Lanercost House - Carlyle Suite

People’s experience of using this service: Relatives were very positive about the caring nature of staff and the quality of care people received. Relatives described their family members as happy and relaxed with staff. One relative said, “We have no concerns at all. My family member is safe and very well looked after.”

Improvements had been made to the way risks were assessed, monitored and communicated to staff. People received their care as planned. The provider had learned lessons from our previous inspection and a recent safeguarding incident. They had put in place a number of improvements in response.

Systems were in place and followed so people were safe. People received their medicines as prescribed. The home was clean.

There were enough staff to meet people’s needs. Recruitment processes had been followed. Staff received a range of training and regular supervision meetings.

People regularly went on trips in the community and a range of activities were planned around their interests to support people with their social needs.

Relatives and staff were very positive about how well the service was run. The provider listened to people’s feedback and made changes based on their views.

The provider had made improvements to the checks they carried out to monitor the quality of the service they provided. They had increased the management presence in the home and carried out more observations of staff practice.

Rating at last inspection: Requires improvement (previous report published September 2018).

Why we inspected: This was a planned inspection in line with Care Quality Commission scheduling guidelines for adult social care services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit. If any concerning information is received we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Lanercost House - Carlyle Suite (Carlyle Suite) 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.

Carlyle Suite accommodates up to 15 people in one purpose-built building. At the time of our inspection 14 people were living there. The service is located in the grounds of Lanercost House care home.

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 found one breach of regulation. This related to people’s risk assessments and the way staff implemented care plans based upon them.

You can see what action we told the provider to take at the back of the full version of the report.

We also made recommendations that the service continue to develop its quality assurance systems.

This is the second time the service has been rated Requires Improvement.

Risk assessments and care plans that should have provided guidance for staff in the home were not always followed or reviewed correctly. We found evidence that staff were not always up-to-date with the training required to safely implement strategies identified in risk assessments and care plans that were designed to keep people safe.

The staff team told us they understood how to protect vulnerable adults from harm and abuse. Staff talked to us about how they would identify any issues and how they would report. Medicines were managed appropriately and equipment was properly maintained and serviced.

Business continuity plans were in place and each person had a personal evacuation plan in place to help keep them safe in the event of a fire or flood. Any accidents or incidents had been reported to the Care Quality Commission as necessary. The home was clean and odour free.

Quality assurance systems were in place. The registered manager had recently changed the way they managed Lanercost House - Carlyle Suite and increased the amount of audits taking place in order to drive up quality and improve the service. We made a recommendation about this.

We last inspected the service in August 2016 where we found the service was no longer in breach of any regulations we inspected and a number of improvements had been made. The service was rated requires improvement as we needed to be sure improvements would be sustained.

Lanercost House Carlyle Suite provides care for up to 15 people and specialises in providing care to people living with dementia. There were 14 people in the home at the time of the inspection.

The home is situated in the grounds of Lanercost House which is a separately registered home belonging to the same provider. A new registered manager was in post and registered with CQC in November 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 registered manager had previous managerial experience and were considered a senior manager in the organisation which brought additional responsibilities. We found this did not detract from the running of the home as a stable management team was in post including a supernumerary deputy manager and a dedicated unit manager. There were clear managerial roles and responsibilities and effective systems were in place to monitor the quality and safety of the service.

Systems were in place to monitor the safety of the service. Routine maintenance checks were carried out on the building and equipment, and individual risks to people were assessed and plans put in place to mitigate these.

Systems were in place for the safe ordering, receipt, storage and administration of medicines. We found a small number of topical Medicine Administration Records (MARs) used to record creams and lotions showed creams had been applied more often than originally prescribed. Steps were taken to update these records by the second day of the inspection to reflect people's change in needs.

A record of accidents and incidents was maintained, and regularly reviewed for patterns or trends.

There were suitable numbers of staff on duty during our inspection. One member of staff was allocated during each shift to closely supervise and carry out regular checks on people. We have made a recommendation about reviewing the levels of observation for people at certain times of the day as we observed they could be more active at times.

Staff had received safeguarding training and were aware of the procedures to follow in the event of concerns. Issues of a safeguarding nature were responded to appropriately by the registered manager.

Staff received regular training and support to carry out their roles effectively. We recommended that skills and resources relating to the support of people exhibiting behavioural disturbance and distress should be further developed in recognition of the specialist remit of the service. Although we found people were supported well there was room for improvement in the detail of care plans and assessment methods.

