This inspection took place on 15 May 2018 and was unannounced, this meant the provider and staff did not know we would be visiting.

Lorne House is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Lorne house were registered for 14 beds and accommodated 13 people at the time of the inspection. Two of these people were in hospital.

The service had a registered manager who was registered in March 2016. 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 was last inspected March 2017 and the overall rating was required improvement. We made some recommendations to the provider about records with medicines and offering too much processed food.

At this inspection we found the provider had made some improvements, however further improvements were needed to become fully compliant with the fundamental standards of quality and safety. This was the second time the service has been rated requires improvement.

We found concerns with risks to people's safety including the management of medicines.

Lorne House was designed, built and registered before 'Registering the Right Support' and other best practice guidance had been published. Lorne House was operating and developing 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 using the service should be able to live as ordinary a life as any citizen, and this was always the case for every person living at the service.

Risks to people arising from their health and support needs were not always assessed and plans were not always in place to minimise them. Where people were at risk of choking, guidelines from Speech and Language Therapist (SALT) were not followed.

Audits were taking place but had not identified the concerns we found at inspection.

Care plans contained detailed information about people’s personal preferences and wishes as well as their life histories.

Feedback was sought from the people who used the service and their families.

People were supported to access the support of health care professionals when needed.

Safeguarding principles were embedded and staff displayed an understanding of what to do should they have any concerns.

There was enough staff to meet people's needs on a day to day basis, staffing levels were not increased to accommodate when staff accompanied people to an activity. Due to two people being in hospital this was not such an issue on the day of the inspection but we discussed this with the registered manager. The registered manager had already acknowledged this and was in the process of recruiting more staff.

Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work. Staff told us they received training to be able to carry out their role and we saw evidence of this. Staff received effective supervision and a yearly appraisal.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received a varied and nutritional diet and enjoyed the food offered.

The interactions between people and staff showed that staff knew the people well and were kind and respectful.

The management team were approachable. People, relatives and staff felt any concerns would be taken seriously and acted on.

We

The inspection took place on 14 March 2017 and was unannounced. This meant the provider and staff did not know we would be visiting. We carried out a further announced visit to the home on 15 March 2017 to complete the inspection.

At our previous comprehensive inspection in January 2015, we identified two breaches of regulations relating to consent and the maintenance of records. We rated the service as ‘Good.’ We carried out a follow up inspection in July 2015 to check that improvements had been made. We found that the provider was now meeting the regulations however improvements were still required. We made a recommendation that the provider should integrate the Mental Capacity Act 2005 into the service’s assessment, care planning and recording systems.

Lorne House provides personal care and accommodation for up to 14 people with learning disabilities. There were 13 people living at the home at the time of our inspection.

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

People told us they felt safe at the service and relatives confirmed this. We found the provider had not passed one safeguarding allegation to the local authority’s safeguarding adults team in line with their policies and procedures. Instead, they had dealt with the concerns raised through their complaints procedure and had carried out their own investigation. We passed this information to the local authority’s safeguarding team.

Checks and tests were carried out to ensure the safety of the premises. There was an ongoing refurbishment programme in place. Most of the bathrooms had been refitted and the laundry room was being extended. A recent environmental health inspection had been carried out following an anonymous concern. Minor issues had been identified and the service had kept its five star [highest] food hygiene rating.

We looked at the management of medicines. There were some omissions and inconsistencies with the recording of medicines. We have made a recommendation about this.

People did not raise any concerns about staffing levels. Some relatives and staff told us however, that more staff were required. The provider was reviewing staffing levels and was going to implement a suitable tool to assess staffing levels.

Recruitment checks were carried out to ensure that applicants were suitable to work with vulnerable people. This included obtaining written references and a Disclosure and Barring Service check [DBS]. We saw that training was carried out in safe working practices. Staff were also working towards a training programme to meet the specific needs of people who lived at the home.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Information about people’s capacity and DoLS authorisations was included in their care files. We noted however, that records did not always demonstrate how staff followed the requirements of the MCA. We have made a recommendation about this.

People told us they enjoyed the meals at the home. Several staff however, raised concerns about the standard of meals at the home and said there was an over reliance on processed meals. We read people’s food records and noted that certain meals were repeated on a regular basis such as hot dogs and chips, quiche and chips and fish fingers.

People had access to a range of healthcare services to ensure their health needs were met.

