M & S Care Limited Seven Gables Inspection report Seven Gables York Lane Totland Bay Isle of Wight PO39 0ER Tel: 01983754765 Website: www.sevengablescarehome.com Date of inspection visit: 01 July 2016 08 July 2016 Date of publication: 25 July 2016 Ratings Overall rating for this service Good Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good 1 Seven Gables Inspection report 25 July 2016 Summary of findings Overall summary This inspection took place on 1 and 8 July 2016 and was unannounced. Seven Gables provides accommodation and personal care for up to 25 older people including people with dementia. There were 23 people living at the home when we visited. There was a registered manager at the home. 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. Medicines were managed safely and people received these as prescribed. People and external health professionals were positive about the service people received. People were positive about meals and the support they received to ensure they had a nutritious diet. Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people's individual care needs and preferences. People had access to healthcare services and were referred to doctors and specialists when needed. Reviews of care involving people were conducted regularly. People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people's legal rights was followed correctly. Staff offered people choices and respected their decisions. People were supported and encouraged to be as independent as possible and their dignity was promoted. There were enough staff to meet people's needs. The recruitment process helped ensure staff were suitable for their role. Staff received appropriate training and were supported in their work. People and relatives were able to complain or raise issues on a formal and informal basis with the registered manager and were confident these would be resolved. This contributed to an open culture within the home. Visitors were welcomed and there were good working relationships with external professionals. Staff worked well together, which created a relaxed and happy atmosphere, that was reflected in people's care. Plans were in place to deal with foreseeable emergencies and staff had received training to manage such situations safely. The registered manager and provider were aware of key strengths and areas for development of the service. Quality assurance systems were in place using formal audits and regular contact by the provider and registered manager with people, relatives and staff. 2 Seven Gables Inspection report 25 July 2016 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? Good The service was safe. Recruitment practices ensured that all pre-employment checks were completed before new staff commenced working in the home and there were enough staff to meet people's needs. People were protected from the risk of abuse; staff knew how to identify, prevent and report abuse. Medicines and risks to people were managed effectively. Staff understood how to keep people safe in an emergency. Is the service effective? Good The service was effective. Staff followed legislation designed to protect people's rights and freedoms. People were supported to access healthcare services when needed. The environment was supportive of people living with dementia and people had access to the outdoors and fresh air. People received a varied and nutritious diet and they were supported appropriately to eat. Staff knew how to meet people's needs; they were suitably trained and supported in their work. Is the service caring? Good The service was caring. People were cared for with kindness and compassion. Staff knew people well, interacted positively and supported them to build friendships. People and their relatives were positive about the way staff treated them. People were treated with respect. Dignity and independence were promoted. Is the service responsive? 3 Seven Gables Inspection report 25 July 2016 Good The service was responsive. People received personalised care and support. Staff demonstrated a good awareness of people's individual needs and responded effectively when their needs changed. The registered manager was reviewing the activities provision to ensure this met people's needs and wishes. The provider sought and acted on feedback from people. There was a complaints policy in place and people knew how to raise concerns. Is the service well-led? The service was well-led. People and their relatives felt the home was well organised. Staff understood their roles, were motivated, worked well as a team and felt valued by the registered manager and provider. The service had an open and transparent culture. A suitable quality assurance process was in place, including formal audits and informal monitoring of the service. 4 Seven Gables Inspection report 25 July 2016 Good Seven Gables Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This inspection took place on 1 and 8 July 2016 and was unannounced. The inspection was undertaken by three inspectors. Before the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed previous inspection reports and notifications we had been sent by the provider. A notification is information about important events which the service is required to send us by law. We spoke with nine people living at the home and two family visitors. We observed care and staff interactions with people in communal areas. We spoke with the registered manager, seven care staff on duty, kitchen and housekeeping staff. We also spoke with five health care professionals who had involvement with the home. We looked at care plans and associated records for four people, staff duty records, staff recruitment and training files, records of accidents and incidents, policies and procedures and quality assurance records. 