About the service: Cale Green Nursing Home is a purpose built nursing home in the Cale Green area of Stockport. It provides personal and nursing care for up to 50 older people and people with physical disabilities. At the time of our inspection the service was supporting 33 people.

At the time of our inspection the home was in the process of being sold and the new owner was in the process of applying to become the registered provider.

People’s experience of using this service:

People and their relatives told us they felt safe and protected from abuse in the home. People said they knew the care team well and that staff understood their needs.

People were not always kept safe from environmental risks. Some doors which should have been locked to prevent people becoming trapped in rooms, or to keep people safe from harmful chemicals were left propped open. Some hot water outlets were not monitored to check whether the temperature of the water posed a scalding risk to people. Fire drills were not being performed in the home.

People’s care records were being re-written to ensure the person received support that was personal to them. We found the care records that had been completed reflected people’s needs well.

Checks were done on people before they started work in the home however we found that sometimes not all the appropriate checks were completed.

People enjoyed the food in the home and were given choices of meals. Where people didn’t like the choices alternatives were offered.

People, their relatives and staff told us the home had improved under the new management and found the management team approachable, open and honest.

The manager did not always have a clear oversight of the quality monitoring and health and safety requirements in the home.

Rating at last inspection: Requires Improvement 12 July 2018

Why we inspected: This was a planned inspection based on the rating of the service at the last inspection.

Follow up: We have asked the provider to let us know what action they will be taking to improve the service to at least ‘Good’. We will continue to monitor the service through information we receive and future inspections.

This inspection took place on 4 April 2018 and was unannounced. The inspection was prompted in part by notification of an incident. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident, however we did examine whether there were on-going risks to people living in the home.

At the time of our inspection the home had voluntarily suspended placements from the local authority. The local authority quality team had been working with the service to address some quality concerns relating to the levels of care within the home, particularly pressure area care. We did not ask the provider to complete a Provider Information Return (PIR) prior to the inspection.

Cale Green Nursing Home is a nursing home for up to 50 people. It is located in the Cale Green area of Stockport. Cale Green Nursing 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.

At this inspection we found the provider was in breach of three regulations of the Health and Social Care Act 2014. You can see the action we have told the provider to take at the end of this report.

People told us they felt safe and there were policies and procedures in place to protect people from abuse. This meant staff working in the home knew how to raise any concerns they had regarding the people living there.

During our inspection issues relating to the safety within the home were identified. Portable Appliance Testing (PAT) had expired, a scalding risk from a shower was present and two rooms posed a potential entrapment risk.

Sufficient levels of staff were on duty. Staff told us they received a good induction which gave them the skills they needed to provide care for the people living in the home. Some care worker training had expired and additional training that had been requested had not been provided.

People’s medicines were managed safely meaning people received the correct medication at the right time. Staff received appropriate training to allow them to support people with their medication safely.

People’s personal and cultural choices and preferences were respected and were included in the way their care and support was planned.

Care and support staff told us they felt well supported and received appropriate training to allow them to support people living in the home. Some care worker’s training had expired meaning their practice may not have been in line with current guidance and may have put people at risk.

People told us they were given a choice of meals and enjoyed the food. Drinks were always available. Where people living in the home needed support to eat or drink, staff helped them with this in a patient and caring manner.

People living in the home told us they felt they were treated with kindness and compassion. Staff demonstrated they knew the people well and treated them as individuals and listened to them.

People were involved in planning and reviewing their care and encouraged to remain as independent as possible.

An activities coordinator provided a range of activities and encouraged people to take part in them. Where people were unable or chose not to join in communal activities, one to one activities were arranged.

People nearing the end of their life were treated with dignity and their needs were kept under review. Training for staff to enable them to use a syringe driver could allow people to have care from people they know and help prevent people having to go to hospital or having visits from district nurses to provide care.

At the time of our inspection the registered manager of the home was leaving. The management structure of the home was being changed to try to provide more management oversight.

