Hamilton's Residential Home

Hamilton’s Residential Home is a residential care home providing personal care to up to 17 older people, some of who were living with dementia. At the time of our inspection there were 15 people using the service.

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

People and their relatives told us they were happy living at Hamilton’s Residential Home. However, we found guidance was not in place for staff, to inform them how best to support people with their medical needs. In some cases, care plans were in place, but not followed putting people at risk of not receiving the care they needed. When accidents and incidents occurred, they were documented, but there was no analysis to look for patterns and trends.

Environmental risks such as rips in the flooring which could cause a trip hazard had not been identified by the provider. Medicines were not consistently managed safely; stock counts had not been completed on all medicines to ensure people had received their medicines as prescribed.

The provider and manager completed a series of checks and audits; however, these had not been effective in identifying and addressing issues highlighted in this inspection. Once issues were known the provider was responsive and implemented improvement and changes, for example putting catheter care plans in place, and fixing rips in the flooring.

People and staff told us there were sufficient numbers of staff to meet their needs. People told us they did not have to wait for care, and staff had time to chat with them. Staff understood their responsibilities around safeguarding and had received training. The service was clean.

People told us there was a positive culture within the service. Healthcare professionals and relatives were involved in supporting people to provide joined up care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection

The last rating for this service was good (published 14 March 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service. The inspection was prompted in part due to concerns received about staffing and infection control. A decision was made for us to inspect and examine those risks. You can see what action we have asked the provider to take at the end of this full report. Following the inspection

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection. 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.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Hamilton's Residential Home is a care home that was providing personal care and accommodation to 17 people at the time of the inspection. Most of the people using the service were older people living with dementia.

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

People’s experience of using this service:

People and their relatives told us that they felt safe living at the service. One relative told us, “I feel [my relative] is much safer here, I wouldn’t go on holiday when they were in the other home but here, I haven’t got any worries.” People were protected from risks and their health conditions were monitored to ensure that they remained well and signs of illness. People’s medicines were administered as prescribed. If people needed to see a health and social care professional such as a GP they were supported to do so.

Staff knew people well and people had a say in their care. When people were not able to make decisions for themselves staff followed appropriate guidance to ensure that decisions were made in the person’s best interests. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Where possible people were encouraged to maintain their independence and do things for themselves. People were treated with respect and their privacy was maintained.

There was a pleasant atmosphere at the service. People told us that they were happy, and that staff were kind and caring. People were engaged in activities when we visited such as listening to music, playing instruments and doing puzzles. Relatives were free to visit people when they chose to do so.

The service was clean, and people were kept safe from the risk of infection. The building was suitable for people’s needs although some areas were tired and would benefit from re-decoration. Where people needed support to eat and drink safely this was provided. People were encouraged to eat and drink and where needed their weight and hydration were monitored.

People and their relatives told us that the service was very responsive when they raised issues and acted upon concerns. Staff learnt from incidents and when things went wrong action was taken. This meant that people were protected from concerns re-occurring.

The service was well-led. People and their relatives were positive about the registered manager and the provider and said that they knew them well. The registered manager carried out the appropriate checks to ensure that the quality of the service was maintained.

Staff had the skills, learning and training they needed to support people. Staff were recruited safely and were happy working at the service and felt well supported.

Rating at last inspection:

At the last inspection on 28 March 2018 the service was rated as Requires Improvement.

Why we inspected:

This inspection was a scheduled inspection based on previous rating.

Follow up:

The performance of this service will continue to be monitored and we will visit the service again in the future to check if they are changes to the quality of the service.

Hamilton’s Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

There was 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.

At our last inspection in August 2017, the service was rated 'requires improvement' and ‘inadequate’ in the ‘well-led’ domain. This service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. We received an action plan from the provider, and they told us they would be compliant with all regulations by 31 August 2017.

At this inspection the service demonstrated to us that improvements had been made and it is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures. This is, however, the second time the service has been rated as, ‘requires improvement.’

At our previous inspection medicines had not been managed safely. At this inspection, improvements had been made, however, there was no guidance in place for staff, to inform them when to administer one person’s angina medicine and handwritten medicine administration records had not been double signed to confirm they were accurate. The registered manager rectified these issues during the inspection.

