The Hermitage Charity Care Trust is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The Hermitage Charity Care Trust is situated in the market town of Uttoxeter and provides personal care for up to 30 females in one adapted building. The premises have been extended and modernised with all bedrooms now being on the ground floor. The care home was gifted in Trust to the ladies of Uttoxeter and is therefore only for females. At the time of our inspection, there were 28 females using the service.

At our last comprehensive inspection in May 2016, the service was rated as Good with the Key Question Effective being rated as Requires Improvement. The service was found to be not consistently following the principles of the Mental Capacity Act (2005) and people were being unlawfully Deprived of their Liberty. This was a Breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A focused inspection took place in December 2016 and found that the provider had made the necessary improvements and the Key Question of Effective was rated as Good.

At this inspection, the Key Question of Caring was still rated as Good. The Key Questions of Safe, Effective, Responsive and Well-Led has now changed to Requires Improvement.

There was 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.

There were enough staff to meet people’s needs but staff had not received up-to-date training. Care plans were not always personalised and people did not always receive care that was responsive to meet their needs. Risks were not appropriately assessed and planned for.

People’s mental capacity had not always been assessed at the right time meaning people did not have maximum choice and control of their lives which meant that staff could not support them in the least restrictive way possible. There were no systems in place to monitor, learn and improve when things went wrong.

People were not supported to have their end of life care and wishes met but the service had begun working with an agency to develop this practice. Medicines were mostly managed safely and people had access to healthcare as required.

Staff knew people well were able to tell us how they protected people from the risk of abuse and/or harm. People were treated with kindness and people knew how to make a complaint. People were happy with the food and drink that was available to them.

Our inspection found a breach of regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to good governance at the service. You can see the action that we asked the provider to take at the end of this report.

We undertook this unannounced focused inspection on 13 December 2016 to check that the provider had addressed the breach in regulation identified at our last unannounced comprehensive inspection on the 27 May 2016. At our last visit we identified that the registered manager had not made any applications under the Mental Capacity Act Deprivation of Liberty Safeguards for people whose liberty may have been restricted. At our inspection in May 2016 we saw that some people’s capacity had been assessed, but they were not in place for everyone that needed support in making decisions. The registered manager sent us a report in June 2016 to address the areas of concern we identified.

The area that required improvement at our last visit was under the key question; is the service effective. This report covers the areas that required improvement and all key lines of enquiry (KLOE) under this question. The KLOEs are a set of questions we use that directly relate to the five key questions we ask of all services. You can read the report from our last comprehensive inspection visit, by selecting the ‘all reports’ link for The Hermitage Charity Care Trust on our website at www.cqc.org.uk

The Hermitage Charity Care Trust provides accommodation and personal care for up to 30 older people, ladies only. They are not registered to provide nursing care. At the time of this inspection visit there were 29 people living at the home.

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.

We saw that improvements had been made to ensure people’s rights were protected, as mental capacity assessments were in place for people that needed support to make decisions. Applications were being made under the Mental Capacity Act Deprivation of Liberty Safeguards for people whose liberty may be restricted.

Staff gained people’s verbal consent before supporting them with any care tasks and helped people to make their own decisions. Staff knew about people’s care and support needs and received training to support their knowledge and learning. People received food and drink that met their nutritional needs and preferences and were referred to healthcare professionals to maintain their health and wellbeing.

This inspection visit took place on the 27 May 2016 and was unannounced.

The Hermitage Charity Care Trust provides accommodation and personal care support for up to 30 older women. There were 30 people who used the service at the time of our visit.

The service had 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 2008 and associated Regulations about how the service is run.

At our previous visit on the 14 November 2014 the service was meeting the regulations that we checked but we did ask the provider to make some improvements. Although best interest decisions were in place for people that were unable to make specific decisions for themselves, mental capacity assessments had not been completed to demonstrate that these people lacked the capacity to make decisions. At this visit we saw that some improvements had been made, some people had received a capacity assessment, but they were not in place for everyone that needed support in making decisions. The registered manager had not made any applications under the Mental Capacity Act Deprivation of Liberty Safeguards for people whose liberty may have been restricted.

