This inspection took place on 15 and 16 November 2016 and was unannounced. Elizabeth Lodge Care Home provides accommodation for 87 people who require nursing and personal care. On the day of our inspection there were 75 people using the service. The home has three floors with units located on the lower ground, ground and first floor.

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 our last inspection on September 2015, we found that some aspects of medicines management were not safe. The service could not demonstrate that staff members had received an appraisal. These resulted in breaches of Regulation 12, and 18 of the Health and Social Care Act 2008.

During this inspection we found that appropriate actions had been taken and improvement had been made to ensure the safe management of medicines. The registered manager had also completed appraisals for the last year for all staff employed.

Although the home had organised activities which took place centrally within the home, we found very little activity or stimulation on the individual units especially involving those people who were unable to leave the unit due to mobility or health conditions.

People and relatives that we spoke with highlighted concerns around the low staffing levels within the home. Appropriate level of need assessments had been completed, which determined the staffing levels. We observed there to be sufficient staff available to support people. However, due to the way staff were deployed and allocated to work on the units, there were occasions where staff were not visible on the units and people were left on their own for a certain period of time.

People were provided with a healthy and balanced diet which allowed for choice and preference. However, some people, on particular units, who were supported in their own bedrooms had to wait up to 30 minutes before a staff member assisted them with their meal.

Risks associated with people’s care and support needs had been identified and these had been assessed giving staff instructions and directions on how to safely manage those risks. However, where people had been diagnosed with a specific health condition that would potentially affect their mobility, this had not been risk assessed or linked into their moving and handling assessment to ensure that care staff had the appropriate guidance on how to support the person and ensure their safety especially when mobilising.

The registered manager, senior managers and care staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager had submitted applications to the local safeguarding authority for each person who required an authorisation to ensure that people were legally being deprived of their liberty which was in their best interest. However, where an authorisation had been granted with conditions that the service had to adhere to, these had not been reflected within people’s care plans to ensure staff were aware of the actions that needed to be taken to meet those conditions.

Mental capacity assessments and best interest decisions had been completed for people depending on the specific decisions that needed to be made. However, these were not consistently available in all care plans that we looked at especially where decisions had been made for people to have a valid ‘do not attempt cardio pulmonary resuscitation’ (DNACPR).

All staff that we spoke with confirmed that they felt supported within their role and received regular supervision. Staff also confirmed that they had received an annual appraisal which discussed their performa

A team of three inspectors, one inspection manager and a specialist advisor (a mental health nurse) carried out this inspection. The purpose of this inspection was to see whether the service had made improvements since our inspection on 3 February 2014, following enforcement action we had taken against the service.

During this inspection we focused on gathering evidence to answer five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

As part of our inspection we spoke with six people who used the service and eight relatives of people who used the service. We also spoke with seventeen members of staff including the Registered Manager.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the 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.

Is the service safe?

People who used the service and relatives we spoke with told us that they felt safe in the home and that staff treated people with respect and dignity. One person said, “Staff are very good” and one relative said, “My dad is safe”.

Since our inspection in February 2014, we found that the provider had taken appropriate steps to ensure that people using the service were protected against the risk of receiving care that may be inappropriate or unsafe as care plans, risk assessments and care records were on the whole up to date and they were available when needed.

The service had systems in place to identify, assess and manage risks related to health welfare and safety of people who used the service. Care records contained risk assessments which provided guidance to staff on actions to take to keep people safe.

Is the service effective?

People we spoke with said that they were satisfied with the care provided in the home and felt that people's needs had been met. People were positive about staff and said that they were helpful and listened to them.

We looked at nine care records and saw that people's care needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out where necessary and there was evidence that these were reviewed. Care plans included information about people's preferred routines and healthcare needs.

During our inspection the provider demonstrated that they were ensuring continuity in people’s care by communicating with healthcare professionals appropriately.

All the staff we spoke with told us that they were well supported by the registered manager and felt able to ask the registered manager questions.

Staff, family members, healthcare and social care professionals were involved in decisions about people's care and we saw evidence of this. Relatives of people who used the service told us that they were kept informed about people's progress.

Is the service caring?

People we spoke with were positive about the staff at the home. They told us that they had been treated with respect and dignity in the home.

During our inspection, we found that people who used the service approached staff without hesitation and people appeared comfortable around members of staff. There was good interaction between staff and people. People looked well cared for and we saw that the atmosphere was relaxed in the home.

