About the service: Highfield Residential Care Home is a residential home that is registered to provide accommodation and personal care to a maximum of 20 people over the age of 65. At the time of inspection 18 people aged 65 and over were living in the home. On the third day of inspection there were 16 people living in the home.

People’s experience of using this service:

• People did not receive a service that provided them with safe, effective, compassionate and high quality care.

• Individual risks to people were not managed and mitigated including risks posed to people by the environment.

• There were not sufficient staff to meet people’s needs or keep them safe.

• People’s human rights were not always upheld as the principles of the Mental Capacity Act (2005) were not adhered to.

• People were not always supported to eat and drink enough to maintain a balanced diet.

• Peoples needs were not holistically assessed to ensure that staff were able to provide the care that people needed.

• People were not always treated with privacy and respect.

• The service was not well led and the provider did not have systems and processes in place to monitor the quality of the care that people received. There had been a consistent failure to improve and ensure care was delivered within the legal regulations of the Health and Social Care Act.

Rating at last inspection: At the previous two inspections in May 2018 and August 2017 the service was rated inadequate and placed into special measures. We identified breaches of regulations 9, 10, 11, 12, 17, 18 and 20A. At this inspection, we found that the necessary improvements had not been made. The service had six repeated breaches and a new breach of regulation 19.

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Enforcement: Following the inspection in August 2017, we imposed conditions on the provider's registration because they failed to make the required improvements in relation to three of the regulations. These included regulations for safe care and treatment, meeting nutritional and hydration needs and good governance. The condition required the provider to submit monthly reports to the CQC in relation to risks to the environment, risks to individuals and review accidents and incidents. The provider sent us monthly reports, however these reports did not include detail of actions taken to address and mitigate risks both to individuals and in the environment.

Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Highfield is a ‘care home’. People in care homes receive accommodation and 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. Highfield accommodates up to 20 people, some of whom may be living with dementia, in one adapted building. At the time of our comprehensive unannounced inspection on 15,17 and 21 May 2018 there were 16 people living in the home.

There was a registered manager 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 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 also the provider. For the purposes of this report they have been referred to as the provider.

We had previously inspected the service on 9 and 10 August 2017. We found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of seven regulations including person-centred care, dignity and respect, need for consent, staffing, safe care and treatment, meeting nutritional and hydration needs and good governance. The overall rating for the service was inadequate.

Following our previous inspection in August 2017, the provider sent us an action plan stating that they would make improvements by 30 November 2017. In addition to this, we issued a Notice of Proposal to impose conditions on the provider’s registration because they had failed to make any improvements in relation to three of the regulations. These included safe care and treatment, meeting nutritional and hydration needs and good governance. As a result, the provider was required to send us a range of monthly monitoring reports.

During this inspection, we found that the provider was in breach of seven regulations. You can see what action we told the provider to take at the back of the full version of this report.

The provider had failed to comply with a number of the regulations as required under the HSCA 2008 (Regulated Activities) Regulations 2014. In addition, the provider had consistently failed to sustain improvements where breaches of regulations had been identified during previous inspections.

The provider was still in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risks within the environment were not managed and mitigated. Individual risks to people were not appropriately assessed and managed. Accidents and incidents were not recorded appropriately and staff did not always complete follow up actions after an accident. People’s medicines were not managed in a safe way and staffs’ competency in this area was not regularly assessed.

There were not sufficient numbers of staff to support people in a safe way that met their care and support needs. Therefore, the provider was still in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s dignity was not always upheld and people told us that staff did not always treat them in a caring manner. Therefore, the provider was still in breach regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Where people lacked the mental capacity to make a specific decision, the provider had not made sufficient improvements to act in accordance with the requirements of the Mental Capacity Act 2005. Decisions which needed to be made in people’s best interests were not documented. Therefore, the provider was still in breach regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s care plans and risk assessments were not detailed and gave conflicting advice a

The inspection took place on 9 and 10 August 2017 and was unannounced.

