The inspection took place on 20 and 21 December 2018. The first day of our inspection visit was unannounced.

The Hunters Lodge Care Centre 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 home is registered to provide accommodation with nursing care or personal care for up to 90 people, some of whom are living with dementia, have physical disabilities or mental health problems. The accommodation is provided within three separate units located on the same site: Kitwood Unit, Terrace Unit and Pavilion Unit. Each of these units is designed to cater for people with specific categories of needs. For example, Pavilion Unit provides care and support to younger adults with mental health problems. At the time of our inspection, there were 73 people living at the home.

There was a registered manager in post who was present during 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.

At our previous inspection in July 2017, we rated the service as 'Requires Improvement’ and identified a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the ineffectiveness of the provider’s quality assurance systems and procedures. As a result of the inspection, we asked the provider to send us a report explaining the actions they were going to take to improve the service. At this inspection, we found the provider was now meeting the requirements of Regulation 17, although improvements were still needed in the monitoring of recruitment practices and staff training provision.

The management team had not always adhered to the provider’s recruitment policy and safe recruitment practices through carrying out consistent per-employment checks on prospective staff. Some staff raised concerns regarding the adequacy of the night-time staffing levels on Terrace Unit, and we identified issues regarding staff deployment on the same unit. Some improvements were still needed in relation to the management of people’s medicines, including closer monitoring of medicines fridge temperatures. The provider had not fully promoted people’s rights under the Mental Capacity Act 2005 when introducing infra-red motion sensors across two of the home’s units. Mealtimes at the service still needed to be better organised to prevent significant delays in some people’s meals, and ensure people were effectively supervised and encouraged to eat. Staff training and supervision meetings had lapsed over recent months.

People told us they felt safe living at the home. Staff recognised their role in protecting people from any form of abuse or discrimination, and were aware of the different forms and potential indicators of abuse. The provider had systems and procedures in place to manage the risks associated with the home’s physical environment, the equipment staff used and people’s individual care and support needs. Staff recorded and reported any accidents or incidents involving people who lived at the home. The provider had measures in place to protect people, visitors and staff from the risk of infections. This included the provision of appropriate personal protective equipment for staff use.

People were supported by staff to make choices about what they ate and drank each day, and had input into the home’s menus. Any complex needs or risks associated with people's eating and drinking were assessed and managed, with advice from nutrition specialists. Prior to people’s care starting, the management team met with them and, whe

This inspection visit was unannounced and took place on 26 July 2017. At our last inspection visit on 30 June 2015 we asked the provider to make improvements to their as required medicines and safety of the environment. At this inspection, we found improvements had been made, however we identified some areas of concern in relation to how a decision is made when a person requires covert medicine and in the auditing of information to drive improvements to the home.

The service was registered to provide accommodation for up to 92 people. People who used the service had physical health needs and/or were living with dementia. At the time of our inspection 86 people were using the service.

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.

The registered manager had not always used their audits to reflect the running of the home and we saw there were areas which would have benefited from a robust process of checks for medicines and accidents information. When agency staff had been used, the necessary checks had not been completed to enable them to have the information to support people and their needs.

When people were unable to make decisions, about taking their medicine covertly, a best interest decision had not been completed. However when other decisions were required we saw that an assessment had been completed and people lacked capacity, and best interest decisions had been completed. Where people were being restricted of their liberty, the appropriate authorisations had been applied for.

People were not always supported to maintain their independence when they ate their meals, equipment and types of crockery had not been considered. People enjoyed their meals and had a choice of what they wished to eat. Their health care was monitored and when required referrals had been made to health care professionals. Any guidance received was implemented and the care plans updated with this information.

There was an opportunity for people and their relatives to give feedback on the service; the registered manager had also provided a range of opportunities to engage with relatives, however there had been limited response to these events. The registered manager was considering other opportunities and ways to ensure information was available.