People were supported with eating and drinking in ways that met their specific needs and preferences. People were supported to choose meals and receive support to eat when required which was sensitive and discreet.

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.

Staff were observed to be caring and attentive throughout the inspection. We received very positive feedback about staff from relatives of people using the service. We observed numerous positive interactions between staff and people, and it was clear staff knew people and their family members well. A number of visitors spoke highly about the way they were greeted by staff and the warm and friendly atmosphere in the home.

A complaints procedure was in place although most relatives told us they had not needed to complain but knew how to if necessary. Complaints had been responded to in line with the provider's complaints procedure and there were opportunities for relatives to escalate their concerns internally or to another body should they not be satisfied with the outcome.

We observed people partaking in activities both spontaneously and planned. We received mixed views about the equality of opportunity to access activities and the range available. We have made a recommendation therefore that the suitability and opportunities for activities remain under review.

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

We also deemed it necessary to impose a condition on the provider’s registration in order to keep people safe. This stated that the registered provider must carry out individual risk assessments in relation to assessing the risks to health and safety of people living in the home. We took this urgent action as we were particularly concerned about the risk of people choking and the hazards people were exposed to.

The findings at this inspection mean that the overall rating is now 'Requires Improvement', and in line with our guidance the service will no longer be in special measures. The provider can now apply to have the imposed condition removed.

Lanercost House - Carlyle Suite is a nursing home for up to 15 older people who require assistance with all aspects of their care needs due to dementia related illness. The home is purpose built and comprises of 15 single rooms with full en-suite shower facilities which are accessible for wheelchairs. On the ground floor are therapy rooms including a kitchen and a sensory room. There are secure garden and patio areas, which are accessible from many of the bedrooms and from the communal areas.

The service did not have a registered manager in post at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Since the last inspection a new unit manager had been appointed for Lanercost - Carlyle Suite. Additionally an overall manager, not yet started, had been appointed to manage both the Carlyle Suite and Lanercost Nursing Home, which was in the same grounds. The intention was for the incoming manager to become the registered manager for both services.

At the previous inspection, February 2016, we had asked the provider to make improvements in meeting people’s health and welfare needs. We found that other improvements were needed around record keeping, safeguarding procedures, and general safety of the building. This led to improvements being necessary in the overall running and monitoring of the quality of service by the provider. These were classed as breaches of the regulations provider must abide by.

We received an action plan from the provider detailing how these improvements would be made. We received regular updates on progress towards meeting the action plan. Throughout this period the provider worked closely and co-operatively with CQC and the local county council commissioning team.

At this inspection of 17 & 18 August 2016 we looked at all the areas where the home had breached the regulations described above, and other areas to ensure that we carried out a fully comprehensive inspection of the service provided. We found that there had been improvements across all areas that we looked at.

The provider, had after the last inspection, ensured that support had been made available to assist the home in meeting safe standards of care through improved quality monitoring and input from senior managers within the organisation.

We found that the home was no longer in breach of the regulations.

At the inspection there were 15 people living in the home. Some people’s ability to communicate was limited due to their illness. Some people told us that they felt safe living there, that staff were “kind”, and treated them well. People were treated with care, respect and dignity. People who used the service told us, “They look after me, it’s a grand place.”

The majority of relatives we spoke with told us that they were happy with the care and support given. One said, “It’s wonderful, I come in when I like”. Another said, “It’s lovely, they look after(relative) really well no worries about this place the girls are great”. However a number still commented on there being too few staff at times.

All relatives said they had noticed improvements since the last CQC inspection. Especially, they said, to the building and more activities being available to people.

The accuracy, quality and detail recorded in people’s risk assessments had significantly improved. Risks to people, as a result of reduced capacity due to dementia, was now well managed. All staff we spoke to on the unit, from nurses to carers to auxiliary staff, were now fully aware of how to ensure people’s safety. All staff were now aware of the risk of people choking and the measures to take to minimise these risks.

The mealtimes were better organised with clearer delegation of staff roles. This meant that people were receiving the support required to enjoy a calm and pleasant mealtime experience. All the people we spoke with were very positive about the food and many commented on how pleased they had been the introduction of the choice of a cooked breakfast every morning instead of just at weekends.

We saw that the way staff were being utilised and deployed in the home had improved. This particularly helped at mealtimes. However we found that at other times people were being left unattended and the lounge area did not always have a member of staff present as was stated by the home as a measure that must always be in place.

