This inspection took place on 22 and 24 May 2018 and was unannounced.

Harbledown 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 service is part of the Nicholas James Care Homes Group and is registered under Uniquehelp Limited. It is a registered nursing home for 56 older people. There were 42 people using the service during our inspection; some of whom were living with dementia and conditions such as diabetes or impaired mobility or with more complex nursing needs. It provides adapted accessible accommodation over three floors.

We last inspected Harbledown Lodge on 18, 19 and 20 April 2017. We rated the service as requires improvement in two key domains safe and well led. The breaches were in respect of the assessment and review of risk to people using the service and safe use of equipment and premises, maintenance of accurate records, and the development and use of effective quality assurance systems.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the service. We carried out this inspection as part of our programme of scheduled inspections; we checked that they had implemented the action plan. At this inspection we found that whilst improvements had been made to meet previous breaches in regard to management of risk; there was insufficient progress to meet outstanding breaches in respect of record keeping and effective audit processes. We have rated the service as Requires Improvement overall, this is the third consecutive time the service has been rated Requires Improvement.

At this inspection we found that inconsistencies remained in the completion of records of food and fluid intake for those nutritionally at risk, and also in repositioning records of those assessed as at risk of pressure ulcers. This information was important to enable monitoring that people were receiving the assessed level of care and support they required. Quality assurance checks to monitor records were undertaken but not completed robustly. A few people experienced distress that presented as behaviour that could be challenging, measures to reduce risk around this were in place but had not been recorded in risk information to ensure all measures had been implemented to safeguard people; we have made a recommendation around this.

There was a new registered manager in post, who is proactive, and shows enthusiasm and commitment to develop the service and given time address many of the previous shortfalls. We have taken this into consideration in our response to this continued rating of requires improvement.

A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People, relative’s and staff said they found the new registered manager approachable; she was a visible presence in the service. Some health and social care professionals thought the service was improving. Staff told us that they felt well supported, they were provided with appropriate induction and training to give them the skills and knowledge needed for their role, they had opportunities to express their views. The registered manager used a dependency tool to help determine how many staff were needed; this was kept under review. People, staff and relatives told us there was enough staff.

People were supported with their religious beliefs. Staff demonstrated values of kindness compassion and commitment in their day to day practice. They were respectful of people’s privacy and dignity. They were not familiar with the

This inspection took place on 18, 19 and 20 April 2017 and was unannounced.

Harbledown Lodge is registered to provide personal care and accommodation for up to 56 older people. There were 42 people using the service during our inspection; some of whom were living with dementia and conditions such as diabetes or impaired mobility.

Accommodation is set over three floors and upstairs bedrooms can be accessed by a passenger lift. There is a communal lounge, activities room, dining room and quiet room on the first floor and a lounge on the second floor. The home has extensive grounds and a part of the garden is accessible and secure, with a seating area. An onsite activity centre and hydrotherapy pool facility was being refurbished and nearing completion.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives gave mainly positive feedback about the service. We found some aspects that were not safe and required improvement to address them.

Some risks to people had not been properly reduced. The risk of falls was not always proactively managed and incidents and accidents were not always managed appropriately to avoid recurrences. Some pressure relieving air flow mattresses were not on the correct settings to provide people with appropriate relief from pressure on their skin. Statutory safety certificates were not present for all equipment used at the service and oxygen cylinders were not safely stored.

Records of people’s care and treatment were not always up to date or meaningfully completed and, although audits were regularly undertaken, they did not always identify shortfalls they were intended to.

A survey of people living in the service found they felt safe. Assessments had been made about environmental risks to people and actions had been taken to minimise them. Staff knew how to recognise signs of abuse and how to report it.

There were enough staff on duty to support people, and proper pre-employment checks had taken place to ensure that staff were suitable for their roles.

Staff had received training in a wide range of topics and this had been regularly refreshed. Supervisions and appraisals had taken place to make sure staff were performing to the required standard and to identify developmental needs.

People’s rights had been protected by assessments made under the Mental Capacity Act (MCA). Staff understood about restrictions and applications had been made to deprive people of their liberty when this was deemed necessary.

Healthcare needs had been assessed and addressed. People had regular appointments with GPs, health and social care specialists, opticians, dentists, chiropodists and podiatrists to help them maintain their health and well-being. Medicines were well managed and people received them when needed.

Staff treated people with kindness and respect. Staff knew people well and remembered the things that were important to them so that they received person-centred care.

People had been involved in their care planning and care plans recorded the ways in which they liked their support to be given. Bedrooms were personalised and people’s preferences were respected. Independence was encouraged so that people were able to help themselves as much as possible.