Staff had received training in a range of areas to support their role and staff had the opportunity to progress with the home. People who used the service felt safe and staff understood their role in ensuring people were protected from harm. Staff recruited to the home had received the appropriate checks to ensure they were safe to work with people. Risk assessments were in place to ensure people’s safety and the safety of the environment. There were sufficient staff to support people’s needs and this was kept under constant review to ensure the staffing levels reflected people’s needs.

People had established positive relationships with the staff felt their decisions were respected. Staff had a kind and friendly approach to the care they delivered. People had the opportunity to engage in activities and entertainment was provided.

Medicines were managed safely and staff had received training and competency checks. People enjoyed the meals and had the opportunity to choose the food they ate. People felt relaxed in the atmosphere of the home and confident they could raise any concerns with the registered manager.

We saw that the previous rating was displayed in the reception of the home as required. The manager understood their responsibility of registration with us and notified us of important events that occurred at the service; this meant we could check app

This inspection took place on 30 June 2015 and was unannounced. At the last inspection on 5 August 2014 the provider was not meeting the legal requirements. We judged there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations including, Care and welfare of people, assessing and monitoring the quality of the service, safeguarding people who use services from abuse, respecting and involving people who use services, consent to care and treatment, staffing and supporting staff.

The Hunters Care Centre is registered to provide accommodation, nursing and personal care for up to 92 people who may have dementia. At the time of our inspection there were 44 people living in the home.

An acting manager had been appointed since our last inspection. The acting manager had worked as a registered manager previously and was going through our process to register for this home.

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 individual risk of harm had been assessed but the layout of the kitchen on one unit presented a risk which had not been recognised. People received their medicines safely however guidance was required so that staff understood when people needed their ‘as required’ medicines.

Staff understood their role in protecting people from abuse and the actions they should take if they had concerns. People who presented with behaviour that challenged their own safety and that of others were supported by staff who understood how to support them with consistency.

People were supported by sufficient numbers of suitably recruited staff. Staff demonstrated the skills required to care for people because they had received training that was appropriate for the people living in the home. New staff were provided with an effective induction period which supported them to understand people’s needs.

People were provided with food and drinks which met their individual requirements. Staff understood how to support people with specific dietary needs.

Staff were kind and polite to people. Staff recognised people’s individual needs and provided care which met their preferences. People’s dignity and privacy was promoted. People were supported to maintain the relationships which were important to them.

People were supported to take part in activities which interested them. People were offered opportunities to participate in social activities both inside and outside of the home. The complaints process was accessible for people and their families. Complaints were investigated and responded to within a timely period.

Management processes had been implemented to improve the leadership within the home. People, their relatives and staff were happy with the management arrangements. There were audits in place to monitor the quality of the care provided. Information gained from the audit programme was used to improve the lives of people living in the home.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.  

This was an unannounced inspection. This meant that the providers, managers and staff did not know we were visiting. At the last inspection in May 2013 the provider met all the regulations we looked at.

The Hunters Lodge Care Centre is registered to provide accommodation with nursing and personal care to 92 people. The home was undergoing significant refurbishment and currently there were 43 people living in three units. The nursing unit provided care for 20 people with dementia care needs; the residential unit with 18 people living with dementia and four people were accommodated in the 17 bedded unit for younger people with mental health needs.

The home did not have a registered manager but a new manager had been appointed who was due to put in an application to register with us. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has a legal responsibility for meeting the requirements of the law; as does the provider.

We saw that some people’s safety was compromised. Where people may have experienced emotional harm appropriate safeguarding referrals were not submitted. This meant that incidents may not be fully investigated.

Staff who were supporting people whose behaviour challenged did not have the appropriate training to do this safely.

Staff were not always following the Mental Capacity Act 2005 for people who lacked capacity to make a decision. For example, the provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for one person, even though their liberty was restricted. This meant their rights were not being upheld.  

People in the dementia care unit did not have enough to do. In the residential unit particularly staff did not have the time to spend with people to provide them with stimulation to promote their well-being.

