Croft House Care Home

Croft House Care Home is a residential care home providing personal and nursing care for up to 68 people. Croft House Care Home accommodates 46 people across three separate floors, each of which has separate facilities. One of the floors specialises in providing care to people living with dementia, the second specialises in nursing care and the third provides residential care.

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

People told us they felt safe and staff were caring and supportive. There were enough staff on duty and they had been recruited through a robust process. The care environment was warm and welcoming and people’s rooms were personalised to their tastes. The home was clean and there was a plan in place identifying improvements and refurbishment to the facilities where required.

There was effective management oversight of the service and quality monitoring systems were in place. Care was person-centred and people were involved in expressing their views about the overall quality of the service. Staff, people and relatives were complimentary about the management team. They were approachable, supportive and informative and had created a culture of effective teamwork.

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 6 July 2022).

Why we inspected

We carried out this inspection based on information shared with us through our enquiries system about care and support for people and appropriate staffing levels. We also needed to follow up on our last inspection where the service was rated overall as requires improvement.

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.

Follow up

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

Croft House Care Home is a residential care home, providing personal and nursing care for up to 68 people. There were three separate units within the home providing residential, nursing and dementia care. At the time of inspection there were 45 people living at the service.

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

The provider acknowledged they had been working through a difficult period and had placed additional resources in the home to make improvements. These were found to be effective.

The management of risk had improved at this inspection. Risks to people were being openly communicated through staff handovers, daily ‘flash’ meetings and in day-to-day discussions. Records showed risks were assessed, monitored and reviewed.

Staffing levels were set using a dependency tool which was regularly reviewed. In communication with relatives, the provider openly acknowledged staffing pressures, but noted the home had been fully staffed for a number of weeks. Most people told us staff were quick to respond to their needs, but some exceptions to this feedback were noted. The recruitment of staff was safely managed.

The management of medicines was safe. Staff were going through refresher training in medicines management and had been assessed as competent. People received their medicines as prescribed, although one relative noted agency workers had tried to incorrectly apply a cream to their loved one, despite them not being prescribed this.

People felt safe living in the home and their relatives agreed with this. Staff had received training in how to safeguard people from harm which meant they were able to recognise and respond to signs of abuse.

There was a focus on lessons learned and continuous improvement in the service. The senior operations manager and other members of the management team had identified shortfalls in service delivery and responded appropriately to these areas.

The culture in the home was improving. However, staff were mindful of a number of changes in the home manager position. At the time of our inspection, a new home manager had just started their employment. They spoke positively about how they wanted to involve everyone in the running of the home.

Quality oversight had improved at the time of our inspection. Staff meetings were taking place to share key information. Responses to a satisfaction survey had been analysed and feedback was on display. Communication with people and relatives was improving.

The staff team worked with a range of partners to provide care for people. A visiting professional told us staff were good at following guidance they provided.

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 and update: The last rating for this service was inadequate (published 5 November 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.

At our last inspection we recommended the provider monitors how staff maintain people’s privacy and dignity. At this inspection, we made observations and spoke with people who felt well supported around their privacy and dignity.

This service has been in Special Measures since 5 November 2021. During this inspection, the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out this inspection based on information shared by the provider as well as information from our partners regarding the safe management of risk. We also needed to follow up on our last inspection where the service was rated overall as inadequate.

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.

Follow up

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

Croft House Care Home is a residential care home, providing personal and nursing care for up to 68 people. There are three separate units within the home providing residential, nursing and dementia care. At the time of inspection there were 54 people living at the service.

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

Infection prevent and control (IPC) risks were not always effectively managed. People were at risk of cross infection due to best practice guidelines not always being followed.

Risks to people’s health and safety were not always safely assessed, monitored and managed. People were at increased risk of harm as a result of dietary needs not being effectively managed and errors being made when utilising skin integrity equipment.

There were not always enough staff safely deployed within the service to meet people’s needs. Staff did not feel supported within their role.

Systems and processes to monitor the service had not been effective in assessing, identifying and addressing areas requiring improvement. Feedback was not always obtained and lessons learned from accidents and incidents were not consistently identified and used to make improvements to the service.

People’s privacy and dignity was not consistently maintained. We made a recommendation that the provider monitors practice in this area.

People were safeguarded from the risk of abuse. The provider reported incidents to the relevant authorities.

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

Rating at last inspection (and update)

The last rating for this service was inadequate (published 23 February 2021). The service remains inadequate for the second consecutive inspection.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 18 December 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 safe care and treatment, staffing, privacy and dignity and good governance.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Croft House Care Home on our website at www.cqc.org.uk.

