The inspection took place on 5 and18 September 2018 and was unannounced for the first inspection visit. The last inspection to this service took place on 15 June 2016 and was rated good overall with a requires improvement in the key question caring and a breach for dignity and respect: Regulation 10 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Inspectors had found that the service was using close circuit television CCTV to monitor people to ensure they were safe without due regard for their privacy and dignity. Following the inspection, the registered manager sent an action plan stating that CCTV was no longer used at this service.

Kalmia & Mallow is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. This service did not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates up to 13 people with a learning disability and, or autism in two separate but interlinked services. The service was fully occupied at the time of our inspection.

The care service has not been 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. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

Since the last inspection the registered manager had left this year and a new manager appointed who is not yet registered. 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.

At our most recent inspection we found the service was no longer providing good outcomes of care for people using the service. We identified four breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They were for staffing, safe care and treatment, person centred care and good governance.

We found the staffing levels had not been assessed in line with people’s changing needs. Staffing levels did not enable people to go out when they chose or help them to become more independent.

Care records were not sufficiently robust in relation to risk or accidents and incidents. They did not show sufficiently what actions had been taken or if the situation could have been prevented. This meant lessons were not learnt.

People received their medicines as intended but the medicines guidance available to staff was not sufficiently robust.

There were adequate staff recruitment processes in place to ensure only suitable staff were employed.

The service was sufficiently clean but not adequately maintained. The service was not sufficiently homely.

Staff were not supported adequately to ensure they worked in line with the organisational values and best practice. They had not received all the training they needed to ensure they could meet people’s assessed needs.

Staff consulted other health care professionals to discuss how best to meet people’s assessed needs but records did not always show how people had their health care needs met.

People were supported to have adequate nutrition according to their assessed needs. However, the dining experience was poor.

Staff had sufficient understanding of the Mental Capacity Act 2005 but had not always acted in the person’s best interest.

The staff knew people well and their interactions with people demonstrated this.

Staff supported people with their assessed needs. Staff were kind and caring and tried to engage with people on a regular basis.

The service did not demonstrate how it was responsive to people’s assessed a

This inspection took place on 15 June 2016 and was unannounced. Kalmia and Mallow is a service for up to 13 people who have a learning disability and is set across two adjoining bungalows. There was a registered manager in post overseeing this and, temporarily, one other care service. 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.

People's relatives told us they felt their loved ones were safe. All staff had undertaken training on safeguarding adults from abuse, they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. The manager had sought and acted on advice where they thought people's freedom was being restricted.

The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people at the service. Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported.

Risks were identified through a range of comprehensive individual risk assessments to help keep people safe. Care plans were up to date, person centred and detailed in order that staff could support people in the way that they liked to be supported.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people's ability to make decisions for themselves had been completed. Staff were heard to ask people for their permission before they provided care.

Care plans were based around the individual preferences of people as well as their medical needs. They gave a good level of detail for staff to reference if they needed to know what support was required.

People were supported to maintain a healthy balanced diet. Dietary and nutritional specialists' advice was sought so that people with complex needs in their eating and drinking were supported effectively.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. When people's health deteriorated staff responded quickly to help people and made sure they received appropriate treatment. People's health was seen to improve due to the care and support staff gave.

The management team assessed and monitored the quality of the service. We looked at a number of audits that had taken place. This ensured the service continued to be monitored and improvements were made when they were identified.

We found a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

A single inspector carried out this inspection. The focus of the inspection was to answer the five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

People told us that they liked living at Kalmia and Mallow. The environment was safe, clean and hygienic. Equipment used at the home was well maintained and had been regularly serviced. There were enough support staff on duty to meet the needs of the people living at the home.

Staff personnel records contained all of the information required by the Health and Social Care Act 2008. This meant that the staff members employed were suitable and had the qualifications, skills and experience needed to support people living at the service.

