About the service: Hawthorne Lodge is a care home providing personal care. It can accommodate 25 older people. The accommodation is a mock Tudor style building located in the Bootle area of Liverpool. Some people using the service are living with dementia. At the time of the inspection 21 people were living at the home.

People’s experience of using this service:

Before the inspection we had received a concern that the home was cold. During the inspection we found the home to be warm thoughout the day. People told us they were often too warm. We found there were no radiator covers in place, meaning there was a potential risk that people could burn themselves. We made a recommendation that the provider consult health and safety guidance regarding the temperature of radiators and explore the need for covers. The provider took immediate action on this and radiator covers were fitted after the inspection.

The home was tired looking and required re-decoration. The environment had not been adapted to suit the needs of people living in the home. We spoke with the provider about both issues and we were told improvements were being made to the home this year.

People told us they felt safe living in the home due to the support they received from staff. Staff understood the risks to people and appropriate risk plans were in place. Safeguarding procedures were followed and incidents were raised with the appropriate professionals.

Staff were supported in their role and had access to relevant training to help ensure they had the necessary skills to meet people's needs.

People’s medicines were managed safely.

Measures were in place to reduce the risks associated with the spread of infection. We found the home to be clean, although there were some malodours present, especially in the stairwells.

Sufficient numbers of staff were employed to meet people’s needs. Staff were caring and always promoted people’s dignity and independence. People were encouraged to be as independent as possible. This included supporting people to continue with social activities outside the home. However, activities in the home were limited and some people in the home told us they were bored and lonely.

A system was in place to monitor applications and authorisations to deprive people of their liberty and any conditions attached to them. Consent to care and treatment was sought and recorded in line with the principles of the Mental Capacity Act. Staff supported people in the least restrictive way possible.

Care plans did not always reflect people’s needs or personal preferences. However, we found people received personalised care responsive to their needs.

People received the support they needed to eat and drink and maintain a healthy and balanced diet. Staff knew people's dietary needs and people told us they enjoyed the food available to them. People could enjoy snacks throughout the day, and were able to choose alternative meals if they did not like what was on the menu.

Staff understood their role and had confidence in the manager. Staff told us they worked well together as a team, and the culture in the home was positive. People, staff and relatives told us the management team were approachable and responsive to any issues. Systems were in place to gather feedback from people, although not all people recalled taking part in meetings or surveys. There was good oversight from the provider and the registered manager was well supported.

Rating at last inspection: Good (Report published 06 August 2016).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

This unannounced inspection was conducted on 27 June 2016.

Hawthorne Lodge is a care home providing personal care. It can accommodate 25 older people. The home is owned by Stirrupview Ltd. The accommodation is located in the Bootle area of Merseyside. There is good access to public transport and many local facilities are a short journey away. The home has 17 single rooms and four double rooms. Each of the double rooms was being used for single occupancy. At the time of the inspection 21 people were living at the home.

A registered manager was 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.

Staff were suitably trained and skilled to meet the needs of the majority of people living at the home. However, the home had recently accepted two short-term referrals for younger people with specific health conditions. Some staff told us that they did not feel confident in their ability to understand the specific needs of these people and provide effective care.

We have made a recommendation about staff training.

The home’s records relating to capacity assessments and best-interest decisions were incomplete.

During the previous inspection we identified that PRN (as required) medicines were not supported by an appropriate care plan. At this inspection we saw evidence of PRN protocols and records. However, we saw that the detail in one protocol was limited.

At the last inspection we saw that the provider had made the required improvements to quality and safety audit processes. During this inspection we saw that these improvements had been sustained.

At a previous inspection we identified a concern relating to cleanliness and infection control. During this inspection we saw that improvements had been made and sustained.

The people that we spoke with and their relatives told us that care was delivered safely. Our observations during the inspection supported this view.

People’s medication was stored and administered in accordance with good practice. Medicines were provided by a local pharmacy using a recognised blister-pack system. We spot-checked Medicine Administration Record (MAR) sheets and stock levels. In each case stock levels were accurate and the MAR sheet completed correctly.

We saw that staff provided care in a safe manner and were vigilant in monitoring risk. Staff were able to explain how they helped keep people safe and made appropriate reference to training, monitoring and safeguarding procedures. We saw evidence in care records that risk was assessed and regularly reviewed for each person living at the home.

Staffing numbers were adequate to meet the needs of people living at the home. A minimum of two care staff were deployed on each shift and the registered manager or joint manager was available between the hours of 9:00am and 5:00pm seven days per week.

