This inspection took place on 9 and 11 July 2018 and was unannounced.

Brambling Lodge 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. Brambling Lodge is registered to provide care and support for up to 27 people who may be living with dementia. At this inspection there were 25 people living at the service.

The registered manager had left the service in January 2018. There was a manager in post who was in the process of registering with the Care Quality Commission. 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 Health and Social Care Act 2008 and associated Regulations about how the service is run. Following the inspection the manager's registration was confirmed.

We last inspected the service in June 2017 and we found three breaches of regulations, the provider had failed to deploy sufficient staff to meet people’s needs and medicines management was unsafe. The provider had failed to use feedback to improve the service, audits had not been effective, records were not always accurate and complete. Following the last inspection, we asked the provider to complete an action plan to show what they would do to meet the regulations. At this inspection, improvements had been made and two of the previous breaches had been met. There was one continued breach and a new breach of regulation was identified. This is the second consecutive time the service has been rated Requires Improvement.

Potential risks to people’s health and welfare had not been consistently assessed. Some people’s health conditions had not been assessed and there was no clear guidance for staff to mitigate risks and recognise when people were unwell. Care plans had been reviewed but were not consistently accurate or did not reflect the care and support being given.

Audits had been completed on all areas of the service, any shortfalls found were rectified. However, the manager had not completed an audit on the care plans reviewed during the inspection and the shortfalls found had not been identified.

At the last inspection, the provider had failed to have sufficient staff to meet people’s needs. At this inspection improvements had been made. There were sufficient staff to meet people’s needs, call bells were answered quickly and staff were always available in the lounge to support people.

Previously, medicines had not been managed safely. At this inspection, improvements had been made. There were systems in place to monitor the administration of medicines and previous shortfalls had been rectified.

People’s needs were assessed before they moved into the service following current guidelines. Staff monitored people’s health and referred them to specialist healthcare professionals when needed. Staff followed the advice given to keep people as healthy as possible. People were supported to be as active and independent as possible. Staff worked with the GP and district nurse to respond to people’s healthcare needs. People’s end of life wishes were recorded and staff had received training to support people to be as comfortable as possible.

Staff received training appropriate to their role, they received supervision to discuss their development and skills. Staff knew how to keep people safe from abuse. The manager had reported and worked with the local safeguarding authority when required. Incidents and accidents were recorded and analysed to identify trends and patterns, action was taken and lessons learned to reduce the risk of them happening again.

People were encouraged to plan their care and express their views. People were supported to have maximum choice and control of their lives a

This inspection was carried out on 13 June 2017 and was unannounced.

Brambling Lodge is a large detached residence, providing accommodation and care for up to 27 older people, some of whom may be living with dementia. Accommodation is set over two floors. There is a lift to assist people to get to the first floor. Bedrooms are situated on the ground and first floor and there are separate communal areas. It is located in the village of Shepherdswell on the outskirts of Dover. At the time of the inspection there were 23 people living at the service.

There was no registered manager working at the service. 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 and associated Regulations about how the service is run. We were supported during the inspection by the manager, operational director and the quality and compliance manager for the provider. The current manager had started working at the service in November 2016 and had just started the process of applying to be the registered manager with the Care Quality Commission.

We last inspected the service in September 2015. We made a recommendation that the provider use dependency assessments to ensure that enough staff were deployed effectively. At this inspection, there were not enough staff on duty, to provide effective and person centred care. Staff were not always available to provide support to people when they needed it, for example at meal times.

Staff spoke with people in a kind and compassionate way; there was a warm and caring relationship between people and staff. Staff knew people well and how to support them if they were anxious or upset. However, people were not always treated with dignity and respect due to not having sufficient numbers of staff on duty.

People’s medicines were not managed and recorded accurately. People did not always receive their medicines when they needed them.

When people lacked mental capacity to make decisions, the principles of the Mental Capacity Act (MCA) 2005, were not always followed. When a person lacks capacity to make a decision, any decisions should be made in the person’s best interests and be the least restrictive available. Decisions had been made when people lacked capacity but there was no evidence that best interests meeting had taken place or why the decisions had been made and if it was the least restrictive option.

The staff asked people for their consent before providing them with care and support. The manager understood their responsibility to gain authorisation to restrict people’s liberty under the MCA and Deprivation of Liberty Safeguards (DoLS), applications had been made in line with current guidance.

Staff knew and understood their roles and responsibilities. Staff had received training relevant to their roles; however, this needed to be updated. Staff had not received regular, planned one to one supervisions to discuss their training and development. Regular staff meetings gave staff the opportunity to voice their opinions. Staff were recruited safely.

Staff told us that they had not always felt supported by the manager; however, this was improving as the manager was settling into their role. Staff told us that the manager was approachable and listened to them.

