The unannounced inspection took place on 29 August and 5 September 2017

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home had previously been able to accommodate 28 people. The provider had applied to the Care Quality Commission (CQC) to reduce this to 25 people. In May 2017 the provider had been issued with a new registration to accommodate 25 people at the service. There were 20 people using the service on the first day of the inspection.

The service had a registered manager. 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 carried out a comprehensive inspection of this service in July 2016. A breach of a legal requirement had been found at that inspection. The breach was because care plans did not always include details relevant to maintaining people’s health and wellbeing. Also people and their families had not been involved in developing and reviewing their care plans. Following the inspection we were sent an action plan setting out the actions the provider was going to take. At this inspection we found action had been taken regarding these concerns and the requirement had been met.

The registered manager had worked with staff and put in place very comprehensive care plans. Care plans reflected people’s needs and gave staff clear guidance about how to support them safely. They were personalised and people where able and their families had been involved in their development. Therefore people received personalised care that was responsive to their needs.

Risk assessments were undertaken for people to ensure their health needs were identified. Accidents and incidents were reported and action was taken to reduce the risks of recurrence.

Everyone gave us positive feedback about the registered manager and said they were very visible at the service and undertook an active role. They promoted a strong caring and supportive approach to staff.

People were supported to follow their interests and take part in social activities. A designated activities coordinator was employed by the provider. They ensured each person at the service had the opportunity to take part in activities and social events which were of an interest to them.

Staff were able to anticipate people’s needs and were respectful, discreet and appropriate in how they managed those needs. There were positive and caring relationships between staff and people who lived in the home and this extended to relatives and other visitors. Staff were compassionate, treated people as individuals and with dignity and respect. Staff knew the people they supported, about their personal histories and daily preferences. Staff showed concern for people’s wellbeing in a caring and meaningful way. Where possible, people were involved in making decisions and planning their own care on a day to day basis.

The registered manager and staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) (2005). Where people lacked capacity, mental capacity assessments were completed and best interest decisions made in line with the MCA for the majority of decisions.

People were supported by sufficient staff to meet their needs promptly. Staff had the required recruitment checks in place and were trained and had the skills and knowledge to meet their needs. Staff had received an induction and were knowledgeable about the signs of abuse and how to report concerns.

People were supported to eat and drink enough and maintain a balanced diet. People were seen to be enjoying the food they received dur

The unannounced inspection took place on 5, 12 and 19 July 2016.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home can accommodate up to 28 people. There were 22 people using the service at the time of the inspection.

The service is required to have a registered manager. 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. Lakenham Residential Home had a registered manager.

Our previous scheduled inspection of Lakenham Residential Home, in September 2015, found the provider had failed to protect people who used the service. This related to ensuring a safe premises, the handling of medicines, consent to care and treatment, deprivation of liberty without authorisation, not notifying the Commission of incidents, assessment of risk and insufficient oversight of the service to maintain safety and promote welfare. Following the last inspection, the provider sent us an action plan. Following this a focused inspection in March 2016, to look at medicine management, found that there was significant improvement but not all risk had been managed. This inspection found that medicine management was safe and there was a lot of improvement with regard to protecting people who used the service, although not all of the improvements were completed or embedded.

People’s legal rights were understood and being promoted although where people had authorised a representative to act on their behalf the detail of those authorisations was not always confirmed. Some of those details were noted, but further improvements were needed

People enjoyed the meals provided but the service were unable to evidence the diet people received was nutritionally balanced. This was because there was no set menu and the cook had not received training in the subject. We have recommended that the service uses current, researched based, best practice in providing nutritious diets for people living with conditions relating to older age or disability.

Whilst Lakenham Residential Home provides a wide variety of communal space there were no environmental adaptations to promote independence for people living with dementia. We recommend the providers consult current guidance on the design of environments for people living with dementia and take that guidance into account for any future upgrading.

An effective recruitment policy protected people from staff who might be unsuitable or unsafe to work in a care home. However, we recommend a review of the service recruitment policy to ensure all aspects of the recruitment procedures are recorded.

Some care plans lacked the detail to ensure people’s needs were fully understood and planned for. Some staff recording showed a lack of understanding in how to respond to a change in people’s needs. Some risk management was reactive to a problem rather than based on continual assessment and response. However, people’s needs were being met.