People were encouraged to express their views about the service, and actions tha

We carried out this inspection on 28 June and 3 July 2017 and the first day of the inspection was unannounced. The service was previously inspected in January 2016 and again in October 2016. The overall rating for the inspection conducted in January 2016 was 'Inadequate' and the service was placed into 'special measures'. Services placed in special measures will be inspected again in six months from the date of the final report being sent to the provider. We again inspected the service in October 2016 to see if the provider had become compliant with those breaches of regulations identified at the inspection in January 2016.

At the inspection carried out in October 2016 we found that overall rating for the service was 'Requires improvement', with the well-led domain being rated 'Inadequate'. We found that the service should remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any key domain over two consecutive comprehensive inspections. The purpose of special measures is to ensure the provider makes significant improvement to become compliant with the Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Cale Green Nursing Home is registered to provide 24 hour nursing care and support for up to 50 older people. The home is located in the Cale Green area of Stockport near Manchester.

At the time of our inspection, 21 people were living at Cale Green Nursing Home.

At the time of our inspection, a registered manager was in post. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection of the service in October 2016, two breaches of regulations were identified and action was required to address those breaches. The breaches related to poor management of medicines (Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Safe care and treatment, and, poor management of records (Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 Good governance.

At this inspection we found that the service had improved and regulatory requirements previously breached at the inspection conducted in October 2016 had been satisfactorily addressed.

People living in the home told us they were happy with their care and felt safe when staff were supporting them with care.

Staff had been recruited safely and staffing levels were maintained at an appropriate level to meet people's changing needs.

Care plans were person centred and included risk assessments that provided staff with clear instructions to follow when supporting people with their care needs. Care records showed they were reviewed on a regular basis and any changes were recorded.

We found the building to be clean and well maintained although some areas, such as corridors and some bathrooms and bedrooms were showing signs of wear and tear.

We observed care staff accessing and wearing protective equipment such as disposable gloves and aprons when supporting people with care related tasks. This helps to minimise the risk of cross infections.

Medicines were safely managed and were administered to people by nurses and trained care staff.

We found the service was meeting the legal requirements relating to Deprivation of Liberty Safeguards (DoLS).Staff understood how to support and help people to make day-to-day decisions and were also aware of their own responsibilities under the Mental Capacity Act (2005) and DoLS.

We saw that staff were receiving training appropriate to the jobs they are employed to carry out.

People's nutritional needs were assessed and appropriate support had been provided.

During our visit we saw people looked well cared for and we observed st

The inspection took place on 18 October 2016 and was unannounced.

The service was previously inspected on 12 and 13 January 2016, when breaches of legal requirements were found, at that time; we found the service was not meeting the regulations relating to mental capacity, medicine management, governance, staff recruitment, infection control, people’s dietary requirements and communication. We rated the service as inadequate and placed it into special measures. We asked the provider to submit an action plan to show how they intended to make the necessary improvements. On this inspection we found the provider was still in breach of two of the regulations. The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

We have made a recommendation to the provider in the report which included. We recommended to the provider completes morning and evening audits of care to ensure people receive their choices in relation to their care plans around getting up and going to bed.

When we visited the service there was no registered manager in place. The owner told us they had started the recruitment process to appoint a new manager to 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.

Cale Green Nursing Home is registered to provide 24 hour nursing care and support for up to 50 older people. The home is located in the Cale Green area of Stockport near Manchester.

At the time of our inspection there were 32 people living at Cale Green Nursing Home.

During our visit we saw people looked well cared for. We observed staff speaking in a caring and respectful manner to people who lived in the home. Staff demonstrated they knew people’s individual characters, likes and dislikes.

We found the service was meeting the legal requirements relating to Deprivation of Liberty Safeguards (DoLS). The service was meeting the requirements of the Mental Capacity Act 2005. Staff understood how to help people make day-to-day decisions and were aware of their responsibilities under the Mental Capacity Act (2005) and DoLS.

