This inspection took place on 20 and 21 June 2017 and was unannounced. The previous inspection was carried out in March 2016 and concerns related to the policies and procedures relating to the administration of medicines, some records relating to monitoring and checks, person centred detail recorded within people’s care plans and systems and processes to audit the service. We asked the provider to send us an action plan about the changes they would make to improve the service. At this inspection we found that actions had been taken to implement these improvements, although some other areas required some minor improvements.

Bethany Lodge Care Home provides accommodation with personal and nursing care for up to 24 adults who need care and support with physical disabilities and complex needs, such as congenital disorders, degenerative illnesses and acquired brain injuries. At the time of the inspection there were 23 people living at the service, most were younger adults although the service also supported people who were older.

People were living with a range of care and nursing needs, many people needed support with all of their personal care, and some with eating, drinking and mobility needs. Other people were more independent and needed less support from staff. There were two lounges, a dining room, and separate toilets and showers or bathrooms. All bedrooms were single with specialist beds and hoisting tracks. There was also an arts and crafts room in the grounds and a hydrotherapy pool at the sister service nearby.

The service had a registered manager who was not available on the days of the inspection, however; the registered manager from the sister service was able to assist in all areas of the 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.

Overall medicines were well managed. People received their medicines safely and when they needed them. Staff followed correct and appropriate procedures in the storage and dispensing of medicines. Some people were prescribed medicines to take ‘as and when required’, there was guidance in place for staff to follow for most people but some people were missing the guidance.

A number of audits and checks were carried out each month by the registered manager or senior staff, but the medicines audit had not been effective in identifying the shortfalls in medicines guidance highlighted during our inspection.

People were supported in a safe environment and risks identified for people were managed in a way that enabled people to live as independent a life as possible. People were supported to maintain good health and attended appointments and check-ups. Health needs were kept under review and appropriate referrals were made when required. Staff followed the guidance of healthcare professionals where appropriate and we saw evidence of staff working alongside healthcare professionals to achieve good outcomes for people.

Recruitment files contained the required information about staff. This helped to ensure that the staff employed to support people were fit and appropriate to be working with people. There were enough staff on duty and they had received relevant training and supervision to help them carry out their roles effectively. Staff were supported to complete an induction when they began work at the service. They were supported, monitored and assessed to check that they had attained the right skills and knowledge to be able to care for, support and meet people's needs. Staff continued to receive training, competence checks and support to meet the needs of people.

Staff knew how to keep people safe from abuse and neglect and any incidents were appropriately referred to the local safeg

The inspection took place over two days on 29 and 30 March 2016 and was unannounced. The service was previously inspected in August 2014 and no breaches in the legal requirements were found.

Bethany Lodge is a purpose built service on ground level providing accommodation, nursing and personal care for up to 24 adults with complex physical disabilities, including acquired brain injury, and congenital and degenerative conditions. There are two lounges, a dining room, and separate visiting or entertainment area and separate toilets and showers or bathrooms. All bedrooms are single with specialist beds and hoisting tracks; the more recent extension has slightly larger rooms. There is a spacious arts and crafts room in the grounds. All areas are wheelchair accessible. A hydrotherapy pool is available for people’s use at a partner service nearby.

At the time of inspection there were 24 people living in the service. The age range of people varied from younger adults to people who were older. Care and support was provided by a matron (who is a registered nurse) and a team of nurses and care assistants supported by the daily presence of the provider. The provider was also the current registered manager though the matron had applied to become the 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. Both the provider and the matron supported our inspection visit.

Staff knew people well and understood their needs, choices and preferences. Personalised detail was absent from some care plans which meant that peoples’ preferences about their care may not be known and carried out.

Medicines were stored safely, and administered by trained nurses, however for people who wished to self- administer medicines there was no protocol in place to ensure that they were assessed as safe to do so.

People were offered a choice of food at mealtimes. People’s intake of food and drink was monitored but records did not accurately reflect how much fluid people were drinking or if the amounts taken were sufficient to maintain people’s health.

People were thoroughly assessed prior to admission and a plan of care created to ensure all their needs were met. Life histories were obtained so staff could apply this knowledge to the care of people. The interaction between staff and people was compassionate and understanding. People and their relatives had confidence in staff to respond to their needs, and listen to any concerns they had. Family members were made welcome so they could be involved in people’s care.

All staff had received training in the Mental Capacity Act 2005 (MCA) and staff understood the principles of the Act and how to apply them. Where people lacked the mental capacity to make decisions the home was guided by the principles of the MCA to ensure any decisions were made in the person’s best interests.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS applications had been made for people who lived in the home to ensure that people were not deprived of their liberty unnecessarily. Staff had received training in adult safeguarding and knew how to follow the home’s safeguarding policy in order to help people keep safe.

Checks were carried out on all staff to ensure that they were fit for employment. Systems were in place to ensure that new staff were recruited and trained to deliver the safest possible care. Staff said they were supported within the team, knew how to perform their roles safely and were given regular training and supervision by the management team. There were opportunities for staff to develop and refresh their skills. There were sufficient numbers of staff available to meet

We carried out this inspection over five hours. During this time, we met the majority of the 24 people who lived at the home, read four people’s support plans and spoke with five people and some of the staff members. The manager was available throughout the inspection. The summary describes what people who used the service, and the staff told us, what we observed and the records we looked at.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People were supported in an environment that was safe, clean and hygienic. Equipment at the home had been well maintained and serviced regularly. There were enough staff and nurses on duty to meet the needs of the people living at the home. A member of the management team was available for any evening and weekend emergency support.