People and relatives told us that staff were caring. We saw positive interactions between people and staff. People’s privacy and dignity was promoted.

Care plans were person centred and documented t

We carried out a new approach comprehensive on 19 and 21 January 2015. At that time we gave the service an overall rating of 'Good'. However, we also identified two breaches of regulation and required that the provider make improvements under the key question ‘Is the service effective?’ We identified a breach of Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010: Consent to care and treatment, where we found that the provider failed to ensure staff adhered to the requirements of the Mental Capacity Act 2005 [This corresponds to regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014]. We also identified a breach of Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010: Records, where we found that the provider had failed to ensure accurate records were maintained in respect of each person using the service and the management of the home [This corresponds to Regulation 17(2)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014]. After our inspection the registered provider sent us an action plan, telling us what they were going to do to make the required improvements.

We carried out this focused inspection on 30 July 2015, to check that the registered provider had taken action and made the required improvements. The visit was unannounced so the registered provider and staff did not know we would be visiting. During this visit we only looked at information relating to the previously identified breaches of regulation, relating to the implementation of the Mental Capacity Act (MCA) 2005, Deprivation of Liberty Safeguards and care records. The inspection team consisted of one adult social care inspector.

Lorne House is a care home providing support for up to 14 people who have a learning disability. It is located on a main road in Stockton on Tees, close to local amenities and the town centre. The care home was set up by a group of parents who had children with learning disabilities and this group formed the charity that now operates the home.

The service had a registered manager in place, who had been in post for over five years. 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 registered provider had implemented a new assessment tool, which considered people’s capacity and decision making abilities and how staff could support people to make decisions. Where people had been assessed as lacking capacity to make decisions about their care and welfare and were subject to constant care and supervision, the service had applied for, and been granted, authorisations under the Deprivation of Liberty Safeguards. Relevant paperwork had been completed and was in place in relation to the authorisation process. However, relevant information about people’s capacity, decision making abilities and DoLS still needed to become a more integral part of the service’s every day care planning processes.

Senior staff had completed further training on the MCA and DoLS, with further training for other staff planned in the near future. Staff we spoke with had an understanding of the principles of the MCA and knew that some people at the service had DoLS authorisations in place. However, staff knowledge about the purpose of DoLS could still be improved.

At the time of our visit we had not received formal notifications about the DoLS authorisations that had been granted. This is a legal requirement and was discussed with the registered manager during our visit. They explained that this had been a genuine oversight on their behalf which would not occur again. They submitted the required notifications for all of the service’s current DoLS authorisations within a few days of our inspection visit.

The care records we looked at included detailed information about the care and support people needed. The majority of the care records we viewed were up to date, detailed and reflected people’s needs. However, we found some improvements were still needed to ensure that people’s actual care plans were always fully up to date.

Overall we found that the registered provider had taken action to meet the requirements of the regulations. However, there remained areas for further improvement, which were discussed and agreed with the registered manager at the time of our visit.

Some concerns were raised around how the provider recruited and oversaw the competency of staff. Concerns were also raised around how the manager ensured safeguarding procedures were followed.

During this inspection we found that people who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We found that all 21 staff had received safeguarding training and this has been regularly refreshed, with the last courses being completed in 2012 and 2013. We saw that the manager checked staff understanding of the process and safeguarding expectations during supervision and within staff meetings.

We noted that the staff team was very stable and all of the staff had been in post for over two years and the majority had worked at the home for over five years. From a review of five staff files, including those of the most recently recruited we saw that the recruitment process met the regulatory requirements. We found that the provider had appropriate processes in place to ensure that staff were fit and able to perform their role.

We met and spoke with staff, three service users and three relatives about the home and their experience of the service. We also looked at four care records and daily recording diaries. We also looked at a care plan protocol which gave guidance to staff on how to complete the care plans.

We saw evidence that regular meetings with people, advocates, staff and relatives had taken place on a variety of topics. Relatives we spoke to told us the care was great at the home and they had no complaints.

We found that that people were provided with a choice of suitable and nutritious food and drink. People were protected from the risks of inadequate nutrition and dehydration.

We found that people who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Also that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We spoke with four people who used the service. People who used the service told us they were happy living at Lorne House. One person told us “I like living here.” Another person told us “I have been to work today.” Another person told us “I am going to the disco tonight.”