There was a process in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguarding (DoLS). Applications had been submitted when needed and records, policies and procedures were held. Staff had been trained and relevant staff knew how to submit a DoLS application.

Is the service effective?

People’s health and care needs were assessed with them. Specialist dietary, mobility and equipment needs had been identified in care plans when required. Relatives told us their family member received the care and attention they required in a way that met their needs. Through our observations and speaking with staff we noted that the staff understood the care and support needs of each person. One person told us. “I love it here the staff will do anything to help you.” Staff had received training to meet the needs of people living at the home.

Is the service caring?

People were supported by staff who used a kind and attentive approach. We saw that care workers were patient and encouraged people to be as independent as possible. People told us that the staff were sometimes busy but did not rush them. Our observations confirmed this. A visitor told us. “I am so happy with the care given to my family member. The members of staff are so polite and respectful.”

Is the service responsive?

Care and risk assessments had been completed before people moved into the home and when their needs had changed. A record was held of people’s preferences, interests and diverse needs. Relatives told us that staff members consulted their family member and encouraged them to make their own decisions. People had access to a range of planned activities and outings. They had been supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff spoken with had a good understanding of the ethos of the home and quality assurance processes were in place. Relatives told us that they were asked for their feedback on the service their family member received and that they had filled in a customer satisfaction survey. Visitors and staff said that they had felt listened to when they had made a suggestion or raised their concerns. People told us that the management of the home had consulted with them before changes had been made to the environment. They said that their views had been taken into consideration.

We spoke with parents who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to for their child.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations, decision making and activities.

Improvements had been made to the plans of care which contained the information staff members needed to ensure that the health and safety of people was promoted.

Improvements had been made and medication was administered, recorded and stored accurately and safely.

Relatives told us that people received the care and support they needed and that staff were very kind.

Staffing levels had been increased to ensure people received the personal, one to one care and support they needed.

Staff members were trained and were supported to provide an appropriate standard of care and support through increased supervision and staff team meetings.

Increased quality audits were being carried out to ensure policies and procedures were being followed and people were safe.

The organisation and accuracy of the records held had improved since our last inspection visit to ensure people safely received the care and support they needed.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant that they were not able to tell us their experiences.

We spoke with relatives and advocates of people living in the home. They told us that the needs of their relative and advocate were met and that they were sometimes consulted about the care and support provided. They were complimentary about the staff that cared for their relative and advocate and told us that they always treated everyone with respect and kindness. They said that the privacy of their relative and advocate was respected but that on some days there seemed fewer staff on duty. They explained that the environment was comfortable and clean but was in need of redecoration in some areas and that some stained carpets needed to be replaced. They said that their relative was provided with opportunities to attend a community day centre and to take part in occasional activities. They told us that their relative and advocate had been taken on holiday by staff members but activities were not provided each day.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk. We observed that people living in the home were given the care and support they needed with their personal care, were appropriately supported to be as independent as possible and had a positive experience of being included in conversations and decision making. However, they were not provided with the one to one and two to one support and attention they required.

Although we did not talk directly to people who live in this home we did observe good interactions between staff and the people being supported. We noted the individual support offered that was dignified and respectful. We heard conversations that involved and included the person. We saw good procedures when people’s money was being used that was safe and appropriate. We noted the enjoyment and laughter of someone about to go out for the day and the inclusive conversation with the doctor, staff member and person who was unwell.

During the visit to Kalmia and Mallow on 21 September 2011 we had the opportunity to speak and observe several people using this service. Although most people could not communicate easily, they showed many signs of well being. They interacted confidently with staff and were able to make their needs known by using a simple sign language. One person we spoke with said that they "liked the staff and that people take me out to my day centre." Another person we spoke with stated that they liked living at Kalmia and that "we go on holidays".

One person we spoke with said that they "liked the staff and that people take me out to my daycentre." and two people we spoke with told us that they felt comfortable to talk to staff about any issues they may have.