5 Seven Gables Inspection report 25 July 2016 Good Is the service safe? Our findings At the last inspection in July 2015 we found people were not always receiving medicines including topical creams as prescribed and staff were not always recording how many of variable dose medicines people had received. Systems were also not in place to fully manage individual risks to people. The registered manager sent us an action plan telling us they had taken the necessary steps to ensure people were safe. At this inspection we found that staff did not always follow best practice guidance in respect of the recording of medicine administration and the management of topical creams. Medicine administration records (MAR) contained a small number of recent gaps where staff had not recorded if these had been administered or not. The registered manager said they usually did a weekly medicines audit, which should have identified the recording gaps however this had been planned to be completed on the day we undertook our inspection. Records of previous weekly audits showed that all boxed medicines were checked against stock levels and records of those administered. Systems to help ensure prescribed topical creams were applied when needed were appropriate and recorded their application. However, systems to ensure topical creams were not used beyond the manufacturers' 'use-by' date had not been effective. We found some topical creams had not been dated when opened and others, which did have the date opened and a date the cream should be discarded on but these were being used beyond the discard date. The registered manager took action to amend their procedures to ensure this situation did not continue. People told us they were happy with the arrangements to receive their medicines. They told us they could get as required medicines such as for a headache if needed. One person said "I always get my medicines on time and they don't go until you've had them". Staff were aware which medicines should be given before or after meals and we saw these were given safely. Suitable arrangements were in place for obtaining, storing, administering and disposing of medicines. Staff administering medicines had received appropriate training and had their competency assessed. They had information to explain what each medicine was for and how it should be given. We observed staff administering medicines to people and saw they followed best practice guidance by administering and recording them individually. Clear guidance had been developed to help staff know when to administer 'as required' medicines, such as pain relief and medicines to help reduce people's anxiety. Systems were also in place to ensure that where people were prescribed medicines regularly these were not given too close together. Where medicines were prescribed with a variable dose records stated how many had been administered. The registered manager told us they were moving to an electronic medicines management system which would help ensure the safe management of medicines and that recording errors did not occur. One care staff member told us "I've had medication training. We are moving to EMAR (Electronic medicines Administration records), they have arranged for [name pharmacy] to come in and do the training." People told us they felt safe at Seven Gables. One person said, "Yes we are safe here". Another person told us, "I feel safe here". Staff had received training in safeguarding adults and knew how to identify, prevent and report abuse, and how to contact external organisations for support if needed. The registered manager described the action they would take should a safeguarding concern be brought to their attention. The 6 Seven Gables Inspection report 25 July 2016 actions described would help ensure people remained safe. Investigations into safeguarding incidents were thorough and where necessary, appropriate steps had been taken to protect people. Risks were managed safely. All care plans included risk assessments, which were relevant to the person and specified the actions required to reduce the risk. These included the risk of people falling, nutrition, moving and handling and developing pressure injuries. Risk assessments had been regularly reviewed and were individualised to each person. These procedures helped ensure people were safe from avoidable harm, whilst promoting their independence. We observed equipment, such as hoists and pressure relieving equipment being used safely and in accordance with people's risk assessments. People had individual equipment, such as slide sheets which were seen in their bedrooms and corresponded to information in the person's care plan. This would ensure they were the right size and type to support the person safely. People and staff said that the use of moving and handling equipment and repositioning was always undertaken by two staff. One person told us "I can't walk and I have to be hoisted. I have to have two [staff]." Care records were initialled by two staff confirming that two staff had been involved with repositioning immobile people. Risk assessments had been conducted and measures had been put in place to reduce the likelihood of people developing pressure injuries. These included staff training in skin care, encouraging people to eat well and mobilise as often as possible. Staff were aware of people who needed to use special cushions or mattresses and we saw these being used consistently. The risks of people falling were managed effectively. Staff knew the support each person needed when