We last inspected this service on 21 and 22 November 2017. At this inspection we rated the service requires improvement in every key question we inspect against and found five regulatory breaches. We found care and treatment was not always provided around people’s assessed needs. The service did not always fully assess a person’s capacity and support people lawfully with decisions in relation to their care and treatment. People were not fully supported with the hydration and nutritional needs. There were not always enough staff to meet people’s assessed needs and the service was not effectively managed or run in the interest of people using it. Following the inspection, we requested and received an action plan and have stayed in contact with the service regarding the improvements they planned to make. We have regularly engaged with the Local Authority quality improvement team who were supporting the service to improve and their view was this was happening.

At our latest inspection on 8 & 10 January 2019 we found improvements had been made but these were not firmly embedded. We found two repeated breach. Regulation 9 of The Health and Social Care Act 2014. person centred care, and regulation 11, consent. We also had concerns about the competencies and skill mix across the service but were confident that this was being effectively addressed so have not made a breach. We have made recommendations for several key areas of practice which if adopted will help to strengthen and improve the service further. We found improvements were still required in four of the five questions and judged the service was not yet good.

Buckingham 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. The care home can accommodate up to 73 people in one adapted building which has three separate units across three floors, one specialising in dementia care. The others are for broadly speaking nursing and residential. At the time of our inspection there were 61 people using the service and two people in hospital.

At the time of our inspection there was a manager at the service but their post was an interim post and they were not registered with the Care Quality Commission. A registered manager is a person who has registered with the 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.’

In summary we found the service was improving and there were systems and processes in place to help identify the risks to people, the resources needed and an emphasis on lessons learnt following incidents. We found however that not all care plans and daily records clearly showed how people’s needs were being met. Care plans were not all up to date and did not clearly reflect peoples’ preferences and preferred routines. Risk assessments and care plans were not cross referenced and information was in different places, making it difficult to track through and gave a poor oversight of the person’s needs. We noted when people’s needs had changed this was not always picked up in reviews which tended to comment, ‘no change’. Daily notes were brief, mainly task oriented, functional and did not appear to reflect any specific objective. We also had concerns about the timeliness of information with care plans, assessments and risk assessments not being put in place quickly enough for new admissions.

The service had reviewed all the care plans on the residential unit and these were more comprehensive and reflected people’s needs. We have recommended that this care plan format should be adopted across the service to ensure they addressed people’s needs in a holistic way. We also recommend

The inspection took place over two days, the first being unannounced, the second announced. The dates were on 21 and 22 November 2017. The last inspection to this service was on 8 and 10 February 2017. At this inspection the service was rated as requires improvement throughout except for caring. There were also a number of regulatory breaches of the Health and Social Care Act 2014. These included Regulation 9: Person centred care, Regulation 14: Meeting nutrition and hydration needs, Regulation 17: good governance and Regulation 18 staffing. Following the inspection the provider sent a detailed action plan telling us what actions they would take to achieve full compliance and improve the service. A new manager was in post from September 2016 prior to our last inspection and is now registered with the CQC. At our inspection in November 2017 the regulatory breaches were repeated.

There was a registered manager in post at the time of our most recent 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.

The service is a purpose built home which can accommodate up to 73 people who may or may not have a nursing need and whom may have a diagnosis of dementia. The home has three floors, ground, middle and top and people on the ground floor receive a residential service where people on the other two floors fall within the category of nursing although some people on these floors did not require nursing care. The residential floor was overseen by a unit manager whilst the first and second floor were overseen by a registered nurse. The home was situated at the edge of Watton a small town in Norfolk. At the time of our inspection there were 61 people using the service.

During this inspection the service demonstrated to us that improvements have been made but progress was slow and had been compromised by poor levels of staffing. There were repeated breaches of regulation from the last inspection. We observed variable care practices depending largely of the levels of staffing and the skill mix on shift. The provider had recognised that the action plan implemented from the following inspection had not been fully acted upon. They had put in a team of internal auditors, (quality team) to support the management team and staff to make and sustain improvements within the service. Some improvements were still in their infancy and the provider had not been able to demonstrate how they would sustain these improvements. They did provide us with an updated action plan and further plans to show how the improvements would be maintained. The registered manager was off sick and there was an interim manager in post who was experienced and familiar with the service.