Some people could become distressed, and verbalised suicidal thoughts. There were no window restrictors on upstairs windows, to prevent people from falling from a height. These were purchased on the day of the inspection and we were sent photographs confirming they had been fitted the next day.

The registered manager completed a range of checks and audits but they had not identified the issues we found regarding the safety of the service. Although relatives and staff were asked their views on the service, people and other stakeholders were not formally consulted with.

People’s care plans were now detailed, accurate and fully represented people’s needs. Risks relating to people’s care and support had been assessed and mitigated where possible, and there was clear guidance for staff to follow if people displayed behaviour that challenged. Records were person-centred and contained people’s choices and preferences. Staff had documented what each person wanted to happen at the end of their life and who they wanted present.

Staff documented how much people drank, and totalled this each day to ensure that people were drinking enough. When people lost weight staff took action and consulted with healthcare professionals. Any accidents or incidents were documented and analysed to look for any trends or patterns and ways of preventing them from occurring in the future.

There was clear guidance for staff regarding how to assist people to leave the service in the event of a fire. Regular checks were completed on the water temperatures and equipment to ensure they were safe for people. The service was clean, and people were protected from the spread of infection.

There were enough staff to keep people safe. Throughout the inspection staff spent time with people chatting and there was a warm and welcoming atmosphere at the service. Staff treated people with compassion and ensured people’s privacy was respected. People participated in a range of activities and during the inspection people sang, danced and listened to music. We were shown pictures of people participating in big events, such as a Valentine’s Day dinner. Food at the service appeared appetising, and people were supported to eat and drink safely.

Healthcare professionals fed back that the service was improving, and that staff listened and implemented their recommendations. The provider and registered manager had also worked with the local safeguarding and commissioning teams to ensure improvements had been made at the service. The registered manager regularly consulted with the local safeguarding team when potential incidents occurred and staff knew how to recognise and respond to abuse.

Staff received the necessary training and support to carry out their roles effectively. People’s care and support was planned and delivered in line with best practice when supporting people with dementia.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. When people were unable to consent to staying the service the registered manager had applied for DoLS as necessary. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice

The provider had greater oversight of the service and representatives of the provider visited the service regularly to check what the registered manager and staff were doing. The registered manager told us they felt well supported by the provider, and had access to the training they needed to keep their knowledge up to date. Complaints and low level concerns were now recorded, and any action taken was also documented.

There was a positive culture at the service and people were encouraged to be involved in planning their care and support.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service. CQC check that appropriate action had been taken. The registered manager had submitted notifications in an appropriate and timely manner and in line with guidance. The registered manager had displayed the rating from our last inspection in the entrance hall of the service.

You can see what action we told the provider to take at the back of the full version of the report.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

There was not currently a registered manager in post. The acting manager had applied to the Care Quality Commission (CQC) to become registered and was waiting for their registration interview. A registered manager is a person who has registered with the 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. The acting manager led the day-to-day running of the service and was supported by the provider and their representative.

We last inspected this service in February 2017. We found significant shortfalls and the service was rated inadequate and placed into special measures. People were not always receiving their medicines safely. Risks relating to people’s care and support were not always adequately assessed or mitigated. The provider and registered manager had not ensured the premises were safe. The provider and registered manager had failed to report serious safeguarding concerns to the local authority and the Care Quality Commission. Full recruitment checks were not always carried out. Staff had performed a physical restraint on a person and caused a physical injury. People were not always treated with dignity and respect. People did not always receive care and treatment that met their needs or reflected their preferences. CQC had not been notified of important events that had happened within the service. The provider and registered manager had failed to establish and operate systems to assess, monitor and improve the quality and safety of the services provided and failed to maintain accurate and complete records.

We took enforcement action and cancelled the registered manager’s registration. We required the provider to make improvements. This service was placed in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. The provider sent us regular information and records about actions taken to make improvements following our inspection. At this inspection we found that improvements had been made in many areas. However, there were still areas where improvements were required.

Medicines were still not managed safely. Although people’s medicines had been reviewed and changes had been made there was no medicines policy in place, which meant that safe systems and processes were not embedded. We found some pain relief tablets were missing. There was no guidance in place when people were prescribed ‘as and when’ medicines for pain relief or anxiety and their administration was inconsistent.