We made a recommendation that the provider regularly reviewed staffing levels and if necessary looked to increase these to allow more flexibility and closer monitoring of people.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.

We found that people’s care needs were being better met. People looked well cared for with good attention to detail to ensure people were well dressed and to their own taste. We saw staff being attentive and considerate to people’s needs and feelings. The operations manager reported that a planned staff change around had meant that the staff team now in place had been “hand-picked” for the right aptitudes for working in the unit.

People’s care plans were more individualised and staff demonstrated good knowledge of people’s backgrounds and how they liked to spend their time. We observed that there were interesting and appropriate activities available if people wanted to join in; and people had more support from staff to go out of the building.

We found that the provider had significantly improved the way medicines were managed and stored. People received their medicines at the times they needed them and in a safe way.

We found that improvements had been made to people’s care, support and treatment plans. These had been made simpler and staff reported that these were easier to use in knowing exactly what support needs were required by each person. We found that nursing staff had been given training and guidance on the company’s, Barchester’s clinical tools to ensure that these were accurate and up to date when monitoring people’s healthcare needs.

We found that staff training and development had improved and that staff felt “better supported” in their roles and responsibilities. Staff had received basic dementia care awareness training. There remained some gaps in staff knowledge about approaches to dementia care. We found overall that the home lacked a cohesive strategy for supporting people living with dementia for whom a consistent approach is essential.

We recommended that the service developed a dementia care strategy for the home, based on current best practice, in relation to the specialist needs of people living with dementia. This would include more advanced training for all staff in supporting people living with dementia.

Staff told us they now received good levels of both formal and informal supervision which had helped them to develop. Staff said that communication at all levels had improved and “hand over” of shifts were well managed to ensure peoples changing needs were passed on to all staff.

Record keeping had improved and staff had received training on this as well as on care planning and tools to use to assess people’s needs.

Infection control measures in the home were good. The staff team had been suitably trained and had access to personal protective equipment. The home was clean and orderly.

The home’s environment had improved with new furniture purchased and suitable redecoration and refurbishment being done. The home looked well maintained, homely and welcoming.

Overall we found improvements in the way the home was being managed. There was a more effective management structure in place. The way the home was monitored by the provider had been strengthened and improvements had been made as a result. We noted a change in atmosphere within the unit: people living in the home appeared more responsive; and staff were positive and enthusiastic about the opportunities for growth and improvement.

The action plans and weekly assessments sent into us demonstrated the level of commitment by the provider and staff within the service to maintain the improvements we saw at this inspection. We

Lanercost House - Carlyle Suite is a nursing home for up to 15 older people. The service provides care and support for people living with dementia. The home is purpose built and has 15 single rooms with full en-suite shower facilities, which are accessible for people using a wheelchair. On the ground floor are therapy rooms including a kitchen and a sensory room. There are secure garden and patio areas, which are accessible from many of the bedrooms and from the communal areas.

The service did not have a registered manager in post at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Since the inspection a manager has been appointed. A nurse with experience of the Carlyle Suite has been put in place as the interim Head of Carlyle unit until a permanent appointment can be made.

At the inspection there were 15 people living in the home. Some people’s ability to communicate was limited due to their illness. Those we did speak with told us that they felt safe living there, that staff were “kind” and treated them well. The majority of relatives we spoke with told us that they were happy with the care and support provided. However a number of relatives told us they were concerned that staff had been under pressure recently and that it was difficult to know who was in charge.

We found a number of breaches related to the safe care and treatment of people, medicines management, staff support and supervision, infection control and in providing effective leadership. We were particularly concerned about the risk posed to people from choking. We took urgent action to ensure that the home put measures in place so that people were protected, as far as possible, from being exposed to avoidable harm or risk to harm.

We found that people’s safety was being compromised in a number of areas. This included: how care plans and risk assessments were written and updated; how medicines were administered and recorded; making sure that high risk areas such as bathrooms and kitchen areas were locked; and having staff on duty who were up to date and knowledgeable of people’s current needs.

We found that some areas of the home’s environment required attention. We found chairs and carpets that were not clean. The home was malodorous. The areas we highlighted on the first day of our inspection were attended to quickly. On the second day of our inspection the provider had the home deep cleaned by professional cleaners. The bedrooms we identified as needing attention had been repainted and new carpets were ordered and had been delivered.

