This inspection took place on 2 and 3 August 2018 and was unannounced. Loring Hall is a residential care home that provides accommodation and nursing care for up to 16 people with learning disabilities. At the time of our inspection 15 people were living and receiving support at the home. 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.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

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.

At our last inspection in June 2017 we found a breach of regulations because the provider’s systems for monitoring the quality and safety of the service were not operated effectively in order to drive service improvements and ensure people’s safety. We also found improvement was required to ensure people’s medicines were safely managed and because people’s care plans had not always been reviewed regularly, in line with the provider’s policy. Following that inspection, we received an action plan from the provider telling us how they would address the issues in respect of the regulatory breach.

At this inspection we found that, whilst the provider had addressed some of the issues identified at the last inspection, they had not sufficiently addressed the issues in respect of the regulatory breach. The provider’s systems for monitoring quality and mitigating risks to people were not effective. Medicines audits had not been carried out on a regular basis and the process used to check in new stocks of people’s medicines failed to identify issues in the recording of people’s medicines. The systems used for monitoring people’s risk assessments did not always drive improvements where they were needed. The provider’s systems for monitoring areas including incidents and accidents, and people’s weights were not operated in a way that enabled them to have oversight of people’s conditions over time to ensure they were receiving safe and effective support.

We also found that people’s medicines were not safely managed. Staff had not always signed people’s Medicines Administration Records (MARs) to confirm whether people had taken their medicines as prescribed. There was not always sufficient guidance in place for staff on medicines people had been prescribed to take ‘as required’. Medicines disposal records showed that two people had missed doses of their prescribed medicines but there was no further information available regarding when these doses had been missed and these issues had not been followed up.

Additionally, the registered manager had displayed the rating from the previous inspection in the home and had submitted notifications about certain events to CQC, but had not been aware to submit notifications where people were subject to Deprivation of Liberty Safeguards (DoLS) authorisations, as required by the current regulations.

You can see what action we have told the provider to take at the back of the full version of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Risks to people had been assessed but improvement was required to ensure risk assessments were updated promptl

This inspection took place on 6 and 8 June 2017 and was unannounced. Our last inspection of the service in April 2016 was a focused inspection and was prompted in part by notification of the death of a person using the service. At the inspection in April 2016, we looked at the safety and management of risks to people using the service and found breaches of regulations as health risks to people were not always assessed and there was not always adequate guidance for staff on how to manage risks. In addition, risks relating to the home environment were not always assessed or managed and medicines were not always managed safely. Staff did not always receive sufficient specialist training relevant to people's conditions. At the time of both inspections, there was an on-going investigation at the service in relation to the death of the person using the service.

We carried out this inspection to check the actions the provider told us they would take to address the breaches to meet the fundamental standards and to conduct a full comprehensive inspection of the service to cover other areas the focussed inspection would not have reviewed. As the investigation was still on-going at the time of this inspection, we have not been able to consider the evidence relating to the death of the person using the service. When the investigation is concluded, we will review the evidence and consider what further action, if any, CQC may need to take.

Loring Hall provides accommodation and personal care support for up to 16 adults with learning disabilities. At the time of this inspection, the service was providing support to 16 adults. The home had a registered manager. However, we were advised at the time of this inspection that they had tendered their resignation and were not actively managing the service. The provider was in the process of recruiting a new manager to run the home and the provider told us the ‘home manager’ would be managing the home until a new manager was recruited. 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.

At this inspection we found that whilst the provider had made some of the required improvements and had addressed most of the breaches previously identified, we found a new breach of regulations as the provider failed to ensure there were effective systems in place to assess, review, monitor and improve the quality and safety of the service and to maintain accurate complete and contemporaneous records. You can see what action we told the provider to take at the back of the full version of the report.

At this inspection we found that although some improvements had been made to the management of medicines further improvements were required. Medicines that required refrigeration were not consistently monitored to ensure they were stored within safe temperature ranges. People’s care plans were comprehensive and holistic and we observed people received support in line with their planned care. However, not all parts of people’s care plans were regularly reviewed in line with the provider’s policy and this required improvement. People using the service and their relatives were not always provided with the opportunity to give feedback about the service to help drive improvements. Although staff received regular supervision and staff performance and development was appraised there was no formal system in place at the time of our inspection. However, the provider told us they were in the process of developing and implementing a staff appraisal system which they expected to be operational within the next few months.