mobilising around the home and provided it whenever needed. When people fell, their risk assessments were reviewed and additional measures put in place where needed. An appropriate system was in place to assess and analyse accidents and incidents across the home and action lessons learnt from them. For example, the registered manager told us they now used movement alert pressure mats for all people when they were first admitted to Seven Gables. They told us this was because they had identified people were at a higher risk of falls when new to the home as they were unfamiliar with the environment and did not always remember to use the call bell system. There were arrangements in place to keep people safe in an emergency, such as in the event of a fire. Staff were aware of the correct procedure to take should the fire alarms sound. Fire detection and emergency equipment was in place and was checked regularly to ensure it would work in an emergency. An external company had completed a fire risk assessment in 2015. The registered manager had consulted with other fire prevention professionals and told us required work had been completed. Personal emergency evacuation plans were available for people; they included details of the support each person would need if they had to be evacuated and were kept in an accessible place. Arrangements were in place with a local church hall, which could be used to shelter people in an emergency and staff had been trained to administer first aid. Environmental risks were managed appropriately. There was a range of environmental risk assessments which were individualise to the home. Where risks had been identified action was taken to manage the risk. For example, a fire exit door to the garden was fitted with an audible alarm to alert staff someone may be leaving the home. Staff had identified that they were unable to hear this in some parts of the home. Therefore an additional pressure mat linked to the call bell system, which could be heard by all staff via pagers, was now also in use. Records viewed showed essential checks on the environment, such as fire detection, gas, water, electricity and equipment, such as hoists and the lift were regularly serviced and safe for use. People were supported by sufficient staff with the right skills and knowledge to meet their individual needs. 7 Seven Gables Inspection report 25 July 2016 People told us care staff were available when they needed them and we heard call bells were responded to promptly. One person said "There are enough staff", another person said "There are enough staff for what we need staff to do". Staff said they felt there were usually enough staff to meet people's needs. One care staff member said "I feel there are enough staff to provide care and meet people's needs. But I feel that sometimes we don't have enough time to do the soft bits. All their needs are met, it would be nice to sit down and have some social time [with people living in the home]". Another care staff member echoed this saying "There are enough staff here. Sometimes if the residents all ring at the same time you can't have enough staff. If two staff are busy and they all start ringing they do have to wait for a bit". Staffing levels were determined by the registered manager who said they listened to care staff and worked some direct care shifts, which enabled them to assess if staffing levels were adequate. In addition to care staff a general assistant was employed who supported care staff with tasks, such as drinks and meals and supporting people in communal areas. All staff, including housekeeping, undertook the same training as care staff and told us they were able to support people when necessary, if care staff were busy. Recruitment procedures were in place to help ensure staff were suitable to work at Seven Gables. These included a full employment history, reference checks from previous employers and a criminal record check with the Disclosure and Barring Service (DBS). The DBS helps employers to make safer recruitment decisions. Staff confirmed this process was followed before they started working at the home. The registered manager told us applicants were introduced to people as part of the interview process. They said they observed applicants interactions with people and they would return to ask people what they had thought of the applicants as part of the recruitment decision making process. 8 Seven Gables Inspection report 25 July 2016 Good Is the service effective? Our findings Staff followed the principles of the Mental Capacity Act (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any decisions made on their behalf must be in their best interests and as least restrictive as possible. Some people had a cognitive impairment and assessments showed they were not able to make certain decisions. These included decisions around the delivery of personal care and the administration of medicines. Staff had documented decisions they had made on behalf of people, after consulting family members and doctors where appropriate. