This was our first inspection of Lutterworth Country House Care Home since the new provider took over in October 2017. Lutterworth Country House Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Lutterworth Country House Care Home provides personal care and accommodation for up to 66 older people some of whom had dementia. On the days of our inspection there were 55 people living at the service.

We inspected on 25 September and 1 October 2018. The first day of our visit was unannounced. This meant the staff and the provider did not know we would be visiting.

The service had a registered manager. A registered manager is a person who has registered with the CQC 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 registered manager had not fully understood their legal responsibility for notifying the CQC of deaths, incidents and injuries that occurred or affected people who used the service.

We have made a recommendation about people's plans of care. Whilst people had plans of care in place, not all were up to date or accurately reflected people’s current care or support needs.

Systems in place to monitor the quality and safety of the service being provided were not always effective.

Whilst the risks to people’s care and support had been assessed, the actions to minimise the risks had not always been followed.

People’s thoughts varied on the numbers of staff deployed to work on each shift. Whilst some felt there were enough staff members to meet people’s care and support needs, others did not. Observations identified times when there were no staff members available in the lounges and limited interactions between the people using the service and the staff team.

Not all of the staff team had been provided with an induction into the service or the necessary training. A training plan was received following our visit showing how this was being addressed.

The staff team supported people to make decisions about their day to day care and support and they were aware of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Mental capacity assessments had not always been completed to ensure any decision made on behalf of a person had been made in their best interest.

Records kept for people who had been assessed to be at risk of not getting the food and drink they needed to keep them well, were not always accurate.

People told us they felt safe living at Lutterworth Country House Care Home and the staff team were aware of their responsibilities for keeping people safe.

Appropriate pre-employment checks had been carried out on new members of staff to make sure they were safe and suitable to work there.

People had received their medicines as prescribed. Systems were in place to regularly audit the medicines held at the service and the appropriate records were being kept.

People had access to relevant healthcare services and they received on-going healthcare support. Nutritional assessments had been carried out and people were supported to maintain a healthy, balanced diet.

People were supported 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.

People were provided with a clean and comfortable place to live and there were appropriate spaces to enable people to either spend time with others, or on their own. Whilst not all of the staff team had received training in the prevention and control of infection they understood their responsibil