There were appropriate safeguarding adults and whistle-blowing procedures in place. Systems were in place to support people wher

We carried out an unannounced comprehensive inspection of this service on 03 and 05 November 2015 at which we found the provider was meeting legal requirements. After that inspection we received concerns in relation to the management of risks to people using the service. As a result we undertook an unannounced focused inspection on 28 April 2016 to look into those concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk.

Loring Hall provides accommodation and personal care support for up to 16 adults. At the time of this inspection, the service was provided to 13 adults with learning disabilities. There was a registered manager in place at the time of our 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.

At this inspection we found breaches of regulations because risks to people had not always been assessed and there was not always adequate guidance in place for staff on how to manage risks. We also found areas of risk relating to the environment were not always safely assessed or managed, and that people had not always received their medicines as prescribed. Medicines storage areas were not monitored to ensure medicines were stored at a safe temperature. There was insufficient guidance in place for staff on when they should administer medicines that had been prescribed as being 'as required' and records relating to the administration of people's medicines had not always been accurately maintained. We also identified a further breach of regulations because staff had not always received sufficient specialist training relevant to people's conditions. You can see what action we told the provider to take at the back of the full version of the report.

There were sufficient staff on duty to meet people’s needs and people commented positively about the support they received.

We considered our inspection findings to answer questions we always ask; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff were aware of the importance of consent and people were asked for their consent

before care was provided. People's needs were assessed and risk assessments were

carried out before care was provided. These were regularly reviewed so that staff were aware of the best way to provide support. The provider and manager were available on a daily basis to oversee the staff and monitor that people were being safely supported, for example in managing challenging behaviour and in travelling in the community. Health care professionals and social services were involved in people’s care planning and in responding to people’s concerns when needed.

There were arrangements in place to deal with emergencies and to make sure people were safe. People’s health needs were included in their care planning to ensure they were healthy. Fire safety equipment and procedures were in place to ensure people would be kept safe in the event of a fire.

There were safe procedures in place to look after and administer medication and staff who were responsible for people’s medication were trained for this task.

Effective recruitment procedures were in place to ensure that suitable staff were

employed, including checking their history of employment to ensure they were experienced and of good character.

Is the service caring?

We spoke with four people who used the service and observed staff working with people, and were told that the staff and manager were very caring and supportive. We saw that staff always took the time to stop and speak with people and spoke with them in a manner they best understood, speaking slowly when needed. One person said: “I can’t fault the staff here, they have always listened to me and helped me when I needed them most, to sort out my problems and to make sure I always had my family told when I needed their help.”

Is the service effective?

We saw that people's needs were assessed and a plan drawn up to meet those needs.

People told us they were happy with the plan provided. Regular reviews were made of the plan provided and people told us they were involved in the reviews. There were suitable policies in place for consent to care, management of medication and recruitment. One person told us: “this is the best place I’ve lived, and the staff know how to support me well. I have learned a lot here and now have a job and feel safe and happy.”

People who used the service were consulted for their views on a regular basis. Any

changes they requested were included in a revised care plan.

New staff had been recruited and were provided with adequate support, guidance and

training to do their job.

Is the service responsive?

People we spoke with who used the service told us that the staff and manager always listen to their concerns and do something to help sort out any problems they are experiencing. People were provided with a range of enjoyable activities and changes were made when necessary to try out new activities. People’s behavioural management plans were reviewed and changed when necessary in response to incidents so that best approaches to helping people to maintain their activities and interests continued to be supported.

Is the service well led?

The registered manager and owner were involved in direct care and worked with all the staff. They felt this meant they could identify any issues quickly and address them if they arose. Staff we spoke with told us that they felt the home was very well managed and that they received direction and training to allow them to support people at the home. Regular staff meetings and supervision sessions were held and staff said they felt able to raise any issues with the management openly and honestly.

