We inspected Nazareth House - Cheltenham on the 7 and 11 February 2019. Nazareth House - Cheltenham provides accommodation and personal care to 63 older people and people living with dementia. It also provides short term respite care for people. At the time of our visit 43 people were using the service. Nazareth House is located in the Charlton Kings area of Cheltenham. This was an unannounced inspection.

At our previous comprehensive inspection in June 2018 we found the provider was not meeting five of the regulations. We found people’s risks had not always been assessed and they had not always received their medicines as prescribed. Additionally, staff did not have access to training and support. People did not receive person centred care and access to stimulation which would have benefitted their wellbeing. People’s dignity and privacy were not always respected. The provider did not have effective systems to monitor and improve the quality of service people received.

Following the June 2018 inspection, we met with the provider and the previous registered manager to discuss the actions they were planning to take to improve the service.

We completed a focused inspection in October 2018 to follow up on enforcement actions we issued against the provider following our June 2018 inspection. We found improvements had been made in relation to the concerns we identified at our June 2018 inspection. The management of people’s prescribed medicines and risks had improved, the governance systems were increasingly effective and staff had received some support and training. However, further improvements were required to the safe management of people’s medicines and the training and support staff received.

At this inspection in February 2019, we found continued improvements had been made to the safety of the service, staff training and support and the provider’s quality assurance systems. However, we identified concerns where staff had not followed the guidance and expectations of the manager and the provider when managing people’s medicines. This placed people at risk of not receiving their medicines as prescribed. The provider and manager were aware of these concerns and informed us of the immediate actions they planned to take.

A registered manager was not in place at the service. The provider had recruited a manager, who had previously been the registered manager of the service. The manager was in the process of registering with CQC. This manager was supported by representatives of the provider and a head of care. 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 provider and manager had systems in place to drive the quality of care people received. While these systems had led to improvements, they were not always consistently being monitored and implemented by senior care staff. Senior staff did not always complete and update records when people’s care was delivered, such as topical cream charts. Senior staff did not always provide all staff with a detailed shift handover. During and following our inspection the manager provided us with an action plan of how they were planning to address these concerns and ensure quality was maintained within the home.

People, their relatives and staff felt staffing had improved at Nazareth House - Cheltenham. There was a high level of agency staff usage to ensure people’s needs were met however the manager and provider ensured agency staff were block booked to maintain consistency. The provider was taking action to address staffing concerns through ongoing recruitment. Care and nursing staff felt they were supported by the manager and head of care. However, further improvements were required to ensure staf

We inspected Nazareth House - Cheltenham on the 30 and 31 November 2018. This was an unannounced inspection. Nazareth House - Cheltenham is registered to provide accommodation and personal care to 63 older people and people living with dementia. This was a focused inspection to follow up on enforcement action we imposed on the provider following our last inspection in June 2018.

At the time of our inspection, 46 people were living at Nazareth House - Cheltenham. Nazareth House - Cheltenham is based in Charlton Kings in Cheltenham. Nazareth House is a large building based on three floors. The home is attached to a chapel and accommodation used by the Sisters of Nazareth. The home has large grounds which people could enjoy, included a wooded pathway and extensive patio. Many of the people living at Nazareth House, chose the home to enable them to continue meeting their religious needs.

We last inspected in June 2018, following concerns about the service raised by healthcare professionals. At the inspection in June 2018 we found the provider was not meeting a number of the regulations. We found people did not consistently receive safe care and treatment, because staff had not always assessed their risks and people had not always received their medicines as prescribed. Additionally, staff did not have access to training and support. People did not have access to person centred care and stimulation which would benefit their wellbeing. Care staff did not always ensure people’s dignity and privacy were respected. The provider did not have effective systems to monitor and improve the quality of service people received.