Is the service responsive?

People who used the service and relatives we spoke with told us that if they had any concerns or complaints, they would feel comfortable raising them with the registered manager. One person who used the service said, “The manager is very good and kind. He looks into all concerns”. One relative we spoke with said, “I know the manager. He listens and responds if I need to complain”.

We saw that the home had a complaints policy and procedure and we noted that the provider had dealt with complaints received in accordance with their policy and these complaints had been resolved.

Since our last inspection, the provider had introduced an “open surgery” every Tuesday and Thursday. The aim of this was to enable relatives and people who used the service to speak with the registered manager about any issues and concerns they had about the service. The registered manager explained that these were informal meetings and by having these meetings, they hoped to deal with people’s concerns and issues before they escalated further.

The service had implemented a new audit system since our last inspection. This audit system introduced an audit schedule for 2014/2015 which listed various areas that the management would carry out audits on a monthly basis which included a medication management audit and a manager’s quality assurance audit.

Is the service well-led?

We found that adequate arrangements were in place for monitoring and reviewing the quality of the service provided to people.

Resident's meetings were held monthly which enabled people to discuss issues regarding the running of the home. This encouraged people to raise queries and concerns with management and members of staff.

Staff meetings were held monthly and we saw evidence to confirm this. We also noted that clinical staff attended a meeting every morning with the registered manager to discuss any concerns and people’s progress.

All staff we spoke with told us that they felt able to consult the registered manager if they had concerns or queries and said that they felt supported. Staff were positive about working at the home and said that the home had improved since the last inspection.

We carried out this inspection to check whether the provider had made improvements in the service from when we last inspected on the 5 November 2013. We served warning notices on the 27 November 2013 following this inspection because the provider was in breach of regulations relating to the care and welfare of people, and poor record keeping.

At this inspection on the 5 November we saw suitable arrangements were not in place to ensure people using the service were treated with dignity and respect during day to day activities and we found that risk assessments and care plans were not up to date and available. Emergency equipment was not in place or being checked regularly. Effective quality monitoring systems were not in place to protect people who used the service against inappropriate or unsafe care.

Improvement had been made in some areas at this inspection. We saw staff were knocking on people's doors and waiting on a response before entering. People we spoke with confirmed that this was happening. One person said, “they are always knocking on our door now.” Another said, “we have a choice, we can get up and go to bed when we want.”

The provider had ensured all five units had first aid kits. We saw from a recent health and safety audit the home did not have named fist aiders. However the manager told us staff had been identified to attend training in February and March 2014 to become qualified fist aiders.

We did not see improvements in all areas however. For example two people's care plans indicted that they needed thickening powder due to the risk of aspiration (food going down the wrong way) to prevent the people choking while drinking. Their care plans did not document how many scoops of the thickener the person should have in each 200mls of fluid. Due to unclear guidance on thickener, people were at risk of receiving inappropriate or unsafe care, which may lead to the risk of aspiration (choking).

We saw five paper care records contained other people’s information such as care plans, risk assessments and information from doctors. For example, in one person's paper care record we found six other peoples care plans. Therefore staff and professionals may not have been confident that people's records were accurate and fit for purpose.

The provider had been auditing care records however, we saw that care plans were not person centred and were missing important detail. Therefore important information about people could have been missing and inappropriate or unsafe care could have occurred.

This evidence and observations showed that the provider was still not analysing information gathered through audits to identify risk of non-compliance with the regulations and so was not taking action to improve outcomes for people using the service.

We are considering what further enforcement action to take following evidence of continued non-compliance with the warning notices served and the compliance actions set at the last inspection.

We saw appropriate arrangements were in place for recording the administration of medicines. These records were clear and fully completed .The records showed people were getting their medicines when they needed them.

We carried out this inspection to see if the provider had made improvements since we last visited on the 19 June 213, at this inspection we saw that people's capacity had not been assessed, effective records were not being kept and hand overs from each shift were not in place, there was insufficient staffing and, staff were not up-to-date with training. Records were not accurate.

On the 5 November 2013 we saw that the manager had reviewed the four people who received covert medication (medication hidden in food or drink). We saw documents had been completed and had included all people who were involved in the person’s care such as a psychiatrist, doctors, relatives, home staff and a pharmacist.