People told us and we saw there were sufficient staff available to support them. Staff had knowledge about people’s care and support needs to enable care to be provided in a safe way. Staff told us that they were supported by the management team and provided with the relevant training to ensure people’s needs could be met.

Staff understood what constituted abuse or poor practice and systems and processes were in place to protect people from the risk of harm. Policies were in place and followed so that medicines were managed safely and people were given their medicine as and when needed. Thorough recruitment checks were done prior to employment to ensure the staff were suitable to support people.

Assessments were in place that identified risks to people’s health and safety and care plans directed staff on how to minimise identified risks. Plans were in place to respond to emergencies to ensure people were supported in accordance with their needs. Care staff told us they had all the equipment they needed to assist people safely and understood about people’s individual risks. The provider checked that the equipment was regularly serviced to ensure it was safe to use.

Staff gained people’s verbal consent before supporting them with any care tasks and helped people to make their own decisions. People received food and drink that met their nutritional needs and preferences, and were referred to healthcare professionals to maintain their health and wellbeing.

People were supported to socialise and take part in activities to promote their wellbeing. People told us that they liked the staff and we saw that people’s dignity and privacy was respected by the staff team. Visitors told us the staff made them feel welcome and were approachable and friendly.

Staff listened to people’s views and people knew how to make a complaint or raise concerns. There were processes in place for people and their relatives to express their views and opinions about the service provided. People felt the service was well managed and they were asked to express their views and be involved in decisions related to the planning of their care. There were systems in place to monitor the quality of the service to enable the manager and provider to drive improvement.

This inspection was unannounced and took place on the 14 November 2014.

The Hermitage Charity Care Trust provides accommodation and personal care support for up to 30 older women. There were 29 people who used the service at the time of our visit.

The service had 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 2008 and associated Regulations about how the service is run.

At the last inspection on 9 May 2014 we asked the provider to take action to make improvements. This was because capacity assessments were not in place for people that lacked capacity to make decisions for themselves, and not all identified areas of need had a risk assessment and care plan in place to ensure people’s safety and welfare was maintained. The provider sent us an action plan after the inspection to confirm that these improvements would be in place by 31 July 2014.

At this inspection all areas of people’s identified need were included in the care records seen, this meant that staff had the information needed to support people effectively.

The manager had undertaken best interest meetings for people that lacked capacity but mental capacity assessments had not been completed for these people. This meant that the provider had not always acted in accordance with legal requirements.

The registered manager had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for people who used the service, even though their liberty may have been restricted.

Sufficient staffing levels were provided to meet the needs of people. Staffing levels were monitored and actions had been taken to recruit additional staff to meet people’s needs.

People received their medication as prescribed but staff were not recording the actual dose administered for variable dose medicines, such as ‘as required’ medicines for pain relief. Therefore if a person asked for more pain relief staff would not be able to determine from the records, whether they had already had the maximum dose or not. This meant that people’s ‘as required’ pain relief was not managed appropriately.

Staff had a good understanding of the safeguarding adults procedure and demonstrated that they knew how to report any concerns disclosed to them. People who used the service told us they felt safe at the home.

The care and support provided to people met their identified needs and preferences and staff demonstrated a good understanding of people’s individual needs.

Care plans were reviewed regularly to ensure people’s needs continued to be met.

People liked the staff and told us that their needs and preferences were met and confirmed that their opinions and views were sought and listened to.

Staff told us that they were supported by the management team and provided with the relevant training to ensure people’s needs could be met.

Audits were undertaken and regularly monitored and assessed to drive improvement; however no written audits were undertaken regarding the management of medicines.

