Alum Care Limited 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. Alum care provides nursing care home for 63 people with complex needs over three separate wings, each of which has separate adapted facilities. At the point of our inspection there were 61 people living at the service who had a range of needs such dementia, acquired brain injuries and complex health care needs

The inspection took place on 19 September 2018 and was unannounced.

The service did not have 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. A new manager had been employed and they had commenced at the service in July 2018. The new manager (known as the manager in this report) assisted us with our inspection.

People were not always safe as risks to them were not always being managed appropriately, in particular those at risk of developing pressure sores and those at risk of choking. Call bells were not always responded to in a timely way and problems with the call bell system meant there was no clear picture of how long people had to wait for care. There was no monitoring or analysis of accidents and incidents that had taken place to identify trends and reduce further risk. The care received by people did not always reflect what we observed in care plans throughout our inspection.

Safeguarding procedures were not followed and appropriate referrals were not made to local authority. People’s concerns were not being investigated appropriately which left people at risk of abuse. Feedback from people, relatives and staff was that there was not always a sufficient number of staff to meet people’s needs. People told us they felt “Vulnerable” due to this. It was unclear how many staff were needed to safely meet people’s needs. There was a high use of agency staff which impacted on the care people received. Staff recruitment checks required improvement, this is important as the service was recruiting new staff to reduce the reliance on agency.

People had access to a wide range of healthcare professionals. This included General Practitioners, Tissue Viability Nurses and Physiotherapists. We asked the manager to provide us with contact details for healthcare professionals who visit the service following the inspection but we did not receive these.

Medicines were appropriately stored, dispensed and managed. Actions picked up on a recent medicines audit and been resolved. People were being cared for by staff who were aware of and carried out safe infection control processes. Aprons, gloves and hand sanitizers were available throughout the service and staff were aware of infection control procedures.

Staff were not up to date with their mandatory training. There were gaps in all areas of training that meant staff would not be up to date with best practice. We did not see evidence that staff were receiving supervision and appraisals.

People’s rights were not protected. The service did not always follow the Mental Capacity Act principles. Mental capacity assessments for specific decisions had not been completed and correct legal authorisation had not been sought to deprive people of their liberty.

People had a choice of foods, however people told us at times they did not have access to food and drink when they wished it. Staff were not sure of some people’s dietary needs. We have made a recommendation to the registered provider in this respect.

There were detailed pre- admission assessments completed before people moved into the service to ensure they

Kings Lodge is a nursing home that provides support to up to 64 people who may have a physical disability and a neurological condition. The home is located in a rural area outside Redhill called South Nuffield. On the day of the inspection there were 57 people living at the home. The people who live at the home have a range of complex nursing needs and are supported with a full range of tasks, including maintaining their health and well-being, personal care, support with nutrition and activities.

On the day of inspection we met the 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 inspection was unannounced and took place on 8th September 2016.

The requirements of the Mental Capacity Act were not being fully met. The registered manager had submitted Deprivation of Liberty Safeguard applications but these applications did not include the full range of restrictions being imposed. This could potentially lead to people having their freedom unfairly restricted.

People, relatives and care professionals said that Kings Lodge was a safe place to live. A person with complex health needs had chosen to return to the service for a respite placement because they felt that it was safe.

People were protected from harm. Staff had the training and the ability to understand risk, and reported accidents and incidents in a timely manner. Staff understood how to report suspected abuse so that action could be taken if necessary. Incidents and accidents were investigated and the manager reviewed reports to prevent them from re-occurring. Any potential risks to individual people had been identified and appropriately managed.

Risk assessments had been completed to ensure the home was safe for people to live in and there were arrangements in place should there be an emergency.

People were supported by sufficient numbers of staff who were recruited safely and had the skills and knowledge to support people. All nurses had an up to date PIN number to prove they were registered.

Medicines were managed and administrated in a safe way and staff had a good understanding of the medicines they were administrating.

Staff had the knowledge and skills to support people with neurological conditions and physical needs. Specialised training was available to staff, which included training courses related to people’s needs.

People’s nutritional needs were met and people had a varied diet. Staff ensured that people had enough to eat and drink.

Staff ensured people were supported to maintain their health and wellbeing and people received support from specialist healthcare professionals when required.

People were cared for by staff who put them at the centre of all they did. People were not rushed by staff and were treated with dignity and respect. People were encouraged to maintain relationships with their family and those that mattered to them.

People’s care met their needs and wishes. Staff were responsive to the needs and wishes of people. The environment was adapted to support people with physical support needs and neurological conditions. Equipment had been introduced to help people maintain their independence. People were encouraged to be involved in how the home was run and people and relatives felt comfortable in raising a concern or making a complaint.

