This inspection took place on the 5 February 2018 and was unannounced.

Lake View is a ‘care home’, operated by South West Care Homes Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

People living at Lake View were older people, some living with physical health conditions, early dementia or mild learning disability The service accommodates up to 29 people. There were 19 people living at the service at the time of the inspection. Included in the service’s registration is a three bedded bungalow in the grounds, for people who are able to live semi-independently without the requirement for 24 hour support.

At our last inspection we rated the service as good, with the key question of responsive being requires improvement. At this inspection we found the evidence continued to support the rating of good, but have rated the key question of safe as requiring improvement. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

We identified some potential risks on this inspection that had not been identified in the provider’s own risk assessments of the environment. The service took immediate action to include the assessments on their programme, and we did not find anyone had suffered harm as a result. We found the laundry area contained an open sluice sink. The registered manager told us this room was used to clean soiled commode and bed pans, as well as to store clean linen and clothing. We have made a recommendation for the registered persons to seek guidance on the effective management and organisation of laundry facilities to reduce the risks of cross infection. Other risks were being managed well, and the service learned from incidents and accidents to prevent a re-occurrence.

People or their relatives told us they had been involved in drawing up their care plans and reviews, and felt the care they received had improved considerably since the current registered manager had been in post. People’s long term health conditions were monitored and supported well. People received their medicines safely, and were supported to have access to community medical, nursing and therapy services to meet their healthcare needs. People were supported to eat and drink well and the service met any special dietary needs people had.

People received effective care from trained and competent staff. Safe systems were in place to recruit and employ staff including the taking of disclosure and barring service checks and evidence of people’s identity. People were protected from abuse because there were systems in place to ensure any concerns were identified and reported to the appropriate safeguarding authority.

Records were well maintained, including computerised systems for care planning. Information was made accessible to better support people’s understanding, where the person would benefit from this.

People’s rights were respected. Staff had a clear understanding of the Mental Capacity Act 2005 and had received training in its implementation or this was planned for newly appointed staff. Staff acted in people’s best interests, and treated people with dignity and respect.

Lake View had clear systems for governance and quality assurance in place which helped ensure people received a safe and high quality service. These included audits and regular assessments, policies and procedures. People were encouraged to give their views of the service through regular resident and relatives meetings and via questionnaires or a suggestions box.

Lake View is a residential care home which provides personal care to a maximum of 29 older people, including those who may be living with dementia or who may have a learning disability. Lake View does not provide nursing care. Nursing was care was provided through local community nursing services.

Included in the service’s registration is a three bedded bungalow in the grounds for people who are able to live semi-independently without the requirement of 24 hour staff support. At the time of this inspection, two people were living in the bungalow and 21 people were living in the main house.

Lake View is owned by South West Care Homes Ltd, which operates 11 residential care homes in South West England.

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 home was previously inspected on 8 October 2016 and received an overall rating of ‘good’. We rated the key question, “Is the service responsive?” as ‘requires improvement’ as we identified improvements were needed in involving people in contributing to planning and reviewing their care, as well as providing more social contact and meaningful activities for people.

This unannounced focused inspection took place on 28 September 2016 in response to a concern raised with us about the number of staff available over the weekend and whether this was sufficient to meet people’s care needs. Following the inspection we received a further concern over staffing levels and whether people’s safety was at risk from lack of staff supervision.. We found the concerns to be partially substantiated as on the two days in question there was a reduced number of staff available for part of the day. This fell below that identified by the home as required to meet people’s needs. However, duty rotas showed the home provided sufficient staff to meet the needs of those people currently living at the home and it was unforeseen circumstances that had led to the reduced numbers of staff on these two days.

We looked at the duty rota for the four weeks prior to and the week following this inspection. These showed four care staff were on duty with support from catering and domestic staff every day, including weekends. On the two days in question where concerns had been raised about staffing levels, the registered manager told us on both days a member of staff had become ill while on duty and had been sent home. Due to the short notice it had proved difficult to obtain cover. While cover had been found for the first day, none could be found for the second day. However, as there were two fewer people at the home on that day, the staff on duty felt confident they could still meet people’s care needs.