Appropriate arrangements were in place for the ordering, storage and disposal of medicines. We did find discrepancies in medicine management at the time of inspection. Medicines were administered to people by nursing and trained care staff at the time of inspection. However the home was still undergoing training for some nursing staff which was on going within the home. We spoke to the provider who showed us an action plan stating when these would be completed by all staff. The home was receiving support and guidance from an independent pharmacy to support improvements in relation to medicines management.

We spoke with staff who told us about the action they would take if they suspected someone was at risk of abuse. We found this was consistent with the guidance within the safeguarding policy and procedure in place at the home.

We spoke to some staff who had not received regular supervisions. The provider had completed an audit on staff files and completed an action plan to ensure all staff receive supervisions in line with the policy.

People told us the food at the home was good and they had enough to eat and drink. We observed lunch being served to people and saw people were given sufficient amounts of food to meet their nutritional needs. However, we did not feel people received a social experience around meal times

At the time of the inspection there were 33 people living at Cale Green Nursing Home. Our inspection team was made up of three inspectors who considered the evidence collected under five outcomes and addressed the following question; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service safe?

People living at Cale Green Nursing Home had an individual care file that included risk assessments and a care plan that described how to meet people’s individual care needs.

A visiting relative told us that they were pleased with the care their relative received. They also told us they had never seen or heard anything that would cause them concern. One relative said “I think [her relative] is well looked after and seems happy and settled.”

The provider had infection control policies and procedures in place with specific guidelines for staff to follow. We found that the provider had effective systems in place to maintain appropriate cleanliness levels within the home and restrict the spread of infection.

Since the last inspection visit on 6 March 2014 we found that improvements had been made to address the shortfalls associated with insufficient staffing levels. We noted the staffing levels recorded on the rota matched the number of staff on duty seen during our visit.

From the day and night rota that we looked at we saw there was enough staff to meet the needs of people who lived at the home. We saw that safe staffing levels were managed on a daily basis and consideration was given to people's level of dependency in the home.

These improvements helped to make sure people were safe and their health and safety needs were met by sufficient numbers of appropriate staff.

Is the service effective?

Staff told us told us that the staff team all worked well together and provided a high standard of care.

Since the last inspection visit we saw that a part time activity coordinator had been employed. They were able to describe the activities that were being provided in consultation with the people living at Cale Green Nursing Home. Some activities included trips out to the park and local shops, reminisce groups, board games and quizzes, birthday and a 50th wedding anniversary party. We saw that a clothing sale party had been arranged for later in August 2014 and we were told that exercise activities were due to start the week following this inspection visit.

During this inspection we spoke with a visiting health care professional who told us they didn’t have any concerns regarding the care delivered by staff. They said that the staff were helpful and knowledgeable about the needs of people living at Cale Green Nursing Home.

We saw the manager had introduced a new recording system and staff had received additional training in the recording of falls and accidents. This meant the service learned from incidents and responded effectively.

Is the service caring?

The atmosphere in the home felt relaxed and friendly. From our observations we saw that care staff had a good understanding of people's individual needs and personalities. We saw that staff were kind and sensitive in their approach to people.

We observed that people looked well cared for and were appropriately dressed. One gentleman did not look like he had had a shave but when we spoke with him he told us that he hadn’t wanted one.

All of the people we spoke with who were living at the home indicated that they were happy and had everything they needed. Comments included: “Its home from home here, you can do whatever you want,” “The food is very nice and there is always a choice” and “They [the staff] are very very good, in fact they are excellent".

Is the service responsive?

We saw that where appropriate the service had accessed advice and care from other health care professionals. For example we saw evidence of visits from the GP, the speech and language therapist and the district nurse. This meant the provider sought relevant professional advice and guidance appropriately.

People were made aware of the complaints system. A copy of the complaints policy was displayed in the home and was presented to people in a format they would understand. Records of complaints we saw had been effectively resolved in a timely way.