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

Enforcement

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

We have identified breaches in relation to safe care and treatment, staffing and good governance at this inspection.

Follow up

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

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

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

Croft House Care Home provides nursing and residential care for up to 68 people. There are three separate units within the home providing residential, nursing and dementia care. All bedrooms are single occupancy with en-suite facilities. The home is situated in its own grounds with car parking facilities in the village of Gawthorpe. At the time of our inspection there were 60 people using the service.

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

Infection prevention and control (IPC) practices were unsafe because staff were not using personal protective equipment (PPE) correctly which increased the risk of infection transmission. Part of the home was awaiting redecoration, but it had already had wall paper and paint work removed. This meant the walls could not be sanitised to manage the risk of infection transmission.

The safe administration of medication was not consistent in the service. There was a heightened risk of medication errors due to the systems in place. A lack of oversight meant audits weren’t effective and correct medication practices weren’t followed.

People were not always treated with dignity and respect. The support some people received in regard to their nutrition and hydration did not promote their dignity or treat the person with respect.

People felt safe living in the service. People appeared to be relaxed and comfortable in the service and people had a good rapport with staff. Staff knew people’s preferences and staff had good interactions with the people using the service. People and their relatives spoke positively about the staff, service and the care people received.

Audits were not robust and did not identify issues affecting the safety of comfort of people who used the service. Where issues had been identified, these were not consistently acted upon.

Staff did not receive manager supervision in line with the provider’s policy.

Staff had been recruited safely and all training was up to date. Staff knew what to do to raise concerns and there were regular staff meetings where updates were provided and any issues of concern could be discussed.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service were in place but the service did not follow 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 30 October 2017).

Why we inspected

The inspection was prompted in part due to concerns received about a COVID-19 outbreak at the service. Furthermore, there had recently been a specific incident where someone had died at the service. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. A decision was made for us to inspect and examine those risks.

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

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

Following the inspection, the provider had taken timely action to provide additional support at the service to ensure the safety and wellbeing of the people using the service. This has mitigated some of the risk identified at the inspection.

Enforcement

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

We have identified breaches in relation to regulation 10 (dignity and respect), regulation 12 (safe care and treatment), regulation 17 (good governance), regulation 18 (staffing) and registration regulation 18 (notification of other incidents) at this inspection.

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

Follow up

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

Special Measures:

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

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

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

Croft House provides nursing and residential care for up to 68 people. There are three separate units within the home providing residential, nursing and dementia care. All bedrooms are single occupancy with en-suite facilities. The home is situated in its own grounds with car parking facilities in the village of Gawthorpe. At the time of our inspection there were 62 people using the service.

There was a registered manager in post when we inspected, however they were not present for the inspection as they were on annual leave. 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 living at Croft House Care Home, and we saw risks associated with their care and support were well managed. Staff understood how to identify signs of potential abuse and how to report these. We saw accidents and incidents were reported and investigated appropriately. Maintenance and servicing records showed this was up to date.

Staff were recruited safely and deployed in sufficient numbers to provide care and support. We saw staff were always visible and able to spend time interacting with people in a meaningful way.

Medicines were managed safely. Records were complete, storage was appropriate and secure and there was clear guidance in place to ensure people received ‘as-and-when’ medicines safely.

People and their relatives told us staff had the skills and training to provide effective care. Staff had a thorough induction and access to on-going training and support to help them remain effective in their roles.

There was a good approach to the management of people who lacked capacity to make decisions for themselves, and the provider recognised when applications for Deprivation of Liberty Safeguards (DoLS) were needed.

People told us they enjoyed the food served in the home, and we made mainly positive observations during the lunchtime meal service.

We saw people had good access to health and social care professionals when this was required.

People and their relatives gave consistently good feedback about the caring nature of staff, and our observations confirmed this. People were involved with writing care plans, which were personalised, and received support to remain as independent as possible. There was a good approach to the management of privacy and dignity.

The provider assessed people’s needs before they began using the service, and used this information to write responsive care plans that were kept up to date. Staff attended a handover at the start of their shift which ensured they had access to up to date information about people’s needs.

There was a range of activities people could join in with, and we saw people had opportunities to access the local community.

There were policies in place to ensure complaints were recorded and actioned appropriately, although we found concerns raised verbally were not being recorded. We made a recommendation about starting to record verbal concerns, even when these were not formal complaints.

We received good feedback about the registered manager, and saw they were proactive in measuring, monitoring and improving quality in the service. People, their relatives and staff were encouraged to be involved in the running of the home.