The registered manager, staff and two people who were able to share their experiences with us told us there were usually sufficient staff on duty to meet people’s needs. At the time of the inspection, the registered manager was on duty with four care staff, as well as catering, domestic and maintenance staff. In addition there was a member of care staff on duty to provide one to one support for one person and another care staff member was on duty to assist with additional laundry and domestic tasks.

Part of the concern raised with us following the inspection was that staff were not supervising people to ensure their safety was maintained over the mealtime. We discussed this with the registered manager. They said staff were assigned to supervise people and while they may have been going to and from the kitchen to obtain food or drinks for people, they would have been available to observe people in the dining room and lounge room.

This report only covers our findings in relation to

Lake View is a residential care home which provides personal care to a maximum of 29 older people, including those who may be living with dementia or who may have a learning disability. Lake View does not provide nursing care. People who live at Lake View access healthcare through local community health services.

At the time of the previous inspection two people living at the service were accommodated in a bungalow in the main house’s grounds. This bungalow was not being used at the time of this inspection and all of the 19 people currently living at the home were accommodated in the main house. All of the people living at the home were living with dementia or a learning disability and three people were being cared for in bed due to their frail health.

Lake View is owned by South West Care Homes Ltd, which operates 11 residential care homes in South West England.

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 home was last inspected on 5 and 6 November 2014 and was rated as requiring improvement. We found improvements were needed in the way medicines were managed; how care planning, risks to people’s safety and mental capacity assessments were recorded; how infection control was managed; the training provided to staff; how the quality of the service was reviewed and how complaints were managed. We also found improvements were needed in relation the environment. Two breaches of the Health and Social Care Act 2008 (Regulated Activities) 2010 were identified. The provider sent us an action plan telling us what they were going to do to meet the regulations and we found at this inspection that improvements had been made.

Prior to this inspection we received information that staff were not wearing protective aprons or gloves when assisting people with personal care or while serving meals, as well as there being insufficient soap available for hand washing. We had asked the registered manager to look into these issues and they provided us with a report of the actions they had taken. During the inspection we saw staff wearing aprons and gloves when assisting people and when serving meals. Toilets and bedrooms had sufficient hand washing soap and paper towels.

The registered manager said the home had sufficient staff to meet people’s daily care needs both during the day and night, and throughout the inspection we saw call bells were attended to promptly. People told us they received timely assistance during the mornings and when they rang their call bells. Staff told us they had time to meet people’s needs and were not under pressure to rush when assisting people with their personal care. However, staff did not have time to sit with people and engage them in conversation or support them with meaningful activities. Other than the planned activities for entertainers to come in to the home several days a week, staff confirmed they only had time to provide spontaneous short interactions such as painting someone’s nails. Also, it was not clear from people’s daily care notes whether staff had spent time with people who were being cared for in their room. The results of recent questionnaires and meetings indicated people felt more social activities were needed to provide meaningful occupation for people during the day.

The registered provider confirmed they had plans to increase the staffing in line with guidance from specialist dementia care organisations. Following the inspection, the registered manager confirmed they were recruiting an additional member of staff into a ‘social’ assistant role.

We found the home to be clean and generally odour free, however, some of the chairs in the lounge room did not appear clean and were stained with food debris. The carpets in the hallways and in some bedrooms were still to be replaced and this had been arranged for later in the year. The joins in some carpets had been temporarily repaired to reduce the risk of people tripping.

People and their relatives where appropriate, were involved in planning their care both prior to their admission to the home and throughout their stay, and we saw, some people’s involvement had been recorded at the time the plans were reviewed. However, for those people who were living with dementia and may not have been able to comment directly about the information in their plan, there was no evidence staff had explored whether they felt their needs were being met.

The care plans provided guidance for staff about people’s preferences in how their care needs should be met and what they were able to continue to do for themselves. The plans also provided information about how people wished to spend their time and the things that were important to them.