Records were not always accurate and did not contain the level of detail necessary to mitigate risks. Risk assessments and care plans were not always updated when people’s needs changed. There were still no step by step guidelines in place to ensure staff supported people consistently when they became distressed or displayed behaviours that challenged. The acting manager analysed accidents and incidents, however staff did not always record incidents when people became distressed or aggressive towards staff meaning this analysis was not complete.

Some people experienced urinary tract infections (UTIs) and although staff recorded the amount that people drank on an online system they did not know how to total these to check people had been drinking enough. One person had lost weight and staff had not taken action.

The guidance in place relating to moving people in an emergency was inaccurate and staff were unable to tell us how they would move people safely in the event of a fire.

People and their relatives said that the acting manager had made a positive impact on the service. Staff said there was a good teamwork and open culture in the service and that the acting manager was supportive. However, improvements the acting manager had made had not had time to be implemented fully. Checks and audits had not picked up the issues we identified relating to medicines, fire safety and the quality of information in people’s care plans.

The environment was now safe. Healthcare professionals fed back that they felt there had been improvements within the service and that listened to their advice and guidance. Staff had received updated training and met regularly with their line manager to reflect on their practice.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there were any restrictions to their freedom and liberty, these had been agreed by the local authority as being required to protect the person from harm. The acting manager had applied for DoLS when necessary. People were supported to make day to day choices about their lives, such as what they ate and where they spent their time.

People told us that staff were kind and caring. There was enough staff to keep people safe, and staff spent time with people. They stopped and spoke with people and treated them with respect and dignity. People engaged in a variety of group and individual activities. People were supported to eat a range of healthy and nutritious foods.

People and their relatives had been asked their feedback on the service. Responses seen were positive and people’s relatives had fed back they were pleased with the changes being made within the service. Not all complaints were currently documented to ensure the acting manager was able to look for any trends and reduce their recurrence. This was an area for improvement,

There were enough staff to keep people safe and staff were recruited safely. The acting manager had submitted notifications when important events had happened within the service, as required by law. They had made safeguarding referrals to the local authority when necessary.

Although we acknowledge that this is an improving service, there are still areas which need to be addressed to ensure people's health, safety and well-being is protected. We identified a number of continued breaches of regulations .The service will therefore remain in special measures. We will continue to monitor Hamilton’s Residential Home to check that improvements continue and are sustained.

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 so 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.

You can see what action we told the provider to take at the back of the full version of the report.

In response to the draft report the registered manager and provider sent us comments and additional evidence. This included some medicines records that the provider told us were available on the day of the inspection. Some of these medicines records had been altered and did not match the copies of records we took during the inspection which is concerning.

Hamilton's Residential Home is registered to provide accommodation and personal care for up to 17 people. Most people were living with dementia. Some people could become anxious or distressed and displayed behaviours that could challenge. There were 15 people living at the service at the time of the inspection.

The service had a registered manager in post. A registered manager is a person who is 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.

Since our last inspection some staff, including senior staff had left the service. There had been a decline in the standards of care and a decline of the overall rating of the service. There were a large number of documents missing from the service. Evidence of audits and checks completed by the registered manager and the provider were unavailable. Relatives had been asked their views on the service but these results had not been collated or analysed. The registered manager told us that relative meeting minutes were also missing, although relatives told us that they had not attended a recent meeting. Stakeholders and staff had not been asked their views about the service.

The registered manager had not notified the Care Quality Commission of important events that happened in the service, as required by law. They told us they were, ‘unaware’ of this requirement, although this had been an issue brought to the registered manager’s attention at a previous inspection. There had been a high level of staff turnover and a number of new staff were now working at the service. Relatives told us they were aware of some changes, and hoped they did not affect the quality of care their loved ones received. One relative said, “Overall I am happy with the care. There is a high turnover of staff at the moment. It worries me a bit that they have to get to know residents from scratch and residents have to get to know them. That could be unsettling.”

People’s medicines were not managed safely. There were stocks of medicines, not prescribed to anyone currently living at the service that could be given for restlessness, agitation and behaviour that could be challenging. The registered manager said when people first came to the service and were restless and agitated then the medicines may be given following consultation with a doctor. Staff did not always give people their medicines as prescribed. There were multiple instances where staff had handwritten changes on people’s medicines records and there was no evidence these had been authorised by a medical professional. There were no guidelines in place for when staff should administer medicine on an as and when basis.