We saw that a new hand over process had been implemented and all staff were now having a full hand over of care before they started each shift. However we saw that people’s needs were assessed but care plans still did not always address people’s individual needs and staff told us that they were not always clear about how to support individual care needs as a result of this.

We saw that each person had their own lifting sling, staff told us that people did not share slings and that they cleaned them regularly. We checked a number of hoists and slings and saw they were in good repair. One relative said, “my mum needs a hoist to be moved”. She confirmed that she had her own sling in her room. Although emergency equipment was not always checked in line with manufacturers guidance.

The provider had undertaken a recruitment campaign and had so far employed four unit managers; these are qualified nurses who will be responsible for the day to day running of one unit. The provider had also employed eight care workers and had a plan to employ more.

Staff were receiving regular supervision. Staff we spoke with said they had frequent training; however they also said they were not always able to attend due to cover not being available for them to leave their units.

Quality assurance and monitoring systems were not effective. We saw that the provider had recently undertaken the yearly survey of people who live in the home and their representatives. We saw the results of the survey it showed that the home had 37 below average scores out of a total of 40. People’s views on the service varied from “not bad," "all right," "quite nice," "I love it” Some people believed the service was not as good as it used to be several people said, “it’s changed so much."

Records were not kept up to date. Of the 10 care plans(electronic and paper version) we reviewed we saw that more than half of the care plans were missing from the paper records. Staff said that either these had been given to relatives to review or had not been printed off the electronic system.

People were not always treated and supported with dignity and respect. We saw staff walking into people’s room without knocking or introducing themselves throughout the day. In one unit in a room where we knew a person was receiving personal care, we saw a carer walk into the room without knocking.

We found three people who were being provided with medication covertly, this is when medication is given without the person's consent or knowledge with food or drink. The home were not following their policy on the use of covert medication.

We looked at care plans, talked to staff and people who used the service and their relatives. Some people told us “the long term staff are excellent, but the agency care staff are not so good, but I do feel respected by them.” Another said “we have a laugh here with the staff.”

We spoke with five people who lived at the home. All said that they did not feel there were enough staff on duty to support them. One said “when its different staff on I often have to remind them to give me my tablets as they forget." We saw that relatives were concerned with the increased use of agency and bank staff.

We spoke with eight staff and looked their records; we saw that all new staff had received a comprehensive induction however staff training was not up to date.

We looked at fluid balance charts, turning charts, sleep charts and peoples care records that live in the home. Turning charts showed people were not being turned often enough therefore people could be at increased risk of tissue damage.

We saw that the home ensured people’s complaints were fully investigated and resolved, where possible, to their satisfaction.

We used a number of different methods to help us understand the experiences of people using the service, because some of the people had complex needs which meant they were not always able to tell us their experiences.

We observed staff supporting people in a friendly and professional way and saw that people were being offered choice with regard to menus, activities and care preferences.

People who use the service told us that staff were kind and respected their privacy. They confirmed that staff treated them with respect and dignity. One person commented, “the staff are really nice and they always knock on my door.” Another person told us, “they look after me very well.”

Most people were able to express their views and were involved in making decisions about their care and treatment. Where people were unable to express their views, their family or other representatives were involved in the decision making process.

We saw that medication records were being regularly audited so that any issues or problems could be identified in a timely manner.

People told us that they felt safe with the staff who supported them. They said they had no concerns or complaints about their care but would speak with their relatives, the manager or the care worker if they needed to. However, we found that the organisation was not always dealing with complaints about the service in line with its own complaints policy.

On the day of the inspection there were sixty nine people living at the home.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not always able to tell us their experiences.

We observed interactions between staff and people using the service to understand what effect those interactions had on peoples’ well being.

We observed staff treating people with respect and kindness.

People who use the service were positive about how staff supported them and told us staff understood and met their care needs.

We observed that people using the service appeared comfortable and well cared for. People who required support with eating and drinking told us they received enough to eat and drink at the home.

All areas of the home were clean and satisfactorily maintained. We observed domestic staff working diligently throughout the home cleaning communal areas and peoples’ bedrooms.

People using the service were positive about the cleanliness of the home and told us domestic staff cleaned their rooms on a regular basis. One person commented, “On the whole it’s very good”.

People who use the service indicated that they were happy with the staff who supported them. One person commented, “They do a good job here”.

Staff we spoke with had a good understanding of the needs of the people they supported.