Highfield Residential Care Home provides accommodation for up to 20 people, many of whom are living with dementia. At the time of our inspection 18 people were living in the home.

The registered manager had been in post since January 2012. A registered manager is a person who has registered with the Care Quality Commission to manage the service. The registered manager is also the nominated individual. A nominated individual is someone who acts on behalf of the provider. 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.

We had previously inspected this service on 12 October 2016. We found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of four regulations including dignity and respect, safe care and treatment, good governance and requirement to display performance assessments.

Following our previous inspection in October 2016, the provider sent us an action plan stating that they would make the required improvements by 30 June 2017.

At this inspection we found that the provider had taken action to meet the requirement of displaying their performance assessment and were therefore no longer in breach of this regulation. However, we still had concerns relating to the safe care and treatment of people, how people were cared for and the governance of the service. The provider had not taken the necessary actions to meet the requirements. We also found that the provider was in breach of four further regulations during our most recent inspection.

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.

The service was not safe. Individual risks to people had not been identified or managed in a safe way. This was because advice given by relevant healthcare professionals was not used to inform risks assessments. People’s risk assessments were not reviewed regularly and assessments to determine people’s risk of pressure ulcers and malnutrition were not carried out frequently. Where people were at risk of developing a pressure ulcer, they were not always repositioned frequently enough to minimise the risk of developing a pressure ulcer.

We found that the provider was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people’s level of dependency was not assessed and therefore staffing levels were not calculated to support people in the safest way possible.

Risks to the environment were not managed appropriately. There was a lack of monitoring around fire safety, electrical safety and the risk of legionella was not mitigated. Health and safety audits failed to identify these risks and were therefore ineffective.

People’s medicines were not managed or administered in a safe way. People did not always receive their medicines as prescribed and topical creams and thickener for drinks were not kept secure. Whilst staff had received the necessary training in administering people’s insulin, people were not referred for a diabetic review when their blood sugars became unstable. This meant that the provider was still in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that the provider was in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as they did not act in accordance with the Mental Capacity Act 2005. Assessments of people’s mental capacity had not been carried out and best interests decisions made for people were not documented.

People were not consistently offered choice about their c

The inspection took place on 12 October 2016 and was unannounced.

Highfield Residential Care Home provides accommodation for up to 20 people, many of whom would be living with dementia. At the time of our inspection 13 people were living in the home.

The manager has been in post since January 2012. 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.

We had previously inspected this service on 23 and 24 April 2015. We did not find any breaches of the regulations but we did find a number of concerns which we asked the manager to address. We looked at these concerns throughout out most recent inspection to see if the manager had made improvements as a result.

We found that there was a clear lack of visible leadership in the home. Staff were unsure of who was responsible for the managerial tasks when the manager was not present. People who lived in the home did not know who the manager was. Whilst staff felt supported by the manager, they did not feel that the manager acted on their concerns. The manager asked for staff feedback but did not address any of the issues that staff raised.

We found a breach of the regulations as there was a lack of robust systems in place to routinely monitor and assess the quality of the service being delivered. There was no auditing to ensure that necessary health and safety checks were being carried out regularly and people’s care records were not audited. The few audits that had been carried out had not been carried out objectively by an independent quality assurance system as stated on the service’s website and had not identified the issues highlighted in this report. The latest rating was also not displayed on the service’s website. This constituted a further breach of the regulations.

There were a number of areas of the service that were not safe and our findings constituted a breach of the regulations relating to the safe administration of medicines. People’s medicines were not always managed or administered safely. People were not always given their medicines as prescribed and there was no regular auditing of medicines. Staffs’ competency in this area was not assessed.

Whilst people we spoke with felt safe living in the home, risks to people had not been identified and steps had not always been taken to mitigate risks to people’s personal safety and wellbeing. There were insufficient numbers of staff to adequately meet people’s needs and attend to the day to day running of the service. People who were at risk of pressure ulcers were not repositioned as frequently as they should have been.

Safe recruitment procedures were not always followed.

