The inspection took place on 20 September 2017. The inspection was unannounced.

Victoria Lodge is based in a residential area of Saltburn within walking distance of the sea front. The home provides personal care for people living with a mental health illness. The service is registered for 14 people and on the day of our inspection there were 12 people using the service.

At our last inspection in July 2016 we found the service was in breach of registration and was rated as ‘requires improvement’. We found during this inspection that the provider had made improvements to their best interest decision processes and recording and had recruited a new manager.

We found quality assurance surveys took place, to check people’s views of the service The service had been regularly reviewed through a range of internal and external audits. We saw that action had been taken to improve the service or put right any issues. People who used the service and their representatives were regularly asked at meetings for their views about the care and service they received.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (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.

A manager was newly appointed to the role and at the time of our inspection was in the process of registering with the CQC.

The atmosphere at the service was relaxed and very welcoming. People who used the service told us they felt at home and had a good rapport with the staff and the providers.

We saw staff interacting with people in a person centred and caring way. We spent time observing the support that took place in the service. People were always respected by staff and treated with kindness. Staff communicated with people well and where necessary used their skills positively to reassure people who used the service.

We found the service adhered to the principles of the Mental Capacity Act 2005 and where people were unable to make decisions for themselves, best interests’ decisions had been put in place. These had involved social workers, family members, advocates and other professionals.

People were encouraged to enhance their wellbeing on a daily basis by taking part in activities that they valued. Staff spent their time positively engaging with people on an individual basis in meaningful activities. People were supported to go out regularly too.

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’s care plans were written in plain English and they also included a personal history and described individuals preferences and support needs. These were regularly reviewed and were written in a person centred way. ‘Person centred’ is when a person is at the centre of planning their care and their preferences are respected.

Care plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care plans showed that people’s health was monitored and referrals were made to other health care professionals where necessary, for example: their GP, chiropodist, mental health practitioners, dentist or optician.

People who used the service were supported on a one to one basis or by sufficient numbers of staff to meet their individual needs and wishes in a person centred way.

Staff training records, showed staff were supported and able to maintain and develop their skills through training and development opportunities that were accessible at the service. The staff confirmed they attended a range of learning opportunities.

This inspection took place on 6 and 11 July 2016. The first day was unannounced which meant the registered provider and staff did not know we would be visiting the service.

At the last inspection on 20 and 26 October 2015 we found the service was not meeting all the requirements of the Health and Social Act 2008. There were gaps in the records of maintenance and safe systems were not in place for hazardous substances. We also found that safe staffing levels were not in place and training was not up to date. The service had no registered manager in post and quality assurance processes were not regularly completed therefore the service did not show good governance. Some records were inaccurate or incomplete.

Victoria Lodge is a large converted terraced house in the centre of Saltburn. The service can provide care and support for up to fourteen adults who have a mental health condition. At the time of inspection only eleven people were living at the service. The service is close to all local amenities. It is located on a quiet residential street and services are provided over three floors. There is a rear courtyard and on street parking.

The home has not had a registered manager in post since 27 February 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 a 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 the inspection the registered provider was supporting the service on a day to day basis.

Safeguarding alerts had been made when needed. Staff understood the procedure they needed to follow if they suspected abuse might be taking place.

Risk assessments were in place for people who needed these and they were specific to people’s needs and were regularly reviewed. Staff understood that people could take reasonable risk.

Emergency procedures were in place for staff to follow and personal emergency plans were in place for everyone. A new robust procedure for recording fire drills had been implemented.

Robust recruitment procedures were in place and appropriate checks had been made for newly recruited staff.

There were sufficient staff on duty. People told us there was enough staff on duty day and night to meet their needs. A dependency tool was used to determine safe staffing levels.

Medicines were managed appropriately. The service had policies and procedures in place to ensure that medicines were handled safely. Medication administration records were completed fully to show when medicines had been administered and disposed of. However, there was no clear record within the medication administration records, of where creams should be applied

Certificates were in place to ensure the safety of the service and the equipment used. Maintenance and fire checks had been carried out regularly by the service. However the stair lift service maintenance certificate was not up to date. The registered provider has since taken action to correct this.

Staff performance was monitored and recorded through a regular system of supervision and appraisal. Staff had received up to date training to support them to carry out their roles safely and had completed an induction process with the provider. People told us they felt staff had the knowledge and skills needed to care for them.

People were supported to maintain their health. People spoke positively about the nutrition and hydration provided at the service. Staff understood the procedures they needed to follow if people became at risk of malnutrition or dehydration.