Following our inspection in June 2018, we issued the provider with three warning notices in relation to safe care and treatment, staff training and support and their good governance systems. We also met with the provider and asked them to provide us with weekly action plans regarding how they planned to improve the service people received. We rated the service as “Requires Improvement” and ‘Is the service well led?’ as “Inadequate.” At this inspection on 30 and 31 October 2018 we found significant improvements had been made, however further work was still required to ensure the service was safe, effective and well led. Following this inspection, we rated the service as “Requires Improvement” in all areas.

At our inspection on 30 and 31 October 2018 there wasn’t a registered manager in place. The previous registered manager left the service shortly after our June 2018 inspection. The provider had an interim manager in place and they had also recruited a permanent manager who intended to register with CQC. The new manager was due to start work at Nazareth House – Cheltenham on 5 November 2018. This manager had previously managed the service. 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 provider had implemented systems to monitor and improve the quality of service people received. We found these systems had been effective in identifying shortfalls in the service and driving improvement. Staffing numbers had improved and risks to people’s health and wellbeing had been assessed and were understood by staff. Although some improvements were being made in relation to medicine management and staff training and supervision, at the time of this inspection, the provider’s planned improvements were still to be completed before all the required regulation standards could be met.

People and staff spoke positively about the improvements made at Nazareth House - Cheltenham since our last inspection. Care staff felt they received more support and were hopeful for the future of the home and were improving the quality of care people received.

We inspected Nazareth House – Cheltenham on the 20, 22 and 26 June 2018. Nazareth House - Cheltenham is registered to provide accommodation and personal care to 63 older people and people living with dementia. We carried out this inspection following concerns raised about the service by healthcare professionals.

At the time of our inspection, 55 people were living at Nazareth House - Cheltenham. Nazareth House - Cheltenham is based in Charlton Kings in Cheltenham. Nazareth House is a large building based on three floors. The home is attached to a chapel and accommodation used by the Sisters of Nazareth. The home has large grounds which people could enjoy, included a wooded pathway and extensive patio. Many of the people living at Nazareth House, chose the home to enable them to continue meeting their religious needs. This was an unannounced inspection.

We previously inspected the home on 17 August 2017 and rated the service as “Good”. At the inspection in August 2017 we rated the key question ‘Is the Service Responsive?’ as “Requires Improvement” as we found additional improvements were required to ensure people's care plans were person centred to their needs. At our June 2018 inspection we found improvements had not always been made and sustained. We found multiple concerns relating to; the quality of care people received.

This is the fifth inspection of Nazareth House - Cheltenham where the service has been rated. At four of these inspections the service had failed to meet all the requirements of the relevant regulations. The registered manager and provider had not demonstrated that they were able to consistently meet the requirements of their registration and operate effective systems to ensure that Nazareth House – Cheltenham met the requirements of the Health and Social Care Regulations. Therefore we have rated the key question ‘Is the service well-led’ as ‘Inadequate’.

There was a registered manager in place at Nazareth House - Cheltenham. The registered manager left the service shortly after our inspection, however was available on all three days of our inspection. 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 were safe living at Nazareth House - Cheltenham. However, we identified shortfalls that impacted on people receiving safe care. People had not always received their medicines as prescribed. Care staff responded to people’s changing needs and health and worked closely with people's GPs. However, they did not always document the support they provided people and did not always follow care plans to ensure people would always receive care that met their needs and kept them safe.

There were enough staff deployed to ensure people’s health needs were being met but staff sickness had led to shortages which impacted on people receiving person centred care, including access to baths when they wanted. We recommended that the service seek advice based on current best practice, around how to use staff most effectively.

People’s privacy and dignity was not always respected and protected. Care staff did not always ensure people were cared for in private, by closing their bedroom doors. Care staff did not always effectively communicate with people living with dementia and did not always speak to people in a caring and compassionate way.

Staff felt they had the skills they needed to meet people’s needs. The registered manager had no overview of the training their staff required. Staff told us they had not always received effective support including one to one meeting with their line manager, and there was no clear record of the support staff had received to aide their professional development. Care staff felt they ha

The inspection of Nazareth House Care Home commenced on 17 August 2017 and was unannounced.