Most people received care that took account of their wishes. However the home was not fully taking into account the cultural needs of some people. 

Relatives of people living with dementia were satisfied with the standard of care provided. They told us their relative was well cared for and had their health and personal care needs met. They told us that staff were caring, treated them kindly and with respect.

People living in the younger persons unit told us they were happy with their care. They said they were well supported and were provided with choices about their lifestyle.

People were having their health care needs met. They saw the GP when necessary  and had access to specialist health care support. People were supported to have their personal care needs met. The nutritional needs of people were identified and where needed a plan was in place showing the support they needed to eat and drink sufficient amounts. People had a choice of food and meal times were a positive experience for people.

Staff were caring and compassionate. We observed that they treated people in a gentle and caring way. People’s dignity was promoted and they were spoken with in a respectful manner. 

We found seven breaches of the Health and Social Care Act  2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

In this report the name of a registered manager appears. They were not in post and not managing the regulatory activities at this service at the time of the inspection. Their name appears because they were still on our register at the time of the inspection. The new manager told us they were in the process of submitting their registered manager application to the Care Quality Commission (CQC), having recently secured the permanent manager’s post at the home.

We carried out this inspection to check on the care and welfare of people who used this service. The visit was unannounced which meant the provider and the staff did not know we were coming.

At the time of the inspection there were 36 people in residence. We spoke with three people who used the service, seven relatives, the manager, two unit managers, other staff and a health professional who was visiting the service on the day.

The manager told us that there were only two units open at the home, Kitwood and Nightingale. Some of the people who used the service were unable to give us their views and we observed the interactions between them and staff.

One person who used the service told us: “I like living here – it’s very nice”. A relative we spoke to said: “I wouldn't want my (relative) to go anywhere else”.

We saw that people received the care they needed.

We saw that people received nutritional meals according to their needs. A relative told us: “The food is very nice here”.

We visited the service to check on the care and welfare of people who were living at Oaken Terrace. The visit was unannounced.

There were 33 people living in the home on two units. Nightingale provided accommodation for older people who may also have nursing care needs; Kitwood provided accommodation for older people who may have dementia.

There had previously been safeguarding concerns which had since been resolved. However, the local authority quality monitoring team continue to monitor the home.

During our visit we used different methods to help us understand the experiences of people using the service. These included observation and looking at records. We spent time in the main lounges. We observed the care that people received. We saw good interactions between the staff and people who live at the home and we saw that people were given choices.

People we spoke with were positive about the care and support that they or their relative received, and we saw that staff had been trained in dementia care, they were enthusiastic on both units and spoke and engaged positively with people.

We saw one to one and small group activities and staff encouraged people to participate.

Regular audits had been undertaken.This ensured that the home was well run and was meeting the needs of the people living there.

We visited Oaken Terrace to review improvements as there were compliance actions made at the previous visit, which took place in February 2012.

When we previously visited Kitwood unit there was clear evidence that the outcomes for people that lived there were good. The unit had been recently refurbished and decorated and people had moved there from other units on the site. Staff informed us that they had received support and training for people with dementia. The staff spoke in a manner which was engaging and polite and we saw some good interactions from staff with people who used the service. The observations included staff offering information about what they were going to do, providing clear explanations, and staff participating in activities in small groups and on a one to one basis.

On Kitwood unit we looked at the new care records that identified the person’s individual needs and these gave staff the personalised information they needed to support them. We spoke with activity staff who told us they visited each area and carried out activities based on topical events and the seasons. The activity staff informed us there were opportunities for people to go on activities in the community including visiting steam railways, historical re-enactment days, garden centres and the theatre.

When we previously visited Henderson unit there was evidence that the outcomes for people that lived there were poor. Our judgement was ‘Arrangements were not in place for people to receive appropriate care’. Staff had informed us that this unit was to be refurbished following completion of Kitwood unit. The management team had recognised that the décor and furniture needed to be upgraded.

