The inspection took place on 25 April 2017and was unannounced. This meant that the provider and staff did not know that we would be visiting.

We last carried out an inspection on 30 March 2016, where we found the provider was in breach of three regulations relating to safe care and treatment, staffing and good governance. At this inspection we found that improvements had been made and they were now meeting all regulations we inspected.

Hillside Lodge Care Home accommodates up to 50 older people, most of whom have nursing needs and some who are living with dementia. There were 47 people living at the home at the time of the inspection.

There was a registered manager in post. 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 and associated Regulations about how the service is run.

There were safeguarding procedures in place. Staff knew what action to take if abuse was suspected. The local authority safeguarding team told us there were no organisational safeguarding concerns with the service.

We spent time looking around the premises. Two shower rooms were not currently being used because they were awaiting refurbishment. The manager told us that quotes were being sought for this work to be completed. Checks and tests were carried out to ensure the building was safe.

Safe recruitment procedures were followed. Some people and staff told us that more staff would be appreciated. We observed that staff carried out their duties in a calm, unhurried manner on the day of our inspection. The registered manager provided us with information which showed that staff had completed training in safe working practices and to meet the specific needs of people.

There were safe systems in place to receive, administer and dispose of medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We observed that staff supported people with their dietary requirements. Staff who worked at the home were knowledgeable about people’s needs. We observed positive interactions between people and staff.

There was an activities coordinator employed to help meet the social needs of people. Some people told us that more activities would be appreciated; others said there were sufficient activities at the home. People were supported to access the local community.

A complaints procedure was available. Feedback systems were in place to obtain people’s views.

‘Real time’ checks and audits were carried out on a computerised management system. This enabled the registered manager and provider to identify any areas for action and monitor whether these had been completed.

All staff informed us they were happy working at the home and morale was good.

The provider was meeting the conditions of their registration. They were submitting notifications in line with legal requirements. They were displaying their previous CQC performance ratings at the service and on their website.

At our last inspection we rated the service as requires improvement. At this inspection we found that improvements had been made and action had been taken to ensure good outcomes for people in each of the five key questions we reviewed.

This inspection took place on 30 March 2016 and was unannounced. A previous inspection undertaken in September 2014 found the home to be fully compliant with legal requirements.

Hillside Lodge Care Home is located in a residential area of Tweedmouth near Berwick, Northumberland. It is registered to provide accommodation for up to 50 people. At the time of the inspection there were 42 people using the service, some of whom were living with dementia.

The previous registered manager had recently retired and had deregistered with the CQC. A new manager was in post and had applied to become the registered manager for the home. 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.

Staff were aware of the need to safeguard people from abuse and had a good understanding of potential abusive situations. They had received training in relation to this area and were able to describe the action they would take if they had any concerns. There had been no recent safeguarding issues at the home. The home had worked with key agencies around previous safeguarding events.

Risk assessments were in place both in relation to the wider operation of the home and linked to the individual needs of people using the service. Regular checks were made on fire and safety systems to ensure they worked effectively. Equipment was checked to ensure it was safe to use.

People told us they did not have to wait long for support and help. We observed call bells did not ring for long periods. The manager told us she had recently increased staffing numbers to provide additional support. However, the recruitment of qualified nurses had proved difficult. There was regular use of agency nursing staff, although this was usually staff familiar with people living at the home, and the clinical lead was working excessive hours to ensure nursing requirements were fully covered. Suitable recruitment and vetting procedures were in place.

We found medicines were appropriately managed, administered and stored safely. The clinical lead carried out regular checks on the storage of medicines. Some topical cream records held in people’s rooms had been removed and destroyed meaning accurate records were not available to ensure they had been applied as prescribed.

A number of areas of the home were not clean. Bathrooms, showers and sluice areas were in need of effective cleaning and in some cases refurbishment. The laundry area was also in need of effective cleaning. The manager had noted the need for these improvements and highlighted it as priority work to be undertaken.

Staff told us they had access to a range of training and updating. Records showed completion of online training was high. Additional training was available to further enhance staff skills. Staff told us, and records confirmed regular supervision and annual appraisals took place.

People told us meals at the home were good and they enjoyed them. Alternatives to the planned menu were available. Staff supported people with their meals appropriately and in a dignified manner. Kitchen staff demonstrated a good knowledge of people’s individual dietary requirements. Diet preference/ requirement sheets were available and updated regularly. Where people were on food and fluid charts, to help monitor their intake, these were completed well and up to date. People’s weight was monitored on a weekly basis.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. Where necessary applications had been made to restrict people’s freedom under the MCA. S

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the 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?

Below is a summary of what we found –

Is the service caring?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service responsive?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service safe?

We found that improvements had been made since our last visit which meant medicines were handled safely.

We found that processes were in place to safely administer and check medicines at the home. Daily audits were in place and where these identified any issues there was evidence that these were addressed. Specific care plans were in place for “as required” medicines and for people who administered their own medication. Medicine administration records were complete and up to date.

Is the service effective?

This was a responsive inspection to previous noncompliance against the regulations and we did not look specifically at this area.

Is the service well led?

The manager had put in place a range of systems to ensure that staff handled and administered medicines at the home safely. She had arranged additional training and support from a local pharmacist for staff dealing with medicines at the home.

We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the 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?

Below is a summary of what we found –

Is the service caring?

We saw people's needs were assessed and care was planned in line with their assessed needs. People we spoke with said," The care is very good, they look after us well" and “I’ve been here five years and I wouldn’t stay if I didn’t think it was any good.”