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

This visit to The Hermitage Charity Care Trust was an unannounced inspection. At the time of our visit 28 people were using the service. We looked at two people’s care records and spoke with these people to get their views on the quality of support they received. We also spoke with the staff that supported them. This is known as pathway tracking and helps us to understand the outcomes and experiences of a selected sample of people. We also spoke with five other people that were using the service. We used the information we gathered to answer our five key questions.

Is the service safe?

Since our last visit improvements have been made to ensure medicines were managed in a safe way.

Recruitment records demonstrated that thorough recruitment checks were undertaken before staff commenced employment, this ensured that the provider and registered manager had assured themselves that the staff employed, were considered safe to work with the people using the service.

Not all identified areas of need had a risk assessment and care plan in place to ensure people's safety and welfare. This meant that staff did not have guidance to follow to ensure people were provided with safe care.

Capacity assessments were not in place for people that lacked capacity to make decisions. This meant there was no written evidence to demonstrate that when people lacked capacity they were supported in the least restrictive way.

Is the service effective?

Information in care plans showed people made decisions about their daily lives and how they wished to be cared for. People spoken to confirmed that they were able to follow their preferred routines. One person said; “I go to bed when I’m ready, there’s no set times.”

In general people’s care packages met their needs and preferences. People using the service told us that staff followed their agreed care plan.

Is the service caring?

People’s preferences and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

People using the service told us they were happy with the support they received from staff. One person said; “I’m very happy here, the staff are very nice, if I need any assistance I just ring the buzzer and they come and help me.” Another person told us; “The staff are lovely, very good.”

Is the service responsive?

Staff spoken with had a good understanding regarding the level of support each person required to maintain their safety and well-being.

People we spoke with told us that if they had any concerns or worries they would tell a member of staff or a family member.

From our observations we saw that people using the service appeared relaxed and comfortable with the staff on duty and were able to openly express their opinions and preferences.

Is the service well-led?

Staff spoken with told us that the registered manager was approachable and did a good job. One member of staff said; “The manager is lovely, she is so approachable.”

Staff were given an opportunity to express their views through staff surveys and team meetings.

Meetings for people using the service were provided on a monthly basis and people spoken with confirmed this. We looked at the minutes and saw that each meeting reviewed the previous matters and provided feedback to people. This demonstrated that people were given the opportunity to raise and discuss any issues.

Surveys were sent out annually to people’s relatives to get their views on the quality of service provided. An evaluation of the survey and actions to be taken was displayed within the home. The questionnaires viewed contained positive feedback about the quality of service received.

We saw that people received their care in a positive and caring manner. We observed care being provided by staff who had the knowledge and skills to deliver the care that each person needed. One relative told us, “I’m delighted with the service. I don’t worry when I leave here, because I know X (person using the service) is safe.”

We saw the staff were respectful to people when providing this support. People were relaxed in the company of staff. One person told us, “The staff are very good here. They do their very best for us.”

People told us they could make choices about their food and drink. We saw that people were supported to eat and drink a healthy and balanced diet that met their individual needs.

We saw that people received support taking their medicines. The systems in place for the storage of Controlled Drugs and recording of these and other medicines were ineffective. This meant that the provider could not account for all of the medicines which were held on the premises, and some Controlled Drugs were stored inappropriately.

We saw that the provider had a system in place to regularly assess and monitor the service which focussed on service improvement.

During our inspection we spoke with six people using the service, two staff on duty, the registered manager and two visitors including a health care professional. People spoke positively about how they were able to make decisions about their care, spend their time and enjoy shared interests and social events.

People told us they were satisfied with the care and support they received and were happy with the staff team that supported them. People using the service told us that they felt safe. We observed the way staff interacted with people and we saw positive relationships.

We found the care and support were delivered in a warm and caring manner. Records were up to date, although some records, such as moving and handling assessments needed reviewing.

We looked at the training offered to the staff team and found that suitable training opportunities were provided.

The provider had systems in place to check on the quality of the care people received. We saw complaints were acted upon to improve outcomes for the people who used the service.

