About the service: Hawthorn Lodge Care Home is a care home (without nursing) for older people with or without dementia. Hawthorn Lodge Care Home is located in the Bestwood Park area of Nottingham. Which provides personal and nursing care for up to 60 people. On the first day of the inspection 37 people were using the service and on the second day 36 people were using the service.

The service had a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

People’s experience of using this service:

People’s medicines were not always managed and administered safely, and we found some issues with staff practices that could impact on the control and prevention of infection. The provider’s quality auditing systems did not always highlight the concerns we found in these areas at inspection.

People felt safe at the service and the risks to their safety were well managed with clear strategies in place to reduce the risks for people. People were supported with appropriate numbers of staff. Their nutritional needs, and health needs were well managed.

People were supported by staff who had appropriate training for their roles. Staff gained people’s consent before providing care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible: the policies and systems in the service supported this practice. They were supported to express their views and opinions about their care. People had formed positive relationships with staff who knew their needs and preferences.

People’s dignity and privacy was maintained by a staff group who also encouraged people’s independence. There was a positive culture at the service and people and the relative we spoke with felt listened to, they could raise complaints or concerns and know they would be addressed by staff.

Rating at last inspection: The rating for the service at the last three inspections has been requires improvement with repeated breaches of regulations. Our last inspection of the service was 4 October 2017.

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement; This was the fourth inspection where the service has been rated as requires improvement. We have asked the provider for an improvement plan to address the on going issues.

Follow up: We will continue to monitor the service and should we need to we will taken further action in the future.

This inspection took place on 4 October 2017 and was unannounced. Hawthorne Lodge Residential Care Home provides accommodation and personal care for up to 60 people. At the time of our inspection there were 42 people living in the home. The service specialises in supporting older people and people living with dementia. However, recently the service had worked with the local authority to support younger adults in self-contained flats located on the first floor of the home. This was a recent change to the services offered at Hawthorne Lodge and the provider was working closely with the local authority to develop the care and support provided to these people.

During our last inspection in July 2016 we rated the location as ‘Requires Improvement’ and identified one breach of the Health and Social Care Act 2008.

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.

People could not be assured that their medicines would be managed appropriately. The records of the medicines that had been administered to people were not always completed accurately by staff. The provider did not have a system in place to audit the management of people’s medicines.

Staff did not always receive regular supervision in line with the providers’ supervision policy. We have made a recommendation in the main body of the report related to the supervision of staff.

The providers’ quality assurance systems had not been effective at identifying or addressing shortfalls in the care and support that people received. The providers quality assurance systems had not identified that people’s medicines were not managed safely or that staff had not received regular supervision. This is the third inspection in a row that the provider has been rated as requires improvement. The provider has not implemented appropriate systems in order to achieve and maintain compliance with the Health and Social Care Act 2008.

Risks to people had been assessed and action had been taken by staff to minimise the known risks to people. People were supported by sufficient numbers of staff that had been subject to robust pre-employment checks.

Staff received the training that they needed to provide effective care to people. People were supported to access healthcare services when they needed to and to maintain a healthy and balanced diet.

Senior staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately. Staff understood the importance of obtaining people’s consent when supporting them with their daily living needs.

Staff knew people well and treated people with respect and dignity. People living at the service were encouraged to personalise their rooms and to feel at home.

People had detailed plans of care to guide staff in meeting their care and support needs. People had been involved in the development of their plans of care and received personalised care and support in line with their preferences.

The registered manager knew people well and was accessible to staff and people living in the home. The registered manager set high standards for staff to aspire to.

At this inspection we found the service to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.

We carried out an unannounced inspection of the service on 12 and 13 July 2016. Hawthorn Lodge Care Home provides accommodation for persons who require personal care, for up to a maximum of 60 people. On the day of our inspection 50 people were using the service and there was a registered manager in place.

A registered manager was present during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our previous inspection on 9 and 10 October 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; assessing and managing the risks to people’s safety, the safe management of people’s medicines, the environment people in which people lived, the care planning process and the management of the home.

During this inspection we checked to see whether improvements had been made. We found some improvements had been made in all areas, but further improvements were still required.