Staffing arrangements promoted people’s safety although some people felt the staff were sometimes unable to respond as they would have wished.

People, their family members, staff and health care professionals commented positively about the improved management and standards of care at the home.

People described a caring, friendly, patient and compassionate staff team.

Staff received the training, support and supervision needed to do their work. The registered manager monitored and worked with staff to improve their practice and find ways of improving people’s lives. The staff worked with community professionals for advice and to improve safety for people.

People said

The inspection took place on 1 March 2016 and was unannounced.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom have been diagnosed with a form of dementia. The home does not provide nursing care. The home can accommodate up to 28 people.

The service is required to have a registered manager. 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. There was no registered manager in post but a new manager was recently appointed. They said they were starting their application to register with the Care Quality Commission.

Our previous inspection, September 2015, found that medicine management at Lakenham Residential Home, was not safe. We issued a warning notice. During this inspection, we found that improvements had been made to address the areas of concern in the warning notice.

Staff had taken action to improve the ordering system to reduce the risk of medicines being out of stock. Staff recorded the receipt of medicines into the home so it was possible to check that administration records were accurate. People we spoke to did not have any concerns about how staff looked after their medicines.

Medicines training had been provided for staff to help ensure staff followed safe practice.

Some further action was needed to make sure that people’s medicines were looked after and given safely.

There was no additional information available to staff when people were prescribed medicines to be given ‘when required’, to help them give these medicines in a safe and consistent way.

There was no formal system to check that staff continued to give medicines safely. This increased the risk of unsafe practice continuing.

There were a continued breach of regulation. You can see what action we told the provider to take at the back of this report.

This inspection took place on 01December 2014 and was unannounced.

When we last inspected this service in May 2014 we found breaches of legal requirements relating to respecting and involving people who use the service, management of medicines and assessing and monitoring the quality of the service. This was because we observed people were not involved in their care planning and review, the storage of medicines requiring refrigeration were not being adequately maintained. Records for the application of topical creams were not always being completed. People’s views were not being sought about the quality of the service they were receiving. Auditing of systems were not always taking place.

The provider responded by sending the Care Quality Commission (CQC) an action plan of how they had addressed the breaches identified. We found the improvements the provider told us they had made was continuing to be developed during this inspection.

Lakenham Residential Care Home is a care home which provides care and support to older people some of whom had a diagnosis of dementia. The home does not provide nursing care. The home can accommodate up to 24 people. On the day of the inspection there were 15 people living at the home.

There was a manager registered with the Care Quality Commission. However they had not worked in the home since May 2014. 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 and associated Regulations about how the service is run. The location Lakenham has a condition of registration requiring the service to have a registered manager in post which it currently does not have.

People with a diagnosis of dementia did not receive activities which would benefit them based on current good practice guidance for dementia care. Staff we spoke with were not familiar with activities specifically designed for people with dementia.

Staff said they had completed an induction programme and were being supported in their roles, but that it was not always a formal process. Supervision records were not always being completed to show the development and training needs of staff.

There were times of the day when there had not been enough staff available to meet the needs of people living at Lakenham. During the lunchtime period people were waiting for long periods before they received assistance with their meal.

There were some recruitment procedures which showed the provider had not gained further information to ensure staff were safe to work with vulnerable people.

During the inspection in May 2014 we identified people were not always involved in their care planning and review. During this inspection there was still no evidence to show people were involved in the writing or review of their care plans. However when we spoke with a relative they told us the ‘manager’ of the home and the social worker was involving them in identifying and planning (their relatives) needs. We have made a recommendation about reporting where people were involved in decisions about their care.

During the inspection in May 2014 we found the provider did not have formal systems to report on the views of people living at Lakenham. During this inspection the provider was relying on regular communication with people using the service, professionals and relatives to gain feedback. No additional surveys had taken place since 2008 to gain peoples’ views. The provider told us through the PIR information that they intended to implement suitable quality assurance questionnaires rather than one to one feedback currently used to measure the effectiveness of the service.

Although most of the people who lived at the home could not provide feedback in a constructive way because of the impact of dementia. We observed staff in general displaying a warm and caring attitude when providing care. However, in one instance we observed a lack of respect when a staff member communicated with a person which compromised their dignity. We have made a recommendation about seeking best practice when supporting people.