During this inspection we met and spoke with people using the service. In some cases people were not able to communicate verbally but most people were able to indicate how they felt about the support and care they received.

People told us that they were satisfied with the care and that staff treated them with respect and kindness.

People with a high level of needs appeared comfortable and we observed friendly and supportive interactions between staff and people using the service.

We were concerned that some people who require their food and fluid intake to be monitored were not receiving a satisfactory amount of drinks throughout the day. This is because fluid monitoring forms we examined were not being fully completed.

Infection control measures were not being adequately implemented by the service and this was putting people at risk from potential infections.

Staff were not receiving the support and guidance they required to ensure that infection control measures were being properly implemented and infection control issues were not being adequately monitored and addressed by the organisation.

People who use the service told us that staff were kind and respected their privacy.

One person commented, “They interact very well with relatives and residents”. They also commented, “They are always quick to put things right”.

We observed staff supporting people in a friendly and professional way and saw that people were being offered choice with regard to menus and activities.

Staff we interviewed were able to give us examples of how they maintained peoples’ dignity, privacy, independence and how they offered choices to people on a daily basis.

The service was not always ensuring that information about people who use the service in relation to care, treatment and risk assessing was being recorded accurately.

We asked people who use the service what they thought about the care and treatment they receive at the service. They generally responded positively about the care they received.

We spoke to a relative whose mother had been at the home for a short while. This relative told us, “The improvement to Mum’s health has been astonishing”.

Some relatives and people who use the service told us they were unhappy about the lack of access to and contact they had with their local doctors’ surgeries.

Staff we spoke with had a good understanding of the needs of the people they supported.

People who use the service indicated to us that they felt safe with the staff at the home. They told us that if they had concerns about their care they would speak with a relative or the staff if they needed to.

One person commented, “I do feel safe here”.

We asked people who use the service what they thought about the quality of care they receive at the home.

People were positive about the quality of care and confirmed that the staff asked them how things were going and if they were happy with the care provided at Elizabeth Lodge.

We inspected the service on 30 September and 1 October 2015. The inspection was unannounced.

Elizabeth Lodge Care Home provides accommodation for 87 people who require nursing and personal care. The units are situated over three floors. There is one nursing unit on the first floor, two nursing units on the ground floor and one residential dementia unit on the lower ground floor. On the day of our inspection 52 people were using the service. At the time of the inspection there was no registered manager in place however there was an interim manager who was overseeing management of the home until the new manager came into 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.

People that we spoke to were positive about the service they received and the staff who supported them. We saw people being treated with warmth and kindness. Staff were aware of people’s individual needs and how they were to meet those needs. Relatives we spoke with were positive about the home and the staff.

The service had a number of systems in place in order to monitor and maintain people’s safety. However these were not always being followed. We found that the safe administration of medicines on the lower ground dementia residential unit was of concern. Staff had signed for medicines that had not been administered, several people had significant allergies to certain medicines but this had not been recorded on the medicines administration chart. We also noted two people were administered medicines covertly, but appropriate procedures had not been followed in recording this decision with the appropriate professionals.

We also observed during mealtimes that people who required assistance and chose to remain in their rooms had to wait up to an hour before a member of staff was available to support them.

There was a lack of consistency around the completion and recording of action taken on charts such as food and fluid monitoring, Waterlow recording and topical cream application charts.

People and relatives felt that the staff had the knowledge and skills necessary to support them properly. They told us that staff listened to them and respected their choices and decisions. Concerns were noted about the high usage of agency staff during the summer months and their competency. However people who use the service also confirmed that agency usage had reduced over the last few weeks.

People using the service could not confirm that they knew who the manager was but were confident that they could raise any issues or concerns with any staff member. However relatives who we spoke to knew the manager and the management team and said they were approachable and available.

Staff supervisions were being completed in line with the provider’s policy. However the service had not carried out an annual appraisal for any staff member employed by the service.

There were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make decisions for themselves were protected. The service was applying MCA and DoLS safeguards appropriately and making the necessary applications for assessments when these were required.

At this inspection there were two breaches of regulation. The first one was regulation 12, which was in relation to safe management of medicines and the other was regulation 18, which was in relation to staff appraisals not have been carried out in over a year. Please refer to the “Safe” and “Effective” section of this report for details. You can see what action we told the provider to take at the back of the full version of the report.