People spoke positively about the food and the choice that was offered. The home operated a four week rolling menu with a choice for each course. We saw people being offered hot and cold drinks with their meals and throughout the course of the inspection.

Throughout the inspection we saw staff engaging with people in a positive and caring manner. Staff spoke to people in a respectful way and used positive, encouraging language. Staff took time to listen to people and responded to comments and requests.

People or their nominated representative were actively involved in the assessment and care planning process. Regular meetings were held for people living at the home where important information was shared and people’s views sought. All of the people living at the home that we spoke with told us they received care that was personalised to their needs.

People spoke positive

We carried out an unannounced comprehensive inspection of this service on 8 & 9 January 2015 when four breaches of legal requirements were found. The breaches of regulations were because we had some concerns about the way medicines were managed and administered within the home; standards concerning the way infection control was managed and the effective recruitment of staff. We asked the provider to take action to address these concerns.

We also were concerned about the effectiveness of systems in place to identify, assess and manage the quality of service provision including risks relating the health, safety and welfare of people. We issued a warning notice to the provider and told the provider to address these issues by 24 April 2015.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook a focused inspection on 4 June 2015 to check that they had they now met legal requirements. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover two of the domains we normally inspect; 'Safe' and ' Well led'. The domains effective, caring and responsive were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Hawthorne Lodge Residential Care Home' on our website at www.cqc.org.uk.

Hawthorne Lodge is a care home providing accommodation and personal care. It can accommodate 25 older people. The home is owned by Stirrupview Ltd. The accommodation is a mock Tudor style building located in the Bootle area of Liverpool. Due to its location there is good access to public transport and many local facilities are a short journey away.

At the time of the inspection the home did not have a 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 and associated Regulations about how the service is run. The home has not had a registered manager since April 2014 following a change to the provider’s board of directors. At the time of our inspection the acting manager had applied for registration.

We found improvements had been made in all areas and the previous breaches had been met. The improvements also meant that the requirements of the warning notice had also been met.

We found the home to be clean and the have developed a good range of policies and procedures to manage the control of infection.

We checked staff recruitment files and found these to be organised and easy to navigate. The provider had carried out audits of all files to ensure that staff had been effectively recruited and any required employment checks had been made. This process ensured staff were fit to work with vulnerable people.

There were systems in place to monitor medication safety and that staff were trained and assessed to help ensure their competency so that people received their medicines safely. We identified some further improvements needed and we therefore recommend that the provider seeks further guidance to ensure that medicines are safely recorded and accounted for.

We met with a representative of the provider who was supporting the acting manager for the home. We were showed improvements in the way the home was managed in terms of overall governance. We saw there were well-developed processes in place to seek the views of people living at the home and their families and visitors, including professionals. The provider was able to evidence a series of quality assurance processes and audits carried out. These helped ensure standards of care were maintained consistently as well as providing feedback for on-going development of the service.

On this inspection we were responding to specific concerns about the home. Although limited in scope, the inspection of Hawthorne Lodge helped answer some of our five key questions:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We inspected the home in response to concerns we received about the adequacy of staff to support people. During the inspection staff told us that there had been recent changes to staff roles and kitchen and domestic staff had not been available over the past week resulting in care staff covering these duties.

People living at Hawthorne Lodge told us they felt safe and well cared for. The care we saw was relaxed and carried out at an unhurried pace. When we looked at the staffing rota we saw that shortages of staff had been covered at key times so people’s care was still able to be carried out.

Staff we spoke with reported that they were still able to deliver safe care which met people’s needs.

Is the service caring?

People were supported by kind and attentive staff. We were told by people using the service that care workers showed patience and gave encouragement when supporting them. We spoke with four of the people living at Hawthorne Lodge and some visitors. All said they enjoyed living at the home and staff were very supportive and caring. One person said, ‘’ Everything is the same. Staff are lovely and I’m looked after well.’’

Is the service responsive?

We spoke with two representatives [board members] of the provider [owners]. They explained that, although staffing was not perfect, they had had to cover the cook leaving at short notice the previous week. They had done this by ensuring extra care staff were in place at key times.

Is the service well-led?

Staff told us they were not clear about their roles and responsibilities since the new owners had started. Some staff roles had changed and there was no registered manager yet appointed so staff felt there was a lack of leadership.

We were told that a representative of the provider visits ‘daily’. It was agreed that these visits would be recorded on the duty rota so that staff could be clear about support available.

The representatives of the provider said they would make arrangements for a new manager to be appointed who would then apply for the position of registered manager.