On two occasions staff had written they had administered people additional medicine they were not prescribed, to help them sleep as they were ‘unsettled’ or ‘agitated.’ We notified the local safeguarding team about our concerns relating to people’s medicines after the inspection.

Some people became distressed and could display behaviours that challenged. When people displayed new behaviours their care plans were not always updated and incidents were not analysed to look for potential triggers or ways of reducing their reoccurrence. We identified two incidents that were potential safeguarding issues and the registered manager had not sought advice from the local safeguarding team. We informed the local authority of these incidents after the inspection.

Staff had regular supervision and had received training in topics specific to people’s needs such as dementia and how to perform a ‘safe hold’ if people needed additional support. However, staff were not always clear about people’s needs or why they needed support. Information in people’s care plans was not always accurate or up to date so there was a risk people may receive inconsistent support. One person had received a skin tear when staff had physically intervened, and there was no information in their care plan about what to do if they became physically aggressive, or how to minimise the risk of this happening again.

There was a lack of guidance for staff to support people with their catheter care. Everyone was identified as requiring ‘encouragement with fluids’ and at ‘increased risk of urinary tract infections (UTIs)’ but staff were not consistently monitoring people’s fluid intake. Some people did have fluid charts in place, but a daily total of what people actually drank was not calculated so staff did not know how much people had drunk daily. There was no guidance about what action staff should take if people were not drinking enough. Two people were admitted to hospital and it was recorded they were ‘dehydrated’ on admission.

On the second day of the inspection, people did not receive the support they needed at lunchtime. Plate guards were not on people’s plates to support them to eat independently and people had to wait to have their food cut so they could eat it. One person sat in the lounge with their lunch in front of them and did not eat their meal. Staff told us, “They would have eaten if they were sitting at the table,” but no one offered the person assistance to move to sit elsewhere.

People’s health was monitored and when it was necessary, health care professionals were involved to make sure people were supported to remain as healthy as possible. However, when people’s health needs had changed, such as their medicines stopped, this was not always recorded and care plans and risk assessment had not been reviewed and updated to reflect these changes.

The physical environment was not always safe. Staff did not take water temperatures in people’s individual rooms. Water temperatures were too high and people were at risk of scalding. There was exposed electrical wiring in one bedroom and the registered manager told us they “Did not know if it was live.” The registered manager locked the door after we had raised this with them and the wiring was fixed on the second day of the inspection.

There was enough staff on shift to meet people’s needs. However, a volunteer who had not had all of the necessary recruitment checks was working unsupervised with people. Other staff were recruited safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there were any restrictions to their freedom and liberty, these had been agreed by the local authority as being required to protect the person from harm. DoLS applications had been made to the relevant supervisory body and renewed in line with guidance. Staff told us they understood the principles of The Mental Capacity 2005 and people were able to choose what they wore and where they spent their time in the service.

People took part in a range of activities during the inspection, including nail painting and arts and crafts. However, information about activities on offer was not displayed in a way that was meaningful to people. The registered manager and deputy manager said they would look into displaying this information pictorially.

Relatives told us that staff were kind and caring and people were relaxed in the company of staff. The registered manager told us there had been no complaints in the past year.

We found a number of 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 the report.

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 so 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.

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Hamilton’s Residential Home provides personal care and accommodation for up to 17 older people, some of whom may be living with dementia. The service is located on a main road in the surrounding area of Canterbury and is set over two floors. Everyone had their own bedrooms which were well decorated and personalised. At the time of the inspection there were 16 people living at the service.

The registered manager was leading the service on the day of the 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. The registered manager was supported by a deputy manager and both said they felt supported by the provider.

Staff were not always recruited safely. There were policies and procedures in place for the recruitment of staff however, they were not always being followed. Pre-employment checks were not always completed. The registered manager started to address this during the inspection. We have made a recommendation about this. There was an established staff team some of who had worked at the service for a number of years. There were enough staff on duty to respond to people’s needs. Staff had received training to help them carry out their duties and had regular support ad supervision from the registered manager.

Most medicines were managed safely however improvements were needed to ensure that creams were stored and recorded safely.