We found the biggest concern was staffing levels which had not been consistently maintained, partly due to high staff sickness rates and unfilled staffing vacancies. Agency staff and bank staff were heavily relied on to meet the needs of people using the service. There was however an improving picture in terms of staff recruitment with all substantive nursing posts filled apart from one night post. Analysis of staff sickness and exploration of why staff retention was poor was underway and was viewed in context of the geographical area and local recruitment issues. The service had employed a person specifically to drive up recruitment. The impact of low staffing had meant people experienced variable patterns of care and social stimulation. It also meant not all staff were familiar with everyone’s needs or responding adequately to them.

We found risks to people’s safety associated with their care and welfare were mostly well managed. Staff regularly checked people to help promote their safety. Bas

Buckingham Lodge provides accommodation and nursing and personal care for up to 73 older people. There were 64 people living in the home on the day of our inspection.

This inspection took place on 8 and 10 February 2017 and was unannounced.

Buckingham Lodge Care Home requires a registered manager to be in post as part of the registration requirements from the Care Quality Commission. There was no registered manager in post at the time of the inspection and there had not been since May 2016. On the day of the inspection there was a home manager who had been in post since October 2016. They have been referred to as the ‘home manager’ throughout this report. The home manager was in the process of completing a CQC registered manager’s application. A registered manager is a person who has registered with the 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.

At the last inspection the home was rated good overall. At this inspection the home has been rated requires improvement in four of the key questions and overall and only rated good in ‘caring’. This means that there were more concerns at the home now than at the previous inspection.

The provider was not consistently taking appropriate action to manage risks. Risks were not always identified and there was no clear guidance in place for staff to follow to manage all risks effectively.

The service was not always acting in accordance with the Mental Capacity Act 2005 including the Deprivation of Liberty Safeguards. People’s rights were therefore not always being promoted.

Staff did not always work within these principals when supporting people who lacked the mental capacity to make decisions.

There were systems in place for managing medicines in the home. A medicine procedure was available for staff and staff had completed training in relation to safe medicine administration. Improvements were needed to the management of ‘when required’ medicines. Healthcare professionals such as chiropodists, opticians, GPs and dentists were involved in people's care when necessary.

Care plans were not all up to date; the information within them was not always current and was contradictory in some incidences. We could not be confident that people always received the care and support they needed.

People and their relatives felt the service was well managed and acknowledged the improvements that had been made to date. Staff felt the management team were approachable and gave them the opportunity to give their views at team meetings.

There was a quality assurance audit in place however the system was not always effective because issues identified at the inspection had not been recognised during the monitoring and auditing process.

Staff had an understanding of abuse and safeguarding procedures. They were aware of how to report abuse as well as an awareness of how to report safeguarding concerns outside of the service. Staff undertook safeguarding training providing them with knowledge to protect people from the risk of harm.

We found the home was in breach of four regulations 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.

This inspection took place on 15 January 2015 and was unannounced.

Buckingham Lodge Care Home is a nursing care home providing care and support for up to 70 older people, some of whom live with cognitive impairments such as dementia. The home has a registered manager, who has been in post since December 2014. 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.

People felt safe living at the home. Staff were aware of how to safeguard people from abuse and acted accordingly.

Most individual risks to people were assessed, reduced or removed and although staff were aware of how to care for people with behaviour that could upset others, there was inadequate information about this for staff members.

There were enough staff available. Staff members all said that staffing levels were high enough to allow staff members to care for people. The required recruitment checks were obtained before new staff started working, meaning the service could be sure that new staff members were of good character or safe to work with people.

There was enough personal protective equipment, cleaning products and housekeeping staff to ensure that the home was clean and hygienic.

Medicines were safely stored and administered, and staff members who gave out medicines had been properly trained. Staff members received other training, which ensured they were able to care for people appropriately. Staff received supervision from the manager, which was supportive and helpful, although formal individual meetings were not frequent enough.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service was meeting the requirements of DoLS. The manager recognised when people were being deprived of their liberty and was taking action to comply with the requirements of the safeguards.

