This inspection took place on 3 and 4 December 2018, the first day was unannounced.

We last undertook a comprehensive inspection at Casa Di Lusso in October 2017, at this inspection the service was rated ‘Requires Improvement’.

We undertook an unannounced focused inspection in June 2018 in response to concerns we had received about the service. At the focused inspection we inspected the service against three of the five questions we ask about services: is the service well led, safe and effective. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff had not received all of the training required to ensure people and staff were safe during incidents and the systems in place to monitor and improve the quality and safety of the service had not been fully effective. We also found one breach of the Care Quality Commission (Registration) Regulations 2009. This was because the provider had not notified the Care Quality Commission and the local authority of safeguarding incidents in line with their legal responsibility.

During this comprehensive inspection we found that improvements had been made, and where improvements were required, the provider had systems in place that identified all except one of the improvements and actions needed.

Casa di Lusso is a purpose built 90 bedded care home specialising in the care of people living with a dementia. At the time of the inspection there were 65 people living at the home. The home is split into eight units all with Italian names, Colosseum, Tuscany, Positano, Pantheon, Pisa, Trevi, Vesuvius and Pompeii.

There was a manager in post who had submitted an application to become the registered manager. The first day of our inspection was the managers first day at the home. 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 Quality and Performance manager was responsible for managing the service prior to the manager being in post and they were continuing this through the managers induction.

Some areas of the care plans needed to be improved. Care plans did not always contain enough detail to inform staff on how to support people with all of their needs and preferences. The provider had a plan in place to address this.

People told us they felt safe living at Casa di Lusso, people’s relatives also thought they were safe. There were systems in place to analyse and review incidents when they occurred and action was taken following incidents to prevent a reoccurrence.

There were systems in place to protect people from harm and abuse. Staff understood their responsibilities to keep people safe from harm.

Risks to people were identified and management plans were put in place to reduce risks. People’s medicines were managed safely.

We received mixed feedback from people regarding the staffing levels at the home. Staff and relatives told us staffing levels had improved. Our observations were that there were enough staff available to respond to people and meet their needs.

There were systems in place to ensure suitable staff were recruited to the home.

There were systems to protect people from the risk of infection. There were a range of checks in place to ensure the environment and equipment in the home was safe. We found the water temperatures were not being consistently taken, the provider addressed this immediately and confirmed temperatures were within a safe temperature range.

People’s rights were protected because the correct procedures were followed where people lacked capacity to make specific decisions for themselves.

The provider had met their responsibilities with regards to the Deprivation of Liberty Safeguards (DoLS). DoLS is a

We undertook an unannounced focused inspection of Casa Di Lusso on 6 June 2018. This inspection was undertaken in response to concerns we had received about the service.

The inspection team inspected the service against three of the five questions we ask about services: is the service well led, safe and effective. No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At the last inspection in October 2017, the service was rated Requires Improvement.

Casa di Lusso is a purpose built 90 bedded care home specialising in the care of people living with a dementia. At the time of the inspection there were 71 people living at the home. The home is split into eight units all with Italian names, Colosseum, Tuscany, Positano, Pantheon, Pisa, Trevi, Vesuvius and Pompeii on the top floor.

There was a manager in post but they were not registered with the Care Quality Commission. 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 manager was not available during our inspection, the Quality and Performance Manager was overseeing the service in their absence.

Although people and their relatives told us they felt safe living in the home, the systems in place to protect people from harm needed to be improved. There were frequent incidents involving people becoming anxious and physically challenging to other people and staff. Incidents were not being reviewed for themes and trends to identify factors that could prevent further incidents from occurring.

Staff had not received all of the training required to ensure people and staff were safe during incidents. Staff from other countries received training that included the English language, where this was identified as a need.

The provider had not notified the Care Quality Commission and the local authority of safeguarding incidents in line with their legal responsibility. The governance systems had not been fully effective in improving the quality and maintaining the safety of people. A new governance system was in the process of being introduced.

People received adequate nutrition and hydration, although records demonstrated prior to the inspection these needs had not been met. Further details were required in some of the care plans in relation to people’s dietary needs.

Staff felt staffing levels had improved but there were key times of the day in the smaller units where an additional staff member would benefit people’s needs being met in a timely manner.

Casa di Lusso is a purpose built 90 bedded care home specialising in the care of people living with a dementia. At the time of the inspection there were 67 people living at the home. The home is split into seven units all with Italian names, Pisa, Positano, Tuscany, Coleseum, Pantheum, Trevy Fountain and Vesuvius. At the time of the inspection the upper floor Vesuvius was unoccupied.

This inspection took place on 23, 24 and 30 October 2017. The first day of the inspection was carried out by two adult social care inspectors and two experts by experience and was unannounced. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The second day was carried out by two adult social care inspectors. The third day of the inspection was carried out by one adult social care inspector. This was the first inspection since the service registered in October 2016.

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.

We found people were not always safeguarded from the risk of developing pressure ulcers. People were not repositioned in line with their care plans and when monitoring records were completed at the end of the shift the incorrect information was recorded. We raised this with the registered manager and they dealt with the issues raised immediately using the organisation’s disciplinary process. Following this action we found there were measures in place to ensure people were safely supported in line with their care plans and staff had received additional support to meet people’s needs.

Although there was strong leadership from senior managers and the registered manager, leadership and management of individual units was not well led. Staff responsible for leading the shifts on units failed to direct staff to carry out tasks or ensure they carried out the repositioning of people in line with their care plans. They also failed to ensure monitoring records were completed correctly.

People told us they felt safe living in the home. One person said, “Yes I feel very safe. I know the staff and they are all lovely.”

There were systems and processes in place to minimise risks to people. These included a robust recruitment process and making sure staff knew how to recognise and report abuse. There were varied opinions on the staffing levels in the home, with some people saying they thought there should be more staff whilst others said they thought there was plenty of staff. Records showed that there were adequate numbers of staff available to meet the assessed needs of people in a timely manner.

People received effective care from staff who understood their needs. Some agency staff were not as clear about people’s needs as regular staff however the registered manager ensured they used the same agency staff as far as was possible so they could get to know people better.

Most staff attended induction training before they started to work in the home although some staff said they had not completed their induction before working on the floor. The care manager said they aimed to ensure all new staff attended the induction process before starting work. All staff said they had plenty of opportunities for training and the organisation also promoted dementia awareness training for all their staff.

People could enjoy a full programme of activities and staff had built up links with the local community to ensure people could stay in touch with organisations such as their place of worship and the Women’s Institute. Links had also been built with a local school and college, to enable people living in the home to contribute to community dementia awarenes