People’s care plans and risk assessments were not regularly reviewed and updated to reflect people’s most current support needs and staff had difficulty in accessing them. People’s care records were generic and did not detail people’s individual care needs.

Another breach of the regulations was found as people were not always treated with dignity and their privacy was not consistently respected. Confidential information about people was spoken about openly. People’s needs were not met in an individualised way. There was limited interaction between staff and the people who lived in the home, and there was a lack of activities for people to take part in.

Staff did not always receive training that was relevant to their role, including the provision of end of life care. New members of staff do not always receive an induction and training was not always updated.

People were not consulted about the food they ate and did not know in advance what they were being served. People told us that they enjoyed the food. People who were at risk of malnutrition did not have regu

We recently received information of concern from relatives about the comfort, safety and welfare of people living in the home. We responded to this information by undertaking an unannounced responsive inspection.

Two inspectors for adult social care carried out this this inspection. The focus of the inspection was to answer five key questions: Is the service safe, effective, caring, responsive and well-led?

Although registered for 20 people, there were only 16 people living in the home at the time of this inspection. We arrived at the home at 8.45am and undertook a complete tour of the premises. During this time we met all the people living in the home and observed staff interactions.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you wish to see further evidence supporting our summary please read the full report.

Is the service safe?

From the records we looked at, we saw that each person had received an initial needs assessment and that care was planned to meet each person’s individual needs.

We observed people’s body language and did not see any signs of discomfort. We saw appropriate moving and handling methods when we observed staff assisting people to stand or mobilise.

We spoke with a community nurse who was visiting one of the people living in the home. The nurse told us that there had been some concerns and issues in the past but they said that they felt the quality of care provided by the staff had improved recently, particularly with regard to pressure care.

However, during this inspection we identified concerns with regard to inconsistent, insufficient and ineffective record keeping. This meant that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not being maintained.

Is the service effective?

We recently received some concerns from people’s relatives regarding the staffing levels in the home. One relative told us that, although the staff were very caring, there were not always enough of them to ensure people’s needs were attended to, when needed.

At the time of this inspection there were sufficient numbers of staff on duty to carry out care and domestic duties. However, we noted that these levels were not consistent and were frequently not sufficient to effectively support people with all of their daily living requirements.

Is the service caring?

All the staff interactions we observed and overheard during this inspection, were kind, engaging and supportive and we saw that the people living in the home were relaxed in the presence of the staff. Throughout the duration of our inspection we saw that staff consistently treated people with dignity and respect.

Our observations during this inspection showed a number of examples of good practice and assured us that people were being supported by staff who genuinely cared about their comfort, safety and wellbeing.

Is the service responsive?

Where possible, people were supported in promoting their independence. We saw two people accessing the outside courtyards when they chose. One person was tidying the garden borders, while another assisted with preparing for the lunch period.

We were concerned that, although people’s care plans included information regarding people’s needs and preferences in respect of bathing, showering and hair washing, people’s needs were not being met consistently.

We were also concerned that insufficient staffing levels meant that the service could not consistently respond to people’s needs in a timely fashion.

Is the service well led?

It is a CQC requirement that the registered manager is in day to day control with regard to running the service. However, we identified that the registered manager was only attending the home on two or three occasions per month and lived a considerable distance away from the service.

This meant that the home was being run on a day to day basis by either the deputy manager or senior staff and not managed efficiently or appropriately.

As a result of this inspection, we identified a number of concerns regarding the lack of effective systems to assess and monitor the service and ensure that people were protected against the risks of inappropriate or unsafe care and support.

With regard to ensuring the maintenance and suitability of the premises, we noted that where issues had been identified, remedial action was not always being taken in a timely fashion.

Relatives told us that where they had raised concerns, they did not feel they were listened to and that they did not receive appropriate responses to their issues or complaints.

A single inspector carried out this inspection. The purpose of this inspection was to follow up the areas of concern we identified during our previous inspection on 7 May 2014 regarding the provider's reporting procedure, particularly in respect of allegations of abuse.

As part of this inspection we spoke with the provider and the deputy manager and looked at some of the records relating to staff training and employment.