The following issues were identified during the previous visit to Henderson unit:

There was a lack of availability of call bells and poor attendance to people when they were in their bedrooms.

Poor feeding practices where the staff were not engaging with the person who was being fed and pureed food was being mixed up. Staff practices at mealtimes were poor. Staff did not engage with the person who they were assisting to eat their meal and pureed food was not presented in an appetising manner as it was mixed all together on the plate.

Care records did not identify the person’s individual needs and staff were unsure of how to care for people. There was no evidence that the person or their relative were involved in the plan of care.

There was a malodour in some areas.

Weight charts and food diaries were not being completed and meal choices and preferences were not being offered.

There was no procedure for the reporting of pressure sores and pressure relieving equipment was not used correctly, with staff unsure how the equipment worked. Turn charts were not being completed.

Identified issues relating to deprivation of liberties had not been referred to the mental health team for consideration.

Prior to the CQC visit the home was under investigation by the local authority for the same issues identified at our last visit.

Following the visit the provider made the decision to close Henderson unit. The people living in the unit were reassessed to ensure their needs were appropriate for the home or were moved to a new care home. The staff from the unit were then interviewed and shortlisted, this was to ensure they were suitably trained to work in the home’s dementia unit.

Two of the four units on the site remain closed for refurbishment and the decision was made to concentrate on the two existing units, ensuring people’s needs were being met by suitable staff.

Currently there are 36 people living at the home on two units. The local authority quality monitoring team continue to monitor the home and a further review of compliance will be completed by CQC in the future.

Oaken Terrace had four separate areas where people have chosen to live. As part of our visit we spoke with people who lived on the Henderson and Kitwood unit. Henderson provides accommodation for older people who may also have nursing care needs; Kitwood provides accommodation for older people who may have dementia. Kitwood had been refurbished and a team of staff have been recruited and trained to meet the needs of people with dementia. The service plans to develop the other three units to a similar standard.

We visited this service because we had received information of concern with regards to how people were cared for when they needed support with pressure care. We also received information that the service was undergoing changes to the environment and with their management arrangements.

Due to the needs of some of the people living at the home not everyone was able to share their experiences of what it was like to live there. We spent some of our time observing people being supported by the staff on duty during our visit.

We saw staff were enthusiastic on Kitwood and spoke and engaged positively with people. We saw many one to one and small group activities and staff encouraged people to participate. People took part in domestic chores around their home. One person told us they like to prepare the tables and help to clean. Staff told us they wanted to encourage people to remain as independent as possible.

During our visit on Henderson unit we saw some people were left without support for long periods of time in their room, without the means of summoning for assistance. We observed that not everybody was always treated with dignity and respect. For example one person was supported to eat but staff did not talk with the person during the meal or introduce themselves.

We saw that people did not always receive appropriate support. Care records did not always record what people needed and staff could not always tell us how the person was supported. Staff did not know how all the equipment for alleviating pressure should be used and we saw some equipment was not being used correctly.

We shared our concerns with the person in charge who agreed to review the care and support needs of people. They said they would look for additional staff to be on duty and confirmed no new people would be admitted to the service. This meant that more support would be provided to the people, and the person in charge stated they were committed to addressing the concerns and improving the outcomes for people.

We shared our concerns with the local safeguarding team and local authority and will continue to liaise with other professionals within the multi-agency investigation currently taking place, to ensure improvements are made.

People who live in this home told us that they felt able to express their views about their care. They said that their views had been asked about their care as their care packages had been developed.

They also told us that should they have any worries about how they were being cared for they would feel confident in talking to the staff or managers about it. One person said, “No complaints at all; very nice people.”

And another said that he could “…certainly trust the staff”.

Everybody that we spoke to said that they liked the meals praising both the quality and the quantity of what they were offered.

People also told us that there were plenty of activities that they could take part in should they wish to with a number of outings taking place each month.

The people living in the home were also complimentary about the staff saying such things as, “no complaints at all; very nice people.”