We undertook an unannounced inspection of Earlfield Lodge on 19 and 21 June 2018. At the last comprehensive inspection of the service in November 2017 seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009 were identified. The service was rated requires improvement.

Following this inspection, we issued a warning notice in regard to Regulation 12, safe care and treatment. People who used the service were at risk due to the unsafe management and administration of medicines. We followed this warning notice up at a focused inspection in February 2018. We found that the service had met the warning notice but further improvements were still required in medicines administration.

The breaches previously identified were followed up as part of our inspection. You can read the report from our last inspections, by selecting the 'All reports' link for Earlfield Lodge, on our website at www.cqc.org.uk. The service remains rated as requires improvement.

Earlfield 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. Earlfield Lodge can provide care and support to 72 older people, some of whom are living with dementia. At the time of our inspection there were 58 people living at the service.

The service provides accommodation in several adjoining premises. The service is over five floors. There are four areas to the service Bluebell, Lilly, Poppy and Buttercup. There is access to a garden and patio area.

Two registered managers were in post at the time of our 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.

Improvements had been made at the service. The previous breaches in regulation identified, except one, had now been met. An action plan monitored the progress of improvements required across the service.

The service had not displayed its previous ratings in the service as required. Training for staff was not up to date. However, future training had been scheduled for some of the areas required by staff. Feedback around the activity provision at the service was poor. There was no one identified as responsible for activity provision within the service.

Changes had been made in the management structure. However, further clarity on staff roles, responsibilities and accountability were needed to ensure the service ran effectively.

Feedback demonstrated that improvements were required in managing staff absence. Improvements had been made in medicines administration. However further areas were identified. Infection control policies were in place. Staff were knowledgeable of these policies. However, areas of infection control were identified for improvement.

The recording of incident and accident had improved. Quality audit systems had been reviewed and changed to monitor the service more effectively. Recruitment procedures had been revised so they were in line with legislation. Systems were in place to ensure these were followed. Enhancements had been made to the environment to ensure it was safe and pleasant. Systems had been improved to monitor the premises, equipment and fire safety assessments.

Notifications had been submitted as required. Systems had been revised so that staff received regular support through supervision. The monitoring of support around food and fluid had improved which had resulted in positive outcomes for people.

The service had made improvements to ensure it was compliant with the Deprivation of Liberty S

We carried out a comprehensive inspection of Earlfield Lodge on 21 and 23 November 2017. Following this inspection, we served a Warning Notice for a breach of regulation 12 of the Health and Social Care Act 2008. This was because people who used the service were not protected from the proper and safe management of medicines.

We undertook a focused inspection on 22 January 2018 to check the provider was meeting the legal requirements in regards to one of the regulations they had breached and had complied with the Warning Notice. This focused inspection looked at the breach of regulation 12. This report only covers our findings in relation to this area. You can read the report from our last comprehensive by selecting the, 'All reports' link for ‘Earlfield Lodge’ on our website at www.cqc.org.uk

Earlfield Lodge provides accommodation and personal care for up to 65 older people, some of whom are living with dementia. At the time of our inspection the service was providing accommodation and personal care to 56 people.

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.

At this inspection, we found the provider had taken action to comply with the warning notice. We made a recommendation about the recording of topical medicines as further improvements were required.

Medication Administration Records (MAR) were being completed consistently. A daily system was in place to identify and take action around any gaps in recording. Photographs of people, descriptions of how people preferred to take their medicines and protocols for as required medicines had been included in people’s medicines records. Records were kept on why as required medicines had been administered.

Self-medication risk assessments had been completed where appropriate. The medicines policy had been reviewed and amended.

We undertook an unannounced inspection of Earlfield Lodge on 21 and 23 November 2017. At the last comprehensive inspection of the service in September 2016 one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. This was in regards to Regulation 12, safe care and treatment. People who used the service were at risk due to the management of medicines. This breach was followed up as part of our inspection. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Earlfield Lodge, on our website at www.cqc.org.uk. The service was rated requires improvement.

Earlfield Lodge provides accommodation and personal care for up to 65 older people, some of whom are living with dementia. At the time of our inspection the service was providing accommodation and personal care to 59 people.

A registered manager was in post at the time of our 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 was not well-led. Quality audits were in place but did not monitor and review all areas of the service. Therefore the extensive failure to meet the regulations found at this inspection had not been identified by the registered person. The current management structure was ineffective as all quality oversight was delegated to senior staff. Notifications had not been sent to the Commission as legally required to inform of significant events such as Deprivation of Liberty Safeguards authorisations and events that stop the service.