Is the service effective?

People were involved in their assessment and care planning. All care and support was planned with people’s consent. Where people were thought to lack capacity to consent to decisions, an assessment had taken place and people who knew the person well were consulted too.

Is the service caring?

People’s care was reviewed regularly, and adjustments were made to make sure they remained comfortable, safe and as independent as possible. Everyone we spoke with said the staff were kind. People said the team were “Great”; the food was “Pretty good, really tasty”. People told us that they could raise concerns with the manager or staff and saw the managers most days.

Is the service responsive?

People’s day to day support was kept under close review, and any changes needed were communicated to the team. People told us the manager and team were easy to speak with and were quick to sort out problems. We saw that the team sought help from other professionals or services without delay, meaning people remained well supported.

Is the service well led?

Records showed us that the management team were up to date on safety matters. There was an effective action plan in case of emergencies. Complaints and comments were responded to quickly and used to improve service provision.

Twenty two people were living at the service at the time of the inspection. We spoke to three people, a relative, four staff and the providers of the service. Due to people's individual communication needs, we were not able directly to gain the views of some of the people about the service and what it was like to live there. We were able to observe how people spent their time during the day, how staff met their needs and how people communicated and interacted with staff.

People told us they were treated with dignity and respect and that their privacy was maintained.

People were involved in developing their own care plans. They had consistent staff providing care and support and their own keyworker, which meant that staff knew people's individual needs and preferences.

People told us they were happy and safe at the service and they could talk to the manager, staff or their own keyworkers about any problems they had.

One person told us there was "Sufficient staff, always someone here to meet people's needs...and the staff are equipped for their caring roles 100%".

People, their relatives or representatives were invited to express their views and opinions on their visits to the service, through "Resident's meetings" and through questionnaires.

People's records were kept individually and information about them was accurate and fit for purpose.

We spoke with four people who used the service. People told us they liked their rooms and had been involved in the choice of decoration and personalisation in accordance with individual lifestyle. For example two rooms had football team posters and colours, whilst another had pictures and favourite soft toys. People told us they could decide when to get up and go to bed. There was a choice of menu and people could have opted to choose to eat their breakfast and evening meal in their rooms. People who used the service said their rooms were cleaned daily and the environment was well maintained.

People told us they had a choice of daily activity within the service and transport provided opportunities to go out shopping, to the cinema and visit garden centres. However, one person told us “the weekends here are really boring” because there were limited opportunities to go out as the transport could only accommodate two wheelchairs at a time. They commented that “the week is better as there is an activities manager who takes us out”. People said the service felt welcoming and that special events were celebrated, evidenced by Halloween preparations.

People who used the service said their representatives were happy with the care they received. If they were not they knew who to speak to and that their concerns would be dealt with promptly and effectively.

One person told us they managed their own medicines and the service was supportive with encouraging independence.

People told us they liked living at Bethany Lodge, they said the staff were attentive, caring and supportive.

People told us liked their rooms and said there was enough to do and that the meals were good. Comments about meals included “lovely, choice of what we want, if we don’t like something they do something else” and “meals are superb”.

People told us they could choose how to spend their day, they can decide when to get and go to bed and what to eat. One person told us they manage their own medicines with support from staff. They told us there was enough to do, one person said “they take you out all the time”. A person who had been concerned about moving in having not liked another setting where they were cared for said “its brilliant staff are superb”.

People and relatives we spoke with said the home was always very clean, residents said bedrooms were cleaned daily, and there were never any unpleasant odours. People told us the environment was well maintained, a resident said “if I bump and scratch the wall with my wheelchair it is painted again straight away”. We saw repainting of marks on walls taking place during our visit.

Relatives told us they were always made welcome at the home, one person said five relatives had joined residents for Christmas lunch and staff had made the day very enjoyable. People told us special events are celebrated, the home is decorated for events such as Easter and Halloween and staff make the events fun.

Relatives we spoke with were very satisfied with the service overall, one relative said “I can’t fault any of it, they are amazing----they should use this as a model home”.

People told us they liked living at Bethany Lodge, they said the staff were attentive, caring and supportive.

People told us liked their rooms and said there was enough to do and that the meals were good. Comments about meals included “lovely, choice of what we want, if we don’t like something they do something else” and “meals are superb”.

People told us they could choose how to spend their day, they can decide when to get and go to bed and what to eat. One person told us they manage their own medicines with support from staff. They told us there was enough to do, one person said “they take you out all the time”. A person who had been concerned about moving in having not liked another setting where they were cared for said “its brilliant staff are superb”.

People and relatives we spoke with said the home was always very clean, residents said bedrooms were cleaned daily, and there were never any unpleasant odours. People told us the environment was well maintained, a resident said “if I bump and scratch the wall with my wheelchair it is painted again straight away”. We saw repainting of marks on walls taking place during our visit.

Relatives told us they were always made welcome at the home, one person said five relatives had joined residents for Christmas lunch and staff had made the day very enjoyable. People told us special events are celebrated, the home is decorated for events such as Easter and Halloween and staff make the events fun.

Relatives we spoke with were very satisfied with the service overall, one relative said “I can’t fault any of it, they are amazing----they should use this as a model home”.