Is the service well-led?

Since the last inspection on 6 March the provider had recruited a new home manager and regional manager to help make sure those systems and procedures would be followed by the staff team.

The provider had clear objectives for both managers who had a lead role with regard to planned service developments, workforce changes, staff training, planned absences and changes in legislation.

The registered manager was described by staff as approachable and supportive. One member of staff told us “The staff are all coming together now and the atmosphere is much better.” Another member of staff “It’s very good here, it’s like a big family, everybody is very nice.”

We saw customer surveys were sent out every six months to people who used the service and their representative. The survey was in a format that people could understand. We reviewed responses from the latest survey. Comments included, "I am happy with my care” and “I like the comfort, safety and companionship at the home.”

We carried out a responsive inspection on 6th March 2014 because we had received some information of concern about the service from the Stockport Health Protection Agency (HPA).

We spoke with four people who used the service and two relatives. We spoke with the provider, the general manager, one registered nurse, two care workers and one domestic worker.

The home manager told us that 21 people were currently being cared for in bed due to their physical condition and 23 people were receiving nursing care.

We saw that some care plans had not been reviewed and updated as needed on a regular basis.

We looked at health and safety records and noted there were potential infection control risks.

We saw that people’s dependency levels had been calculated inaccurately and did not correspond with peoples identified needs as recorded in their care plans.

We looked at the staffing needs analysis which did not clearly show that there were enough nurses for people to expect a consistency of care.

We saw that some records required to be kept to protect people’s safety and wellbeing were not properly maintained and fit for purpose.

We spoke with five people who lived at the home. One person spoken with told us they were happy with the care and support they received at the home. They told us, “They’re good to us here”. We saw staff treating people kindly and in a respectful manner.

We looked at the care plans of six people who used the service. We noted that the care plans had been updated to include more detail about their needs.

We found four people who had mental health needs were being supported by staff who had not received mental health awareness training.

Five people spoken with told us they were provided with enough food and drinks throughout the day and night. However we had some concerns that people were not receiving the correct consistency of food when they had been assessed as having a swallowing impairment. This meant that people were at risk of unsafe care due to aspiration or choking.

We looked around the building and found there were still shortfalls in relation to the maintenance of the premises. However we found the provider had made significant improvements to some of the equipment used at the home.

We saw improvements had been made to care records and new auditing systems had been implemented to ensure these records were accurately maintained.

During this inspection we spoke with seven people who lived at the home, three visitors, six members of staff and the registered manager. We also talked to Stockport Social Services Quality Assurance team as part of our inspection process.

People we spoke with told us that they were happy and had no complaints. Some of the comments we received were: “The food is good, can’t grumble,” “I can’t really complain about anything,” “I am very happy here” and “I am happy with the way they (the staff) treat me.”

We spoke with three visitors to the home all of whom were complimentary about the care their relative received. We were told that the level of care was good and the staff were: “Very nice and respectful.” One person said: “They have been a Godsend, they really look after him well.”

During this inspection we did have some concerns about the lack of detail in people’s care plans. This meant that people living at the home might not be protected from receiving unsafe or inappropriate care.

We had concerns about the safety and availability of some of the equipment. This meant that some people may not benefit from equipment that meets their needs.

Staff told us that training was good at Cale Green Nursing Home. However, a number of staff told us that morale was: “Very low and they did not feel valued.” We were told that the staff provided a high standard of care but they did not feel they received any acknowledgment for the work they do.

During our visit we looked at the care plans of three people living at the home and relevant provider records and monitoring processes. We also spoke with the home manager. The records and documentation we reviewed and information provided by the manager assured us appropriate steps had been taken to ensure people were protected from the risks of unsafe or inappropriate care and treatment.

Two compliance inspectors visited Cale Green Nursing home on 27 June 2012. We were unable to gain access to all necessary documents and records therefore one compliance inspector returned to the home on 28 June 2012.