There were procedures in place to monitor the quality of the service. Policies and procedures were in place including medication, safeguarding people and health and safety. However policies and procedures had not been reviewed for some time in order to update current good practice guidance.

Systems were in place to protect people from the risk of abuse. People told us they felt their relatives were safe and secure. However, the provider had not demonstrated how they had responded to information of concern reported by staff in daily notes.

We saw that staff knew the people who lived at Lakenham well. Staff knew where people liked to sit and what they liked to do. Where we observed people becoming confused and distressed, staff were able to reassure them.

We found the provider had taken steps to address breaches in medication management. Medicines were being dispensed safely and in accordance with prescriptive instruction.

Steps had been taken to carry out mental capacity assessments and best interest decisions were being recorded where necessary The registered manager demonstrated an understanding of the legislation as laid down by the Mental Capacity Act (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). Staff understood what was meant by restrictive practice in respect of depriving somebody of their liberty.

The provider told us the staff team worked very closely with people and their families and any comments were acted upon straight away before they became a concern or complaint. There were no complaints currently being investigated by the service.

We found a number of Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which correspond to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of the full version of the report.

We gathered evidence against the outcomes we inspected to help answer our five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We gathered information from people who used the service by talking with them.

This is a summary of what we found-

Is the service safe?

We felt that the service was safe.

People told us they felt safe living at Lakenham Residential Care Home.

We found Lakenham Residential Care Home to be clean and there were no unpleasant odours.

On the day of our inspection there were 14 out of 24 people living at the care home.

We assessed the staffing numbers of the home, which showed that there was sufficient staff on duty to meet people’s needs throughout the day.

We found that people’s care plans contained risk assessments to support staff to reduce and prevent a risk to the person or to themselves.

Is the service effective?

We did not find that the service was effective.

People who lived at Lakenham Residential Care Home were complementary of the care and support they received and told us, staff were “kind”, “caring” and “respectful”.

People we spoke with told us they did not feel that there was enough to do, one person commented, “There could be a bit more going on”.

We found people’s dignity was not always respected whilst being assisted with meals.

There was no evidence in people’s care plans that the person and or their relative/representative had been involved in the creation of their care plan.

People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medication.

Is the service caring?

We found the service to be caring.

People who lived at Lakenham Residential Care Home told us staff were kind and caring. Comments included, “first class, it really is” and “we are well looked after”.

During our inspection we found staff to be attentive to people’s care needs and request for assistance.

We found staff engaged in friendly conversation with people, however, we observed at times staff spoke with people in a childlike manner. Although, this was not with any unkindness, it was not respectful to people.

Is the service responsive?

We found the service to be responsive.

We found in people’s care records that staff involved external health care professionals such as dieticians and psychiatric nurses to support people with their changing care needs.

During our inspection we observed staff responding to people’s need when requested.

We found that when a complaint was received the provider fully investigated the concerns and when requested, liaised and worked with the local authority and the Commission to resolve concerns. We saw that the provider used complaints to implement changes as necessary to improve the standards and quality of the care delivered.

Is the service well-led?

We found the service to be well-led.

The service did not have a manager who was registered with the Care Quality Commission; however, we were informed that an application was being made.

It was clear from our observations that the provider and managers were actively involved in the care and support of people who lived at Lakenham Residential Care Home and they were passionate about ensuring people received good care.

Staff we spoke with told us they enjoyed working at Lakenham Residential Care Home and told us they felt the provider and head of care were supportive and approachable. Staff told us training was important to the provider and that training was reflective and responsive to the areas which staff required to improve or refresh their knowledge.

We found the provider did not have effective systems in place to monitor the quality of the service being provided. We found the monitoring of medication and the environment required improvement.

We visited the home between 7am and 2pm. We spoke with six people who were living there and were able to observe eight others. We met with seven members of staff on duty and the provider and we spoke with three health care professionals who had visited recently. We toured the premises and looked at equipment that was needed for people’s care. We looked at care records and service records for the equipment.

We made this visit because we had received information about Lakenham Residential Home. We were told that there were not enough staff in the home, that staff were expected to work singly when two staff were needed for safe achievement of tasks and that necessary equipment was faulty. During this visit we found that the provider was taking action to provide sufficient staffing. We found that staff were working together in a safe way. New hoists had been purchased. The provider undertook to admit no more people to live in the home until staff recruitment had been achieved to ensure no further increase in caring responsibilities for staff.