We inspected Lorne House on 19 and 21 January 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

Lorne House is a care home providing support for up to 14 people who have a learning disability. One of the facilities is a bedsit on the top floor, which has a small domestic kitchen next to it. The care home was set up by a group of parents who had children with learning disabilities and this group formed the charity that now operates the home.

The home had a registered manager in place and they have been in post for over five years. 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.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards training but were unclear about the requirements of the Act. We found that there was no information to show whether relatives had become Court of Protection approved deputies, or if they had enacted power of attorney for care and welfare or finance or if they were appointees for the person’s finance. No records were in place to show that staff completed capacity assessments where appropriate and made ‘best interest’ decisions. We found that people we spoke with were able to discuss a range of decisions they made but did need support with understanding some complex information. We found that other people had difficulty making decisions; were under constant supervision; and prevented from going anywhere on their own. Staff did not know whether people were subject to DoLS authorisations, which are needed if people lack capacity to make decisions and these types of restrictions are made. We found that the registered manager was being guided by the supervisory body and was waiting for them to determine if 13 people needed DoLS authorisations. They recognised that further action was needed to ensure the staff understood how to apply the requirements of the MCA.

We saw that assessments were completed, which identified people’s health and support needs as well as any risks to people who used the service and others. These assessments were used to create support plans for people to follow whilst they used the service. The people we spoke with discussed their support plans and how they had worked with staff to create them. We found that staff needed to ensure these were updated and altered as people’s needs changed. At times staff were not recording the review of people’s needs that they had completed. Staff were able to discuss in-depth the support each person needed and how they worked with people.

People living at the home required staff to provide support to manage their day-to-day care needs; to develop impulse control; as well as to manage their behaviour and reactions to their emotional experiences. We found that the manager had taken appropriate steps to ensure, that when people became anxious staff found out what would reduce this distress and provided a consistent response.

Three of the people we met were very able to tell us their experiences of the service. They were complementary about the staff and found that home met their needs. People told us that the registered manager was approachable and sorted out problems they had around living in a group. People told us that they made their own choices and decisions, which were respected by staff but they found staff provided really helpful advice.

The other people we met had difficulty discussing abstract ideas, such as their views on whether the support provided at the home was appropriate but were able to share their views about day-to-day life at the home. People told us they liked living at the home and that the staff were kind and helped them a lot. We saw there were systems and processes in place to protect people from the risk of harm.

We observed that staff had developed very positive relationships with the people who used the service. We saw that where people experienced high levels of anxiety staff were able to discreetly reduce the impact on the individual and those people around them. Interactions between people and staff that were jovial and supportive. Staff were kind and respectful; we saw that they were aware of how to respect people’s privacy and dignity.

People told us they were offered plenty to eat and assisted to select healthy food and drinks which helped to ensure that their nutritional needs were met. We saw that each individual’s preference was catered for and people were supported to manage their weight and nutritional needs.

We saw that people living at Lorne House were supported to maintain good health and learn about how to be healthy whilst using the service. 

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work. The checks included obtaining references from previous employers to show staff employed were safe to work with vulnerable people.

Staff had received a range of training, which covered mandatory courses such as fire safety, infection control, food hygiene as well as condition specific training such as working with people who experienced learning disabilities and specific physical health conditions. We found that the staff had the skills and knowledge to provide support to the people who used the service. People and the staff we spoke with told us that there were enough staff on duty to meet people’s needs. We saw that the number of staff on duty varied throughout the day to reflect how many people were in. This was reflected in the rotas but at least two care staff covered the service during the day, with this going up to three at times and there was a waking night staff and one of the team leaders slept at the home. Also throughout the week day there was the registered manager, an administrator, the cook, the driver and the housekeeper.

We reviewed the systems for the management of medicines and found that people received their medicines safely.

We saw that the provider had a system in place for dealing with people’s concerns and complaints. People we spoke with told us that they knew how to complain and felt confident that staff would respond and take action to support them. People we spoke with did not raise any complaints or concerns about the service.

We found that the building was very clean and well-maintained. Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. We found that all relevant infection control procedures were followed by the staff at the home. We saw that audits of infection control practices were completed.

The provider had developed a range of systems to monitor and improve the quality of the service provided. We saw that the manager had implemented these and used them to review the service.

We found the provider was breaching two of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These related to adhering to the requirements of the MCA and maintenance of the records keeping. You can see what action we took at the back of the full version of this report.