Croft House contains four units over two floors. Downstairs are two nursing units, one with 18 beds and one with 12 beds. On the first floor there is a small residential unit with 12 beds and a dementia unit that has 24 beds. On the days we inspected there were 27 people in the units upstairs and 18 people in the units downstairs. There are stairs and lifts to the first floor. The home has dining and lounge areas in each unit, four conservatory areas downstairs and a large garden which is accessible to the people.

The service did not have a registered manager in post. 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.

After the last inspection a ‘peripatetic’ manager had been appointed; their role was to make improvements at the home while the provider recruited a new registered manager. At the time of our inspection the peripatetic manager was still in post and a new manager had been recruited; they were in the process of transitioning into the role from their current home. The plan was for the new manager to apply to register with CQC when they became the home manager full time in August 2016.

We took enforcement action after the last inspection. At this inspection we checked to see if improvements had been made in all the areas we identified. We found that all aspects had been addressed either fully or partially. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

As the previous inspection in November 2015 rated the home as inadequate we placed it into ‘Special Measures.’ At this inspection we found there had been improvements which were sufficient for the service to be rated as requires improvement overall with no inadequate domains. This meant the service could come out of special measures.

At the last inspection in November 2015 we identified issues with the accuracy of people’s risk assessments. At this inspection the quality of risk assessment was mixed. Some were completed properly and others were not, and some were missing entirely. This constituted a continuous breach of Regulation 12 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Recruitment records did not include prospective employees’ full employment history and this was not investigated with them and recorded at interview. This was a breach of Regulation 19 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Although pressure area care and pressure ulcer management had improved, we found issues with the adherence to pressure ulcer treatment and prevention care plans. This was a continuous breach of Regulation 12 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Feedback from people about the food was all positive and we saw food and fluid care plans and risk assessments were much improved. However, we found issues with the recording of food and fluids for people either losing weight or at risk of weight loss. This was a breach of Regulation 17 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

There were ongoing problems with the quality and consistency of record-keeping in care files and in daily records. This was a continuous breach of Regulation 17 of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

Records showed the provider had greater oversight at the home since the last inspection. However, concerns remained around the potential sustainability of improvements due to the upcoming change in manager and previous issues with provider oversight.

Most aspects of medicines management were done well. However, we identified some issues with medicine protocols that lacked detail or were missing and records showed there had been problems when people’s medicines had run out.

The recording and reporting of accidents and incidents was better, but not all reports contained the same level of detail.

We observed there were sufficient staff on duty to meet people’s needs and this was supported by a dependency tool which incorporated the number of staff people needed to support them. Care workers told us there were enough staff, although feedback from the people and their relatives about staffing levels was mixed.

Progress had been made to ensure all people who lacked capacity to make their own decisions had been assessed and any decisions made on their behalf were done according to the relevant regulations. However, some best interest decisions we saw were generic or had not followed the correct process.

People said they felt safe at Croft House. Staff awareness of safeguarding, its prevention and reporting, was improved. Care workers could describe the forms of abuse and said they would report any concerns appropriately.

We saw cleanliness at the home was much improved. Issues with broken equipment and facilities identified at the last inspection had all been addressed.

Care workers received the training they needed to meet people’s needs. Most staff had received supervision or an appraisal in 2016 and there were plans to ensure all staff would have one by the end of August 2016. Staff told us they felt supported by management.

Records showed people had access to a range of healthcare professionals. People said they could ask to see a GP if they wanted to and relatives told us they were informed if their family members’ health changed.

Environmental changes the home had made to become more dementia-friendly, particularly on the dementia unit, were impressive. Care staff had received dementia training and some had taken part in a dementia experience to help them empathise better with people who lived with dementia.

People and their relatives told us the staff were caring, promoted people’s independence and respected people’s privacy and dignity. Care workers felt the atmosphere at the home was much improved and staff were much happier.

People had access to advocacy services. Care files contained information on people’s end of life care wishes if they and their relatives (if relevant) had been happy to discuss this area of care.

We saw care plans were much improved. They were detailed and person-centred and regularly reviewed and evaluated. The home had made an effort to try and obtain people’s personal histories so care workers could interact with people better.

People now had access to meaningful activities. Their participation and enjoyment of activities was evaluated so care workers would know what people liked to do best.

The way the home recorded and responded to complaints had improved since the last inspection. We saw complaints received since the last inspection had been handled properly.

We received very positive feedback about the efforts of the peripatetic manager to improve the culture and atmosphere at the home. Levels of communication and team-working at the home had improved considerably.

An effective system of audit and quality assurance monitoring was now in place.