People and relatives told us they felt safe at Brambling Lodge. Systems were in place to protect people from harm and abuse and staff knew who to report any concerns to if they felt they were not being dealt with. Accidents and incidents were reported and analysed to identify any patterns or trends to help reduce the likelihood of the incident or accident happening again. Staff completed checks on the environment and equipment to ensure people were kept as safe as possible.

Care plans and risk assessments were detailed and person cen

Not all the people living at Brambling Lodge were able to talk to us directly to tell us about their experiences. We spent time with the people and observed interactions between the people and the staff.

We found that staff were engaging with people each time they walked past. We saw that staff were encouraging people to participate in the activities and their daily routines. Staff listened to people and took their views seriously and answered their questions in a way that they could understand.

Individual personalised care plans were in place to make sure people were receiving the care they needed. We found that there were systems in place to make sure people were receiving their medication safely.

Relatives told us that staffing levels were satisfactory and we saw that staff attended to people promptly when they needed attention.

Systems were in place to monitor the service that people received to ensure that the service was satisfactory and safe.

Relatives and people using the service told us they did not have any complaints but would not hesitate to speak to the manger or staff if they had any concerns.

Some of the people who use services had special communication needs so we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

People and relatives told us that they were satisfied with the care being provided. They said that they did not have any complaints but would feel confident to raise any issues with

the manager or staff.

Relatives said that privacy and dignity was handled discreetly and in a sensitive manner. They said staff were polite, respectful and caring. The manager was very approachable and the service was well organised.

Visiting health care professionals said the care was person centred and they were satisfied with the service being provided.

This inspection was carried out on 16 and 18 September 2015 and was unannounced.

Brambling Lodge is a large detached residence, which is registered to provide accommodation and care for 27 older people, some of whom may be living with dementia. Accommodation is set over two floors. There is a lift to assist people to get to the first floor. Bedrooms are situated on the ground and first floor and there are separate communal areas. It is located in the village of Shepherdswell on the outskirts of Dover. At the time of inspection there were 26 people living in 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.

Where people lacked the mental capacity to make decisions staff were not always guided by the principles of the Mental Capacity Act (MCA) 2005 to ensure any decisions were made in the person’s best interests. One person had not been supported in relation to a decision about a healthcare need. Other people, however, had been supported with best interest meetings.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the service was currently subject to a DoLS authorisation, the registered manager was making applications to the appropriate authority to make sure people were not being deprived of their liberty unlawfully.

People’s needs were assessed so staffing levels could be managed and people felt there was usually enough staff on duty. However, people said they sometimes had to wait for staff to support them. Observations and feedback from staff indicated that there were times when staff were busy and did not always have the time to give people the support they needed when they needed it.

Staff recruitment and selection procedures were thorough which helped to ensure people were cared for by staff that were suitable to work in the caring profession. People were involved in the recruitment of new staff.

Staff knew and understood their accountabilities and responsibilities. Staff had received training relevant to their role to help them to develop their knowledge and skills. Staff received regular support and supervision and were confident in the support provided by the registered manager. Regular staff meetings gave staff the opportunity to voice their opinions. Staff felt they were listened to.

Accidents and incidents were reported and recorded. A new system was in place to analyse trends and patterns of any incidents to reduce and help prevent the likelihood of reoccurrence.

Care plans and risk assessments were under review and actions were being taken to improve the information contained in these, to further develop the care and support people received. Staff knew and understood different people’s needs and how to make sure people stayed safe. Staff knew how to support people. Staff helped people to stay safe

People and their relatives told us they felt safe at the service. Systems were in place to protect people from harm and abuse and staff knew who to report any concerns to. The registered manager understood her responsibilities on how to keep people safe. The environment was safely maintained and free from clutter so people could move around safely.

People and their relatives told us they were happy with the care they or their relative received at Brambling Lodge. People told us staff were “Kind”, “Caring” and “Friendly”. People were supported to maintain their independence by staff that knew and understood their needs. People were supported to make choices. People were provided with a range of different activities they enjoyed.

People were supported to have a healthy diet and to choose what they wanted to eat and drink. People’s healthcare needs were managed and people were referred to appropriate health care professionals when needed. People were supported safely with their medicines. Any risks associated with medicines were assessed and managed.

There were systems in place to manage complaints. People and their relatives told us they felt able to raise any concerns or complaints. The provider had systems in place to gather and review feedback from people and their relatives to find out their opinions. People‘s views were listened to and comments acted on.

There were systems in place for monitoring the quality of the service provided and actions were taken to address any shortfalls.

Staff understood the aims and philosophy of the service, their roles and what their accountabilities were. Staff were motivated and had confidence in the registered manager.

We have made a recommendation about using dependency assessments to ensure that staff are deployed effectively.