend”.

“We have lots of different activities in the afternoons, exercises, ball and balloon games, dominoes, darts, singing and things”.

“We are having a garden party with a barbeque on Saturday – that will be a good time”.

“The cooks are both very good. One especially makes beautiful cakes.”

“We choose what we want for each meal. There is chicken casserole and mash, or cheese omelette and chips today”.

“There is always plenty to eat and we can ask if we want anything”.

People said that they could talk to the care staff or the manager at “any time”.

The inspection took place on 15th and 16th December 2014 and was unannounced.

The service provides care and accommodation to 19 older people with nursing needs. There were 13 people living in the service at the time of our inspection. The nursing accommodation is set in a large detached house that includes 17 single bedrooms and one double bedroom, 10 of which have en-suite facilities. People had varying needs depending on their health. Some people were living with dementia.

There was 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 April 2014 we identified breaches in the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. People weren’t given the information they needed in a suitable format. People or their relatives had not been involved in planning or reviewing their own care. Meetings had not been held to assess people’s capacity to make decisions where these had been needed. The premises were not secure and equipment had not been safely maintained. Arrangements for keeping people safe in the event of an emergency were not in place. People waited too long for care they needed at lunchtime due to the level of staffing. Risk assessments had not been completed. People were not fully protected from the risk of abuse because staff did not have access to information they could refer to. Records were not accessible or accurate.

The provider sent the CQC an action plan which described how and when the improvements would be made. We found that many actions had been taken and the provider had improved the service. The new systems for monitoring the overall quality of the service, identifying the need for improvements and taking action were being used. Although improvements had started to be made they were not all in place or embedded into practice yet.

The premises were secure and protected with an alarm system. People had personal emergency evacuation plans in place and staff were trained in fire awareness. Staff were trained and had the information they needed to protect people from the risk of harm and abuse. Risk assessments were centred on the needs of the individual and included clear measures to reduce identified risks and guidance for staff to follow. Medicines were stored and administered safely. Nurses kept accurate records relevant to the administration of medicines.

People lived in a clean and well maintained environment. Improvements and minor repairs in the service were ongoing. Staff had a thorough understanding of and were following safe infection control practice which helped to minimise people’s risk from infection. People’s own rooms were personalised to reflect their preferences.

People’s needs had been assessed and this had been used to consistently make sure enough staff were on duty to provide safe, effective and responsive care. Staff had time to spend supporting people in a meaningful way that respected individual needs. Recruitment procedures were followed including checking references and criminal records. Staff had the training and experience to support people and meet their needs.

People and their relatives told us they were satisfied with the care, the staff had a good knowledge of their needs and met these in a way that suited them. One person told us, “The girls (staff) know what to do”. Another person told us, “The staff know me well and understand me well”. Two relatives said, “The staff know my mum well and what she likes, they know how to get the best of her” and, “The staff are well trained”.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS). All staff were trained in the principles of the MCA and the DoLS and were knowledgeable about the requirements of the legislation.

People told us they enjoyed their meals and they had enough to eat and drink. Food was freshly prepared and people were supported to eat when they needed to be. Staff knew about people’s dietary preferences and restrictions such as how one person could not tolerate certain foods and fluids and this need was met.

Healthy living and wellbeing was promoted by staff. Specialist equipment was provided. General wellbeing checks were recorded by staff at regular intervals. People were referred to healthcare professionals when needed. The manager told us, “We have a good relationship with the GPs, district nurses, dieticians and the local hospice team who come and visit us and they respond quickly to our referrals”. The health professionals we spoke with agreed with this view.

People’s individual assessments and care plans were reviewed regularly with their participation or their representatives’ involvement. These were updated to reflect people’s changing needs, wishes, preferences and goals. The care that was provided was consistent with people’s planned care needs.

A range of activities was available but these had not taken account of people’s needs or wishes. Two people told us, “I often don’t feel like joining because it is not very exciting” and, “The activities are all right I guess”. The registered manager and activities co-ordinator were aware of people’s views and had begun to look into how to provide more stimulation for some of the people who were living with dementia. They told us, “At present the activities programme is not as stimulating as it could be due to people’s varied levels of ability but we are working on improving it”. We have made a recommendation about this.

People’s feedback was sought and they were involved in the planning of their care. Complaints, comments and suggestions were taken into account and most but not all of these had been acted on. People had the opportunity to share their views about the care and service through monthly residents meetings and yearly satisfaction questionnaires.

There was an open and positive culture at the service which focussed on people. Staff told us, “The manager and senior nurse are approachable; we can talk to them any time and discuss any concerns”.

We recommend that best practice guidance is sought and followed regarding providing meaningful activities of people’s choosing.