This inspection took place on 4 and 8 January 2018 and was unannounced.

Worstead Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Worstead Lodge accommodates up to 20 people, some of whom may be have learning disabilities and/ or autism, in one adapted building. At the time of our inspection there were 19 people living in the home.

The home did not have a registered manager in post. They have not had a registered manager in place since July 2016. A manager from the provider’s other location was overseeing the day to day management of the home. No application had been submitted to us for them to become the registered manager for both services. 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 medicines continue not to be managed in a safe way. At our previous inspection on 26 and 27 May 2017 we found that the provider was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection in January 2018 we found that the provider had not made sufficient improvements in this area and remain in breach of this regulation. Medicines audits were not regularly carried out and staff were not routinely observed to ensure good practice in relation to managing people’s medicines safely. Records relating to the administration of people’s medicines were not always complete and therefore we could not be sure people received medicines as the prescriber intended.

We found further breaches of the regulations which related to the governance of the service. There were a lack of effective systems in place to monitor and assess the quality of service being delivered. Audits were not carried out on a frequent basis and the quality assurance measures in place did not identify areas for improvement. Staff recruitment records were not complete. Appropriate references had not been requested and there was no employment history for one member of staff.

In addition the provider did not notify of us of a significant event which they were required to by law.

Individual risks to people’s health and wellbeing had been identified and planned for. Risk assessments were detailed and gave staff sufficient information about how they could manage known risks. Risks within the environment had been identified and appropriate risk assessments were in place which documented how the risk was being managed and what steps staff could take to maximise people’s safety.

Staff understood their responsibilities in relation to safeguarding. They knew how they would report any concerns and to whom. There were consistently enough staff to support people and staffing levels were adjusted accordingly to meet people’s needs.

Accidents and incidents were recorded and these were reviewed regularly by the provider so any trends or patterns could be identified.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that the service was working within the principles of the MCA but staff did not have a good understanding of how the MCA affected their work.

Staff received training relevant to their role and they were supported to pursue further training to develop their skills and knowledge. Staff were further supported through supervisions with a senior member of staff.

People were supported to maintain a healthy nutritional intake and were given a choice about what they would like to eat. Mealtimes were informal and were sociable. Risks

The inspection took place on 26 and 27 May and was unannounced.

Worstead Lodge provides residential care for up to 20 younger people who are living with a learning disability. At the time of this inspection there were 19 people living within the home. The accommodation includes two self-contained bungalows, two self-contained converted stables and the main house where people had access to a number of communal areas.

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 service did not have procedures in place that fully reduced the risks associated with the management of medicines. Good practice was not being followed in all areas. Although the individual risks to the people who used the service had been identified and reduced, those associated with the environment had not been fully identified, assessed and managed.

The home had a system in place to monitor the quality of the service being delivered and this was effective in most areas. However, the system had failed to identify the issues associated with the safe management of medicines.

The people who lived at Worstead Lodge benefited from being supported by staff that were trained and competent in their roles. Staff had received an induction and the service had processes in place to ensure this was effective. Staff felt valued and supported in their roles. Safety checks had been completed to ensure that only suitable people were employed.

An open and inclusive culture was promoted and staff treated people with respect and kindness. Staff encouraged people to be independent and empowered them to make decisions for themselves whenever possible. The service worked in partnership with those that lived at the home in order to ensure it ran smoothly. People described the home as welcoming with a special atmosphere.

Processes were in place to help protect people from the risk of abuse and staff understood these. They gave us examples of abuse and the symptoms that may indicate potential abuse. Staff understood their responsibility to report any concerns they may have and knew the procedure for this both inside and outside of the organisation.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Staff understood the need to gain people’s consent before assisting them and they demonstrated that they fully encouraged people to make their own decisions where possible. However, staff knowledge of the MCA and MCA DoLS was variable and training had not been provided.

People had been involved in the decisions around what support they required and the support plans we viewed confirmed this. People, and their relatives, told us their needs were met. The support plans, and our observations during the inspection, demonstrated this. Support plans were individual to the person and gave staff clear information on the support people required and wished for. They showed that people’s independence was promoted and encouraged.

The service supported people to follow their interests and hobbies. This was done on an individual basis and the service went to great lengths to ensure people engaged in the activities they enjoyed, providing support where required. People told us of all the activities they engaged in which were many and varied.

People received interventions from, or had access to, a variety of healthcare professionals in order to maintain their physical and emotional wellbeing. Their nutritional needs were met and people were encouraged to participate in preparing meals for themselves and others who lived in the home. Participation in the running of the home was promoted in a m

We reviewed the evidence we obtained during our inspection and used this to answer our five key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see further evidence supporting this summary please read the full report.

Is the service safe?

We saw that there were detailed risk assessments in place that covered many aspects of people’s daily life and each of these had been completed specifically for the individual they referred to. The risk assessments we looked at were up to date and had been regularly reviewed.

All the areas of the main house that we saw were safe and accessible for the people living in or visiting the home and no hazards to people’s health or safety were noted. One person also showed us around one of the new bungalows that they lived in. We saw that all areas were clean and well maintained with no health or safety hazards noted.

The manager told us that a member of staff ensured that general maintenance matters were dealt with promptly.

A recent visit from the Fire Safety Officer confirmed that the fire precautions in place in the main house were ‘generally of a good standard’, with one minor area for consideration. The fire officer’s report in respect of the flats, situated in the grounds of Worstead Lodge, stated that the fire precautions in place were satisfactory, with no areas for consideration noted.

Is the service effective?

The information we looked at, together with discussions and observations, confirmed to us that people were supported to follow lifestyles of their choosing and be as independent as possible.