This was a focussed inspection and was prompted in part by information of concern we had received about the service. The information shared with CQC indicated potential concerns about safe care and treatment and the leadership within the service. This inspection examined those concerns and reported on the findings in the safe, responsive and well led domains. During our inspection in November 2016 we found the care provided to people was not always person centred and tailored to their individual needs and preferences. At this inspection we also checked whether the provider had taken action to address this shortfall.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Nazareth House’ on our website at ‘www.cqc.org.uk’. The last comprehensive inspection was carried out on 22 and 23 November 2016. At that inspection the service was rated overall as “requires improvement.” Our findings at this inspection have not changed the current rating of ‘good’ for the key question Safe or for the ‘requires improvement’ rating for the key question Responsive because we did not look at all the areas related to these two key questions. We will review these two domains in full at our next comprehensive inspection. We have reviewed the rating of the Well-Led question and have changed this to ‘good’ And as a result we have reviewed and changed the overall rating for this service to ‘good.’ .

Nazareth House provides care to predominantly older people. Some live with dementia and others have physical needs which they require support with. It can accommodate up to 63 people in total and at the time of the inspection there were 53 people living there. The provider adopts the core values set by the Sisters of Nazareth which are love, justice, hospitality, respect, compassion and patience.

The service 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 and associated Regulations about how the service is run.

People felt safe living at Nazareth House. Staff had received training around safeguarding people from harm and abuse, and demonstrated a good understanding of safeguarding principles. The registered manager had carried out the relevant checks to ensure they employed suitable people at Nazareth House. There were regular health and safety checks of the property to ensure it was safe for the people living there.

Following our previous inspection in November 2016 improvements had been made to the recording of people’s care needs. Care plans were person centred and had been developed in partnership with the people receiving care. People needs and preferences in relation to their care were clearly recorded. Where people used their call bells to request staff support, we found the response times to these had improved and people received support in a timely manner.

The registered manager and staff were aware of the vision and values of the service and worked hard to provide a service which was person centred for each individual. There was a positive culture within the service. The registered manager offered strong leadership throughout the service. The staff and people living at Nazareth House spoke positively about the registered manager. The registered manger carried out quality assurance checks and audits regularly and where issues had been identified, action had been taken to address them.

This inspection was carried out on 22 and 23 November 2016 and was unannounced. We had previously carried out an unannounced inspection of this service on 28 and 29 January and 1 February 2016 where we found breaches of regulations relating to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These included a lack of adequate staff training and support, the principles of the Mental Capacity Act 2005 not adhered to, a lack of management of risks and ineffective quality monitoring arrangements. The provider wrote to us to tell us how these would be met and by when. During this inspection we found these regulations had been met, although, the systems and ways of working which had achieved improvement still needed to be fully embedded and sustained.

On 12 and 17 May 2016 we carried out another inspection after receiving information of concern which included: not enough care staff to meet people’s needs, issues arising from a high dependency on agency care staff, poor staff practices relating to people’s safe moving and handling, unsafe medicines management and a lack of consistent and effective day to day management. We had also received several notifications from the provider reporting incidents of poor moving and handling practices which we had difficulty establishing whether they had been fully investigated and acted on. At this inspection we had checked on the progress made by the provider on some areas of the breaches found in January 2016, which the provider had told us would be met at the end of April 2016. We looked at some aspects of risk management, staff training and the recording of some people’s food and fluid intake.

During the inspection in May 2016 we were concerned about the lack of suitable arrangements to ensure the safe evacuation of people in the event of a fire. We requested that the local fire safety office carry out an urgent visit. They carried out a fire safety assessment on 13 May 2016. Immediate guidance and advice was given to the management team in place at the time by the fire safety officers, on how to improve staffs’ awareness on what to do in the event of a fire. A notice of non-compliance was issued by the fire safety department under relevant requirements of the Regulatory Reform (Fire Safety) Order 2005. This was subsequently met by the provider.