We focussed on two of the key questions that were relevant to this inspection: Is the service safe? And, is the service well led?

This is a summary of our findings. If you would like to see further evidence supporting this summary, please read the full report.

Is the service safe?

A discussion with the provider and deputy manager, and records looked at, assured us that the provider was aware of their legal obligation to report notifiable events to CQC in accordance with the Health and Social Care Act 2008.

Since our previous inspection, CQC had continued to receive information and notifications in respect of any expected or unexpected deaths and Deprivation of Liberty Safeguard (DoLS) applications.

Following this inspection, the provider assured us that they would issue all the staff with key point hand-outs, as a means of ‘refresher training’ in safeguarding and understanding what constituted abuse.

This meant that people who used the service were protected from the risk of abuse because the provider took reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Is the service well led?

During this inspection we reviewed some information that related to a more recent allegation of abuse and found that the provider had responded appropriately to this.

We also saw evidence that the provider had more appropriately identified, assessed and managed certain risks relating to the health, welfare and safety of people living in the home. For example, since our inspection on 7 May 2014, the provider had appropriately investigated the conduct of another person employed in the home, following an allegation of misconduct.

We recently received information of concern about the safety and welfare of people living in the home from two anonymous sources. We responded to this information by bringing forward the date of the home’s scheduled inspection.

We reviewed the evidence we obtained during our inspection and used this to answer our five key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see further evidence supporting this summary please read the full report.

Is the service safe?

There were detailed risk assessments in place that covered most aspects of people’s daily lives and each of these had been completed specifically for the individual they referred to. The risk assessments we looked at were all up to date and had been regularly reviewed.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The registered manager advised us that one person living in Highfield Residential Care Home was currently subject to a restriction, as defined by the provider's Deprivation of Liberty Safeguards (DoLS) policy document, dated 2009.

We saw that an appropriate DoLS application had been made, which assured us that that relevant staff had been trained to understand when an application should be made, and how to submit one.

The provider had consistently notified CQC in respect of expected or unexpected deaths, accidents such as falls or injuries and Deprivation of Liberty Safeguard (DoLS) applications.

However, we identified three separate issues that had occurred in March 2014 but had not been reported to the Norfolk Safeguarding Team and CQC.

This meant that people who used the service were not fully protected from the risk of abuse because the provider did not always take reasonable steps to identify the possibility of abuse and prevent abuse from happening.

Is the service effective?

In the care plans we looked at, we saw that people had been assessed appropriately in respect of their mental capacity. We saw that where people were unable to make certain decisions for themselves, these had been made in their ‘best interests’ with the involvement of appropriate people such as their next of kin or representative.

Discussions held with the deputy manager and senior staff, plus records seen in daily reports and people’s care records, identified those people who were at risk of falls. Risk assessments and guidance for staff on how to manage these identified risks were seen to be in place.

Is the service caring?

We did not have any concerns regarding the level of care that was being delivered by staff to people living in the home during this inspection. We observed that the staff were knowledgeable of people’s needs and consistently interacted with people in a warm and friendly manner. We also observed some people engaging in friendly banter with staff and having a ‘laugh and a joke’.

Observations, discussions and the care records we looked at provided a number of examples of good practice in a genuinely caring environment.

For people who were reliant on assistance to move from one place to another, we observed staff regularly interacting, checking if they were ‘alright’ and asking what they wanted to do or where they would like to be. For example, we heard one member of staff asking a person in their room if they would like to come through to the lounge. The person responded, “No, I’m quite happy here thank you”. Later in the day we heard another person say, “I’d like to go back to my room now.” In both instances we observed that the staff responded appropriately and respected each person’s wishes.

Some of the comments and responses we received from people included: “They’re (staff) all very good here.” “Marvellous dear, I couldn’t wish for better.” And, “Everybody’s very kind – I’m very well looked after thank you.”

Is the service responsive?

We spoke privately with the senior on duty, who gave us a full description of each person living in the home and their current needs. People’s care records, observations and discussions with the deputy manager throughout the day, showed that the staff had good knowledge of people’s needs.