Staff felt that there was a culture or openness and honesty in the service and said that they enjoyed working there. This created a comfortable and relaxed environment for people to live in.

Systems were in place to encourage feedback from people, relatives and staff and were subject to continuous review.

People’s safety had been protected through cleanliness and robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had

Our inspection team was made up of two inspectors.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

This helped us answer our five questions:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

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

Is the service safe?

Most people told us that people were always treated with dignity and respect by the staff. However, we saw some examples which showed that this was not consistent throughout the staff team. One example was a member of staff who placed grapes in two people’s mouths, without asking if they wanted any or giving them the opportunity of taking their own fruit.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to treating people living with dementia with dignity and respect at all times.

Visitors said that they felt that their relatives were safe living at the home. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

Staff received regular training to ensure that they had the necessary skills and experience needed to support the people living in the home.

There were safe systems in place for the receiving, administration and disposal of medicines. However, the storage of medicines was not safe.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to the storage of medicines.

The Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The home had proper procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager had submitted one application and told us that they would be submitting more applications to safeguard the people who lived in the home in the near future. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Most people that we spoke to told us that they were happy with the care that was delivered and that it met people’s needs. This was also evidenced in responses to questionnaires. Where people were not satisfied with all aspects of care, they were confident that the home manager listened and would take the appropriate action.

People’s health and care needs were assessed with them and/or their representative and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required and they reflected people’s current needs.

Staff had a good understanding of people’s care and support needs and knew them well, including information about people’s family and past lives.

Staff had received training in key areas so that they could meet the needs of the people who lived at the home. Nurses had received specialist training in specific areas and all staff had received training in dementia care.

Is the service caring?

People were mostly supported by kind and attentive staff. We saw that staff stopped to talk to people who were confused to give assurance. We found an exception to this when a staff member did not answer a person’s query about their medication in a patient and understanding manner.

At lunchtime we saw that people were able to eat at their own pace and were not rushed.

People’s preferences and interests were recorded in detail in their plans of care and staff demonstrated that they understood people’s individual needs and preferences.

Is the service responsive?

People’s needs had been assessed before they moved into the home. This included people’s needs with regards to their nutrition and hydration. Where people had been assessed as at risk of poor nutrition an action plan was in place to minimise the risk.

People were assigned a key worker, who took a specific interest in their care and welfare.

People had access to activities and one to one conversations with the activity coordinator. However, as there was only one coordinator for the 50 people who lived in the home, there were times when people had limited stimulation.

People were supported to maintain relationships with their friends and relatives. Visitors told us that they were always made welcome.

Visitors knew how to make a complaint if they were unhappy. They said that the manager listened to their concerns and took action to try and address them.

Is the service well led?

The service had a quality assurance system, which consisted of internal audits and an external audit from a member of the company. This included all aspects of care, such as care planning, staff training, health and safety, medicines management and the environment.

People completed survey questionnaires about their level of satisfaction with the service. The last time this was done, most people were positive about the support given by the home. Comments included, “Mum seems to be happy with staff and is comfortable in their presence”; and, “Staff are always friendly and welcoming when we visit.”

Staff told us they were clear about their roles and responsibilities.

Our inspection of the 12th April 2013 found that improvements were needed to ensure people were cared for in a clean, safe and suitable premises.

Since our last inspection the provider had sent us an action plan showing how they intended to improve the service and achieve compliance. A new manager had been recruited and started work at the home two weeks before our visit.

People and staff told us that they had noticed an improvement in the service. One staff member told us, "It's so much better, the place is cleaner and we know what we are doing before we arrive for work." One person who used the service told us, "it is much cleaner." We found that the premises was well maintained with on- going improvements identified.

The service was clean and tidy with correct infection control procedures in place. We found people's medication was stored appropriately and administered safely.

People we spoke with who used the service and their relatives were happy with the service they received. People felt the staff met their needs and supported them. One person who used the service told us, "I don't need help to dress and wash but they will always help wash my hair if I ask." People told us they were aware of their care plans and they could look at them if they asked.

People who used the service and staff we spoke with felt there was sufficient numbers of staff on duty to meet people’s needs. We saw that there was at least one member of staff in each area of the home at any one time.

We found that in the clinical room there were systems in place to make sure the correct procedures were followed for infection control. However other areas of the home were not clean, therefore people were not fully protected from the risk of infection. We saw that there were areas of the home that had not been adequately maintained to promote the wellbeing of people who used the service.

