About the service: Garlinge Lodge is a residential care home that was providing personal care to 11 older people, some who were living with dementia, at the time of the inspection.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

• The home was safe but it was not well managed as there was not good oversight of the quality and safety of the home.

• Following the last inspection, we issued three warning notices. These were in relation to risks in the premises, staffing levels and governance systems failing to identify shortfalls in the quality and safety of the service. We met with and asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and well-led to at least good.

• The provider had made improvements and had become compliant with two of the warning notices around risks in the premises and staffing levels. They now met the characteristics of Good in the key question of safe.

• Some improvements had been made in relation to the warning notice around good governance. Care records had improved and risks to people were understood and mitigated. However, further improvements were needed to ensure good oversight of the quality and safety of the home. A system needs to be established to analyse trends and promote learning from incidents, audits and feedback received to support continuous improvements.

• Sustainability of the home was not ensured as the leadership was heavily reliant on the registered manager consistently working long hours and there was no emergency plan in place should they become absent for any reason.

• The home had not become fully compliant with the warning notice around good governance in the key question of well-led. There continued to be a breach of regulations with this and therefore the home remains as Requires Improvement in well-led and overall.

• Systems were in place to protect people from abuse and avoidable harm, risks to people were mitigated, medicines were managed safely and there were enough suitable staff deployed to keep people safe and meet their needs.

• There was a relaxed and caring culture in the home. All feedback from people, relatives, visitors and staff was positive. The registered manager was a visible presence in the home and knew people well.

• More information is in the full report.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published on 31 January 2019). This service has been rated Requires Improvement at this and the last three inspections.

Why we inspected: This was a focused inspection to check their progress and if they had now met the regulations.

Follow up: We have asked the provider to complete an action plan and to provide us with regular updates. We will follow-up on the improvements needed in well-led and all key questions at our next inspection.

We held an unannounced comprehensive inspection at Garlinge Lodge Care Home on 20 and 23 November 2018.

Garlinge Lodge is a privately owned residential care home for older people and people who are living with dementia or physical health needs. The service is registered to accommodate up to 14 people in one adapted building. The care is provided over three floors and people with the highest levels of dependency were on the ground floor. People had access to a toilet on each floor and a bathroom on the ground and upper floors. There was a dining room, lounge and conservatory on the ground floor with a lift for people to access from all floors.

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. Over the course of the inspection 13 people were provided with accommodation and personal care.

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 21 September 2017, the service was rated ‘Requires Improvement’ overall and in all the key areas. There were eight breaches of the Health and Social Care Act (2008) (Regulated Activities) Regulations 2014. The provider had failed to ensure that people had personalised care plans that addressed all their individual needs; people’s rights to privacy and dignity were not always upheld; the principles of the Mental Capacity Act 2005 (MCA) were not consistently followed when seeking consent from people to care and treatment; risks within the premises had not been assessed and managed to ensure people’s and staff safety; medicines were not always managed safely; premises were not properly maintained and suitable for the needs of people living with dementia; there were not always effective systems in place to monitor and improve the quality and safety of the service and there were not enough staff to ensure staff could work in a safe way when caring for people.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good. At this inspection although there had been some improvements, there were three continued breaches of regulations and one new breach of regulations. This is the third consecutive time therefore that the service has been rated as Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

Since the previous inspection the registered manager had ensured staff no longer routinely worked long hours and had made some changes to improve staffing levels. However, there continued to be insufficient staff to ensure people’s needs were met and they were kept safe, as people were at higher risk of falls when staffing levels dropped. People and relatives thought they were kept safe. One person said, “I felt anxious living alone, I am happy here…I feel safe, I have had no falls…there is always someone about.”

Action had been taken around the concerns we raised at our last inspection for risk management within the premises. However, there were further instances where people were not kept safe from environmental risks, to include cleaning chemicals not stored safely and no risk assessments for portable electric radiators. Other environmental risks such as fire, legionella and food hygiene had been managed and all the expected health and safety certificates were in place. Some refurbishment had been completed to improve the environment for people with dementia although further improvements were needed.

Garlinge Lodge is a residential care home offering personal care and accommodation to older people and people who are living with dementia. The service is registered to accommodate a maximum of 14 people in single bedrooms. It does not provide nursing care. There were 13 people living at Garlinge Lodge at the time of our inspection including six people who were living with dementia.

This inspection was carried out on 21 September 2017 and was unannounced. The inspection team included two inspectors.

There was a manager in post who was registered with the Care Quality Commission (CQC). 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 our last inspection in August 2016 we found that the registered provider was not meeting the regulation relating to the provision of person centred care. This was because they were not ensuring that people had opportunities to engage in social activities that met their needs. At this inspection we found that some improvements had been made and people had access to a weekly programme of activities. However, there were further areas of shortfall in relation to person centred care. People’s needs had been assessed before they first moved to the service, but they did not have a care plan that addressed all their assessed needs. People’s care plans lacked the detail necessary to ensure staff could provide personalised care, particularly in relation to dementia and to supporting people to continue with hobbies. People were not given regular opportunities to go out of the home and engage with their local community.

At this inspection we found that seven other regulations were also being breached.

There were insufficient numbers of staff to ensure that staff could work in a safe way when caring for people. Some staff routinely worked very long hours, which placed the people they cared for at risk.

Risks within the premises had not been assessed and managed. This included ensuring that fire evacuation procedures were correct and practiced. Areas of the home had not been properly maintained. The registered provider had not sought advice on appropriate environments for people living with dementia when planning the decoration of the premises.