We found that there were not always sufficient staff on duty to meet people’s needs; to supervise people and spend time on a one to one basis with socialising and offering meaningful activities. While the home had very good facilities downstairs, including a sensory room, craft room and an adapted kitchen, the use of these were dependent on staff availability. Over the three days we visited we did not see anyone using these facilities or being taken out of the home by staff. We also found that there was little in the way of equipment or adapted environment for people living with dementia to be engaged with on the top floor, where people spent most of their time.

We saw that staff were attending to the basic care needs of people. However, staff did not always keep up with the other tasks that were assigned to them, such as updating people’s notes and domestic duties of keeping the kitchen clean and tidy. We found that people’s needs were not consistently reviewed and re-assessed. This meant care plans and risk assessments did not identify all the health and social care needs of people. Some plans we saw lacked sufficient details for staff about how they should care for people.

Staff lacked supervision and guidance from senior staff. Staff supervisions and team meetings had not been completed for several months. However we did find that the introduction of new staff was well managed and new staff reported that the induction period and training had been very thorough.

People had a choice of meals and drinks, which they told us were good and that they enjoyed them. People who needed support to eat and drink received this in a supportive and discreet manner. The way nutritional intake and weight was monitored for people who were losing weight was inconsistent. Although the home did seek expert advice when required, from a dietician and from a person's GP.

Communication in the service was inconsistent between staff and between shift changes. This meant that staff were not always up to date with the support people needed. This placed vulnerable people at risk of receiving unsafe care and treatment.

Staff had received training relevant to their roles. The provider had effective systems when new staff were recruited and all staff had appropriate security checks before starting work.

People were able to see their friends and families as they wanted. There were no restrictions on when people could visit the home.

The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves.

We saw caring and positive interactions from staff. Staff were aware of people’s preferences about their care and daily lives and respected their wishes, wherever possible.

We saw that staff were skilled at engaging with people who could challenge the service. We spoke with mental healthcare professionals working with the home and they told us that staff were good at taking up offers of training and following their advice.

The provider had systems to measure the quality of the service. However due to the lack of clear leadership these had not been maintained, and where audits had been completed the actions arising from them had not been followed through. This had resulted in repeated issues being identified in a number of internal audits with no improvement.

The service had not had consistent leadership for sometime. Over the past eighteen months two managers had been appointed but left for various reasons. The Carlyle Suite would also normally have a Head of Unit but this post had also been vacant for a year. We saw that many of the issues we found on inspection stemmed from the lack of leadership and clear direction.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Where we have found breaches of a higher level of risk we will ensure that appropriate enforcement action is taken. We are currently following our enforcement policy and will report on the outcome once any action has been completed.

You can see what action we told the provider to take at the back of the full version of the report.

People were being well supported and encouraged by staff to maintain skills and to be involved in their care, wherever possible. Staff were observed treating people with respect and in a sensitive and considerate manner. A noticeable feature was a sense of humour and affection shared between staff and people in the home.

The relatives we spoke with were satisfied with the care and one told us, 'We have been amazed how well he has settled since coming out of hospital. The staff are really good with him. He looks so much better, happier and his health has improved.'

We found the home to be appropriately staffed to meet the range of complex needs of people living in the home. The staff team were experienced and well trained with specialist skills in caring for people with dementia. The organisation had a physiotherapist and an assistant to ensure that people were encouraged to be as mobile and independent as possible.

The home had developed a good working relationship with the local healthcare teams in order to ensure people had access to expert healthcare advice.

People were being well supported and encouraged by staff to maintain skills and to be involved in their care. Staff were observed treating people with respect and in a sensitive and considerate manner. We observed warm and caring interactions between people using the service and staff. One person told us, 'The staff are 'brill', they always have time for a chat and I'm often out for a bar meal with them.' Relatives we spoke with were also complimentary on the care and treatment their relatives received. One relative told us, 'It's been very reassuring since my wife came here. I'm made to feel welcome at anytime and always kept informed and included in their care.'

We found the home to be appropriately staffed to meet the range of complex needs of people living in the home. The staff team were experienced and well trained with specialist skills in caring for people with dementia. The organisation had a physiotherapist and an assistant to ensure that people were encouraged to be as mobile and independent as possible.

The home had a good working relationship with the local healthcare teams in order to ensure people had access to expert healthcare advice. The organisation had a well established quality monitoring system in place to ensure the quality of the service provided.