For three people who required intensive care and support, we saw that all the records had been completed appropriately. For example, the records showed that people were consistently being assisted to change positions in bed, either two hourly or three hourly, depending on their identified need. This was to ensure pressure areas were relieved and reduce the risk of pressure sores developing.

We looked at the notes completed by the night staff between 10pm and 8am and saw regular interactions had taken place with people as required. For example, responding to people’s call bells, assisting people to go to the toilet, providing personal care and turning people, as needed, to relieve pressure areas.

Is the service well led?

The provider delivered some in-house training for staff in areas such as infection control, safeguarding, dementia awareness, health and safety and the theoretical aspects of fire safety. They confirmed that the practical aspects of fire safety training were delivered by Norfolk Fire Service. Other mandatory training for areas such as first aid, moving and handling and medication was also delivered by appropriate external professionals.

Four members of staff said that they regularly received one-to-one support with their manager and felt well supported. They also said they were happy in in their work, felt confident and knew each of the people well that they supported. All four staff stated that they felt they received appropriate training for the work they carried out.

However, during this inspection, we identified concerns with regard to the provider's lack of action taken in respect of allegations of abuse. The provider had not responded appropriately to a recent allegation of abuse and they had failed to appropriately investigate the conduct of a person employed in the home, following an allegation of misconduct.

We conducted this inspection to follow up concerns identified at our previous inspection carried out on 04 July 2013. These concerns related to the administration and storage of medication and several issues relating to the upkeep of the premises.

Following our July 2013 inspection we required that the provider send us an improvement action plan, which was received. This told us what steps would be taken to remedy the issues identified.

During this inspection we spoke with the deputy manager who showed us around the premises room by room. We found that improvements had been made. The medication cabinets in people’s rooms containing creams were locked and cream administration charts were being completed.

Improvements had also been made in relation to the premises. For example, all rooms, with the exception of one, had new curtains or blinds fitted. Several carpets had been replaced. We spot checked several beds and did not find any worn bed linen. We noted a few issues requiring attention that we discussed with the deputy manager.

On our visit to Highfield Residential Care Home we were told by one person, "The staff are nice and kind and we have a laugh." Another person said, "They look after me well". People were occupied by walking around the premises, completing Sudoku puzzles, looking at books or watching the television.

We looked at some care plans that gave us an individual picture of people's needs. They had been reviewed regularly and risks had been acted on appropriately.

The midday meal was observed. We noted that people were supported suitably to eat their meal and that the food was offered with choice and enjoyed. Drinks were encouraged and staff were aware of those not drinking enough. Records were held of what was eaten and people were weighed each month that showed us people were maintaining their weight.

Medication procedures, when using the blister packs was managed safely however we found some medication management was not carried out correctly. Prescribed creams were not recorded as and when applied and medication cabinets within bedrooms were permanently locked so creams were left out making them easily accessible and unsafe.

The home environment was cluttered and potential hazards were noted. Bedrooms were clean but carpets, furniture and fixings were in a poor state of repair making them unsuitable.

During this follow up inspection visit we looked specifically at the concerns raised at the inspection of August 2012 that made four outcome areas non compliant. We had received an action plan from the provider addressing the areas of concern and the action taken to improve the service.

We found that during this visit people were addressed and offered care and support that was respectful and dignified. Staff were courteous, people were dressed in suitable clean clothing and choices were offered to allow preferences.

Although care plans were still to be rewritten and information made relevant to each person we found the care and support was suitable and appropriate and safe care was being offered to people who lived in the home.

Staff training had been improved upon with a number of planned training sessions attended since the August inspection. Where there was a shortfall in the training the provider had already booked further sessions to take place during 2013.

The concerns highlighted in the August report regarding the monitoring and auditing of the care and support provided had been acted upon. Staff had been designated areas of responsibility, checks we were told would be made by the provider and action taken to improve any concerns. Questionnaires on the quality of the service had been sent to relevant people for their opinions.