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. We found the provider was following the necessary requirements. The registered manager had applied for DoLS authorisations where necessary and was waiting for these to be assessed and approved by the local authority. Staff understood their responsibilities and knew how to keep people safe in the least restrictive way. Staff sought verbal consent from people before providing care and support by checking they were ready and willing to receive it. One person said "They always ask before they do anything". Records confirmed that staff complied with people's wishes; for example, one person often refused personal care. Staff described how they respected the person's decision and would then return shortly after and try again. A care staff member said "We don't restrain people. If people are difficult about their care, we just keep going back, or try another carer." The person's care plan detailed the action staff should take which correlated to that described by staff. The registered manager was aware of the lead person for the local authority for the MCA and told us how they had sought guidance from them when required. People had confidence in the knowledge and the ability of staff to provide effective care. One person said, "I have every confidence in them." Another person told us "They know what they are doing". Staff demonstrated a good understanding of the needs of the people they cared for and how to communicate with them effectively. A care staff member told us "They [registered manager and deputy manager] do spot checks on your competence. They give us a list of areas for improvement. They look at everything: moving and handling, dignity and respect. We don't know when they are doing them. They just do them and then let you know a couple of days later". A visiting health professional said "I think they [people] are well cared for". New staff received induction training, which followed the Care Certificate. This is awarded to staff who complete a learning programme designed to enable them to provide safe and compassionate care to people. They worked alongside a more experienced member of staff until they had been assessed as competent to work unsupervised. Two new staff who were completing their induction showed us their care certificate work books and told us they had been supported by the registered manager and deputy 9 Seven Gables Inspection report 25 July 2016 manager. Training for experienced staff was refreshed regularly and we saw training dates had been set for the coming year. Most staff had also obtained vocational qualifications relevant to their role or were working towards these. A care staff member said, "I started here in January [2016]. I have completed the care certificate and I am currently doing NVQ 3. I had an induction, I was shown around the home and did some shadowing and read people's care plans". Another staff member told us "I have done NVQ3". People were cared for by staff who were appropriately supported in their work. Staff received a range of supervisions with the registered manager or deputy manager. Supervisions provide an opportunity for managers to meet with staff, feedback on their performance, identify any concerns, offer support, and discuss training needs. In addition, staff received a yearly appraisal. Staff told us supervisions were beneficial; for example, they said they had requested additional training and this had been arranged. The management team also worked some care shifts, which they said enabled them to directly supervise how staff provided care for people. People were supported to access healthcare services when needed. One person told us "If you need a doctor you only have to ask". Records showed people were seen regularly by doctors, specialist nurses and chiropodists. The registered manager had arranged for an optician to visit the home enabling everyone who wished to have their vision checked and purchase new spectacles if required. Details of a mobile dentist were available should this be required. Health information about people was known and records showed that when required staff consulted GP's and out of hours services, such as paramedics and 111. We spoke with five visiting health professionals who were positive about the way Seven Gables met people's health care needs. They told us they were contacted appropriately and that staff followed their guidance. Records showed staff had sought advice when they had identified concerns, such as changes to people's skin condition or when they thought people may have a urine infection. People were positive about the meals at Seven Gables. They said they liked the food and they were able to make choices about what they ate. One person said, "The food is good. We get choices". Another person told us "I've never asked for anything that wasn't on the menu. I think if you asked them for something specific they would buy it in. But I've never asked". Another person said "You've got a jug in your room with a lid on. Night staff change the water every night. They come around with tea and biscuits in the morning and afternoon". People received a varied and nutritious diet including fresh fruit and vegetables. Staff were aware of people who needed special diets or had particular food preferences and we saw these were provided. The chef was also aware of people's preferences and specific dietary needs, which they said they were able to meet. Daily records showed people had received sandwiches and snacks in the evening and at night when requested. Staff monitored the amount people ate and drank using food and fluid charts which were fully completed. Staff added up the amount people had drunk each day to assess whether this had been sufficient. Some people needed to be encouraged to eat and this was done in a discrete and supportive way. Staff said they had time to support people and we saw they did not rush people with their meals. People were offered choices for example, a person was asked "tea or juice today?" they replied "both" and were given both tea and juice. The provider had undertaken refurbishment and redecoration of many areas of the home. Signs supported people to find their way around the home. The lounge's had been redecorated and provided with a new plain carpet, which