Staff members understood the MCA and presumed people had the capacity to make decisions first. Where a lack of capacity had been identified there were written records to guide staff about who else could make the decision or how to support the person to be able to make a decision.

People enjoyed their meals and were given enough support to eat the meal of their choice. Drinks were readily available to ensure people were hydrated. Improvements were needed to ensure that meals were kept hot until people were ready to be served and records to show how much people ate and drank were completed in enough detail.

Staff at the home worked with health professionals in the community to ensure suitable health provision was in place. There had been improvements to the information available to health care professionals and in following their advice and this needed to continue.

Staff were caring, kind, respectful and courteous. Staff members knew people well, what they liked and how they wanted to be treated.

People’s needs were responded to well and care tasks were carried out thoroughly. Most care plans contained enough information to support individual people with their needs, although greater detail was needed in plans addressing behaviour that may upset others.

A complaints procedure was available and complaints had all been dealt with appropriately.

The manager was supportive and approachable, and staff felt that they could speak with her at any time.

The home monitored care and other records to assess the risks to people and whether these were reduced as much as possible.

Two adult social care inspectors carried out this inspection. They were accompanied by the CQC Chairman for some of the visit. The focus of the inspection was to answer the five key questions; is the service safe, effective, caring, responsive and well led?

As part of this inspection we spoke with nine people who used the service, three visitors and a visiting health care professional. We also spoke with the head of care, the Chief Operating Officer who represented the provider, and 10 members of staff. We also reviewed records relating to the management of the service which included six care plans, daily records, staff records and quality assurance monitoring records.

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

Risk assessments for care needs were completed and provided appropriate guidance for the identified risk to be reduced. They stated they were involved in reviewing their care plan and were supported to make decisions regarding their immediate care needs and wishes.

People received the care and support they required to improve their health and well-being. Care records were written in detail and provided clear guidance to staff members, Reviews of care plans were completed so that staff had guidance about supported each person safely.

Applications had been appropriately made in regard to Deprivation of Liberty Safeguards for people whose liberty was restricted. Staff members and the manager showed they had appropriate knowledge regarding recent guidance.

There had been an increase in staff members in all areas of the service since our inspection in March 2014. People using the service said there were now enough staff available to meet their needs. Information from staff members, the manager and records shows that there were enough staff available with the skills and training to care for people appropriately.

Is the service effective?

People told us that staff members helped them with everything they needed assistance with. They told us that they were satisfied with the care they received. Care records provided clear and detailed information about people's care needs and preferences.

Health needs were responded to and people had access to health care professionals if they needed this. Information and guidance given by health care professionals was included in people’s care records so that staff members knew how to promote their health.

Is the service caring?

People said that staff members were polite and kind; they respected people's privacy and dignity, and involved them in their care. Staff members knew people's care needs and their personal preferences when we spoke with them.

People said that staff members were polite, kind and respectful, although one person felt they did not all stay long enough to chat with them. One visitor told us that the care staff, “Were brilliant”. We observed interactions between people and staff members and we found that the members of staff were patient and understanding of people's individual needs. However, we found that there were missed opportunities for staff to spend time with people.

Is the service responsive?

We saw that people's individual physical and mental support, care and treatment needs were assessed and planned for. Their individual choices and preferences regarding their support and care were respected.

Is the service well led?

There had been an annual survey to gather the views of people using the service last year and a further survey was due to be sent out. Responses from the last survey were mixed and actions to individual issues could not be identified, although senior staff from the provider’s head office were visiting the home to support and monitor improvements. There were other systems in place to monitor and assess the quality of the service provided; the service had analysed this information for any trends or themes resulting from complaints, accidents or incidents.

On the day of our inspection visit the inspection team consisted of a specialist advisor specialising in dementia care and three compliance inspectors.

We spoke with people using the service and their relatives who told us that staff consulted them and respected and acted on the decisions they had made about the care and support they had agreed to.

People living in the home told us that activities were provided, but not every day and that they were sometimes bored.

We found that the plans of care were being redesigned and reviewed to ensure that they were complete and contained up to date information.