We spoke with one person who used the service and two visitors in private. We also spoke with several other people when observing care in the communal areas. One person said that they felt staffing levels were not always “sufficient to fully meet people needs”. They said that at times they had not been able to find a member of staff when needed. However, they also said that staff did the very best they could but they “were very busy”. One person said that their relative had their medical needs attended to promptly. Another said that people were well cared for. One person using the service told us that staff supported them with their needs and they always felt “well cared for”. A visitor told us that the manager is “very hands on”. Another visitor said that they thought the manager was often counted as a member of staff on shift.

People we spoke with also told us that staff were “very good”. They said that staff treated them with respect and promoted their dignity. We also spoke with two visitors who said that staff always did their “very best to care for people”. We asked people about how they were involved in the planning and how their care was delivered. One person told us that they were supported to make their own decisions about their care and what they would like to be helped with. One relative told us that they had not been involved in the planning of care for their relative who had dementia.

This inspection took place on 23 and 24 April 2015 and was unannounced.

Highfield Residential Care Home provides care and accommodation for up to 20 older people, some of whom may be living with dementia. At the time of our inspection there were 15 people living in the home.

There is a registered manager 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 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 is also the Nominated Individual and a director of the company and will be referred to as the registered manager throughout this report.

The registered manager relied upon the deputy manager to help ensure the effective operation of the service on a day to day basis. However, the deputy manager’s ability to do this consistently was compromised, particularly when needing to cover care shifts.

There had been improvements to the number of staff members available during the early shifts and there were usually enough staff available to meet people’s needs during this time. However, the registered manager calculated the staffing levels on the numbers of people using the service and not on their specific needs. For this reason we recommend that they refer to the current good practice guidance about how to ensure that staffing levels are appropriate and based on the assessments of people’s dependency.

Staff understood what constituted abuse and were confident with regard to following the correct reporting procedure. Appropriate recruitment procedures were followed, which helped keep people safe from staff who were unsuitable to work in care.

Appropriate systems were in place to ensure the safe management, storage and administration of medication, so people received their medication as prescribed.

Improvements had been made to the delivery of care and people’s care records were being maintained and audited on a regular basis.

Staff were appropriately trained and knew the people well that they supported. Staff understood the importance of gaining consent from people before providing care or support and, where people did not have capacity, staff ensured their rights were protected.

People had enough to eat and drink to meet their needs and their individual dietary needs were catered for appropriately. People also had access to external healthcare services and where concerns around people’s health or needs were identified, appropriate and timely referrals were made to the relevant professionals.

Staff treated people in a friendly and caring manner and staff respected people’s privacy and dignity and offered prompt reassurance if people became confused or distressed.

Assessments of people’s needs were carried out before people moved into the home, to ensure the home could meet these needs appropriately and effectively. Care plans contained individual information about each person and people were involved in planning their own care as much as possible. However, due to the lack of an appropriate dependency tool being used in respect of staffing levels, there were not always sufficient staff available to ensure that people’s ongoing choices were consistently met with regard to when they received personal care, such as washing or bathing, nor what time they were assisted to or from bed.

There was no formal structure for activities. Although the staff consistently tried hard to engage people during the course of their duties, not everyone living in the home was able to be supported to follow their interests or take part in social activities of their choosing.

The conservatory was being used as a full time office for the administrator and the provider’s separate homecare service. This meant that in addition to a reduction in people’s choice of communal areas, confidentiality was compromised.

There had been improvements to the complaints procedure and people were being supported to make any concerns known to staff or the management. There had also been improvements to people’s care plans, medication records and day-to-day record keeping.

We saw improvements to the systems for assessing and monitoring the quality of service that people received. Systems for identifying, assessing and managing risks to people’s health, safety and welfare had also been improved.

Occasional staff meetings were held by the registered manager but staff were not able to add to the agenda or ‘have their say’, which meant that staff were not fully included or involved in the development of the service. Staff were not always comfortable raising issues or concerns directly with the registered manager but did receive additional support from the deputy manager.