was more suitable for people living with dementia who may have become confused by the previous patterned carpet. There was an on-going programme to redecorate the rest of the home 10 Seven Gables Inspection report 25 July 2016 including bedrooms as they became available. Bathrooms had been redecorated as had the dining room with future plans to replace other carpets around the home. Pictures and furniture was being replaced as required and the registered manager told us people had been consulted about the changes. They said people had helped choose the colours for the small lounge to be repainted and where various pictures should be hung. People had access to the garden, which had suitable outside furniture providing an opportunity for fresh air. 11 Seven Gables Inspection report 25 July 2016 Good Is the service caring? Our findings People were cared for with kindness and compassion. One person said of the staff, "I have never seen staff being uncaring. I would say they were kind". Another person told us "The staff have got time for you". Whilst a third person said the staff are "very friendly, helpful and polite". These comments were echoed by other people and visitors we spoke with. A visiting health professional said "They [care staff] definitely seem caring and compassionate". Without exception, all the interactions we observed between people and staff were positive and friendly. We saw staff kneeling down to people's eye level to communicate with them. Staff gave people time to process information and choices were offered. Staff did not rush people when supporting them. We heard goodnatured banter between people and staff showing they knew people well. People were clearly relaxed and comfortable in the company of staff. Staff spoke warmly about people and knew how to relate to them in a positive way. One staff member said "We talk to the people. We explain things to them". We saw staff knew what was important to people, for example staff said to a person "Wales are playing this afternoon [football] we will try to put it on TV for you". We noted the person had a Welsh background. Another person was asked "I think there is a service on this morning for people who died in the war. Would you like to watch it?" The person replied yes and the service was put on the TV. People's privacy was respected at all times. Before entering people's rooms, staff knocked, waited for a response and sought permission from the person before going in. Confidential care records were kept securely and only accessed by staff authorised to view them. Two bedrooms were each shared by two people. Privacy screens were available in these rooms and we saw staff used these when necessary. People told us staff always remembered to close curtains and doors before providing care. Staff treated people with dignity and respect and described the practical steps they took to preserve people's dignity when providing personal care. This included keeping people covered as much as possible and telling people what they were about to do. Staff were able to tell us if people preferred a specific gender of care staff to provide personal care. This information was also included in care plans and staff said they were able to meet these preferences. Care plans included specific individual information as to how people's dignity should be maintained. For example, in one person's care plan we saw "[name person] likes to be immaculately dressed and cares a great deal about their appearance". Another stated that the person "likes to wear makeup daily". Staff were seen to respect people during interactions. Staff apologised for reaching over the table at lunch time saying "sorry for leaning over". People were offered the choice and informed before clothing protectors were used at lunch time. People's independence was promoted. At lunch time staff encouraged a person to eat without taking over. Plates with higher sides, but which still looked like routine diner plates were provided where necessary. This supported people to eat independently without appearing to be using specialist equipment. Care plans specified what people could do for themselves and what they needed help with. For example, one stated 'staff are to encourage [name person] to remain independent as far as reasonably possible, and encourage [name person] to wash their upper body, requires assistance with lower body and back". 12 Seven Gables Inspection report 25 July 2016 When people moved to the home, they and when appropriate their families were involved in assessing, planning and agreeing the care and support they received. People had signed care plans to show involvement and agreement with their care plan. Comments in care plans showed this process was ongoing. Family members told us they were kept up to date with any changes to the health of their relatives. Keyworkers had a monthly review meeting with designated people to discuss their care plans and how they wanted their care needs to be met. Keyworkers were a named member of the care staff team who had particular responsibilities for named people. Care files contained information about people's lives, preferences and what was important to them. One staff member said "It's really nice when people talk about their lives, some of them are quite interesting". Staff were able to tell us about people's life histories, such as their previous occupations. Seven Gables supported people to maintain family relationships. We spoke with two family visitors, they said they were always made to feel welcome and could visit at any time. The registered manager described how family members who they knew would be on their own at Christmas were invited to join their relative for Christmas lunch and could join them at other times for meals if they wished. Care plans also detailed any spiritual beliefs or needs a person may have. For example, one care plan stated '[name person] is C of E practising'. The local vicar visited the home most weeks and the registered manager was aware of how to access other religious leaders if required. 