The service was not safe. Medicines administration was not being managed safely and areas previously highlighted to the provider had not been addressed. Environmental risk assessments were not in place and regular checks of all areas were not conducted to keep people safe. Recruitment procedures were not followed in line with the provider’s policy. This meant effective checks were not completed before new staff began their employment.

People were not always being deprived of their liberty in accordance with legislation and guidance. Food and fluid records were not being consistently maintained. Staff were not supported through regular supervision and training. This meant that staff development needs were not always being identified and staff may not have had sufficient training in particular areas of their role.

Care plans were not always person centred as people’s background and histories were not consistently completed. Mixed feedback was received about the provision of activities at the service. The service was fully staffed. However, observations were made that staff were not always responsive to people’s needs in a timely manner.

Staff completed an induction when they started at the service, which orientated them to systems, processes and people. People had access to healthcare and the provider had good relationships with other health professionals. People and relatives knew how to raise concerns and complaints and felt comfortable to do so. Complaints were investigated and responded to. Staff were aware how the Mental Capacity Act (MCA) 2005 applied to their role.

People received care and support from staff that were kind and caring. Family and friends were welcomed at the service. People’s independence was encouraged and promoted. People, relatives and staff’s views were sought through different methods, such as meetings and questionnaires. Effective communication systems were in place.

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to tak

The inspection took place on 22 and 23 September 2016 and was unannounced. At the last inspection in June 2015 we found the provider was not following the principles of the Mental Capacity Act 2005. After the inspection, we issued a requirement action in relation to the breach of the Health and Social Care Act 2008, which we identified. Following the inspection the registered provider sent us an action plan stating that they had met the relevant legal requirement. During this inspection, we found that the registered provider had made improvements in relation to assessing people’s mental capacity and providing care and treatments in their best interests.

Earfield Lodge is a care home providing accommodation for up to 65 older people some of whom are living with dementia but do not having nursing needs. During our inspection there were 59 people living at the home. The home is a large detached house situated in a residential area of Weston Super Mare and is set out into four separate units called Buttercup, Poppy, Lilly and Bluebell Cottage. Poppy and Lilly units provide residential care to older people, Lily and Bluebell Cottage provide care to older people who are living with dementia.

A registered manager was in post at the time of the inspection visit. 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 were not receiving their medicines safely. We found other concerns in relation to the management of people's medicines. Improvements were needed in the management of people's medicines. This is a breach of Regulation 12(1) (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the end of this report.

People told us they felt safe living at the service. The environment was kept clean and free from hazards. Equipment and hazardous substances were safely stored and used appropriately.

Staff received training in relation to keeping people safe and they were confident about the action they needed to take if they had any concerns about people's safety, including safeguarding concerns. Care plans included information about people's abilities to make decisions and where required applications had been made to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations in respect of people. Staff obtained people's consent prior to delivering care and support and they respected people's decisions.

People received the care and support they needed with their healthcare needs. They attended appointments as required with their GP and other health care professionals involved in their care. Prompt referrals were made for people to other professionals when concerns about their health and wellbeing were noted.

Risk assessments had been carried out when planning people's care and appropriate risk management plans were put in place instructing staff on how to provide people with safe care and support.

People's dietary needs were understood and met. People told us they liked the food they were offered and that they were given plenty to eat and drink. Mealtimes were a positive experience for people and they had a choice of food and drink and where they ate their meals.

Staff received training and support which they needed to meet people's needs. Training was provided to staff on an ongoing basis and their competency was checked to make sure they understood and benefited from the training undertaken.

Regular staff meetings and one to one supervision sessions enabled staff to explore their training needs and discuss any additional support they needed to carry out their roles effectively.

People's privacy, dignity and confidentiality w

The inspection took place on 8 June 2015 and was unannounced. Earfield Lodge is a care home providing accommodation for up to 65 older people some of whom are living with dementia. During our inspection there were 57 people living at the home. The home is a large detached house situated in a residential area of Weston Super Mare and is set out into four separate units called Buttercup, Bluebell, Lilly and Bluebell Cottage. Buttercup and Lilly units provide residential care to older people, Bluebell and Bluebell Cottage provide care to older people who are living with dementia.

There was a registered manager in post 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.