The home was led by a manager who was a positive role model. Organisational values providing compassionate care by helping, understanding and caring were reflected in the support given by staff and the management team. A new auditing system had recently been started, which mirrored CQC methodology.

People and staff were involved in the running of the service. Feedb

During our last inspection on the 24 March 2014, we found the provider had not met the regulations in relation to safety and suitability of premises.

We carried out this follow up inspection to check that the provider had taken the necessary action to improve the safety of the building. We also checked to make sure that changes to the premises had been carried out as detailed by the provider in the action plan they had sent us.

We found people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We saw closed circuit television cameras had been fitted around the outside of the home to monitor less well supervised areas. The provider had therefore improved security in the home which meant people were better protected. We saw keypads had been fitted to areas containing hazards, for example, the lift machinery cupboard, the medication room, the chemicals room, and rooms containing access to high voltage.

We noted that windows had been repaired and made secure. We found that some window restrictors had been fitted and the new building's windows had been restricted to protect people. The provider may find it useful to note that some window restrictors had not been fitted.

People who used the service said they liked the home and their rooms which were warm enough. One person told us they had lived in many homes and this one was “far the best”.

The last inspection found shortfalls in 2 out of 3 areas looked at and set compliance actions. The areas where shortfalls were found were outcome 1 (regulation 17) Privacy and dignity and outcome 10 (regulation 15) The environment.

At this inspection we reviewed the actions the provider had taken in response to the compliance actions set.

The last inspection report identified shortfalls under outcome 1 (regulation 17) regarding protecting people’s privacy and dignity when using the toilet. At this inspection we found that the shortfalls had been met and the compliance action closed. We therefore found that people who use the service were treated in a way that respects their privacy and dignity.

The last inspection report recorded shortfalls under outcome 10 (regulation 15) regarding the environment and set a compliance action. At this inspection we found that the provider had made some progress but more was required. This compliance action therefore remained open and we found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

It was seen as responsive that the provider, once they clearly understood what was required, started to take immediate action during the inspection to make improvements in the remaining areas of non-compliance. For example, setting up systems authorising funding and ordering equipment that would assist compliance during the inspection.

Our inspection was unannounced and started at 7:55am, before the manager arrived.

We noted that the home was hygienic, clean and fresh.

People told us they had enjoyed their meals, liked the food and got enough to eat. They said they had choices of food and they could have a snack or a drink at any time.

People said they liked their rooms, their taps worked and they were warm enough in winter.

One person told us that they were offered their choice of food, they got enough to eat and the food was good, except sometimes the meat was a bit tough.

We saw that people decided what to eat on the day as opposed to deciding weekly menus. This offered more flexibility and choices.

People were supported to be able to eat and drink sufficient amounts to meet their needs.

We saw that the building and grounds had been made accessible, were well kept and that the home benefited from having its own pets, for example, dogs and chickens.

We found that staff did not always provide care in a way that acknowledged, recognised and protected people’s right to privacy, dignity and respect.

We found that the home was not always protecting people against the risks associated with unsafe or unsuitable premises, by not fitting secure restrictors to windows that had been risk assessed as needing these; and leaving a fire door, alarms and three fire exits unable to close securely.

People who used the service told us that they were asked for their consent before any treatment or care was provided.

One resident told us that "staff always knock before they enter my room and if I do not want to have a shower at a specific time then they will go away and come back at a time that is suitable for me".

A relative told us that "we like Kings Lodge because they put the need of the residents first. They always ask us for our opinion and they always listen to the residents".

We spoke to five people who used the service who told us that they were very happy with the care and treatment that they received. We saw many examples of people interacting with staff in a positive and caring way.

People told us that the staff were "Very good" and "Very kind". We saw on the day of our inspection that staff treated people in a caring and supportive manner. People also told us that they knew about the care and treatment they had and that they were always kept informed about this.

We spoke to three relatives of people who used the service. The told us that they were happy with the care that people received and that they felt that staff do a "Very good job". One relative told us that they felt the staff gave "Very good care" whilst others told us that staff were always "Very kind".

This was confirmed by our observations on the day as we saw that staff spoke to people in a respectful and caring way. We noted that the staff and the people were very relaxed in each others’ company

Generally the people we spoke to were positive about the home. They said they liked the food and there was plenty of choice.

We were told by people who use the service, that they liked their rooms and that the home was usually clean and fresh. They also told us that staff were available when they needed them and staff usually responded promptly when they used their call bells.

People who use the service said they can give their views on the quality of the service by speaking to the home's management and during resident and relatives' meetings. They know who to speak to if they are worried or unhappy about anything and that the home's management are available to them.