13 Seven Gables Inspection report 25 July 2016 Good Is the service responsive? Our findings People received personalised care and support that met their needs. One person said the staff "Are always very accommodating". When people's needs changed staff were responsive. For example, they had noted changes in two people's skin condition and had requested the district nurses to visit whose guidance they were following. Topical creams were being applied, action was being taken to support people to sit on a special pressure relieving cushion and have a rest on their bed in the afternoon. In both cases there was subsequently an improvement in the person's skin condition. Staff demonstrated a good awareness of people's individual support needs and how each person preferred to receive care and support. For example, they knew which people needed to be encouraged to drink; the support each person needed with their continence; and when people liked to get up and go to bed. They recognised that some people's mobility or cognitive ability varied considerably from day to day and were able to assess and accommodate the level of support they needed at a particular time. We joined the handover between the morning and afternoon care staff. Information was provided to the staff in a clear and informative manner in relation to any particular concerns about individual people. A weekly update was provided for all staff and available in the staff office. Staff were required to sign to confirm they had read the update. This provided written information for staff about any changes, such as in care or medicines and information about any new people admitted to Seven Gables. Staff referred to the update report when we asked then how they were kept informed about any changes in people's needs. Care plans provided information to enable staff to provide appropriate care in a consistent way. Records of care viewed confirmed that people received appropriate care and staff responded effectively when their needs changed. People or their relatives had signed care plans demonstrating they had been involved in identifying how their needs would be met. Care plans contained specific individual guidance where necessary. For example, we saw in one care plan there was guidance for staff stating 'if you notice any of these signs or symptoms report to the management'. The form then listed possible indicators that the person may have an infection. The registered manager explained that they purchase activities staff from external providers. However, often people were not very interested. For example, on the first day of our inspection nobody wanted to join the activity. People said they could choose to join activities and one relative felt there should be more mental and physical stimulation for people. A staff member told us "We have an organist, singers, video days, exercise classes. We have activities most days. They [people] love the organist. He's been coming here for years". The registered manager said they had identified that people were increasingly less interested in group activities possibly as a result of their increasing physical frailty. They were therefore planning to provide some additional staff hours to enable individual activities, such as hand massages, reading or talking with people to occur as an alternative to some of the less popular group activities. They also described how they had contacted an older person's charity who had arranged for a volunteer visitor for one person. Requests for volunteers to visit other people had also been made and the registered manager was waiting for the charity to identify suitable volunteers. 14 Seven Gables Inspection report 25 July 2016 The registered manager sought and acted on feedback from people, such as in respect of the redecoration of the communal areas. Surveys were also sent out yearly to people. We viewed the returned surveys for the previous year. These were all positive about the care people had received. The registered manager had also sought people's views via meetings. One person said "We had a residents meeting about the menu. There was supposed to be another residents meeting, but they didn't have it because nobody wanted it". The registered manager confirmed that people were not interested in a formal residents meeting so they sought people's views on an individual basis. People knew how to complain and there was a suitable complaints procedure in place. One person told us, "I've never made a complaint. I wouldn't be worried about complaining". Another person said, "I've got no complaints what so ever". There was information about how to complain available for people or visitors in the home's hallway along with a suggestion box where anyone could place anonymous comments if they wished to do so. The registered manager said there had been two formal complaints in the preceding year. We viewed the records relating to these complaints, which showed that they had been investigated appropriately. The person raising the complaint was provided with a written response apologising and detailing the action the registered manager had taken in response to rectify the problem. The registered manager identified that by speaking with people on a daily basis and relatives when they visited they were able to rectify most minor concerns before they became formal complaints. 