This service was opened in April 2018 and this was its first inspection, it took place on 13 and 19 November 2018 and was unannounced.

Amethyst 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. This service is registered for four people, on the day of our inspection two people were living in Amethyst Lodge.

At the time of the inspection the registered manager had not worked at the service since September 2018. There was no manager in place and no one had been asked to act up while a new manager was being appointed. 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.

This care service supports people living with a learning disability and should be 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. Meaning, people with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen. However, it was not always evident that the provider understood these principals, there was not always enough staff on duty to promote independence and choice.

We had not planned to inspect this location on this occasion. This inspection was prompted after we discovered breaches in another service owned by the same provider, which is in close proximity to Amethyst Lodge, and a third service also owned by them. All three services are managed and staffed by the same team. Having identified breaches of regulation in relation to staffing and quality assurance in Swanrise we decided to inspect the other two services.

We did not meet the people living in the service on this occasion, but we did observe how the staff who worked with them interacted with people who lived in the other services owned by the provider, that they also worked with.

Although both people who lived in the service had 1-1 care staff support, we found that there were not sufficient staff on duty to keep people safe. The 1-1 care staff worked long hours and there were no staff members available to stand in for the 1-1 care staff to have a break or to step in to offer assistance if it was needed in emergency situations. On the second day of the inspection, a decision had been taken to permanently add a floating staff member to the rota, however this person was to move between the three services within the same grounds and was not effective.

We saw that people did not always receive care that was personalised to their needs. People’s daily activities were sometimes restricted because of staff not being available to support them. Staff had not always been given update training to ensure their knowledge and skills were refreshed and kept up to date. Training and supervisions had fallen behind.

Risks in people’s environment were assessed and steps have been put in place to safeguard people from harm without restricting their independence unnecessary. Risks to individual people had been identified and action had been taken to protect people from harm. However, because staffing levels were not sufficient, people were not always protected from risk.

The service had not been well led; failings in place prior the registered manager leaving had not been identified by either the provider or the previous general manager, who had also recently left. However, we acknowledge that these have now been identified and the provider was taking action to make improvements. An acting manager had not been put in place while a new manag