We spoke with three people who used the service. We also spoke with four staff members and three relatives. The feedback we received about the service from people living there was very positive. People expressed satisfaction with their care and support, and said they enjoyed the various activities on offer. Some of the comments people made included: “I am very happy with everything here. I have no worries at all." The relatives we spoke with were equally positive about the home. They said they were confident that their relative’s needs were being met, and that they were being cared for. One person said “I like it here. We can do what we like to be honest. There are no rules, apart from, Be nice" We observed staff being warm and accepting of people. Staff approached people in a sensitive and calm manner and in a way which showed they knew the person well and how best to assist them. The staff we met appeared to be caring and well informed regarding the needs of the people they supported. This was supported by comments from relatives. One said, "The staff know my relative very well, and I feel confident that they look after them in the the best possible way. If I didn't know this, I would be making a complaint, and removing my relative from this home." One person said “This is our home, and it is always clean and tidy. We found documentary evidence to show that the service provider was involved in the monitoring of the quality of service that people receive.

We spoke with people living at the home about the service they received. They

told us they were happy with the way staff supported them and the tasks they carried out for them.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, “I have just got a new wheelchair – the staff were good at organising this and it helps to get me around and I can retain some independence.”

We spoke with three staff. They told us they had received relevant training and understood how to report abuse they were aware of. They felt supported in their job and received supervision from their manager.

We asked people who used the service about the skills of the support workers. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

We spoke to people about the service they received with regards to their involvement in the quality of the service. They told us they had attended a recent meeting so that their views could be known. They said they were able to contact the manager if they ever had a problem with the service.

Most people’s medicines were administered by care workers. People we spoke with explained that medicines usually came at the same times every day. One person told us that they were happy for staff to look after their medicines and confirmed that care workers applied their creams every day. A second person told us how they were supported to self-administer some of their medicines. We looked at how people living at Hawthorne Lodge could access treatment for minor ailments. One person explained, ‘If you ask they’ll bring what you need’.

On the day of the site visit to the home we spoke to a number of people living there and asked them about their experiences of how the service involved them and kept them informed. All said that they felt encouraged to express their views openly. They were of the opinion that these views were taken into account by the staff in the decision making and care provided. An example was a discussion with one person who spoke about how the manager and staff were working with social workers on their behalf to make plans for the future. The person said that they were kept fully informed of progress and staff were very positive in their support.

Many expressed the view that they were treated with dignity and respect and felt safe in the home. People also said that staff explain and discuss the care provided and the treatments they would receive.

We spoke with two health and social care professionals who have visited the home. Both said that the people they had reviewed were receiving good support from staff and that staff were very keen to support people in the home.

We spoke with a number of people who live in the home and discussion referred to their views on being supported to consent to care and treatment. Generally they spoke positively about how staff included them in the care and confirmed that staff asked for their consent to care and treatment as required. For example one person said that staff conferred with them about a recent referral to the GP as a visit was needed. Another was fully aware about the role of visiting professionals in their care and a visiting physiotherapist said that on previous visits staff were good at explaining any input and involving the person in any decisions about treatment needed.

Generally people were relaxed and talked freely. We spoke with one person who said ‘The staff are excellent. I get my medication regularly. There’s always somebody when I need them’. Another spoke about the support staff gave them when needing a bath. We spoke with one person who talked about a number of medical needs they had and how staff supported them daily as well as accompanying them for medical appointments when necessary.

This shows that the home is responsive to peoples care needs.

People spoken with said that meals provided were good and there was a choice available. One person commented that the food has improved in the recent past.

Those people spoken with were very relaxed around staff and said that they were listened to so that any concerns could be addressed. We observed staff interacting with people living in the home in a positive and supportive manner. Residents, when asked, said that they felt ‘safe’ and they were confident that any concerns would be listened to and addressed.

We received positive comments from people about the staff which helped evidence their competency and approach to care. One person said ‘the staff and manager have been very helpful in sorting out my problems’. Another commented; ‘staff are very good at organising my [medical] appointments. They are brilliant’.

Hawthorne Lodge is a care home providing personal care. It can accommodate 25 older people. The home is owned by Stirrupview Ltd. The accommodation is a mock Tudor style building located in the Bootle area of Liverpool. Due to its location there is good access to public transport and many local facilities are a short journey away.

This was an unannounced inspection which took place over two days on 7 and 8 January 2015. The inspection team consisted of an adult social care inspector and an ‘expert by experience’. 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 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. The service has been without a registered manager since April 2014.