There were areas of the home requiring maintenance and repair. The care manager told us there were plans to improve the environment in Buttercup unit to make it more dementia friendly. They had plans to adopt a similar approach to the Bluebell unit, where they had adapted the environment to meet the needs of people living with dementia.

During our visit there was a strong odour present in Buttercup unit. The cleaners told us they were busy covering breakfast duties as well as completing domestic tasks. The Department of Health’s Code of Practice on the prevention and control of infections and related guidance was not being followed at the time of our inspection.

People and their relatives told us they felt safe at Earlfield Lodge. One person told us “I feel quite safe here, there are always staff around and I can talk to them if I feel troubled” and another person said “I feel safe because staff treat me well and look after me”. A relative told us “I have no worries about safety”. Systems were in place to protect people from harm and abuse and staff knew how to follow them.

People’s medicines were administered safely. The service had appropriate systems in place to ensure medicines were stored correctly and securely. People received their medicines when they needed them. One person told us “Staff bring me my tablets four times a day, they know what they are doing”.

Relatives thought staff were busy but there were enough staff available to meet people’s needs. Staff thought there were enough staff available as long as no staff were off sick. Staff appeared busy at times on Buttercup unit; however they were able to attend to people’s needs.

There were recruitment procedures in place to ensure only suitable staff were employed by the organisation to work with vulnerable people. Staff received appropriate training to understand their role and to ensure the care and support provided to people was safe. New members of staff received an induction which included shadowing experienced staff before working independently. Staff told us they felt supported by the senior staff and managers.

We found people’s rights were not fully protected as the manager had not followed correct procedures where people lacked capacity to make decisions for themselves. Where decisions were made for people the principles of the Mental Capacity Act 2005 were not always followed. Mental capacity assessments were not completed and where decisions had been made there was no evidence it was in the person’s best interest.

Most people were happy with the food provided; one person told us “Meals are good and adequate, I get enough to eat and plenty of drinks in between”. Other comments included “Food’s not bad”. People and their relatives thought there was enough food and drink available. Drinks and snacks were available throughout the day.

People and their relatives were happy with the care they or their relative received at Earlfield Lodge. One person told us “The staff are very kind and we are well looked after” and a relative told us “I think staff attitude is good and they are very patient and kind, my relative is obviously fond of them”.

People’s needs were set out in individual care plans and people’s told us their care needs were being met. People’s relatives told us they were involved in planning their family member’s care and staff listened to them and took notice of their wishes. People’s care plans did not always reflect an accurate level of staff support required. However, the staff we spoke with were able to describe and demonstrate knowledge of people’s individual needs. The plans were regularly reviewed by staff and there was evidence this was discussed with the person.

People and their relatives were confident they could raise concerns or complaints which would be listened to. The provider had systems in place to collate and review feedback from people and their relatives to gauge their satisfaction and make improvements to the service.

The registered manager had systems in place to monitor the quality of the service provided, however we found these systems were not effective and they did not always identify shortfalls in the service.

We found one breach 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 this report.

We have made recommendations about the provider having effective sytems in place to monitor and manage infection control and developing effective auditing systems.

We considered the evidence we had gathered under the outcomes we inspected. We spoke with six people who use the service, five members of staff and the manager. We also looked at twelve care plans and records related to the management of the service. Our inspection team was made up of one inspector. We used the evidence to answer five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service safe?

People told us that they felt safe. Safeguarding and whistleblowing procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the provider to maintain safe care. The provider had robust policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. At the time of inspection, two people were subject to Deprivation of Liberty Safeguards. These had been put in place in a manner consistent with the law.

Is the service effective?

People's health and care needs were assessed with them and they or their representatives were involved in the compilation of their care plans. People said that they had been involved in the process and that care plans reflected their current needs.

Is the service caring?

We spoke with people who live at the home. We asked them for their experience about the staff that supported them. Feedback from people was positive, for example one person said, "I don't have anything negative to say. I enjoy living here". Another person told us, "The staff are lovely. It's a home from home".

People who live at the home and their families were asked to complete a satisfaction survey by the provider. These were used to help improve the service in the future.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The home worked well with other agencies and services to make sure people received care in a coherent way.

People knew how to make a complaint if they were unhappy. Complaints were dealt with in a timely and satisfactory manner.

People engaged in a range of activities both in the home and in the wider community.

Is the service well-led?

The service operated a quality assurance system which identified and addressed shortcomings. As a result, a good quality of the service was maintained.

