Our inspection took place on 12 July 2018 and was unannounced.

Lewin House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection.

The service can provide nursing care and treatment for up to 70 adults. At the time of our inspection, the service accommodated 64 people across four separate units, each of which had separate adapted facilities. Some of the units specialised in providing care to people living with dementia.

The provider is required to have a registered manager as part of their conditions of registration. 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 the time of our inspection, there was a registered manager in post.

At our last inspection on 10 and 11 August 2016, we rated the service “good”. At this inspection we found the evidence continued to support the rating of “good” and there was no information from our inspection, or ongoing monitoring, that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated good:

We found people were protected against abuse or neglect. There were personalised risk assessments tailored to people’s individual needs. Sufficient staff were deployed to provide support to the person and ensure their safety. Medicines were safely managed. There was appropriate infection prevention and control.

At our last inspection, we found a breach of the regulations regarding obtaining and recording people’s consent to care and treatment. The service was now compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were assisted to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Staff received appropriate induction, training, supervision and support. This ensured their knowledge, skills and experience were relevant to their role. Access to other community healthcare professionals ensured the person could maintain a healthy lifestyle.

Staff had developed positive relationships with people who used the service and their relatives. There was complimentary feedback from people, relatives and other healthcare professionals about staff and the service. People’s privacy was respected and they received dignified support from staff.

The service provided person-centred care to people. We made a recommendation about equality, diversity and human rights training. People’s care plans were detailed and contained information on how staff could provide the right care. There was a satisfactory complaints system in place. Care of people with dementia was a strength of the service, and staff were passionate to develop this area to an outstanding level.

The service was well-led. There was a positive workplace culture and staff felt that management listened to what they had to say. The management had appropriate methods in place to measure the safety and quality of care.

Further information is in the detailed findings below.

This inspection took place on 10 and 11 August 2016. It was an unannounced visit to the service.

We previously inspected the service on 7 January 2014. The service was meeting the requirements of the regulations at that time.

Lewin House provides nursing care for up to 70 people. This includes care of older people, people with dementia and rehabilitation. Sixty four people were being cared for at the time of our inspection.

The service had 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.

People expressed positive comments about the care at Lewin House. These included “I’m looked after well, I can’t fault them,” “Staff treat me well,” “They are very pleasant and helpful,” “They are patient, lovely staff” and “They look after me in every way.” Visitors told us they found staff “Very approachable,” “They are kind and compassionate and patient and very courteous to me and my wife” and “I don’t think they could improve on the care they give.”

People were protected from the risk of harm. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Staff had been recruited using robust procedures to help ensure they had the right attributes to care for people. Although we received mixed feedback on the adequacy of staffing levels, we found there were sufficient staff to meet people’s needs during the inspection.

We found risk was managed well, to help people be as independent as possible. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care. People’s medicines were handled safely and given to them in accordance with their prescriptions.

People told us staff were kind and caring towards them. They were cared for by staff who received appropriate support and training to meet people’s needs. This included supervision, annual development reviews and an on-going training programme.

We found the home did not always work within the principles of the Mental Capacity Act 2005, to demonstrate how decisions had been made on behalf of people who lacked capacity. Improved recording was needed to show staff complied with conditions attached to authorisations by the local authority to deprive people of their liberty.

People knew how to raise any concerns about standards of care.

The building was well maintained and complied with gas and electrical safety standards. Equipment was serviced to make sure it was in safe working order. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

The service was managed well. The provider regularly checked quality of care at the service through visits and audits. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to providing care where people could not give consent. You can see what action we told the provider to take at the back of the full version of this report.

When we visited the service on 13 and 20 August 2013, we had concerns about the management of people’s medication and staff training. We set compliance actions for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant.

We returned to the service on 7 January 2014 to check whether improvements had been made. Records and checks of medicines showed staff were now handling people’s medication appropriately. Written guidance was in place where people were prescribed medicines for occasional, “as required” use. The protocols helped staff make decisions about when to give these medicines. We saw medication administration records were kept up to date and were accurate. This provided a proper audit trail of medication given to people.

We looked at staff training records. These reflected courses had been undertaken by staff to bring their learning up to date. For example, moving and handling, infection control and safeguarding people from abuse. This meant people were now cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We were satisfied the provider had made sufficient improvements to become compliant with these two standards.

There were 58 people living at the home at the time of our inspection. During our visit we spoke to six people using the service and five staff. People told us staff where friendly and they would know where to go to complain about things. One person said, “They are good at looking after you and they always answer the bell promptly.”

Staff we spoke with where aware of people's preferences and how they liked to have their personal care delivered.

We spoke to a relative who told us “the service is good”. They commented on the turnover of staff and informed us that thy did not know who their key-worker was.

The people who used the service and staff we spoke with both told us they had a range of activities that they chose from. Staff said they asked people each day if they would like to participate in the planned programmes.

There were arrangements for monitoring the quality of services; however, medications management was not always carried out in accordance with best practice.

Staff had access to training and professional support, despite this at times they felt that the staffing levels were not adequate to meet the needs of all service users at all times.

People told us that their rooms and the communal areas are kept clean and fresh. People that we spoke with were pleased with standards of care. One person said 'carers are brilliant and friendly'. People told us they felt staff understood what their needs were and were able to meet these needs. One person said he was happier at the home than where he previously lived. A visitor commented that staff are sometimes busy doing paperwork away from the lounge, leaving people unsupervised.

When we visited the service on 8 March 2013, we had concerns about how medication was being managed. During these visits, we checked to see whether improvements had been made. Whilst we found some improvement, we still had concerns about the use of antipsychotic medication prescribed for use “as required.” We found examples of it being given without evidence to validate its use. We could not be confident antipsychotic medication was being handled appropriately at the service.

At our last inspection on 8 March 2013, we had concerns about staff cover. This was because the arrangements to cover staff absences were not effective enough to ensure there was adequate staff provision. During these visits, we checked to see whether improvements had been made. We found the home was in a better position and had made use of relief and agency staff to cover gaps on rotas. We were confident sufficient improvements had been made to ensure the home was appropriately staffed at all times.

There were concerns about the support staff received at our inspection on 8 March 2013. We used these visits to check whether improvements had been made. We found improvement to staff supervision and appraisals. However, there were still concerns about training. We saw examples of staff not updating training in line with the provider’s requirements. This meant people were cared for by staff who had not kept their skills and knowledge up to date.

We looked at how complaints were managed. There was an effective complaints system and copies of the complaints procedure were available in the entrance hall. Records we looked at showed complaints were investigated appropriately.