When we spoke with people living at Hawthorne Lodge and their relatives they told us they felt safe. People spoken with said, “I feel very settled here”, “I’m generally happy and settled here at the moment’’, “I’m very settled here now, I have no regrets about coming to live here.’’ People were observed to be relaxed in the environment. The staff we spoke with could describe how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. All of the staff we spoke with were clear about the need to report through any concerns they had.

At our last inspection in July 2014 we had found the home in breach of regulations relating to staffing. At that time, levels of care and support staff, including domestic and kitchen staff, were not sufficient to ensure people received a consistent level of care. On this inspection we asked about staffing at the home. We found that people living at the home and their relatives felt staff were more settled and delivered safe care. There was now settled staff working in the kitchen. Domestic staff hours were still under review. People spoken with felt more could be done in terms of the amount time staff spent actively engaged with people socially. We fed this back to the acting manager in terms of service development.

We looked at how cleanliness and hygiene was managed in the home. Overall we observed the home to be generally clean. We did, however, observe an example of a lack of consistency. One bedroom we saw was not clean although the person in it told us it had been cleaned earlier by care staff. We also had a concern before our inspection from a relative that ‘standards had deteriorated since the last manager left’, citing a lack of cleanliness on occasions in their relative’s bedroom. A recent audit by Liverpool Community Health [LCH] [infection control] also highlighted some issues that needed addressing.

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

We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We looked at four staff files and asked the manager for copies of appropriate applications, references and necessary checks that had been carried out. We found the information required was missing or inadequate on some staff files. These did not provide adequate checks to ensure staff suitability to work with vulnerable people.

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

We looked at how medicines were managed in the home. We found that people were receiving their medicines but there was risk that that errors could occur. This was because some medication records were confusing and lacked clarity. The audits carried out by the staff had not identified these. There was also a lack of available policies and procedures relating to medication administration for staff to reference. We discussed these anomalies with the acting manager and staff. Staff felt that the current risk was low in terms of any medication errors as they were familiar with the people living at the home and their different medicines. We did not find any evidence that people had not received their medicines. The medication administration records did not support a safe practice however.

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

Some arrangements were in place for checking the environment to ensure it was safe. For example we saw some documented evidence that regular checks were made including nursing equipment and fire safety. A ‘fire risk assessment’ had been carried out and this included personal evacuation plans [PEEP’s] for all of the people living in the home.

We observed staff provide support for people and the interactions we saw showed how staff communicated and supported people in a positive manner. Staff were able to explain each person’s care needs and how they communicated these needs.

People we spoke with and their relatives told us they were happy with the access to medical support when it was needed. One person told us they had been into hospital recently for treatment and had just returned. When we looked at the person’s care file we saw the care plan had not been updated to reflect the person’s changing care needs. We discussed the need to update care plans to reflect changing care needs, so that any short term care needs could be adequately monitored. This also included details of care for people with specific medical conditions so that staff would have a more detailed reference to carry out care.

We looked at the training and support in place for staff. Following our last inspection in July 2014 we found the provider was in breach of regulations because staff morale was low and there was a lack of organised training in place. The provider had sent us an action plan which said they disagreed with the findings of the inspection and that ‘training is organised and provided to all staff’. The breach remained in place however.

On this inspection we asked for training records for staff but these were not available at this time. The manager told us they had completed an audit of staff training needs and was aware of what training was needed for staff. They said, for example, ‘’Quite a few staff needed to do infection control training.’’ We were told ‘most’ staff have completed training in moving and handling. The manager was not able to tell us whether staff had completed key training in abuse awareness and safeguarding processes. There was no overall training matrix available for the manager or staff to access. The manager said they monitored staff training through supervision. We were told all staff had attended one supervision session to date. There had been no formal appraisals carried out since the new owners had taken over the company in April last year.

Following the inspection the manager sent us a training plan for the forthcoming six months. This identified and plotted training for staff in ‘statutory’ subjects such as moving and handling, medication, safeguarding, infection control and fire awareness. In addition three staff are to undertake training with respect to the care needs of some of the people living at the home who may be living with dementia.

We asked about basic qualifications of staff which could evidence knowledge to carry out effective care. The manager told us that some staff had a qualification in care such as NVQ [National Vocational Qualification] or Diploma. All of the senior staff [four in total] had such a qualification. In total, however, out of 22 staff on the duty rota only eight had such a qualification [although three staff had recently started a course].

Staff spoken with said they felt supported by the manager and the training provided. They told us that they had had a supervision session with the manager and there were support systems in place such as staff meetings and provider representatives attended.