Improvements had been made to the premises but further work was required to ensure that the premises were safe for all people living at the home. The assessment of the risks to people’s safety were now carried out more thoroughly and regularly reviewed. Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the registered manager and had been investigated. The processes for the safe management of people’s medicines had improved, but further improvements were required. This included the processes where people received their medicines ‘as needed’. There were enough staff to keep people safe. People were protected from the risk of harm because staff could identify the potential signs of abuse and knew who to report any concerns to.

Improvements had been made to the way people’s day to day health needs were met. However, people’s care records did not always reflect the care carried out by the staff, and in some cases, lacked specific guidance for staff when supporting people. The ground floor of the home provided people living dementia or other mental health related conditions, with assistance to lead independent lives. However more work was needed to support people in other areas of the home.

People were supported by staff who had completed a detailed induction and training programme. However staff did not always receive regular supervision of their work. The principles of the Mental Capacity Act (2005), including Deprivation of Liberty Safeguards, had been followed when decisions were made about people’s care. People spoke positively about the food provided at the home and we observed an organised lunch time experience.

People were treated with respect and dignity by staff, although we did see one negative interaction which impacted on a person’s right to be treated with dignity and to have their privacy respected. People felt staff were kind and caring. People’s records contained limited information about their life history; however plans were in place to address this. People were involved with decisions about their care and support needs. People were encouraged to lead independent lives. Information for people on how to access independent advice about decisions they made was easily accessible.

People’s care records contained detailed care plans which enabled staff to respond to their needs. People were supported to follow the activities that interested them. People’s diverse needs were respected, however some staff spoken with unaware of a person’s needs. People felt able to make a complaint and were confident it would be dealt with appropriately.

The registered manager’s auditing processes had improved s

This service was inspected by a single adult social care inspector. In order to answer the questions below we spoke with three members of staff, eight people who used the service and two relatives. We also reviewed five people’s care records. There were forty seven people using the service at the time of our visit.

If you wish to look at our findings in detail please see the full report.

Is the service safe?

The environment was clean. The premises were secure from anyone entering unannounced, and care records were only accessed by authorised staff. People told us they felt safe. There were sufficient numbers of staff on duty to meet the needs of the people in the service. Staff members were confident to raise safeguarding concerns to the manager. Procedures for the correct administration of medicines were being followed.

Is the service effective?

Each person had a care plan that described their individual care needs. Staff had a good understanding of people’s needs and risks. One relative told us, "The staff are very kind here.” There were sufficient infection control measures in place. Staff were knowledgeable and received good training and were supported appropriately by senior staff.

Is the service caring?

Our observations throughout the visit were positive. Staff showed a great deal of patience and good humour when they were assisting people. One staff member told us, “We work as a team to do what we can for people.” Questionnaires sent to people’s families were complimentary. People in the service were not rushed, and a relative told us, “It’s lovely here.”

Is the service responsive?

People’s care needs were assessed before they were admitted. Care plans and risk assessments reflected people’s individual needs and were updated promptly when necessary. People and their relatives were invited to meet with their keyworkers each month to review their care plans. However, people did not currently have individual, structured activity programs in place because there was no activities coordinator currently in post.

Is the service well-led?

There were systems in place to monitor the quality of the service being provided. These included feedback by the use of monthly audits, complaints received and questionnaires issued. All findings were addressed in a timely way. Staff received a good level of training, were well supervised and had a good understanding of the aims of the service. Care records were up to date and all risks had been assessed.

One person who used the service told us, “I come here for respite care and everything is not perfect but I like it. The carers are nice generally.”

An external healthcare professional told us, “The service is ok; people are cared for. Staff communicate well with my team and they’re willing to listen and learn.”

We saw person centred information which met individual people’s needs in two out of the three care plans we looked at. Care plans and risk assessments for identified care needs were in place.

We spoke with two relatives of people who used the service. They told us, “My relative is safe,” and, “I’ve got no concerns about the staff.”

Staff told us who they would report or have reported issues to if they had safeguarding or whistle blowing concerns.

Since our last inspection, effective systems had been put in place to reduce the risk and spread of infection. The manager and provider of the service had taken action to address the issues found at our last inspection and had implemented measures which minimised the risk of infection.

A relative of a person who used the service said, ““The cleanliness has improved.”

