The inspection took place over two separate dates 27 February 2018 and 15 March 2018. A second day was scheduled, as severe weather meant not all the inspection team could be present on the first day of inspection. The first day of inspection was unannounced the second day was announced.

The service was last inspected 17 January 2017 and was found to be providing a good service and meeting all of the associated regulations. We brought forward a planned inspection to this service because of concerns raised by the local authority. We also received a higher number of safeguarding concerns and incidents between people using the service than expected for a service of this size. We wrote to the provider last year after concerns were raised with us about staffing levels, insufficient activities and whether the registered manager was being adequately supported. The provider sent us a suitable response and the local authority quality improvement team have been working with the service to help them identify and carry out improvements.

At our inspection, 27 February and 15 March 2018, we found the service had made some improvement and was addressing the concerns raised since our last inspection. We have rated the service as Requires improvement in responsive and well led because people have not always received good outcomes of care and at times had not been safe in the service.

Lancaster House 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. The service does not offer nursing care. Lancaster House is a service registered for 31 people following an application last year to extend the service from 17 to 31 people. The homes registration includes caring for people with dementia, mental health, older people, and younger adults. At our inspection on the 27 February there were 27 people using the service. Whenever possible the service considered where people’s needs could best be met. The annex was predominantly for younger adults with mental health needs. The other unit was mainly but not predominantly for older people with mental health or living with dementia. Some people had a dual diagnosis of mental health and dementia.

The home is situated in the town of Watton within easy reach of amenities and had adequate parking.

The service has a registered manager who had a background in mental health. They have been registered since 2015. 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 on 27 February and 15 March 2018, we found improvements were being made but not firmly embedded. Undoubtedly, there had been a number of concerns with this service since the change of their registration to increase their bed numbers. The increase in numbers is likely to have had an impact on the stability of the service and we found some people’s needs were not compatible with others. This was being addressed by the service and some people had moved on or were being supported to find an alternative service. Effectively the registered manager’s workload had increased and they did not have any administrative support or a deputy manager. They were working long hours including being permanently on call for this service with insufficient support from the registered provider. This put a strain on the service. This situation has since improved. The registered manager is supported informally by the registered provider and has extended networks of support. They have in place two senior staff who they have sufficient confident in and able to share some of the responsibilities and on-call so they can have some

Lancaster House provides accommodation and personal care for older people, people living with dementia and people who may have mental health support needs. There were 17 people currently living at the home on the day of our inspection. However a new extension and recently been built and the home had increased the registration to accommodate up to 31 people.

This inspection took place on 17 January 2017 and was unannounced.

A registered manager was in post at the time of our inspection. 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 who lived at the home were protected from the risk of abuse and avoidable harm. Staff had been trained to recognise the signs of potential abuse and knew what action to take if they suspected abuse had occurred. Accidents and incidents were investigated as required and known risks were recorded and mitigated when possible. Staff had been recruited safely and relevant checks were completed before they commenced working within the home.

Staff knew about and were following the guidance in people's risk assessments and care plans and the risk of unsafe care was reduced. People's records were up to date and indicated that care was being provided as detailed in people's assessments.

Staff received a comprehensive induction and on going training, tailored to the needs of the people they supported. Staff were knowledgeable about the Mental Capacity Act and enabled people to make decisions for themselves as far as possible. Staff were supported through regular supervisions.

People's needs were met by caring, patient and considerate staff. People’s privacy and dignity was respected by staff. People, their families and staff were all complimentary about the home. Staff were enthusiastic about working with the people who lived at the home and developed positive relationships with them.

The registered manager encouraged an open, inclusive culture within the home. Relatives were free to visit their family members and were warmly welcomed. Relatives said they felt comfortable raising any issues or concerns directly with the registered manager. There were arrangements in place to deal with people's complaints and issues appropriately if they were raised.

The management team assessed and monitored the quality of the service. A number of audits had taken place. This ensured the service continued to be monitored and improvements were made when they were identified. Meetings were held regularly and people's comments were listened to and implemented to improve the service when possible. The registered manager understood their responsibilities to inform the CQC when specific incidents occurred within the service.

This inspection was unannounced and took place on 7 January 2016.

Lancaster House is registered to provide accommodation and personal care for up to 19 older people, some of who may be living with dementia. There were 18 people living at the service at the time of the inspection.

There was a registered manager in place. 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 aware of the procedures for reporting concerns within the service, therefore protecting people from the risk of harm. People were supported by staff who had only been employed after the provider had carried out pre-employment checks. Staff were well trained and supported by the registered manager. There were enough staff to meet people’s needs.

Risks were identified through individual risk assessments. Care plans were up to date and contained clear guidance for the staff to follow so they could provide people with the care they needed.

People’s health, care and nutritional needs were effectively met. People were provided with a varied and balanced diet. Staff referred people appropriately to healthcare professionals in a timely manner when their support needs indicated that additional input was required.

The CQC monitors the operations of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. Staff did not all have a good understanding of the legislation around MCA.

There were 14 CCTV monitoring cameras covering the external grounds and also internal communal areas of the service, including corridors, the dining room, kitchen lounge area and the manager’s office. People had not been consulted about the use of monitoring cameras and the impact on their privacy had not been considered. We found no assessments to show that people who lacked capacity had been considered when installing the CCTV.

People were treated with kindness and respect by the staff who understood people’s needs and provided care and support to them when they needed it.

The registered manager is experienced in care and management and demonstrated good leadership. Effective systems were in place to monitor the quality and safety of the care provided and improvements were made where shortfalls had been found.

There was one breach 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.

We conducted this inspection visit to check that the provider had carried out the improvements identified at the previous inspection visit in June 2013.

We spoke with people who lived at the home who told us that they liked living in the home and that they received the care and attention they required from excellent staff.

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

Relatives told us that recent staff changes had occurred and that people received the care and support they needed from staff who were kind, polite and respectful.

We found that improvements had been made and that staff members were supported to provide an appropriate standard of care and support to people through increased staff training, supervision and staff team meetings.

People told us their complaints were listened to and resolved. We found that improvements had been made and that a new system had been provided for recording the details of all complaints the manager and provider received.

We spoke with people who lived at the home and relatives who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to.

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

We found that care staff members did not have access to plans of care that contained all of the information they needed to ensure that the health and safety of people was promoted.

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

People told us that their medication was available when they needed it and that they received it on time.

People said that staff members were, “Excellent.” Staff training was not complete and up to date for all staff members and they had not all received regular supervision and attended staff meetings.

People told us their complaints were listened to and resolved. We found that no record was held of the concerns and complaints that people had raised.

We spoke with six people who lived in the home. People told us that their needs were met and that they were consulted about the care and support that they were provided with. People were complimentary about the staff that cared for them and told us that they always treated them with respect and that their privacy was respected. They told us that there were not always enough staff on duty to assist them and that they sometimes had to wait for help. They also told us that the environment was comfortable and clean and that they were provided with good quality meals.

We also 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 comment. We observed that people living in the home were given the support and attention they needed, were appropriately supported to manage their behaviour and had a positive experience of being included in conversations and decision making.