We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. People living at the home varied in their capacity to make decisions regarding their care. We saw examples where people had been supported and included to make key decisions regarding their care; for example when being admitted to the home, and also when reviewing care in the home. The home had a copy of the MCA Code of Practice available for reference.

We were told, at the time of our inspection, of a person who was on a Deprivation of Liberty Authorisation [DoLS]. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found the manager and senior staff we spoke with aware regarding the process involved if a referral was needed.

People reported that the food in the home was varied, nutritious and plentiful. They said, “The food here is good. It’s made fresh in the kitchen every day and there is enough choice of what I like for me, ‘’The food here is alright. They always offer me something I like for my main meal.’’

During the inspection we observed the lunchtime meal in the dining room. People were observed to be supported to eat and lunchtime was a pleasant and social occasion.

People living at the home and their relatives spoke well of the staff and commented that they were kind and caring. Comments included: “Yes, the staff are very good; they look after me very well”. “The staff are very kind and helpful, they are always telling me to be careful’’, “The staff here are very kind and helpful”, “The staff always treat me with respect”, “The care is fine, but it could be better with more staff”, “The staff here are really good with mum, she needs a lot of physical care and they treat her with respect and kindness.’’

Throughout the inspection we observed staff supporting people who lived at the home in a dignified and respectful way. When staff interacted with people there was warmth and staff had patience and understanding.

People told us they felt they were listened to and generally staff acted on their views and opinions. This inclusion was not always reflected in the care planning records which only gave sporadic evidence that people had been consulted regarding their care.

The majority of activities in the home centred on the daily routine and were undertaken on a communal basis. There was little evidence of a ‘person-centred approach’ [by this we mean looking at people’s preferences for activity on a more individualised basis] to the care of the people staff supported. We spoke with staff who told us that they spent time with people when they could and certain members of staff had set activities that they provided when on duty. For example karaoke, quiz and arm chair exercises. We were told these were not planned as such. We were told that previously [before the running of the home changed] there was more emphasis on planned activities with [for example] an art group up and running. We fed this back to the acting manager in terms of further development of the service.

People said they had no concerns or complaints about the home, and would either speak to the manager, or ask their relative to intercede with the manager on their behalf. People said “I have no complaints, but I’d tell my daughter if I had any worries” and “If I had any concerns I would talk to the manager, but there has been nothing major so far.’’

At our last inspection in July 2014 we found the provider in breach of regulations regarding the management and running of the home in that there was lack of formal processes to audit and monitor standards in the home and a lack of clear management direction. On the visit we checked to see if improvements had been made.

We met with the acting manager. We were told they had been in this position for approximately three months and had worked in the home as a carer for longer. We asked the acting manager about plans for further developments in the home. They said that the provider had plans to develop some of the fabric of the building but could not give any further information as to any further development of the service.

On the first day of the inspection we met with a representative of the provider and we were concerned that some information relating to health and safety had not been passed on effectively to the acting manager. The acting manager had not seen a recent infection control audit report. There was, therefore, a concern the acting manager and staff could not responded to appropriate professional and expert advice in a timely manner.

We asked the acting manager about their role and how this related to the provider in terms of areas of work and accountability. We were unable to get clear picture of this. The acting manager advised us they currently had no specific job description and was not able to identify clear parameters to their role. The role of the provider in providing ongoing support to the acting manager was also not clear. This lack of clarity impinged on the acting manager’s awareness and knowledge of the running of the home. For example, much of what we asked for in terms of regulatory requirements, policies, procedures and records could not be produced for the inspection at the time.

From the interviews and feedback we received, the acting manager was seen as open and receptive. Staff told us they received going support.

A process was in place to seek the views of people living at the home and their families so this could inform service development. A survey had been sent out in May 2014 and the results showed positive feedback.

We enquired about other quality assurance systems in place to monitor performance and to drive continuous improvement. The acting manager told us about weekly health and safety audits they had conducted but these could not be located at the time of our visit and were sent to us later by the provider. We were shown how accidents and incidents were recorded. The manager advised us these were not audited. This meant there was no assessment and analysis of these to inform any overall patterns or lessons that may need to learn for the home.

On this inspection we found there were breaches of regulations covering infection control, requirements relating to staff employed at the home and medication management. We were concerned that the home’s current auditing and monitoring of these had not effectively identified any shortfalls or improvements needed.

We found on inspection that issues requiring the home to notify the Care Quality Commission had not been made. These included an injury to a person living in the home, a person being on a DoLS authorisation and two safeguarding investigations. The acting manager said they would notify us retrospectively and would seek to review the regulations and guidance available regarding notifications.

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