People’s medicines were not always managed safely. Staff left medicines unattended which left people living with dementia at risk.

The principles of the Mental Capacity Act 2005 (MCA) had not consistently been followed when obtaining consent from people to care and treatment. This meant that people’s right to make their own decisions had not been promoted and care had been provided without people’s consent.

Staff did not always ensure that people’s right to privacy and dignity were upheld.

The service was not always well led. Systems for monitoring the quality and safety of the service were not always effective in ensuring that shortfalls were identified and improvements made. The registered manager did not monitor patterns of accidents in the home, such as falls, to identify where risks could be reduced. The registered manager had not sought and used resources and best practice guidance to continually improve care at the service.

People’s care records were not completed with sufficient detail to show that they had received the care they needed and to allow the registered manager to review that care.

The risk of infection spreading in the service had been minimised and the premises were kept clean, but we found that two commodes had not been properly cleaned on the underside. We made a recommendation about this.

A person using the service told us during the inspection that it was their birthday. The staff and registered manager were not aware of this, but arranged a cake once we a

The inspection took place on 08 and 09 August 2016. Garlinge Lodge is a large house that provides residential accommodation without nursing care, for up to 14 older people. There were 12 people living in Garlinge Lodge at the time of our inspection, eight of whom lived with dementia or short term memory loss.

There was a manager in post who was registered with the Care Quality Commission (CQC). 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.

Staff knew how to raise an alert if they had any concerns about people’s safety. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

There was a sufficient number of staff deployed to meet people’s needs. Thorough recruitment procedures were in place which included the checking of references.

Medicines were stored, administered and recorded safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

Staff knew each person well and understood how to meet their individual needs. Staff communicated effectively with people and treated them with kindness and respect. They had received all essential training and attended regular one to one supervision sessions.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options had been considered. Staff sought and obtained people’s consent before they helped them.

A system was in place to assess people’s mental capacity when necessary and hold meetings to decide particular decisions in their best interest, as per the requirements of the Mental Capacity Act 2005.

Staff provided meals that were in sufficient quantity and met people’s needs and choices. People told us they enjoyed the food that was provided. Staff knew about and provided for people’s dietary preferences and restrictions.

People’s individual assessments and care plans were reviewed monthly or when their needs changed. Information about the service, the facilities, and how to complain was provided to people and visitors. People and relatives’ feedback was sought during satisfaction surveys.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred routines. Staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People were not involved in the planning of activities that responded to their individual needs. The provider had not ensured that a suitable amount of activities and outings were provided to stimulate people’s interests and meet their social needs. We have requested the provider to take action.

Staff told us they appreciated the registered manager’s style of leadership. The registered manager was open and transparent in their approach.

The registered manager placed emphasis on continuous improvement of the service and carried out monitoring checks and audits to identify any improvements that needed to be made. However the provider had not identified a shortfall in regard to the provision of activities, a lack of outings to combat isolation and a lack of measures to maintain links with the community. We have made a recommendation about this and will check that action has been taken at our next inspection.

Our inspection of 6 September 2013 found that there were gaps in the processes for managing infection control, and the maintenance and upkeep of the home that may put people at risk.

At this inspection we found that the provider had addressed all these gaps. This included separating the sluice sink and laundry facilities, carrying out a water and legionella risk assessment, and making changes to cleaning processes in the home. Maintenance issues had been addressed, which included removing uneven flooring, and cleaning rusty and dirty bath hoist seats.

We spoke with four people who use the service. They were positive about the service. One person told us “I’m happy here” and “looked after well”. Another person said it was “lovely” and “quaint and sweet”. One person said that they “find it very good” and “we have everything we want”; and another that it was “very good”.

We had concerns about how infection control was managed in the service.

There were adequate process for the safe handling and administration of medication.

The environment was maintained, but there were areas that needed to be addressed as they presented risks to people using the service.

The people we spoke with were positive about the staff. One person told us the “staff are fine, even the new ones” and another that the “staff are very good” and “they respond quickly”. Staff received training, supervision and appraisal to give them the skills to care for people effectively.

One person told us “I wouldn’t want to be anywhere else”. People expressed their views and were involved in making decisions about their care and treatment. People told us “I can choose the food – it’s very good” and “They come round with a sheet and I can choose what I want to eat”. People told us they were always treated with kindness. One person said “Staff are always respectful of my privacy”.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People told us “I can always ask staff for help and they will take their time” and “I get help when I need it. I feel very comfortable and looked after”.

We saw that people were relaxed with staff, who listened to their views and concerns. People told us that they would speak with staff if they had a problem or were worried about anything.

At the time of our visit there were enough qualified, skilled and experienced staff to meet people’s needs. One person told us “I have a buzzer in my room and if I use it, I don’t have to wait very long for staff to come”. One person told us “I have no complaints at all. I can talk to the staff and they are very nice”.

People who lived in the home who we spoke with were very positive in their views about the service. We spoke with six people who lived in the home. They all told us they were very happy with the service. They said; “I really like living here" “The food is very good and always plenty of it.” “They look after you really well.” “They are always helpful and very kind.” People told us they had to wait for help when staff were busy.

We spent time in the lounge where we saw that staff were patient and kind when they were helping people. We also spoke with a district nurse who was visiting the home. She told us that there were no concerns about care in this home.

People told us they enjoyed the activities provided in the home. They told us about people who came in three times a week to do activities with them such as discussions, quizzes and exercise. People who we spoke with told us they felt safe in the home and knew who to talk to if they were unhappy about anything.