We observed that the ethos of Worstead Lodge was very much about empowering people by supporting them to do things for themselves, rather than having things done for them.

During our previous inspection on 30 August 2013, we had been concerned that there were some shortfalls in areas such as care records, record keeping and some other administrative areas. The provider sent us a plan of the action they intended to take to rectify the non-compliance issues. During our inspection on 10 April 2014, we found that appropriate action had been taken and that people’s care records and support plans had been reviewed and updated accordingly.

We saw that the care records were being regularly audited and people’s individual needs and assessments of risk were also being reviewed and updated on a regular basis.

All the information we saw was clear, detailed and individual. It was also easily accessible by staff, providing clear guidance with regard to how each person required support, in accordance with their needs and wishes.

We saw that staffing levels were increased at key times during the day, such as evenings and weekends, when more people were at home. We were satisfied that the staffing levels were appropriate, as many people were very independent and required only minimal support, such as verbal prompting or encouragement. We also saw that people had regular one-to-one time with their keyworkers on their days at home.

Is the service caring?

When we spoke about the staff, one person told us, “I need the staff to help me with things like cooking and they do that. They help me stop getting anxious; I worry and get upset quite a lot and they help me feel better…”

We saw from one person’s care records that they needed staff to help with cutting their food into manageable sized pieces. We noted that the person had agreed to this being done for them in the kitchen, which also maintained their dignity.

All the people we spoke with told us that the care and support they received was good and confirmed that they had regular discussions about their care with the staff. One person told us, “I talk to my keyworker a lot…” Another person said, “My keyworker checks that I’m alright and we talk about things I need or things I want to do…”

Is the service responsive?

One person had some difficulties with eating and swallowing and maintaining a healthy weight. We saw that there had been thorough assessments carried out by appropriate professionals such as the dietician and the speech and language team. We also noted from the care records, that staff followed the support guidance for this person in a ‘Nutrition and Dietetic Care Plan’ that had been provided by the dietician.

On the day of our inspection, we observed that an impromptu staff meeting had been called to enable staff to discuss the best way of meeting some specific support needs for one particular person.

We noted that quality assurance questionnaires had been sent out to people’s relatives in February 2014. We saw that, in one instance, the provider had provided a written response to a person’s relatives in order to reassure them in respect of a few issues they had raised.

Is the service well led?

Since our previous inspection on 30 August 2013, a permanent manager became registered with the Care Quality Commission and was predominantly based at Worstead Lodge. This meant that there was a clearer leadership and management structure within the home.

In addition, a new member of staff had been employed to provide some part time administrative support.

Eight members of staff told us that they were happy and felt confident in the work they did and knew each of the people they supported very well. All eight staff also told us that they were supported well by their manager or other seniors.

The manager told us that the staff team had gone through an unsettled period but that they had come through this very well. The manager also said, “They’re all good workers; hard working and very caring. The new staff are also very good.”

During our visit we saw that the manager had an 'open door policy' and actively encouraged comments, suggestions and feedback from the people living in the home, their friends and family and relevant professionals.

People we spoke with told us that staff were polite to them and that they respected their individuality and privacy. They described staff as "..kind" and "...friendly."

Staff told us that managers were supportive and approachable; however the provider's arrangements for supervision and appraisal were not adequate.

We looked at the support plans for three individuals living in the home and found that they actively promoted people's independence. One person described how staff had discussed written information with them and made sure they understood it. Communication between staff about people's needs was effective and promoted continuity of care and support.

People were offered choices in their daily lives and were encouraged and enabled to be active in their local community by participating in activities and groups. Some people received one to one support to manage their money. People's health needs were managed proactively by staff encouraging individuals to maintain a healthy lifestyle, such as by choosing their meals wisely.

We found there were effective systems in place to reduce the risk and spread of infection and to monitor the quality of the service. Surveys of people living in the home, their parents, families and visiting professionals were completed in November 2011. We saw that improvements had been made in response to people's feedback

People we spoke with told us that they did lots of things at Worstead Lodge, such as going to work, spending time with their friends, boyfriends/girlfriends and shopping in town. One person told us that they like to visit their daughter regularly.

People told us they could do what they wanted and that they had regular meetings where they talked about things that happened in the home. People also told us that staff listened to what they said and that the meetings were good.

People also told us that they met and sometimes helped to interview new staff before they started working in Worstead Lodge.

One person told us how they had problems with their hips and that walking was sometimes very difficult but how the staff had been very good at helping them with doctors' appointments and helping them to control the pain.

All the people we spoke with told us that they felt safe living in Worstead Lodge and that the staff looked after them well. Each person also said that they could talk to the staff if they weren't happy with anything.

One member of staff told us that they would like it if all staff could drive the company car, as this would help people to be able to have more outings if they wanted.

We acknowledged that the organisation had faced some significant challenges during the past year, which had led to some shortfalls, mostly in record keeping and administrative areas. However, we found that people living in the home were happy and had continued to be well supported.

One person said they were really happy with their room and liked it a lot. They said: “It’s nice to have my own room – it’s my own space.”

This person told us that the food in Worstead Lodge was always nice and said: “We’ve got a menu book – I’ll show you.” This person pointed out that the front page had a list of the food people didn’t like, then showed us how the following pages listed the main meals that people had been served.

The person we spoke with told us that there was always plenty to eat and drink in the home and that they could always have something different if they didn’t want the main option.

We observed people making drinks for themselves and others as they chose, during the course of this inspection.

One person we spoke with said, of the staff: “They’re all alright.” A second person said: “Yes, they’re good. I like them.”

One person also told us: “I can talk to any of the staff if I have a problem. They always listen.”