Nazareth Care Charitable Trust is a Charity which works closely with the Sisters of Nazareth. Nazareth House - Cheltenham is one of the Charity’s care homes. It can accommodate up to 63 people who require support and care. During this inspection 53 people were receiving care. Although many people who followed the Catholic faith chose to live at Nazareth House all faiths’ and backgrounds were welcomed. Care was provided predominantly to older people by staff who were employed by the Charity. A group of Sisters and one Catholic Father lived on site and provided pastoral support and guidance to those who lived there. The Sisters were involved in some decision making and had some financial input in the up keep of the building. They were very visible within the care home.

A new manager had been employed since the last two inspections. They had been in post since May 2016 and were now 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.

People told us they felt safe. They were looked after by staff who had received support to access necessary training since the last two inspections. This had included update training in areas that were considered not safe in May 2016 such as fire safety, the safe moving and handling of people and medicine management. People’s medicines were now managed safely. Further on-going training ha

This inspection was carried out on 12 and 17 May 2016 and was unannounced.

Nazareth House provides care and accommodation for up to 63 older people. At the time of our inspection there were 45 people using the service. Many people reside at Nazareth House because the Sisters of Nazareth provide spiritual support and guidance to those of the Catholic faith. There is a chapel attached to the care home where people can take part in daily devotions. Nazareth House however welcomes and cares for people of other faiths and those who have no particular faith.

At the time of this inspection the service was without a registered manager and had been since May 2015. A registered manager is a person who has registered with the Care Quality Commission (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. Since May 2015 there had been other managers, both permanent and interim, but not registered with the Care Quality Commission. During this inspection the management team were different to those present at our last inspection in January 2016.

We carried out an unannounced comprehensive inspection of this service on 28 and 29 January and 1 February 2016 where we found breaches of regulations relating to the Mental Capacity Act 2005, management of risks, staff training and support and quality monitoring arrangements. The provider wrote to us to say what they would do to meet legal requirements in relation to these breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Since then we received further information with concerns relating to: not enough care staff to meet people’s needs, issues arising from a high dependency on agency care staff, poor staff practices relating to people’s safe moving and handling, unsafe medicines management and a lack of consistent and effective day to day management. We had also received several notifications from the provider reporting incidents of possible poor moving and handling practices which we were having difficulty establishing whether these had been fully investigated and acted on. As a result we undertook this unannounced focused inspection to check if people were safe. We also checked on the progress made by the provider on some areas of the breaches found in January 2016, which the provider told us would be met at the end of April 2016. This included: some aspects of risk management, staff training and the recording of people’s food and fluid intake where people needed this monitoring closely. This report only focuses on the above areas and is not a follow up on all breaches of regulation found in January 2016. These will be followed up in due course when we carry out the next planned comprehensive inspection.

During this inspection we were concerned enough about the lack of suitable arrangements to ensure the safe evacuation of people in the event of a fire, to share our concerns immediately with a local fire safety officer. They carried out a fire safety assessment on 13 May 2016. Immediate guidance and advice was given to the new interim management team by the fire safety officers on how to improve staffs’ awareness on what to do in the event of a fire. A notice of non-compliance was issued by the fire safety department. They will follow this up in due course to ensure the provider meets with the relevant requirements of the Regulatory Reform (Fire Safety) Order 2005.

During this inspection some aspects of the management of medicines were not safe. Previous and current management staff had begun to take some action to address this. However, this was still work in progress. People’s needs were not always being met in a timely way and support was not always available when people wanted or needed it. The service had continued to use high numbers of agency s

The inspection took place on 28 and 29 January and 1 February 2016 and was unannounced.

Nazareth House provides care to predominantly older people. Some live with dementia and others have physical needs which they require support with. It can accommodate up to 63 people in total and at the time of the inspection there were 51 people living there. The provider adopts the core values set by the Sisters of Nazareth which are love, justice, hospitality, respect, compassion and patience

A registered manager was not in place. 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 last registered manager had stopped managing the service in May 2015. Since then another manager had been appointed and had left in December 2015. The current new home manager had started employment with the organisation on 25 January 2016. They had been working in the home for four days when this inspection started. They were an experienced adult social care manager who brought with them various qualifications and skills which would benefit Nazareth House.

