The inspection took place on 25 and 26 September 2018. This was the first inspection of Ormsby Lodge since a change of ownership and registration.

Ormsby Lodge 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. Ormsby Lodge offers accommodation and support for up to ten people with a learning disability. At the time of our inspection there were no vacancies.

The care service has been developed 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.

There was a registered manager in place. 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.

Medicines were not always administered safely. Risk assessments did not always promote positive risk taking and did not always result in the least restrictive course of action. Some risks had been identified but there was not a risk assessment in place. People were not always protected from the risk of infection because the water system had not been checked for Legionella.

The service was not working within the principles of the Mental Capacity Act 2005. People’s privacy and dignity was not always respected. There was not a system of annual appraisal and regular supervision in place for staff. The governance and leadership did not support the delivery of a high-quality service. The auditing system was not robust and did not identify the concerns we found during the inspection.

The provider had policies and procedures in place designed to protect people from abuse. People’s needs were met by suitable numbers of staff. Accidents and incidents were recorded appropriately and kept under review by the registered manager.

People were supported by staff who had access to relevant training. People were involved in menu planning at the weekly meeting. The staff team and registered manager worked in partnership with other services and organisations. People had access to healthcare professionals and staff supported people to attend appointments.

People were treated with kindness and respect and during the inspection we observed staff interacting positively with people. Staff communicated with people using communication methods they understood, such as Makaton, where people used this. People were encouraged and supported to join local self-advocacy groups.

People had individual support plans in place which gave staff detailed guidance around personal care, communication needs People were involved in creating their support plans and accessed them when they wished to. People were supported to maintain relationships which were important to them, such as family members. People enjoyed a range of activities and interests within the home, at the day centre and in the local community the provider had a complaints procedure in an easy read format.

The registered manager promoted a culture which was open and inclusive.

We identified breaches of Regulations 10, 12, 13 and 17 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 back of the full version of the report.