Some people were living with dementia and spent time relaxing in the lounge. A door to the lounge regularly banged shut and made people jump and appear anxious. We made a recommendation that the provider seeks advice and takes action to ensure that the environment is suitable for people living with dementia.

People told us they felt safe and looked after in the service. Safeguarding procedures were in place for staff to follow. Staff had completed safeguarding training and knew what action to take if they suspected abuse. The registered manager was confident in dealing with and reporting abuse to outside agencies like the local council safeguarding team.

People had individual care plans that reflected their care needs. People felt staff treated them as individuals and had a good understanding of their needs and how they wanted to be supported. Risks to people were identified and assessed. There was guidance in place for staff on how to care for people effectively and safely and keep risks to a minimum. People or their relatives were involved in writing their care plans. People received care that was responsive to their needs. People pursued their interests and hobbies. There was a range of activities on offer.

Accidents and incidents were recorded and monitored. The service had procedures for responding to emergencies like a loss of electricity or a flood. Safety checks were carried out regularly to ensure the building and equipment was safe.

The registered manager and staff had a good understanding of the Mental Capacity Act 2005 (MCA). When people could not make decisions for themselves the registered manager and staff followed the principles of the MCA and acted in people’s best interests. The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS were applied for in accordance with legal guidance.

People were supported to maintain healthy diets and were offered healthy and nutritious meals and regular drinks. People told us they liked the food. People were supported to attend health care appointments and staff worked with local doctors and district nurses to support people’s health needs.

People talked positively about staff referring to them as “caring” and “friendly. Caring relationships had developed and people were treated with dignity and compassion. When people could not communicate verbally, staff were able to understand what they wanted. People responded to staff with gestures and smiles, nodding and holding hands with staff who were offering them assistance. Staff respected people’s privacy and dignity and supported people to remain as independent as possible.

There was a complaints procedure in place and a copy was available to people and their relatives. There had not been any complaints in the last 12 months. The manager told us complaints were used for learning and improving.

People told us they thought the service was well led. People and their relatives were complimentary about staff and their behaviours towards their family members. The registered manager had experience of working with people living with dementia and showed dedication to working with people and the staff team.

Staff felt supported by the registered manager. The provider had introduced a reward system to recognise staff contributions. Staff said this made them feel valued. People could make comments through surveys and a comment box, although staff were not currently surveyed. Staff views were obtained through one to one and staff meetings. Action had been taken in response to people’s feedback. Staff carried out audits and checks of the service to identify shortfalls and monitor improvements.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. CQC check that appropriate action had been taken. The registered manager had submitted notifications to CQC in line with CQC guidelines.

We made two recommendations following this inspection.

We recommend that the provider reviews the recruitment information and checks for all staff to make sure their recruitment procedures have been followed.

We recommend that the provider seeks advice and takes action to ensure that the environment is suitable for people living with dementia.

We observed how staff interacted with people who used the service and found that people were approached in a respectful manner and saw that staff explained what was going to happen before engaging a person in any care activities.

We were told and we saw that staff meetings had taken place and that staff received regular supervision and training to enable them to fulfil their roles effectively.

We found that there were systems in place for auditing and checking the quality of service and that there was an ongoing improvement programme in place. The views needs and wishes of the people who used the service were included in how the service continued to develop. People's views and their needs and wishes were taken into consideration in the development and improvement of the service.

People's care plans and other documentation had recently been reviewed and we found that they were more person centred, up to date and stored correctly.

Most of the people who used the service had varying levels of dementia which made communication difficult for them. However, people who could, told us that they had no concerns around their care. One person who used the service said "Staff are very good. I have no concerns". A relative we spoke to told us 'I am happy with the care my relative gets but I do worry that there are not enough staff on duty'. Another relative told us, 'The care is good but staff do not have time to engage with people and there don't seem to be any activities'.

We observed how staff interacted with people who used the service and found that the care people received was adequate but we were not confident that that there were enough staff on duty to maintain and manage the standard of care.

Peoples care plans and other documentation were not up to date or stored correctly and we found that the provider did not have a process in place to take the needs of people using the service, and the skills and experience of staff into consideration when assessing the numbers of staff required to deliver the service. We found that the provider did not have robust processes in place to ensure that staff were supported to provide care and support that met people's needs in a safe way.There were no systems in place to check the quality of service.