We carried out a comprehensive inspection of Larkswood on 12 and 13 March 2018. The inspection was unannounced.

Larkswood is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Larkswood is registered to provide personal care for up to 18 older people. At the time of the inspection there were 17 people living at the service.

The service had 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.

We last inspected the service in December 2016. At that inspection, we asked the provider to take action to make improvements as we found systems to assess, monitor and improve the quality and safety of the service were ineffective. We also identified the adaption and design of the home did not always consider the needs of people living with dementia and there was a lack of personalised activities. These areas of practice required improvement. At this inspection we checked to see if the provider had taken actions to address these issues.

Quality assurance and information governance systems were in place, however these remained in need of improvement. The service had not been able to consistently identify or act on quality and safety issues. There was no on-going development plan in place to help ensure the service could continuously learn and improve the quality of care it was delivering.

The provider had made changes to the home environment to consider the needs of people with dementia. This helped people with dementia to be at ease in the service and remain as independent as possible. There was now a range of personalised activities that people had helped choose on offer every day.

Medicines were not always being managed safely. Recording and guidance for administering medicines and ordering, storing and disposal of medicines were areas of practice that all required improvement to ensure people were not being placed at risk of avoidable harm.

The registered manager had not always complied with their obligations to submit relevant statutory notifications or display the service’s Care Quality Commission (CQC) performance assessment rating.

There was a ‘Consent to Care and Treatment Policy’ in place. Staff received MCA training and could explain the consent and decision making requirements of this legislation. Staff had a good awareness of people’s capacity and gave us examples of how they put this into practice when supporting various people.

However, formal assessments of people’s mental capacity to be able to make decisions about different activities had not always been carried out. It was not always documented that people, or a relevant person acting in their best interests, had been involved and consented to their care. This requires improvement to help make sure people have the right support to make their own decisions.

An assessment of people’s physical, psychological and social needs was carried out with the person and other relevant people before they started using the service. People’s differences were respected during the assessment process and there was no discrimination relating to their support needs or decisions. The assessment process required improvement to make sure there was enough detail about the support they needed, why this was and what their preferred support outcomes were.

People had been involved in planning their care and had the opportunity to regularly review this. Staff talked to people, relatives and other staff to be able to know about them and how they liked to be suppor

This inspection took place on the 29th and 30th December 2016 and it was unannounced.

Larkswood is a residential care home which is registered to provide accommodation for up to 18 people who require support with personal care. People had a mixture of needs some people were living with dementia and some people had mental health needs. At the time of our visit there were 16 older people living at the home and two people receiving short term care.

Larkswood is situated in Worthing in close proximity to shops and the seafront. The atmosphere was friendly and warm. Bedrooms are spread out over two floors, serviced with a lift with one bedroom on a mezzanine level. Bedrooms were personalised with people’s own belongings including personal photographs. Eleven bedrooms had en-suite facilities including toilets and the remaining rooms had sinks. Communal areas included a spacious lounge area and a dining room which both provided access to the garden and patio area.

The home had a registered manager who had been in post since December 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 2008 and associated Regulations about how the service is run.

The home was previously inspected on 19 September 2014 and then again on 3 and 4 September 2015 and we identified different breaches of Regulations during both inspections. In September 2015 we found improvements had been made and action taken by the provider to address the concerns from our inspection in September 2014. However, we identified new breaches of the Regulations in relation to managing medicines, assessing people’s capacity to consent to care and treatment and assessing risks to people surrounding their nutritional needs. Recommendations were also made in relation to improving how risks were assessed on behalf of people, staff training, adaption and decoration of the home, caring approaches used, personalised activities and quality assurance systems. We found at this inspection the provider had taken action to address the breaches and concerns identified however, this was not always consistent and further development was required. As such, the service remained 'Required Improvement' overall.

The previous inspection noted significant gaps in people’s medication administration records. This was in breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found actions had been taken and there were no significant gaps in people’s MARs. At this inspection we found improvements had been made and this regulation was now met.

At the last inspection we found the service was not working in accordance with the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). Appropriate capacity assessments were not carried out when people could not consent to their care and treatment. This was in breach of Regulation 11Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider completed an action plan of how this was to be addressed. At this inspection we found improvements had been made and this regulation was now met.