Some staff demonstrated good knowledge and understanding of the requirement of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and knew what action they would take should they suspect a person lacked capacity. However, documentation was not always in

Victoria Lodge is registered to provide accommodation and personal care for 14 people. The service is aimed primarily for people who need support to maintain their mental wellbeing. At the time of our visit there were 13 people who used the service. The building is close to local amenities and shops. It is located in a quiet residential street and services are provided over three floors.

The inspection team consisted of one inspector. During the inspection, we spoke with five people out of 13 people living at Victoria Lodge, the proprietor, the manager and three staff. We looked at three sets of care records and four staff files. We also observed care practices within the home.

The management of the home was good and we saw strong leadership in place and a positive environment for people and staff. Staff spoke highly of their manager and the support which they received.

We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Everyone we spoke with told us they felt safe and secure living at the home. Staff we spoke with understood the procedures which they needed to follow to ensure that people were safe.

Victoria Lodge was clean, hygienic and well maintained; although the provider may wish to note that the downstairs toilet needed resealing and the boxed in work needed updating and painting. At the time of our visit there was scaffolding in place as re pointing work was been carried out. There were good processes in place that ensured infection prevention and control of the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care home. While no applications had been submitted to the local authorising authority, the home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards and there was evidence to show that this had been followed appropriately. Staff had received training in relation to these topics along with the safeguarding of vulnerable adults and had an understanding of the actions to take. This meant that people were safeguarded as required.

Peoples care plans were person centred and provided information on their personal life history, who and what is ‘important to me’ and ‘how I would like you to meet my needs.’

Is the service effective?

Everyone had their needs assessed and had individual care records which set out their care needs.

It was clear from our observations and from speaking with staff that they had a good understanding of the care and support needs of people living at the home and that they knew them well. Assessments included mental health, needs for any mobility aids, specialist dietary requirements and road safety assessments.

People spoke highly of the staff and said that they were happy with the care that had been delivered and their needs had been met.

People had access to a range of health care professionals some of which visited the home and all was documented in the care files.

People were encouraged to maintain links with their local community and we were told that the people who used the service liked visiting ‘mind’ where there were activities such as a disco on a Tuesday night.

Is the service caring?

People were supported by kind and attentive staff who showed patience and gave encouragement when supporting people, whilst helping them to remain independent.

Care plans were individualised and included people’s preferences, interests, aspirations and diverse needs. Our observations of the care provided showed that staff were very knowledgeable about people’s needs and wishes.

People told us that they were happy with the care and support provided to them.

Is the service responsive?

There was clear evidence contained within people's care plans to show how they worked with other health and social care professionals.

People told us that they knew how to make a complaint if they needed to.

The home was responsive to people’s needs, wishes and preferences. We saw that the people who used the service could come and go as they pleased.

Is the service well-led?

There were systems in place to assure the quality of the service they provided. The way the service was run was regularly reviewed. Actions were put in place when needed and we were able to see that these actions had been addressed.

Regular audits were carried out which were used to identify changes and improvements to minimise any risks to people and staff.

We saw people had completed a customer satisfaction survey. This was reviewed and an action plan developed where needed.

There were enough staff on duty at all times and staff had time to sit with the people who used the service.

What people said:

People who were able to express their views told us they were satisfied with the care and support they received. One person told us, “The staff are nice, friendly, helpful people.” And another said, “The manager is nice, she is motherly and understanding.”

Everyone we spoke with told us they enjoyed living at the home and they were happy with the care provided. People told us, “It’s the best home I have ever lived in.” and “The staff understand me and make me feel better.”

Staff told us they enjoyed working at Victoria Lodge. Staff spoke highly of their team and of their manager. One staff member told us, “I feel very supported; the manager helps me with everything.” Another told us, “It’s like a nice family all in one place.”

We spoke with seven people living at Victoria Lodge. They told us they were supported to do what they wanted and were involved in planning their care and the day to day routines of the home.

One person said; “I’ve been here thirteen years, I’ve got no complaints here, my Mam likes coming here to see me”

Another person commented; “I feel safe here, it’s very friendly here.”

People told us they were happy with the care and support they received. For example, one person remarked;

" I’m independent, I shower myself and I go shopping.”

Another person said; “I set the tables, I make the tea, I take turns dusting and washing up.”

People also made positive comments about the staff, and the comments we heard included: “Me and the staff, we are a team." and “The staff are lovely here”

The atmosphere in the home was relaxed and happy; we heard lots of laughter and observed warm and kind interactions between staff and residents

We spoke with six people living at Victoria Lodge. They told us they were supported to do what they wanted and were involved in planning their care and the day to day routines of the home. One person said; “I enjoy getting stuck in … helping with the cleaning.” Another person commented; “Everyone has a key worker who helps plan things with you.” People told us they were happy with the care and support they received. For example, one person remarked “It’s good for me here.” Another person said “It’s alright here, I can come and go as I please.” People also made positive comments about the staff, and the comments we heard included: “They’re a good bunch.” and “You couldn’t get a nicer manager.”