People who used the service told us that they felt the manager was very good at managing the home and was always present to speak with about any concerns.

There were a range of systems in place to monitor the quality of people’s care, and to make sure any concerns about staff, management or the way in which care was delivered were addressed.

The deputy manager told us that they had met with the local authority, and with people who used the service and their families, to agree the best process to help people to understand and agree to their care plans, and to be involved in consenting to any treatment proposed. We found that the provider had agreed a way of including people in decisions about their care and treatment, by assessing people's abilities to consent and providing advocacy support for people where necessary to help make important decisions. People were now being supported to understand their care and treatment and to formally agree to the care provided.

We saw that staff were respectful and involved people in making decisions about activities, using verbal and non verbal communications to help people to make suitable choices. For example all of the people who lived at the home attended activities of choice, such as bingo, football matches, church and computer skills classes. Pictures, objects and symbols were used to enable people to make choices, and some procedures such as complaints and the key-worker system were available in picture format.

We saw staff were involved with people who lived at the home, and there was clear methods of communication used, with staff taking time to listen to people and respond to their needs. We saw that staff treated people with courtesy and respect, and five people we spoke with said that the staff were very helpful and respectful and helped them to have lots of activities.

Care planning and reviews took place regularly with involvement from people, but care plans were not signed as agreed by people who used the service or their representatives.

We found that the staff understood people’s care needs and how to protect them from risk and harm. Care staff were appropriately qualified and had adequate training and supervision.

Appropriate checks were being done by the provider to ensure that the quality of people’s care was maintained.

Some of the people who used the service could not fully communicate verbally. Staff helped them to tell us their views about the home.

People who lived at the home said that the staff were good, listened to them, and were very helpful. One person said:” I can speak often with staff and the manager and they have helped me to get a job and to buy things I need”. Four people said that the food was good and they were happy living at home and felt safe there.

We were told by people who lived there that there were activities outside of the home that they took part in, such as playing golf, going to the cinema and bowling. We saw people going off to play golf and when they returned they told us they had enjoyed it .

We used a system for observing people in their homes during the inspection to observe people being supported by staff. We saw people receiving support and interacting with staff over a number of hours. We found that staff frequently spoke with people who lived there and treated them in a sensitive and respectful manner. People appeared to be relaxed and happy in the company of staff. A meal was prepared and served and we were told that people living at the home were able to take part in preparing meals.

This inspection took place on the 03 and 05 November 2015 and was Unannounced. At the last inspection on 30 April 2014 the provider met all the requirements for the regulations we inspected.

Loring Hall provides accommodation and personal care support for up to 16 adults. At the time of our inspection, the service was provided to 13 adults with learning disabilities.

A registered manager was in post at the time of our 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.

The management team carried out a range of audits and checks to improve the quality of the service provided and to ensure it was safe. There were procedures in place to protect people from the risk of abuse. Staff had received safeguarding training and demonstrated they knew what to do if they suspected abuse had occurred. Risks to people had been assessed and assessments were regularly reviewed to ensure risks were safely managed.

There were enough staff on duty to safely meet people’s needs and recruitment checks had been made on staff before they started work for the service. Medicines were safely stored and administered within the service and there were arrangements in place to deal with foreseeable emergencies.

Staff had undergone an induction when starting work and had received appropriate training to ensure they had the skill required for their roles. Staff were also supported in their roles through regular supervision.

People had enough to eat and drink and enjoyed the meals on offer. They had access to a range of healthcare professionals when needed and were involved in making decisions about their care and support. Some adaptations had been made to people’s rooms where required, to ensure their needs were safely met.

Staff were aware of the need to ensure people consented to the support they received and treated people with dignity and respect. The registered manager demonstrated a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

People told us they were treated with kindness and compassion and staff demonstrated a good knowledge and understanding of the people they supported. People’s care plans were person centred and people were involved in the planning of their care as much as they wished to be.

The provider had a complaints procedure in place and people told us they knew how to raise concerns if they had any. People told us that the service was well led and the culture of the service was open and positive.

People were invited to express their views about the service and took action in response to people’s feedback.