Those people who were able to express their views told us they felt safe at the home. They said the staff were always caring, friendly and respectful and they were being well cared for. One person told us “yes, it’s lovely” and another, “oh yes, I’m safe.” When asked what would make life better for them at Lake View, people said, “nothing, I have everything I need” and “I can’t think of anything, no I’m fine.” For those people who weren’t able to share their experiences with us, we saw them approaching staff and holding their hands, or smiling when staff approached them, indicating they felt safe in staff’s company. We saw staff treating people with kindness and patience. Staff no longer wore a uniform to remove a potential barrier to forming relationships with people.

The home was currently being redecorated and clear signage had been placed around the home indicating where the toilets and bathrooms were. A further smaller seating area with a television was being created in the hallway to promote interaction between people. The front door had been disguised as a book case and the registered manager confirmed this reduced the risk of people who may be unsafe to leave the home unsupervised using this door. At the previous inspection, people told us their belongings were not always safe and other people wandered into their room. We saw locks had been fitted to the bedroom doors providing privacy and security.

Risks to people’s welfare and safety had been assessed and management plans described how to reduce these, such as those associated with reduced mobility or with swallowing difficulties. People’s personal emergency evacuation plans had been updated since the previous inspection and now held more detailed information about how to protect people in the event of a fire. Medication practices were safe and people received their medicines as prescribed. People had regular access to healthcare professionals such as GPs, and staff were observant for changes in people’s usual self as an indication they may be unwell.

Staff recruitment processes were safe, with references from previous employers and police checks being carried out prior to staff starting to work at the home. Staff knew people well and told us they enjoyed working at the home and they were well supported by the registered manager. One staff member said, “I love my job. It’s a nice place to work” and another said, “we want people to feel happy and comfortable, to know they matter.”

Since that inspection, staff had received training in supporting people living with dementia, safeguarding people who may be vulnerable due to their poor physical or mental health and understanding the principles of the Mental Capacity Act 2005 (MCA). Throughout the inspection, we saw staff routinely ask people’s consent before staff assisting them. We heard them say, “can I help you with that?”, “have you finished, shall I take it” and “would you like to?” We saw some people were unable to make decisions over their care and required best interest decisions to be made for them by people who knew them well and healthcare professionals, where relevant. Records of these decisions were seen in people’s files, although some had not been fully completed. Authorisation had also been sought to legally deprive some people of their liberty as the home used a keypad lock on the front door to prevent people who would be at risk if they were to leave the home unsupervised.

People told us they enjoyed the food at the home. Comments included “the food is very nice” and “yes lovely”. We observed the lunchtime meal and saw some people could not remember the choice they had made the day before, and said they did not want the meal when it was presented to them. Staff provided them with the alternative, which they accepted. We discussed with the registered manager the way in which people who may have memory difficulties were supported to choose their meals. The registered manager agreed to change this. People would now be shown both choices at the time of the meal to allow them to choose which they preferred.

People, staff and social care professionals told us the home was well managed. People said they were listened to and felt able to discuss any issues of concern they may have with the staff and registered manager. Prior to the inspection, a number of social care professionals contacted us to inform us of the “excellent care work being carried out at Lakeview residential home.” The company’s philosophy is “to encourage and support our residents in making choices, in being independent.” The registered manager recognised there were improvements to be made at the home and said they were determined to “continually improve”. They had recently completed a Diploma in Health and Social Care at Level 5 and they regularly attended meetings with other care home managers in the local area where good practice and resources were shared.

At the time of this follow up inspection 21 people were living at Lake View. People told us that they were treated with respect. Comments included, "They (care workers) are kind and polite". We also used our short observational tool for inspection (SOFI) to help us understand the experience of people who could not talk with us. We observed that people were treated kindly by care workers.