People’s risks had not always been well managed. This had particularly related to the management of falls where actions to avoid reoccurring falls had not always been taken. Staff were committed to those they looked after but at times were unable to meet people’s needs in a way which suited people best. Response times to call bells for example needed to improve. Staff recruitment practices were good and protected people from those who may be unsuitable. People’s medicines were administered by staff but some arrangements potentially meant some people were not getting their medicines as prescribed. Improvements to the environment had been made and continued to ne made but not all risks had been addressed. This particularly related to evacuation processes in the event of a fire. People had access to health care professionals when needed. However, confusion in applying the appropriate legislation when people lacked mental capacity meant people’s rights were not fully protected. Staff had lacked effective training and adequate support which had resulted in some of the shortfalls identified above. People were supported to eat and drink and potential risks in this area were identified and managed.

People or their representatives had not always been involved in planning and reviewing care; as a result not all care plans were personalised. Care records had not been well maintained but as from November 2015 improvements had started to take place and we saw updated records. This had not caused significant shortfalls in people’s care but had meant that staff who did not know people’s needs lacked guidance about these. This could potentially lead to inconsistent or unsafe care if not addressed. People had opportunities to partake in social activities but they wanted to be able to go on more trips. Staff worked hard to make the activities enjoyable and meaningful to people. This work was very well supported by volunteers. People had been able to raise complaints and have these taken seriously, investigated and resolved where possible. There had been an increase in complaints during the time of unsettled management but the new home manager had plans to ensure people could express any areas of dissatisfaction and have these resolved before a complaint was necessary.

The staff at Nazareth House were caring and compassionate. People who mattered to those receiving care were also welcomed and supported. The Sisters of Nazareth Convent provided additional time and pastoral support to anyone of any denomination. This was clearly appreciated by people who lived at Nazareth house and those who visited.

The service had lacked consistent

An adult social care inspector carried out this inspection. The focus of the inspection was to follow up on actions required of the provider following an inspection on 18 and 19 April 2014 and to answer two key questions; is the service safe and effective?

As part of this inspection we spoke with the registered manager and two staff members. We reviewed care records and other relevant documents. These included policies and procedures and staff training and support records.

Below is a summary of what we found. The summary describes what staff told us and the records we looked at.

Is the service safe?

The service was safe because, since the last inspection in April 2014, appropriate arrangements had been made to ensure people's medicines were administered safely. The service was safe because checks were carried out to make sure medicine records were maintained accurately. The service was safe because individual staff competencies in medicine administration were reviewed. The service was safe because since the last inspection people's care records had been reviewed and amended so as to ensure information about people's care and treatment was relevant and updated. This was with the exception of one person's care records, which after review still did not give appropriate or relevant information. This was rectified during the inspection.

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

Is the service effective?

The service was effective because the training and support needs of staff had been identified. Staff received support and training to enable them to deliver people's care safely. In this report the provider is made aware of one example seen during this inspection where staff lacked understanding in the completion of relevant care plans and risk assessments. The registered manager told us that additional training and support would be provided in relation to this.

The service was effective because the service had started to make improvements to how staff received training, making it more relevant and meaningful to the situations staff encountered during their work. The service was effective because it identified shortfalls in staffs' performance and put actions in place to resolve these.

We spoke to four people who used the service and five members of staff. When talking to people about their opportunities to make their own decisions and have their wishes listened to one person said "I am quite free to make my own decisions, I am not told what to do". Another person said "I like to be independent, there are no restrictions put on me and no one ever tells me what to do". We saw evidence to show that people who lacked mental capacity to make decisions for themselves were protected by the Mental Capacity Act 2005. The service worked alongside other providers and care professionals to ensure good outcomes for people. Where needed the staff would challenge other providers that did not do this. There were good safeguarding arrangements in place to protect people and staff were made aware of their responsibilities in respect of this. Although the environment required modernising and upgrading, and there were plans in place to do this, it was maintained safely.