At the previous inspection we found when people were at risk of malnutrition there were gaps in people’s daily food records which meant staff could not ensure that people’s needs were being met in this area. This was in breach of Regulation 14 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found improvements and actions had been taken by the provider to ensure daily records were completed on behalf of people who had been assessed with this need therefore this regulation was now met.

The previous inspection recommended the provider sought guidance regarding effective quality assuranc

We looked at the personal care or treatment records of people who use the service, carried out a visit on 19 September 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members.

What people told us and what we found

We considered all the evidence we had gathered under the outcomes we inspected. We spoke with eight people using the service and two relatives and a visiting social worker. We also spoke with the acting manager and four care staff. We also looked at care plans and other documentation within the home. We used the information to answer the five questions we always ask.

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, and the staff told us.

Is the service safe?

The service is not as safe as it could be.

At the time of our visit there were 14 people who lived at the home. We spoke with eight people. They raised no concerns about their safety with us during our visit and said if they had concerns they would discuss them with the acting manager.

Each person's care file included risk assessments which covered areas of potential harm. When people were identified as being at risk, their plans showed the actions required to manage these risks, however they were not regularly reviewed.

Safeguarding procedures were in place to protect people from the risk of abuse. We found staff understood their roles and responsibilities about safeguarding the people they supported.

We found evidence that people were not always protected from the risks of unsafe or inappropriate care and treatment as the care provider did not maintain accurate and relevant records. We have asked the provider to tell us how they intend to ensure they comply with their legal obligations concerning planning and delivering safe care.

Systems were in place to ensure medication was administered safely and according to people’s needs. There were procedures in place to manage and mitigate foreseeable emergencies. These included procedures in relation to flooding, fire and evacuation and the loss of power.

Is the service effective?

The service is not as effective as it could be.

People were being cared for by staff with the appropriate skills. Staff we spoke with were able to tell us about the individual needs of people who lived at the home.

There was not always evidence that people’s social and emotional needs had been met. There was no forum in place to enable people to be involved in decisions about their care and support needs. People we spoke with felt they were cared for by a consistent team of staff who were caring and skilled.

Is the service caring?

The service is not as caring as it could be.

The people we spoke with told us they were happy with the care and support provided. We saw staff had meaningful conversations with people as they moved through the home. We noticed that staff were attentive to people’s needs and fostered a friendly atmosphere in the home. We spoke to people who used the service. One person said “The staff are lovely, they have a tough job but they do it well”. Another person said “In the circumstances they do well as it can get very busy”

Staff said they were aware of people’s preferences, interests, aspirations and diverse needs, but felt they needed more time to meet those needs.

Is the service responsive?

The service is not as responsive as it could be.

People’s needs had been assessed before they moved into the home. The home’s policy stated that care plans were reviewed monthly but we saw no evidence that they had been updated to reflect people’s current needs. We also found the home's acting manager was not able to produce all of the records requested during the inspection.

There were no activities organised in the home in which people could participate in order to help meet their social and emotional needs. The staff we spoke with told us that they needed more time to arrange these.

The service does not have a formal complaints policy. Although the service had not received any written complaints, the provider took account of verbal concerns to improve the service

We saw that staff were responsive to individual’s needs. People had the food they wanted and their personal care was attended to promptly. However we found that care plans did not always contain information about the needs of the person concerned. Some people also told us that their social and recreational needs were not being met. One person said “I am a bit bored to be honest.” Another person said” There’s not much to do and it’s nice to get out”

Is the service well-led?

The service is not as well led as it could be.

We found the provider did not have systems in place to continually monitor and identify shortfalls in the service and any non-compliance with the essential standards of quality and safety. We have asked the provider to tell us how they will make improvements to ensure they meet their legal obligations concerning this.

All of the people we spoke with who used the service and the staff spoke positively about the acting manager at the service. The staff told us that they felt well supported and that the manager was approachable. They told us that they felt confident to raise any issues or concerns with the manager and that they always felt ‘listened to’.

The acting manager said the home was developing processes to collect people’s views about the care and support they received and also a system to help ensure staff learnt from incidents and accidents.

We found that assessments of care were inadequate. We also found records about staff training, supervision, deployment and personal development records were not available for inspection.

On the day of our inspection there were eleven people who used the service. We spoke with six people and three members of staff.

People told us that they were very happy in the home and told us staff were kind. One person told us “Care is very good.” People told us they had a choice in how they spent their days.