We observed staff delivering care and noted that they were patient and compassionate and supported people to be as independent as possible or addressed people’s needs where they were unable to do so themselves.

People we spoke with told us that a range of activities took place and that trips out of the home were arranged. One person told us, “There are activities, yes. You can choose if you go or not. I would have been down there today but I’ve had visitors.” We saw people who used the service having their nails painted and an activity in the afternoon where some people made small felt bags for Easter. This meant there were a range of activities available to keep people active and mentally stimulated.

Is the service responsive?

People’s needs were assessed and their care plans reviewed and revised in line with the changing needs. People had access to a range of outside services to ensure their health and wellbeing was maintained including doctors, dentists and opticians.

We observed staff delivering care and found that they supported people appropriately and responded to people’s individual needs. People were offered a choice of meals and particular nutritional needs, such as special diets and food likes and dislikes were catered for. People we spoke with told us that they food was good. One person told us, “There is a choice of what you can have; not every time, but usually. There are plenty of drinks.”

We saw that complaints and safeguarding incidents were investigated and, where necessary, action taken to change or improve care delivery.

Is the service safe?

People were cared for in an environment that was safe and well maintained. Fire and safety systems were regularly checked and fire drills undertaken. People had individual personal emergency evacuation plans which detailed the help they would need if there was a fire or similar event.

Systems to record and monitor medicines were incomplete or contained errors. Records to indicate why people had not been given certain medications were not always complete, there was an error on one person’s record for medication used to thin the blood and a number of people did not have care plans for “as required” medication. Some hand written entries on the medication record sheet were not clear. A daily audit of medicine records had not picked up any of the issues we found. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst the manager told us that no applications have needed to be submitted, people’s care plans reflected that these issues had been considered and indicated that appropriate actions or best interest meetings would be held if the need arose. Nursing staff within the home had received training on DoLS and the Mental Capacity Act 2005.

Is the service effective?

People told us they were happy with the care that had been delivered and their needs had been met. One person who used the service told us, "The care is very good. The care workers are very good, too.” It was clear from our observation and from speaking to staff, that they understood people’s care and support needs. One staff member told us, “It’s a good bunch of carers here and the nurses are good.” We observed several members of staff delivering care and saw that it matched the actions outlined in people’s care plans.

People nutritional needs were assessed and food and drink was supplied, taking into account individual needs and preferences. The cook for the home had a good understanding of people’s individual nutritional requirements. People’s weight was regularly monitored and, where there was concern about possible weight loss additional advice was sought. One person told us, “The food is very good. It must be as I’ve put on quite a bit of weight.”

Is the service well led?

The home had a range of quality assurance system in place to monitor the quality and consistency of care. The manager carried out a range of checks and audits. We saw copies of documents regarding checks on medication, care records, nutrition, equipment and the general environment within the home.

People who used the service confirmed that there were regular residents’ meetings and we saw copies of minutes from this meeting. One person we spoke with told us that they were able to raise issues in the meetings. They told us, “Generally things are OK; but I would tell them if it wasn’t any good.”

Staff confirmed that there were regular staff meetings and we saw minutes from these meeting. Staff told us, and records confirmed that they had regular supervision with a senior member of staff and yearly appraisals. One staff member told us, “Yes, we get supervision every three months, although sometimes more frequently. We can talk about care needs and issues or training.”

People told us they were happy with the care they received and staff checked they were in agreement with it. We saw they were relaxed and there were good interactions between people who used the service and staff. We saw staff consulted people before they provided care and support.

We found people's needs were assessed and care was planned in line with their needs. One relative told us, “My mother’s care is here is very good and I am more relaxed now. The carers keep me involved in all aspects of her care and we have regular reviews.” Care plans were regularly updated and contained clear information about individuals' care.

At the time of this visit there were enough qualified, skilled and experienced staff available to meet people’s needs. Staff responded promptly to requests for assistance.

People were asked their views about the service provided and these were taken account of. People were aware of the complaints procedure. The provider had systems in place to monitor care delivery and ensure the health, welfare and safety of people who used the service was maintained.

People's personal records, including medical records, were accurate, fit for purpose and held securely. Staff records were kept in an appropriate form.

During our inspection we spoke with four people who used the service, one relative and four staff.

We established that people expressed their views and were involved in making decisions about their care. We observed staff checked with people that they were happy with how they were being treated. One person told us, "They always knock on the door before they come in."

We saw people's needs were assessed and care was planned and delivered in line with their needs. We noted care plans were reviewed on a monthly basis. One person told us, "I’ve been here for two years; I wouldn’t be here if I didn’t like it." We spoke with one relative who told us, "I am very happy with the staff, they are all very friendly. They are doing everything possible to make her comfortable."

We observed the home was tidy and established there was a schedule for ensuring it was kept clean. We talked to four members of staff who were all able to describe in detail the correct procedures for dealing with infection control.

We saw there were effective recruitment and selection processes in place and established an application process and effective interview procedure had been followed.

We saw a complaints system and policy was in place and noted people's complaints had been investigated and resolved, where possible, to their satisfaction. One person told us, "If you have got a problem you just tell anyone. They will sort it out for you."

People told us that they were involved in making decisions about their care and lifestyle. They said that they were satisfied that they got a good service that suited their individual needs. People said that they were happy living in the home. One person said, “As far as I’m concerned it’s home. We don’t just sit around like dopes, there’s things to do. I love it.” They told us that staff were friendly and there was a good atmosphere. People also told us that they felt safe and were able to voice their opinions and concerns.