We spoke with people who use the service, their relatives, staff and the registered manager. We spent time with people and observed interactions between people using the service and the staff. The six people we spoke with gave us positive feedback about the service. They told us, "I love it here, this is my home and I have no complaints." "I can do want I want to my room." "Staff will also get the doctor if I request it, so I feel safe living here." People told us they were supported by the staff and that their wishes were respected and their privacy maintained. People said they felt listened to and were able to be as independent as they wanted to be. One relative told us, "We were able to move the room around to how he wanted it."

We found records and care plans up to date and people had consented to their care and treatment. We saw that all safety checks and services on equipment were undertaken regularly. There were effective systems in place to make sure people and staff were asked their views of the service. Records were kept securely and in good order so that confidentially was maintained.

We spoke with 5 people who live at the home and 1 relative.

The people we spoke with were very happy living at the home. All said they couldn’t think of anything the home could do better, and all spoke very positively about the food. People said the laundry service was very good, and their rooms were kept clean and tidy.

People said they liked the staff and had good friendly relationships with them. People said the manager was very helpful, and was always around to speak to. People who were less able to express their views were observed to be relaxed, interacting with staff and some were taking part in activities in the lounge.

The relative we met with spoke very highly of the home and said if she was unable to visit she was confident that her loved one was receiving excellent care. She said the staff were “wonderful” and she was looking forward to sharing a meal with her husband on her birthday at the home.

The inspection took place on 8 and 10 December 2015 and was unannounced. At the previous inspection on 27 August 2014, we found that there were two breaches of legal requirements as people’s privacy and dignity was not always met and medicines were not stored appropriately. Both of these issues had been addressed at this inspection.

Harbledown Lodge provides accommodation with personal and nursing care for up to 56 older people, some of whom are living with dementia. There were 48 people living at the home at the time of inspection. The accommodation is over three floors and upstairs bedrooms can be accessed by a passenger lift. There is a communal lounge, activities room, dining room and quiet room on the first floor, and a lounge on the second floor. The home has extensive ground and a part of the garden is accessible and secure, with a seating area.

The service has a registered manager who was available and supported us during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Assessments of risks to people’s safety and welfare had been carried out. However, for some people, there were not clear treatment plans in place to minimise the occurrence of pressure areas developing. Staff had not all received training essential to their role.

Quality assurance systems were in place, but where shortfalls had been identified they had not been prioritised so that action could be taken to address them in a timely manner.

Staff asked for people’s consent before they carried out care tasks. However, the assessment processes in place demonstrated that not all staff understood the principles of the Mental Capacity Act and how to apply them to ensure that decisions were made in people’s best interests.

Health and safety checks were effective in ensuring that the environment was safe and that equipment was in good working order. The service carried out regular fire drills and checks of firefighting equipment to ensure it was in good working order. Some areas of the service required attention due to unpleasant odours

Staff knew how to follow the home’s safeguarding policy in order to help people keep safe. Accidents and incidents were recorded and monitored so that any trends or patterns could be identified and the necessary action taken.

Comprehensive checks were carried out on all staff at the home, to ensure that they were fit and suitable for their role. There were enough staff on duty to meet people’s needs.

Nurses gave people their medicines and their competency in doing so safely was assessed on a regular basis. Since our last inspection of the service, changes had been made to the storage of medicines so that it was fit for purpose.

People had their nutritional and fluid needs assessed and monitored and professional advice was sought from the dietician and speech and language therapist as needed. People were offered a choice at mealtimes and had the support they needed and could take the time they needed to enjoy their food.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. DoLS applications had been made for people who lived in the home to ensure that people were not deprived of their liberty unnecessarily.

People’s health care needs had been assessed and clear guidance was in place for staff to follow, to ensure that their specific health care needs were met. Staff liaised with a number of health professionals as appropriate.

New staff received a comprehensive induction, which included shadowing more senior staff. Staff said they felt well supported and received supervision and attended regular staff meetings.

Staff knew people well and they were valued by staff who treated them with dignity and respect and ensured their privacy was maintained. People were provided with a range of group and one to one activities; by the activities coordinator who was enthusiastic and passionate about their role.

The complaints policy was displayed in the home and relatives felt able to approach any member of staff if they wished to discuss a concern. Any concerns or complaints received were dealt with appropriately.

The registered manager was a visible presence in the home. They had initiated a number of improvements to the service which relatives and professional’s had commented on such as more activities available and a more committed staff team.

The views of people, relatives and staff about the quality of care provided at the home were regularly sought and a report was made of their views, together with the action that had been taken to address any shortfalls. The staff team were clear about the aims and values of the home and put these into practice

The staff team were clear about the aims and values of the home and put these into practice.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.