One person told us, “Staff are first class, I have no complaint. Meals are good and varied. I could have a bath or shower every day if I wanted.” One health care professional said, “I have had no problems. Staff always contact us if there are concerns with our patients. All has been going well at Lakenham for the people we have been working with.”

We visited Lakenham Residential Care Home on 23 July 2013 because we had received information of concern. We had been told that people were not being helped to eat their meals and that staff were not given the resources to maintain good hygiene in the home. Also, an Environmental Health Officer had visited the home and found that improvements were needed in the kitchen.

We spoke with six people living in the home and were able to observe four others. We met with the provider, the unregistered manager, three staff on duty and two regular visitors to the home. We toured the home and looked at care records and other documents related to the running of the home.

One person told us “the staff are very helpful. They always check on me before I go to sleep to make sure I am alright and see if there is anything else I want.”

We found that people were being given food that was appropriate for them and that staff knew when they were not eating and took appropriate action. People enjoyed their meals and were given food that was suitable for their health conditions and their ability to eat.

We found that staff had the equipment they needed to maintain good hygiene. We found the house was clean and free from unpleasant odours. Staff were responsible for cleaning the rooms of the people whose care they had provided. We saw that staff worked very hard to achieve this as they were answering call bells and watching for the safety of people living in the home.

On the day of our visit we were told that there were 16 people living at Lakenham Residential Care Home. We spoke to three people living at the home, spent time observing the care people were receiving, spoke to five members of staff, which included one of the owners and cook, looked at three people’s care files in detail and looked at the medication administration records for 10 people.

Before people received any care or treatment they were asked for their consent and staff acted in accordance with their wishes.

People we spoke with who lived at the home said that their care and welfare needs were being well met. Comments included: “I love it here, we can see the sea”; “They (the staff) always ask if they can help me, they help me with anything” and “My needs are always met, I have no grumbles.”

Medicines were safely administered. We saw the medication recording records which were appropriately signed by staff when administering a person’s medication.

We observed that staff were well organised, motivated and competent in their roles. Staff provided support in a caring manner making sure that people were comfortable and content.

People were made aware of the complaints system. This was provided in a format that met their needs. Comments included: “I have no concerns, but would speak to staff if I had” and “I have no grumbles.”

We carried out a review on 19 September 2011, which included an inspection of Lakenham Residential Home. We found that improvements were needed with regard to quality assurance systems as these had failed to identify inconsistent and poor practice with regard to assessment, care planning, responding to changes in people’s needs and infection control.

The purpose of this review was to check compliance in these areas. We looked at key outcomes covering respect and involvement, care and welfare, safeguarding people from abuse, infection control, staff support and assessing and monitoring the quality of the service.

We looked at the records of four people in detail; and where possible we spoke to the individual and or their carer. We observed other people being attended to whilst we were visiting.

People we spoke to said that their needs were being met, with comments like “We like it here” and “They’re very friendly. I had a fall, they were very good, they got the doctor out straight away”. Some people told us that the home had improved with comments like “it’s much better now”. A visitor commented that their relation’s health had “really improved” and they were “very satisfied with the home and how she’s cared for, the staff are so very kind”.

Three health professionals told us that the team make “timely referrals for advice”. One professional spoke specifically about the complex needs of a person they had been visiting and said “all of the care has been appropriate and sympathetic to her needs”. All of the professionals remarked that there had been a “lot of changes” and “improvements” particularly around infection control practices. For example, we were told “staff change their gloves all the time” and “there has been a lot of training around hygiene and hand washing”.

Robust quality assurance systems had been put in place to monitor care practices, assessment, care planning, responding to changes in people’s needs and infection control. For example, infection control audits had taken place every month, action taken to address shortfalls and awareness of best practice raised at team meetings and in training sessions with care workers. Care workers demonstrated that they had a clearer understanding of their roles and responsibilities and were following the home’s procedures. As a result of these actions standards had improved and the service was compliant.

We carried out this responsive review in response to an overall multi agency safeguarding strategy which is being coordinated by Devon County Council. The alert focuses on key themes, which highlight that the home may not:

• Identify changes in people’s needs in a timely way

• Seek support from appropriate professionals in a timely way, when changes occur to people’s needs.

• Have effective communication systems.