During a previous inspection on 18 December 2012 we found that improvements were required. Some people who did not have family support had not been enabled to be involved in their own care. We also found a lack of mental capacity assessments in some cases and decisions taken in people's best interests had not been recorded. This meant that their rights had not been protected. Some care plans did not contain sufficient, up to date information or strategies to support people.

During our inspection on 26 June 2013 we found that the provider had taken effective action in all these areas. For example, records showed that people had received advice from health professionals and access to advocacy services to enable them to make decisions. Mental capacity assessments had been undertaken as necessary and best interests decisions were clearly recorded. Care plans were up to date and contained strategies to support personalised care.

We found that the provider had effective quality monitoring systems in place and managers were aware of the need to sustain recent improvements.

There were 20 people living at Lake View during our inspection. We saw many examples of staff interacting in a friendly, kind way with people. People told us that the staff respected them. Comments included, “They are always very nice to me” and "We are well looked after." People told us that they felt safe at the home. We saw that many people engaged with and gained pleasure from organised activities at the home.

However, we also saw that some care records contained insufficient detail to support staff to meet people's needs. For example, patterns of people’s behaviour were recorded but not strategies to assist staff to respond or reassure the person. Where a person lacked capacity to make decisions for themselves, suitable arrangements had not always been made to ensure decisions were made in their best interests.

The home had initiated an action plan to increase involvement of people and their families in their care decisions. However, care records showed that some people who did not have any family involvement in their care had not been enabled or supported to discuss or make decisions about it.

We were provided with evidence that pre-employment checks on staff had been carried out and that staff had received necessary training. Staffing levels were under review.

We had received information of concern that medications which were prescribed to be given only “as required” were given all the time. We did not see any evidence to substantiate this.

This inspection took place over one and a half days on 5 and 6 November. The first day was unannounced.

The home was last inspected on 26 June 2013 when the provider met the regulations we inspected against.

Lake View is a residential care home which provides personal care for to up to 29 older people, including those with dementia or learning disabilities. Two people lived more independently in a detached bungalow, but also received personal care from staff working at the service. On the day of our inspection there were 22 people living at the home. Lake View does not provide nursing care and people who live at Lake View access healthcare through local community health services. The home is owned by South West Care Homes Ltd, which operates 10 residential care homes in South West England.

There was a registered manager in post at Lake View. 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 walked around the building and found some areas that required attention. For example, some carpets were ripped. Some areas, such as the entrance hall were in need of redecoration. The provider had produced a plan to deal with any environmental issues.

Some people living at the home felt there were not enough staff on duty to meet their needs.

Medicine management was not entirely safe. Not all entries on record charts were double signed to ensure the correct information had been recorded. Other aspects were found to be sufficient, including the administration of medicines.

Improvements were needed to ensure people’s capacity to make decisions was appropriately assessed and the way in which they were asked for their opinions on the quality of care provided. People’s capacity to make decisions for themselves had not been assessed.

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

People told us they felt safe. Staff had received training in safeguarding people from abuse. Staff also received some relevant training to enable them to meet people’s needs. However, no training in caring for people with dementia had been provided.

People were asked for their consent before staff provided any personal care. Healthcare needs were met by visiting professionals. Health and social care professionals that we spoke with had no concerns over the care being provided by the home.

There was a robust recruitment procedure in place. This minimised the risk of recruiting staff who may be unsuitable to work with vulnerable people. We saw good interactions between staff and people living at the home. Interactions were professional, caring and friendly. Where staff identified people’s personal care needs they responded promptly. People told us they enjoyed a range of activities including musical entertainment and visiting animals.

Care plans contained some confusing information. However, staff knew people’s needs and we saw that people’s needs were met in a personalised way. We saw a range of risk assessments and these showed the measures that were taken by the home to reduce any risks.

People’s views were not regularly obtained about the quality of care provided and they were not always involved in planning their care. While people knew who to complain to, there was no recorded evidence the complaints had been dealt with.

The registered manager had been in post for just over a year. The registered provider carried out a number of audits to enable them to measure the quality of the service being provided. Where shortfalls had been identified action plans had been produced in order to address the issues.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.