We spoke with some of the people living at Cale Green Nursing Home, a visiting relative and some of the staff who worked there. People we spoke with told us they were happy with their care, they were respected and felt safe and well cared for.

People told us they liked the food and they were always given a choice.

The visiting relative said the home was “alright” and staff were “really pleasant.”

Staff told us that they encouraged people to have choice around their day to day lives and they respected people’s privacy and dignity.

We did not speak with the people who lived there about this outcome.Our findings were based on interviews with staff, the manager, viewing of records and observations and checks made throughout the home.

Staff spoken with told us:

Food often runs out. Especially at weekends.

The needs of those people who are vegetarian and diabetic were not being catered for.

There was no hot water available after some people have had their baths in the mornings and some people have to wait until the afternoons when the water has re heated.

The boiler was not big enough for the size of the home.

Staff told us that there was a lack of light bulbs to replace those that had failed.

Staff told us that equipment was broken and unsuitable to meet the needs of the people who used them.

Staff told us that there was a limited budget to pay for repairs.

People told us that there is always a good atmosphere and a nice welcome to the home.

People told us the staff ask every day what they wish to have for their meals.

People told us that there are never any issues with food and alternatives are available.

People also told us sometimes they run out of bread and coffee.

People told us that the staff are always very polite.

People told us that the staff always help them with their personal care in a dignified and respectful manner.

People told us that they get on well with the staff and the management are approachable.

People told us that if they made a complaint they are confident that they would be listened to.

Relatives told us that the staff work very hard and are very good.

Relatives told us that they are very happy with the care.

People told us some staff were "very good" and they were treated with respect but some people said staff did not always understand their needs or did not fully listen to them. One person said staff had insisted that she went to bed at 3pm against her wishes.

Most people we spoke to did not think there were enough staff on duty at all times to properly care for everyone. One person said staff went away on other jobs and didn't return. Another person said she had to go to bed before the night staff came on duty, when she would prefer to go to bed later and she could not choose what time she got up in the mornings. Several people told us about the need to "see it from the staff point of view" and said they tried to fit in with the staff because they were short staffed.

One person told us he loved living at the home and felt highly valued as he helped with arranging and carrying out social activities and events.

People said that if they were not well staff were quick to get their GP and appointments with their dentists and opticians etc were made for them.

Everyone we spoke to thought the food provided at the home was good.

One person said the home was very clean and hygiene was well maintained.

Everyone knew who the manager was and told us she was approachable and friendly. No one could remember any recent resident meetings or being asked to give their views about the home in any other format, such as by survey, but everyone said they could speak to the manager if they had a problem and felt she would deal with it. One person said "Overall I would score the home 8/10 – they just need to listen to people at bit more".

This inspection took place on 12 and 13 January 2016. Our visit on the 12 January was unannounced.

The service was previously inspected on 27 and 28 April 2015, when breaches of legal requirements were found.

When we visited the service there was a Registered manager 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.

Cale Green Nursing Home is a nursing and residential home that is registered to provide care and support for up to 50 older people. The home is located in the Cale Green area of Stockport near Manchester.

At the time of our visit 44 people were living at Cale Green Nursing Home.

The Care Quality Commission (CQC) carried out a comprehensive inspection at the location on 27 and 28 April 2015. At the time of the inspection we identified breaches of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Person centred care, Safe care and treatment, Safeguarding people from abuse and improper treatment, Premises and equipment, Staffing, Fit and proper persons employed and Duty of candour. As a result the Care Quality Commission gave the provider an overall ‘Inadequate’ rating and the location was placed into 'Special Measures'.

The purpose of special measures is to ensure the provider makes significant improvement to become compliant with the Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made and provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. Following our adult social care inspection methodology, services placed in special measures will be inspected again in six months from the date of the final report being sent to the provider.