• Have experienced and skilled care workers in sufficient numbers to meet the needs of people.

We carried out a responsive review with an inspection to Lakenham Residential Home on 19 September 2011 and because of the concerns we looked the key outcomes 1, 4, 7, 8, 14 and 16.

We were not investigating this alert because this is being looked at as part of the safeguarding process. The purpose of this review was to check compliance in these key outcome groups for people currently living in the home.

We looked at the records of five people in detail; and where possible we spoke to the individual and or their carer. We observed other people being attended to whilst we were visiting.

People we spoke to said that their needs were being met, with comments like “it is ok here and the staff are nice” and “the staff are very caring and thoughtful". A visitor commented that their relation was “much calmer” because of the care they received.

We have identified some key areas of concern. Quality assurance systems have failed to identify inconsistent and poor practice with regard to assessment, care planning, responding to changes in people’s needs and infection control. We did not find that outcomes for people were poor, but we did find that this was not monitored sufficiently to ensure care and support was consistent, appropriate and always following best practice. We have set compliance actions in respect of these and we will be reviewing these again in the near future with a further unannounced visit to the residential home.

We carried out a comprehensive inspection on 17, 21 & 24 September 2015. The first visit was unannounced. The second two visits were announced because we wanted the provider to be available so they could contribute information and we wanted visitors to know we were available to speak with.

We last inspected the home in December 2014 and found breaches in the regulations relating to: recruitment of staff, person centred care, staffing and the governance of the service. The inspection report was not published until May 2015 and the service was rated ‘Requires Improvement’. The provider sent us an action plan following that inspection. We found during this inspection that three of the breaches were now met but one breach was not and we found some new concerns.

Lakenham Residential Care Home provides care and support to older people some of whom have been diagnosed with dementia. There are three places commissioned by the local authority to provide people with respite care. This means there can be quite a quick turnover of people using the service. The home does not provide nursing care and can accommodate a maximum of 28 people. At the time of the first inspection visit there were 22 people living at the home.

The service is required to have a registered manager. 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 service has a registered manager but they had not been in day to day control of the home for several years. They had not completed the process to have their name removed from the register of managers.

The management of medicines in the home posed a risk to people, such as not having their medicines available to them when needed.

People were not sufficiently protected from risks because of the way the service was managed. There was not clear leadership or oversight of the service to protect people. Our May and December 2014 inspections also found breaches with regard to management of the service.

People were not protected because adequate servicing and checks of the premises had not been undertaken. Regular fire alarm checks had not been done since June 2015, portable appliance testing had not been carried out since 2013. There were risks within the home’s environment which had not been assessed: a radiator which was hot and could cause scalding, wardrobes which could be pulled away from the wall and therefore at risk of falling on people. This meant that people were not always safe and risk was not monitored and managed, as part of good management arrangements.

The Care Quality Commission was not always notified of incidents so they could make judgments about risk at the service.

Staff had not acted to gain authorisation to deprive people of their liberty where a person was subject to continuous supervision and control, such as monitoring people’s movements. This was because the provider was not aware of a Supreme Court judgement which had widened and clarified the definition of deprivation of liberty.

People’s rights were not upheld because family members were making decisions on their behalf without the lawful authority to do so.

Our December 2014 inspection found recruitment practice to be unsafe. This inspection found recruitment practice was improved and checks were undertaken on all staff who had joined the home since we received the provider's action plan. 

People received regular drinks and nutritious meals through the day time period and food and fluids were available on request during the night time.

Staff and management were kind, caring and considerate of people using the service. One person’s family said, “The girls here are lovely. They genuinely care. They treat mum how you would want her to be treated”.

There were enough staff to meet people’s needs. Staff received training in their roles and regular supervision of their work through one to one meetings with the provider.

People’s emotional needs were understood and met, such as staff supporting a person needing attention and reassurance. Staff were very responsive and ensured they gave people the attention they needed. People were supported to present in a clean and dignified way.

Activities and social interactions with people gave opportunities for friendships and achievements. The arrangements for entertainment were improved because the television and music system had been replaced and an activities worker had been employed.

People’s views had been surveyed and responded to. Complaints were investigated and followed up. People and their family members were consulted and involved in decisions about care and treatment.

There were seven breaches of regulation. You can see what action we told the provider to take at the back of this report.