People told us that staff understood their needs and provided appropriate care and support. We were told that staff responded quickly and dealt with any issues when people asked for assistance. One person told us “If I want anything staff will get it for me.” Another person told us that staff are “Very responsive, they act quickly.”

We found that people were protected from the risk of abuse and that staff understood about safeguarding vulnerable adults. One person said “I feel absolutely safe here.”

We found that the two areas identified as non-compliant in the previous inspection in November 2012 had been attended to. For example we found that annual training courses had now been planned and a new quality monitoring processes had been introduced.

You can see our judgements on the front page of this report.

On the day of our inspection there were 11 people living in the home. We spoke with five people who used the service and three members of staff.

People told us they were very happy in the home and everyone remarked on the kindness of the staff. One person told us "I can't think of anything that could make it any better." Another person said "This is a wonderful place to live, it's just like home, the staff are so kind."

People told us that staff understood their needs and provided appropriate care and support. We were told that staff were responsive when people asked for assistance and quickly dealt with any issues. One person told us "I only have to mention something and it's done."

However we found that over the past two months, documentation had fallen short of the home's own standards. For example the monthly reviews of the care plans and ongoing quality monitoring had not taken place. The manager acknowledged this and told us that plans were in place to rectify the lapse.

The provider was not able to evidence that during 2012 staff had undertaken their annual update of mandatory training.

Larkswood is a residential care home which provides accommodation for up to 18 older people who require support with person care, some of who were living with dementia. At the time of our visit there were 15 people living at the home. The inspection was unannounced and took place on 3 and 4 September 2015.

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.’

The home was previously inspected on 19 September 2014 and we identified breaches of the Regulations in relation to involving people in decisions about their care, care planning and delivery, accuracy of records and overall quality monitoring of the service. We found that improvements had been made and action taken by the provider to address the concerns from our previous inspection. However we identified new concerns and breaches of Regulations at this inspection.

At this inspection we found that the provider had taken action to improve how they involved people and there were now residents’ and relatives’ meetings where people were involved in decisions about the service. People and their relatives were invited to take part in reviews of the care people received.

We found that the provider had taken action to improve the quality of people’s care plans and risk assessments were now in place for people and were reviewed regularly. However we identified new concerns following reviews which identified changes to the support people needed. Care plans were not always updated to reflect these changes.

The previous inspection noted that there were no planned activities or external visits from entertainers. From this inspection we saw that monthly and weekly activities were planned which people enjoyed and looked forward to. However these were not consistently recorded to evidence they took place and there was limited evidence that planned activities took people’s individual likes and dislikes into account.

The previous inspection noted concerns about staffing levels as the registered manager was one of the two carer’s on duty. At the time of this inspection the provider had taken action to improve this and staffing levels had been increased. However we identified a new concern related to the training offered to staff and lack of specific dementia training. The training offered was not up dated to ensure that people’s needs were met specifically relating to supporting people with dementia.

At the time of the previous inspection there was no effective system in place to regularly assess and monitor the quality of the service that people received or to identify and manage risks to health, safety and welfare. The provider now had a quality monitoring system in place which checked areas including accidents and maintenance. This system did not cover areas in which we identified issues at this inspection relating to lawful consent and person-centred care. We have recommended that the provider consider developing this further to ensure a robust monitoring system.

The previous inspection identified that people were not protected from risks of unsafe or inappropriate care and treatment because care records were not always available or accurate. We saw that the provider had taken steps to address these concerns and training records were now in place and staff meetings and resident and relative minutes were available to review.

At the time of this inspection medicine administration records did not always show whether people had received their medicines or not as staff had not made a record of this. Arrangements were in place for the safe ordering and disposal of medicines. Consent to care and treatment was not always sought in line with legislation and guidance. Where people did not have capacity to consent formal processes were not always followed to protect their rights.

People were supported to maintain good health and had access to health professionals. Staff had regular contact with people’s GP surgery and other health care professionals.

When people were at risk of malnutrition we found gaps in people’s daily food records which meant that staff could not ensure that people’s needs were met.

People and relatives gave mixed views about staff providing a caring and respectful approach. We also observed variations in staff approach in this regard.

People and their relatives knew who to contact if they needed to raise a concern or make a complaint.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the end of the report.