The staff we spoke with were clear about their roles and responsibilities. They had a good understanding of the needs of the people they were caring for and were properly trained and supported to carry out their duties.

At the last inspection of Earlfield Lodge we issued a compliance action because people were not always being treated with respect. This short inspection visit was carried out solely to check that improvements had been made in this area.

At the last inspection we found that people who had dementia were not always treated with respect and dignity. We found that people who had dementia were served meals on plastic plates and given drinks in plastic picnic beakers. This practice was not person specific and there was no rationale in care plans for it.

At this inspection we spent time observing lunch time in the part of the home which cared for people with dementia. We saw that people were shown two different meals to choose from and were served vegetables according to their wishes. Everyone was served their meal on a china plate and provided with glasses to drink from. People were able to eat in a relaxed and unhurried atmosphere. This meant that people with dementia were treated with the same respect as other people who lived in the home.

People who were able to express their views said they were able to make choices about their day to day lives. One person told us “There are no strict rules, you can please yourself what you do.”

We observed that staff spoke with people in a friendly and polite manner. People appeared very comfortable and all were well dressed and clean which demonstrated that staff took time to assist people with their personal care needs.

At lunch time we saw people who lived in the part of the home which cared for people who had a dementia were given meals on plastic plates. Drinks were served in plastic picnic beakers. In the main part of the home food was served on china plates and people were given glasses for their drinks. This practice did not uphold the dignity of people with a dementia.

The home had policies and procedures for the safe administration of medication. There were adequate storage facilities for medicines including storage for medication which required refrigeration. This meant that all medicines could be safely stored at their required temperature.

People who lived at the home were satisfied with the staff who supported them. Comments included; “The staff are pretty good,” “The staff are alright they treat me well” and “The staff are all friendly and will do anything for you.”

The home had systems in place to regularly monitor and assess the quality of the service provided. These included audits and satisfaction surveys.

People told us that they were happy with the care that they received. One person said “It’s lovely here, I get everything I need” another person commented “I’m looked after very well, the carers are all very kind.”

People who lived at the home said that they were able to make choices about what time they got up, when they went to bed and how they spent their day. One person said “You decide what you do each day, there’s never any pressure.”

Two people in the main part of the home said that they knew about their care plans. Other people asked said that they thought their needs had been discussed with family members when they moved into the home. The home used an electronic care plan system and there was no evidence that people who lived at the home had had input into their care plan. This meant that care plans had not been personalised to reflect individual wishes and preferences.

People we spoke with said that they thought there was usually enough staff on duty to meet their needs. People said that if they rang their bell for assistance then staff responded promptly. We noted that on the day of the inspection call bells were not left ringing for extended periods of time.

People who were able to express an opinion said that they would be able to speak with a member of staff if they were unhappy about the service they received. Two people said “We would definitely complain if we weren’t happy and they would sort it out.”

The purpose of this review was to visit the service to follow up two anonymous concerns that were raised with us.

We started our review on 8th March but we also asked one of our pharmacy inspectors to visit. The pharmacy inspector visited on 21 March 2012.

We spoke with several people who lived at Earlfield Lodge. We asked them whether they felt their care needs were being met. All of the people we spoke with confirmed that they were. One person told us “they look after me well here”. Another person said the staff are very kind to me”.

We spent an hour observing care provided in the area of the home where people with dementia were accommodated. Not all of the people we spoke with were able to tell us whether the care and support they received was to their satisfaction because of dementia or ill health.

We observed care and support being given to people at Earlfield Lodge and saw it being delivered with sensitivity and kindness. We saw that members of staff knew people by name and when asked about these people’s individual care needs they knew what was required.

We saw that members of staff respected people’s privacy and dignity and helped people to be as independent as they wanted to be, without compromising their safety and health.

We spoke with people in the home and observed their interactions with staff. None of the people we spoke with raised any concerns about staff and all staff we observed interacting with the people who lived in the home were caring and respectful. During our visit we noticed a person who needed assistance with their care needs, the member of staff we approached was reluctant to help and dealt with this person in an abrupt manner.

We asked care staff about their responsibilities for safeguarding people living in the home. They were able to tell us of the signs which may alert them to a potential abuse and also the reporting mechanisms for any concerns through the manager. We found that staff were clear about how they could report concerns directly to the local authority, or to us.

We spoke with four people about medicines and they told us that they were happy with the way medicines were given. They told us that the staff were ‘very good’. One person we spoke with told us that they look after their own medicines, and that they like to be able to do this. We saw that safe, lockable storage was provided in their room. We looked in their records and saw that there was a risk assessment. This showed that it had been checked that it was safe for them to manage their own medicines.