People who use the service said “There is good food, the smoke room and my bedroom are nice”, “I get help with my shopping, which is good”, “We’re asked where we want to go on trips in the summer and at Christmas”, “Birthdays are very special and Christmas is fantastic, a very loving family home”. “I’m happy here; I don’t think the home can be improved”, “The staffs are all good in here”.

We inspected Victoria Lodge on 20 and 26 October 2015. The first day of the inspection was unannounced which meant that the staff and registered provider did not know that we would be visiting. We informed the registered provider of our visit on 26 October 2015.

Victoria Lodge is a large converted terraced house in the centre of Saltburn. The service can provide care and support for up to fourteen adults who have a mental health condition. At the time of the inspection only eleven people were living at the service. The service is close to all local amenities. It is located on a quiet residential street and services are provided over three floors.

The home has not had a registered manager in place since 27 February 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 the time of the inspection the registered provider was supporting the service on a day to day basis alongside a management consultant.

Checks of the building and maintenance systems were undertaken to ensure health and safety. However the registered provider had failed to assess all areas of hazards in the service leading to a failure to ensure electrical safety and legionella safety had been completed periodically. The registered provider organised that these checks be completed as soon as they could arrange this.

We found that safe systems were not in place for the control of hazardous substances.

We saw that staff had an informal system of working to ensure they knew the whereabouts of people each day and that a missing resident’s policy was in place. We found that this system often meant staff did not know the whereabouts of people who were out accessing the community and what time they would be returning. The system was designed to react to a missing person once they noticed a person missing, rather than proactively planning for the individual needs and risks of each person, particularly where there was known risks.

We found that one of the registered providers was working as part of the staffing numbers but was not taking part in the care and support tasks expected of the staffing deployed. We found that this meant that there were insufficient staff on duty to ensure people’s needs were met. We discussed this with the registered provider and they agreed not to be a part of the staffing numbers.

Not all staff had been trained in the basic induction topics. Some staff had refresher training in essential topics. This means not all staff had received the knowledge to provide support to the people they cared for.

There were systems and processes in place to protect people from the risk of harm. Staff were able to tell us about different types of abuse and were aware of action they should take if abuse was suspected. Staff we spoke with were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures. Not all staff had up to date safeguarding training and one person had never received this training even though they had commenced employment in 2014.

There were not effective systems in place to monitor and improve the quality of the service provided. We saw there were a range of audits carried out both by the registered provider and senior staff within the service. We saw that not all had been completed regularly and that some had not been fully completed. We found that some of the audits were of a tick box nature and did not describe what was being checked.

We found that recruitment and selection procedures were in place and that checks had been undertaken before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people, but the registered provider failed to ensure the most recent employer provided references for one candidate as is required. They were also not ensuring all gaps in employment were investigated and the reason for them recorded.

Staff understood the requirements of the Mental Capacity Act (2005) (MCA) and the Deprivation of Liberty Safeguards. We found no evidence of MCA assessments or best interest decisions made where they are delivering support to people who they feel do not have capacity in certain areas.

We saw that staff had received supervision on a regular basis and most people had received an annual appraisal, the registered provider had a plan in place to ensure all staff had received an appraisal within an acceptable timeframe.

We saw people’s care plans were person centred and written in a way to describe their care, and support needs. These were not reviewed as needed. We saw evidence to demonstrate that people were involved in all aspects of their care plans. The registered provider was implementing a new system of support and care planning which they stated would ensure the views of how someone wants to be supported will be built into the plan

Risks to people’s safety had been assessed by staff and these records had been reviewed. Risk assessments had been personalised to each individual and covered areas such as scalding, finance and moving and handling, choking, health and behaviour that challenged. This enabled staff to have the guidance they needed to help people to remain safe.

Appropriate systems were in place for the management of medicines so that people received their medicines safely.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful, patient and interacted well with people. Observation of the staff showed that they knew the people very well. People told us that they were happy and felt staff cared about them.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff to hospital and doctors appointments.

People’s independence was encouraged and people who had the skills and motivation led very active lives. Where people who needed more support to plan and access activities we saw they had less active lives.

The registered provider had a system in place for responding to people’s concerns and complaints. People were regularly asked for their views. We saw there was a keyworker system in place which helped to make sure people’s care and welfare needs were closely monitored. People said that they would talk to the registered provider or staff if they were unhappy or had any concerns.

We found breaches 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.