We visited this service in March and September 2011 and compliance actions were made. This meant the home needed to improve outcomes for people using the service in some areas. We saw that information needed to be recorded to demonstrate how decisions had been made. People did not always receive support in the safest way, or in the way they wished. We also saw that effective systems were not in place to monitor risks or review the quality of the service provided.

During this visit we checked to make sure improvements in these areas had been made. The home had sent us an action plan as required. We visited the home to ensure the plan provided to us was an accurate reflection and demonstrated compliance.

People spoken with told us they felt staff treated them well and respected them. They also commented that they received support from regular staff, which promoted consistency. One person told us, “If I could, I would live at home but I can’t, this is the next best thing. I choose my own clothes, get up when I want and when I ring my bell they come as fast as they can to help me.” Another person said, “They are very good and I decide what I want to do from day to day.”

We saw that the communal areas were homely and comfortable. Chairs and furniture were organised to offer cosy seating areas that gave a less formal appearance. We saw people choosing to sit in either of the two lounges and some people chose to go to their bedrooms throughout the day. People were encouraged to freely move around the home as they wished.

A visitor told us that the care staff were good and knew people’s needs well. They told us that they had visited a number of care homes and chosen The Hermitage because they were impressed with the appearance, cleanliness and high maintenance. One relative told us, “My relative is happy here, the staff have got to know their needs well.”

In August 2011 we received information that caused us concern and therefore we visited the home to see if these concerns were accurate. We had been told people living at the home had to get up early to meet the needs of the staff; because of this information we arrived at the home at 06.30. We found seven of the 28 people living at the home were up at this time. We found that some people may not be able to get up in the morning at their preferred time due to the way in which the home operated.

We also visited this service in March 2011 and four compliance actions were made. This meant the home needed to improve outcomes for people in these areas to ensure compliance. We saw that improvements to medication administration practices were needed. We needed more evidence to ensure procedures were in place to promote a clean environment and prevent the spread of infection. The home did not have sufficient systems in place to assess and monitor the quality of service provision, and suitable arrangements were needed for obtaining the consent of people in relation to the care and treatment they received.

When we undertook the planned review in March 2011 people using the service told us they enjoyed living at The Hermitage and they considered it was their home. People said their privacy and dignity was always respected and their independence promoted. “I have a lot to be thankful for, you can have a laugh with the staff, they are a cheerful bunch”.

During this visit people told us they were happy with their bedrooms and that they could either remain in the privacy of their own room or join other people in the communal areas. They said their rooms were kept clean and when they moved in, they were encouraged to bring in some of their personal belongings. People said the staff were kind, worked hard and knew them well.

Visiting professionals spoken with considered The Hermitage was a good home and they were satisfied with the care provided. We did not see any visitors to speak with during this visit.

People told us that they enjoyed living at The Hermitage Charity Care Trust and confirmed their privacy and dignity was respected and their independence promoted.

One person told us, “the manager is sorting out a piece of equipment to help me, they are all very helpful.”

People told us “the staff are lovely.” One person said, “I have been in another home, I would rather be here.”

People told us they were happy with their bedrooms and that they can either remain in the privacy of their own room or join other people in the communal areas available. They said their rooms were kept clean and when they moved in, they were encouraged to bring in some of their personal belongings to make their room feel homely.

People said the staff were kind, work hard and knew them well. One person said, “I have a lot to be thankful for, you can have a laugh with the staff, they are a cheerful bunch”.

Five people told us they could, and do, get bored, comments included: “There is not a lot that we do.” “I would like to see more going on.” “I don’t want to stay in the lounge, there is nothing to do.” “I don’t do much, but I read.”

We spoke with two visiting professionals, both spoke favourably about The Hermitage Charity Care Trust and considered people received good care. “They take care of the residents, people look cared for and the staff are pleasant and helpful.”

Everyone spoke enthusiastically about the food and verified they had plenty to eat and drink.

Staff told us they enjoyed working at The Hermitage Charity Care Trust. Staff felt they worked well as a team and supported each other in order to do a good job, they confirmed the management team offered support.