People using the service told us that they had received the nursing care and support they needed and that staff were kind and respectful.

People told us that their personal laundry sometimes took a long time to be laundered and returned to them.

We found that recruitment security checks had been carried out on each member of staff and that they had suitable skills, qualifications and experience to care for people.

People using the service told us that they had to wait for between fifteen to twenty minutes sometimes for a member of staff to answer the call bell.

Improvements were needed to care planning records. We found that they were being redesigned and reviewed to ensure they were complete and up to date.

People spoken with and their relatives told us that people were safe and were provided with the care and support they needed.

Our observations showed us that staff members were responsive to the needs of people and that they were given the support and attention they needed.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted and protected.

Medication was administered, recorded and stored accurately and safely.

People living in the home and their relatives told us that adequate staffing levels were not always provided and they often had to wait for assistance from staff.

We spoke with people who lived at the home and relatives who told us that staff consulted them and respected and acted on the decisions they made about the care and support they agreed to.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations, decision making and activities.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted.

Relatives told us that people received the care and support they needed and that staff were very kind.

The environment was well maintained and the cleanliness of the home was adequate in most areas. However, some carpets were stained.

Staffing levels were inadequate which meant that people had to often wait to receive the care and support they needed.

People told us their complaints were listened to and resolved. We found that there was a complaints system in place that met the needs of people living in and visiting the home.

We carried out a follow-up inspection looking at the improvements the provider had told us they would make in medication procedures and care planning.

We spoke with people using the service but their feedback did not relate to medication. People we spoke with told us that their needs were met and that they knew that records were held in the home that contained their personal information. They told us that they could ask to see their records at anytime but had not done so.

We spoke with four people who lived in the home. People told us that their needs were met and that they were consulted about the care and support that they were provided with. People were complimentary about the staff that cared for them and told us that they always treated them with respect and that their privacy was respected. They told us that sometimes they had to wait for help because staff members were very busy. They also told us that activities were not provided everyday and that sometimes they were bored. They explained that the environment was comfortable and clean and that they were provided with good quality meals.

We also 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 comment. We observed two groups of six people for forty-five minutes. For much of the time during our observation people were seen to be seated around the television and left on their own in the lounge. We saw that when staff members were with people that they used explanation and negotiation when working with the person and used reassurance and praise appropriately. We noted that each person had their opinions respected and were included in the general conversations that occurred. We saw that staff responded well to the needs of people, gave them individual attention, listened and spoke to them in a positive, encouraging manner and encouraged them to make choices.

We did not speak with anybody living in the home about the way in which their medication was managed. Our Pharmacist Inspector looked at the improvements that had been made to the medication administration and record keeping systems, used in the home.

We spoke to several people during this visit. One person told us that "They felt safe, with staff being both kind and caring." Another person told us that "I am very happy here and there is always someone to talk to."

We had a series of conversations with people who live at Buckingham Lodge and they told us that they were able to attend meetings where they can raise any concerns or

issues that they have.

People we spoke to told us that they felt safe and comfortable to talk to staff about any issues they may have.

People we spoke to told us that they found the staff "Kind and caring." One person stated that they felt the staff worked very hard but sometimes they were too busy to just "Stop and chat."

The majority of people we spoke to had varying verbal communication skills but several people were able to participate in a conversation and we also noted people's non verbal cues.

People spoken to indicated that they were generally satisfied with the level of care and support they received at Buckingham Lodge. Those people we spoke to indicated they could choose when they got up and when they went to bed each day and that staff "were kind and caring, although sometimes it took staff a long time to answer the call bell."

One person we spoke to stated that "Some are kind but some rush me to get ready."

A relative we spoke to told us they were happy with the care and support provided to their family member and that staff were kind and caring. People told us they get the help and support they need from staff when they ask for it. One person we spoke to told us "I get good care and have no complaints". Another person we spoke to told us "I like it here."

People who were able to communicate verbally told us that they felt safe and well cared for.

People we spoke to stated that they felt safe and comfortable about talking to staff. One person we spoke to said, "People are kind to me and listen and the staff seemed to know what they were doing".