This inspection was in response to concerns which had been raised by the local authority who commissioned services at the home. These concerns related in particular to the Elderly Mental Infirm (EMI) unit, which offers care provision to up to 24 people with mental health conditions including advanced dementia and people who display behaviour which challenges others. The concerns related to the amount of incidents which had been occurring on this unit where people who used the service were assaulting each other.

Croft House Care home is a large building laid out over two floors. On the ground floor there are two general nursing care units, one with 18 beds and the other with 12 beds. On the first floor there is a small residential unit with 12 beds and the Elderly Mentally Infirm (EMI) unit with 24 beds. On the days of our inspection there were 61 people living at the home.

There was no registered manager in post at the time 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.

There had been a manager appointed to the service and there was a deputy manager, neither were present on either of the days during our visit. The Regional director arrived during the morning of the first day of our inspection and was present for the remainder of the inspection.

We found the standards of care in the service had deteriorated significantly since our last inspection. There were multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

We found people’s care needs had not been adequately or accurately assessed and there was no care plan in place for one person who lived at the service. People’s care plans were out of date and the information did not reflect their current needs or describe the care which required by them or was being given to them.

We found people in the service were not treated with dignity and respect. Some of the people living in the service were unable to access the toilet without assistance and were being left for long periods without access to assistance. Staff did not recognise how people’s dignity could be promoted and did not assist people promptly when they needed help, as people did not have access to care bells or were unable to use them.

The people living in the service were not asked for their consent for care to be carried out. The provider and the staff failed to recognise restrictive practices which were in place. Mental capacity assessments were not carried out for the people living in the service to measure whether they were able to make their own decisions and which decisions they were able to make. Where people’s liberty was being restricted there were very few Deprivation of Liberty Safeguards in place.

There were very few risk assessments in place for people in the service and those that were in place were not adequate to identify and reduce identified risks to keep people safe. We found large numbers of people were left in bed as a matter of course, even when they were expressing that they did not want to be in bed. People who remained in bed were not receiving adequate pressure area care and there were incidences of serious pressure areas in the service as a result. People who had pressure area wounds were not receiving the correct treatment to ensure that their wounds would heal, and records of treatment and visits from external health professionals were not detailed.

Staff did not recognise safeguarding incidents that were occurring. There were few safeguarding referrals made to protect vulnerable people living in the service until incidents were highlighted by CQC during the inspection, and those which had been made recently were highlighted by other visiting professionals and had not been instigated by the provider.

We found that some people were left without access to drinks and snacks. We saw that food records were inaccurate and were not filled in at mealtimes, which meant staff could not accurately monitor people’s food and fluid intake. We found evidence of weight loss in some of the people living in the service, and people were not being weighed regularly to monitor their weight. We found people who required specialist diets were not receiving these this was particularly in relation to people with diabetes.

There were no processes in place to monitor the performance of the service or to maintain accurate records of the care which was being delivered. We found that there were no records for accidents and incidents which we found referenced in care records. We found that there was no effective leadership within the service.

There were not enough staff to care for people safely and to meet their needs. Staff were not well trained and were not competent in all areas of their roles.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement or there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

During our visit we spoke with three people who lived on the general nursing unit and one relative to gain their views. They told us they were happy with the care and support provided by the staff on the unit, and said staff were responsive and caring.

We spoke with five members of staff from the general nursing unit who were knowledgeable about the care and support needs of the people living in the unit. During our visit we observed people's experiences of living in the home and their interactions with each other and with staff. We saw staff spoke kindly and respectfully to people living in the home. They interacted well with people as they supported them with activities such as eating their meals at lunchtime, and taking their medication.

We reviewed three people's care records and found they provided clearly written information which provided a clear picture of the needs and preferences of each person. We found information relating to people's care and well-being was maintained in a single file which staff reported made it easier for them to access, and record information about each person throughout the day.

During our inspection we observed staff on the general nursing unit appeared to be task orientated and were not pro active in providing people with any meaningful physical or mental stimulation. For example, we saw people were left unattended for over half an hour in the lounge area. People's welfare and safety were at risk due to the lack of positive and meaningful interaction.

The manager told us the home they had been successful in recruiting staff and greatly reduced their use of agency staff. People living in the home and relatives spoken with confirmed the staffing levels had increased throughout the home and were complimentary about the staff. However, staff told us there were still times when the staffing numbers fell below the expected level.

People who lived in the home and their relatives said they knew who to speak to if they had a worry or concern. They told us they felt able to make comments and were confident the staff or manager would do all they could to put it right. One relative said; 'I had concerns about the lack of staffing and so I brought it to the manager and to other people's attention and it has now been sorted.'