During unannounced visit and review we found that Earlfield Lodge needed to make improvements in medication administration, and staffing levels to ensure the service maintains compliance. The provider had not carried adequate risk assessments in relation to the premises and we found the provider to be in breach of the regulations for the management of the premises.

One person who has lived in the home for a number of years told us how she is supported to be as independent as possible and how the staff help her to administer her own medication safely. This person also told us about the activities that people can choose to get involved with in the home such as the bingo and whist sessions that they enjoy with their friends. They also spoke about the memory sessions where staff play old records and the pet visitor who comes into the home each fortnight.

There is a chapel in the home and a communion service is usually held once a fortnight. We were informed that the Priest had not been available to take this service recently and other arrangements were being looked at by the owner of the home. Staff support people to attend church services if they choose to.

One person spoke very positively of the trips the owner organises on a weekly basis. We heard how the people who live in the home take it in turns to join in with these events and that the minibus had been altered so that wheelchairs can be accommodated. We were told that the trip last week was to Burnham park and that they were escorted to a café during the outing

People told us about the weekly Tai chi session which people can choose to join in with and how other new activities are in the process of being organised with the new activities coordinator.

We heard that “my daughter can visit at any time. We can stay in the lounge or go to my room when she visits. We are free to go any where we want”.

One person’s relative told us that their relative has dementia. They said “the staff have patience with the people who live in Earlfield Lodge who have dementia”. “It is a very therapeutic environment here”, “The staff organise games and play old records for people to sing a long to”. They also spoke about the person who brings their pet dog to visit the home each fortnight which their relative enjoyed. This visitor also told us about the provider / manager taking people out on trips to local places of interest every week. They said the owner then treats them to a snack in a local supermarket as part of the outing

During our visit, we saw both in the dementia care unit and the main part of Earlfield Lodge that people were consulted by staff about what was going to happen. The members of staff we talked with and observed delivering care were asking people to consent verbally to appropriate everyday tasks and activities. This included coming into the dining room for a meal, getting dressed, and going out for visits and activities in the community. We saw staff seeking consent from people before entering their rooms

We saw that on the whole staff were friendly and responsive to the people they were caring for.

We observed staff attending one person with increased care needs and they were seen to be caring and explaining everything they were doing throughout.

One person who lives in the home told us that they had an appointment to attend the Eye Hospital in Bristol. They said that the provider/ manager will take them to the appointment and a member of staff will accompany them to see the eye specialist.

One member of the domestic staff told us that they felt people who live in the home are treated well by the care staff and the majority of people who are cared for generally seem happy living in the home.

One visitor spoke about the care provided for their relative. They said the owner of the home visits people in hospital to assess their needs. They explained that their relative is now terminally ill and had stopped eating. They told us how their relative, as far as they were able, and they as a family had been fully involved with end of life care planning process with Earlfield Lodge staff and health professionals. This visitor said “The staff do above and beyond for people living here. Many staff have been at this home for a long time and are very caring.”

We spoke to people who use the service and they told us that they were happy and thought the home is a nice place and there is a lovely conservatory. Other people told us the home was not too noisy and they have tea in their rooms. A relative told us that they had no concerns and when a cardigan was lost it was replaced.

Despite there having been some difficulties in the recent past with insufficient staffing, at the time of this review the service had recognised and remedied those problems. Some people who use the service have a higher level of dependency requiring assistance from staff for all their care needs. We observed that these people were receiving the care they required.

For people with dementia an assessment of their ability to make decisions was not being undertaken, as few staff have had appropriate training and are unsure how to document these assessments on the computer system.

We found that there were some underlying risks to people’s safety as some people’s needs had not been fully assessed and documented. The registered manager has delegated many of the management responsibilities within the management structure. We found a lack of clarity for people’s roles and responsibilities, which was having an impact on the service people receive.

We asked people we met about the attitude of the staff who care for them and about Mr Butcher, the owner. We were told a number of positive comments about the owner, one person said he was,' very kind', another person told us that he was 'always polite and he stays calm'. These comments help to demonstrate that people feel well supported. The people we met also told us that the staff are, ‘kind,’ ‘really good,’ and also, ‘really helpful'. Everyone we spoke with said that if they had any concerns they could talk to the owner or any of the senior staff who work at the home.