Appropriate arrangements were still not in place in relation to the recording of medicines. Medicines were not always handled appropriately and procedures for the correct administration of medicines were not followed.

During our inspection we found that work to improve the premises and building had been started but further work was still needed. The provider acknowledged this and had identified an on-going programme of works and maintenance to ensure the premises were both safe and suitable for the delivery of care to people who used the service.

One person who used the service told us, “I’ve got no complaints.”

A relative of a person who used the service said, “The home’s well run. The manager sorts things out if things aren’t right.”

People who used the service, their relatives and staff members were able to discuss and raise issues with the manager.

Two people told us the care they received was good. One person said care, “Was sometimes good, sometimes a bit haphazard.”

Three people told us the service was clean, one person said, “Reasonably clean.” During our tour of the premises the environment did not smell clean. Our observations meant that people may not always be cared for in a clean, hygienic environment.

Appropriate arrangements were not in place in relation to the recording of medicine. The medication administration record (MAR) charts we looked at were not fully completed. Medications had been given but the administration of those medicines had not been recorded and staff had not signed the relevant section of the MAR charts. A recent provider audit identified issues with this standard.

Two relatives of people receiving care told us, “The building needs attention.” During our tour of the premises we observed that the interior and exterior environment was dated and required redecorating and some repair.

Two people told us there were enough staff to support them. One relative told us, “Staff numbers are ok. Staff work well with the numbers they have.” We did not see evidence of insufficient staffing levels during our inspection.

One person told us they had made a complaint and the service had responded appropriately. A complaints procedure was in place and contained appropriate detail.

Records were kept securely. Nobody raised any concerns regarding the security of records at the service.

We carried out an unannounced inspection of the service on 9 and 10 October 2015. Hawthorn Lodge Care Home provides accommodation for persons who require personal care, for up to a maximum of 60 people. On the day of our inspection 48 people were using the service and 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.

People were supported by staff who could identify the different types of abuse and knew who to report any concerns to. People told us they felt safe at the home and that there were enough staff to support them.

The risks to people’s safety were not always appropriately assessed and well managed and were not always regularly reviewed. Parts of the premises and equipment were not managed appropriately to keep people safe. People had personal emergency evacuation plans (PEEPs) in place. Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the registered manager and were investigated. People’s medicines were not always safely managed.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The DoLS are part of the MCA. They aim to make sure that people are looked after in a way that does not restrict their freedom. The safeguards should ensure that a person is only deprived of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them. The registered manager had applied the principles of the MCA and DoLS appropriately and was making further applications for more people to the authorising body.

People had access to external healthcare professionals however the guidance and recommendations made by them were not always implemented. People spoke positively about the staff and were supported by staff who received supervision and appraisal of their work. However these were not always completed often enough to ensure people received effective and consistent care and support. The majority of the staff training was up to date; however some staff required refresher training in some areas. The majority of the people we spoke with told us they liked the food and drink provided at the home. Limited adaptations had been made to the design of the home to support people living with dementia.

People felt the staff were kind and caring and treated them with respect. Information for people on how to access independent advice about decisions they made was not easily accessible. People told us they felt included in decisions made about their care and support although people’s records did not always reflect this. People did not always have the privacy they needed. Some toilet doors did not have privacy locks on them and posed a threat to people’s dignity. The language recorded within people’s care plans was not always respectful. People were encouraged to do as much for themselves as possible and staff understood people’s likes and dislikes.

People’s care records contained an initial assessment of people’s needs however they did not provide easily accessible guidance to staff to provide care that met their personalised needs. The current care planning system used a mixture of electronic and paper records and this resulted in some records not being appropriately completed. People’s life history was not always recorded within their care records. Some people were not always able to get out of bed at the time they wanted to; although people told us they felt the staff responded well to their other needs.

People spoke positively about the activities at the home and felt confident in raising a complaint if the needed to.

The registered manager’s auditing processes were not always used effectively and had not identified the issues raised within this report. The registered manager had not ensured that the CQC were always provided with the appropriate statutory notifications. People and staff spoke positively about the registered manager and staff understood the aims and values of the service. People were encouraged to become involved with development of the service and were given the opportunity to give their opinions during ‘resident meetings.’

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of this report.