We issued the provider with compliance actions to address the regulatory breaches. We also served two Warning Notices to the provider to address breaches in Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed. Warning notices notify a registered person that we consider they are not meeting a condition of registration, a requirement of the Health and Social Care Act 2008, a regulation, or any other legal requirement that we think is relevant. Compliance actions can be a precursor to enforcement action.

We gave the provider a clear timeframe within which to improve the quality of care they provide and we inspected the service again in January 2016 within six months of publishing the April 2015 final inspection report.

In May 2015 the Care Quality Commission received an application to cancel the manager’s registration and the current manager became registered with the CQC in September 2015.

At this inspection we found eleven breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, management of medicines safeguarding people from abuse, meeting nutritional and hydration needs, premises and equipment, staffing, safe care and treatment, and good governance. We are currently considering our options in relation to enforcement. We will update the section at the back of this report once any enforcement action has been concluded.

Not all care plans were written in a person centred way, were not responsive to people’s needs and did not include the relevant health and safety concerns relating to their care and treatment. This placed people at risk of receiving unsafe or inappropriate care and exposed them to the risk of actual harm.

Two people, one of whom was nearing the end of life and receiving palliative care, had been provided with shared bedroom accommodation. There was no evidence of a best interests process having been followed in relation to the continued appropriateness of shared accommodation for either person. This indicated a lack of consideration of these people's dignity. 

We saw that 16 people were offered treatment in "Kirton" chairs. there were no written records in place to show that the service had considered the person's consent to the use of the chair, sought the assessment of a physiotherapist, or considered other less restrictive options.

There was an overall lack of recorded risk assessments about the health, safety and welfare of people using the service. Where risk assessments were in place the instructions needed further clarity, so staff could make sure people received personalised care to meet their individual needs.

We looked at the systems in place to manage medicines in the home. Records in relation to the storage, administration, management, recording and disposal of medication showed medicines were not being managed safely.

People using the service were at risk of cross infection because we saw staff barrier nursing a person without wearing appropriate protective clothing such as disposable gloves and aprons that would help to prevent cross infection.

Following the inspection the CQC made two safeguarding referrals to the local authority adult safeguarding team. The first referral was for a person at very high risk of their skin integrity being compromised. This person’s skin integrity care plan had not been completed and was blank. The second referral related to potential risks associated with a person’s diabetes and the lack of safe care and treatment provided in relation to the person’s diabetic care and monitoring. Following our inspection, the provider informed us that on review of the referrals no further action was taken by the local safeguarding team.

Systems in place to regularly clean the kitchen were not being followed and despite there being a cleaning schedule outlining the method of cleaning for each item of equipment in the kitchen. We found the cleanliness of the kitchen was below the required standard. This exposed people to the risk of becoming ill from eating contaminated food prepared in a kitchen which presented a health risk to people. Two days after our inspection the local authority inspected and awarded the kitchen 5 stars.

Cleaning products were not stored safely and were stored in an unlocked store cupboard on the ground floor of the home. In several instances the storage cupboard door was left wide open.

A cracked window pane in the ground floor dining room was temporarily covered using gaff tape and had not been replaced following our last inspection at the location in April 2015. A further window in the dining room had no window restrictor, restricting how far the window could open, to prevent people from falling from the window.

Some policies and procedures in place did not ensure compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Registered manager was not aware of relevant nationally recognised guidance or quality and safety standards that had changed over time. This meant care; treatment and support did not always meet current best practice.

The staff recruitment and selection policy and procedure in place were not followed to make sure that a registered nurse was suitably skilled and experienced with the necessary clinical competencies to look after people within the home.

People told us that they felt safe in the home and staff knew how to protect people from the risk of abuse.

Not all people’s privacy and dignity were respected by staff despite staff members having received training in this topic.

We saw there were good relationships between individual staff and people who used the service and we saw that care was provided with kindness.

Where they were able to tell us about their experiences people who used the service told us staff were kind and caring. They told us they would feel able to raise any concerns they might have with staff or the Registered manager.