15 Seven Gables Inspection report 25 July 2016 Good Is the service well-led? Our findings People were positive about their experience of living at Seven Gables and felt that it was well run. One person said "The manager is approachable. [Name senior staff] is as well". Another person said, "The manager is very approachable". Relatives were aware of who the registered manager was. One visiting health professional said "If a relative had to go into care this is one of the homes we would consider". Staff told us they enjoyed working at the home. We observed staff worked well together, which created a relaxed atmosphere and was reflected in people's care. Staff said the aim of Seven Gables was to provide a safe home for people. One staff said they aimed to "treat people as we would want to be treated ourselves". We saw positive, open interactions between the registered manager, staff, and people who appeared comfortable discussing issues in an open and informal way. The registered manager regularly worked as a member of the care staff team and was aware of people's needs. One care staff member said "The manager is very supportive. He's been here a long time, he is very different from other managers I've had, it is much more relaxed here". Another staff member said "[name registered manager and deputy manager] are very good leaders. They will pick us up for bad practice, like talking about tasks with each other when we should be talking to the resident". There was an open and transparent culture within the home. Visitors were welcomed and there were good working relationships with external professionals. One visiting health professional said "The manager is very good. Very organised". People said the registered manager was always around and they felt able to talk to them about any concerns. They were confident these would be sorted out. Staff said they were able to raise issues or concerns with the registered manager and were aware of the different organisations they could contact to raise concerns. For example, care staff told us they could approach the local authority or the Care Quality Commission (CQC) if they felt it was necessary. The registered manager was aware of their responsibilities under the duty of candour requirements, although they said there had not been any incidents when this had been necessary. They described the action they would take, which included writing to people or relatives. Providers are required by law to notify CQC of significant events that occur in care homes. This allows CQC to monitor occurrences and prioritise our regulatory work. Checks of CQC records showed all incidents had been notified as required. Formal and informal systems were in place to monitor the quality of the service people received. The registered manager said that working directly with care staff enabled them to informally monitor the way staff worked and thus monitor the quality of care provided. They also provided on call support. The registered manager told us they ensured the quality of the service provided by talking to people, relatives and staff. More formal quality assurance systems were also in place, including seeking the views of people about the service they received. Surveys had been sent to people, visitors, staff and external professionals. The surveys could be completed anonymously and those already completed showed everyone was happy with the service provided at Seven Gables. The registered manager undertook formal audits of the service including those relating to infection control, health and safety, medicines, care plans and other records. There was a development plan in place to 16 Seven Gables Inspection report 25 July 2016 improve the quality and safety of the service. This included enhancing the environment and plans to move to an electronic medicines system. This showed the registered manager was continuously identifying areas of the service that could be improved and working to achieve these. The registered manager said the provider was open to the planned improvements and was willing to support these financially where necessary. The provider visited the home most weeks and was available by telephone at other times. Staff said they felt confident to speak with the provider when they visited the home but could also contact them directly at any time should they feel the need. The registered manager had engaged with a service which provided support to care home providers. This covered all aspects of managing a care home and provided policies, procedures and information to keep the service up to date. These were reviewed internally by the registered manager and amended when required. Policies and procedures were available to all staff at all times with a copy available in the main office. This ensured that staff had access to appropriate and up to date information about how the service should be run. The registered manager said they also received updates from websites about any medical or equipment alerts and changes in guidance from the National Institute for Health and Care Excellence (NICE). The registered manager had developed links with nearby care homes and was a member of the local care homes association. The registered manager had control over budgets within the home and were able to authorise most expenditure. This meant there was no delay as they were able to directly contact external professionals and approve emergency repairs to ensure the safety of the environment and services provided. Repairs were therefore completed quickly with limited impact on people. 17 Seven Gables Inspection report 25 July 2016