We considered all the evidence we had gathered under the outcomes 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?

The inspection was completed by one inspector. We spoke with two people who lived in the home, one visitor and eleven members of staff. This is a summary of what we found.

Is the service safe?

Staff were aware of people's needs and were meeting them safely. Staff were also aware of people's individual risks and took action to manage these. The service worked with other health care professionals in order to meet people's needs.

Care records were not always up to date and did not give staff updated information about people's required care and treatment. People were therefore at risk of not receiving safe and effective care or treatment through a lack of accurate information about them. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The service's policies and procedures relating to what staff should do following an accident had been discussed with staff and reiterated. Training had been organised for some staff in first aid so that they could give first aid to people safely. Further training for this had also been booked. Changes to the call bell system meant that call bells were responded to correctly.

The arrangements for medicine administration had been reviewed and some staff had received additional support to ensure their practices were safe. Despite this we twice observed practices that meant some people's medicines were not administered safely. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

There were no restrictions in place. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Staff had not yet received training on the above, however, the new manager was aware of how to apply for an authorisation under the Deprivation of Liberty Safeguards. Strategies were in place to keep people safe but not deprive them of their liberty.

Is the service effective?

People told us they liked living in the home and it provided them with what they needed. Other people who were not able to share their experiences with us looked comfortable and relaxed. Both people spoken to confirmed that they were able to receive visitors when they wanted to. Both these people's bedrooms, and many more were highly personalised with private belongings making the person's personal space look like their own piece of home.

People’s health and care needs were assessed and people's needs were met even though care records were not up to date. Arrangements for the administration of two people's medicines needed a review so that they could continue to have their preferences met but the safety of their medicine administration was improved.

Is the service caring?

We observed staff being very kind and patient with people who used the service. We also observed this same approach with one person who was being verbally challenging back to staff when they approached the person. One person said (about the staff): "most of them are very kind." and a visitor spoke highly of the staff and said: "they are brilliant."

People’s preferences, wishes and diverse needs were respected and noted in their care records. Staff spoken with had a good understanding of how people wished to be supported and provided care in accordance with their wishes.

Is the service responsive?

People wishing to move into the home were assessed to make sure their needs could be met. When needed other social and health care professionals were involved to ensure the appropriate care and support was being provided. Increased risks to people were identified and managed.

Once concerns had been expressed about the service in November 2013 the provider had listened and had put arrangements in place to address these. Changes to how the provider and service managers were assessing and monitoring the service's performance meant that a more proactive and less reactive approach to identifying shortfalls and making improvements was in place.

One person who used the service said (in relation to how the sevice was being managed) said: "there has been a vast improvement over the last few months." This person also told us, they and others had been asked for their views of the service and where they would like to see changes. They said this approach had been new but appreciated. One visitor echoed this appreciation.

Improvements to the environment had started with some bathrooms having been refitted, resulting in areas that could be kept clean and which provided comfortable bathing facilities. Two people told us that improvements had been made to the food after people had expressed that it required improvement.

Is the service well led?

The management of the service itself has altered and senior staff were being supported to lead their individual areas more effectively. Arrangements within the service had been introduced so as to promote and encourage effective communication between the staff teams and the managers. Where needed the use of agency staff had been allowed but an active recruitment plan was also in place.

Staff were being supported to follow the provider's policies and procedures and action had been taken where this had not happened. The provider was continuing to review and adapt the way in which staff worked to make sure people’s needs were met and the service ran smoothly.

Arrangements for staff training and support had been poor. Although managers had started to make improvements to staff training and how staff were informed of their responsibilities, this work was in its infancy. A compliance action was therefore set in relation to this and the provider must tell us how they plan to improve this further.

You can see our judgements on the front page of this report.