This inspection took place on 10 and 13 December 2018 and was unannounced.

Lake and Orchard Residential and Nursing Home is registered to provide residential and nursing care for up to 99 older people who may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Accommodation is provided across two units ‘Lake’ and ‘Orchard’, both spread across two floors. Lake provides residential care, whilst Orchard provides nursing care. Both units support people who may also be living with dementia. At the time of our inspection, there were 61 people using the service; 30 people living on Lake and 31 people living on Orchard.

The registered manager had left the service shortly before our inspection. A new manager was in post who told us they were going to apply to become the registered manager. 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. A ‘peripatetic manager’ had also been working at Lake and Orchard Residential and Nursing Home since our last inspection and they were supporting the new manager during their induction period. The management team were also supported by a regional area manager and two deputy managers; one who worked on Lake, and one who worked on Orchard.

At the last inspection completed in April 2018, we rated the service requires improvement overall with inadequate in well-led. We identified three breaches of regulation relating to person-centred care, staffing and the governance of the service. Following the inspection, we met with the provider and asked them to take action to make improvements, and this action has been completed.

Work was ongoing to improve the service. Significant progress had been made since our last inspection, but further improvements were needed to achieve a good rating.

Sufficient staff were deployed, but improvements were needed to the way staff were organised, supervised and deployed at busy times and to support with meals on Orchard.

There remained some inconsistencies in staff’s approach. Some staff did not always offer people choices and worked in a more task orientated way. Greater supervision and leadership was needed to monitor and address these inconsistencies and to promote good person-centred care.

Areas of the service were tired, worn and in need of redecoration. There were other environmental and maintenance issues throughout the service that needed to be addressed. The manager and peripatetic manager were aware of these issues and outlined the plans in place to address this. Renovation work was taking place at the time of our inspection to improve the dementia nursing unit, but further improvements were needed.

The overall rating for this service is ‘requires improvement'. Whilst this is the sixth consecutive time the service has been rated inadequate or requires improvement overall, the continued improvements and trajectory showed positive leadership. The provider had made significant progress since the last inspection and was now compliant with the fundamental standards of quality and safety. This progress demonstrated an ability and ongoing commitment to improving the service. We will continue to work with the provider to monitor progress and support improvement to achieve at least a good rating overall.

We received positive feedback about the new manager and the positive impact and changes being made. The provider was embedding a more robust system of audits.

Staff were safely recruited. They were trained to recognise and r

This inspection took place on 27 March and 4 April 2018 and was unannounced.

Lake and Orchard Residential and Nursing Home is registered to provide residential and nursing care for up to 99 older people who may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service is purpose built and accommodation is provided in two units ‘Lake’ and ‘Orchard’ spread across two floors. Lake provides residential care; Orchard provides nursing care. Both units support people who may also be living with dementia. At the time of our inspection, there were 59 people using the service; 24 people were living on Lake and 35 people were living on Orchard.

The service had a registered manager. They had been the registered manager since February 2018. 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. The registered manager was supported by a regional area manager and two deputy managers; one worked on Lake, the other worked on Orchard.

At the last inspection in January 2017, we rated the service Requires Improvement overall. We identified four breaches of regulation relating to safe care and treatment, premises and equipment, staffing and the governance of the service. We asked the provider to take action to address our concerns. At this inspection, we identified ongoing concerns about the quality of the care and support provided.

Staff did not consistently provide safe support with moving and handling. Care and support was not always person-centred and staff did not always provide effective care to meet the needs of people living with dementia. The care and support provided on Orchard was task-based. At times there was little or no interaction, activity or meaningful stimulation for people. Records did not evidence people were regularly engaged with meaningful activities.

Staff profiles and records of induction were not always available for the agency staff who worked at the service. The provider requested updated information to ensure agency profiles listed the correct dates of training completed, included previous experience and confirmed their professional qualifications and registration were up-to-date. Permanent staff raised concerns about the impact of using agency staff. Agency staff lacked supervision and direction and did not consistently provide safe, effective or caring support to meet people’s needs. This showed us sufficient numbers of suitably skilled and experienced staff had not been deployed to meet people’s needs.

Records were not always well-maintained. Care plans were not always kept up-to-date and did not consistently provide clear person-centred information about how people’s needs should be met.

Whilst some improvement had been made and the breaches of regulation relating to safe care and treatment and premises and equipment had been met; this was the fifth consecutive time the service has been rated Inadequate or Requires Improvement overall. It was the third consecutive time we have found breaches of one or more regulation. This showed inadequate governance. The provider had not operated effective systems to monitor and improve the quality and safety of the service. It showed a failure to provide a consistently good service to meet people’s needs.

There was a new breach of regulation relating to person-centred care and continued breaches of regulation relating to staffing and the governance of the service. You can see what action we told the provider to take at the back

The inspection took place on 17 and 18 January 2017 and was unannounced.

Lake and Orchard Care Centre offers accommodation for up to 99 older people living with dementia and/or with a physical disability requiring nursing or rehabilitation services. The centre is divided into two units named Lake and Orchard. There were 64 people resident on the day of our inspection: 42 people in Orchard and 22 in Lake.

We last inspected this service on 9 and 10 November 2015 and found a breach of regulation in relation to the management of medicines. We asked the provider to take action to make improvements and this action had been completed.

At this inspection we identified that risks to people's health and safety had not always been identified and managed, there were not enough staff working at the service, the environment did not meet people's needs and the systems in place for monitoring the service were not consistently effective. You can see what action we told the provider to take at the back of the full version of the report.

The perimeter fence was not secure on day one of the inspection but this was made safe the same day.

Risks to people's health had not always been identified which could have resulted in harm.

There was a registered manager employed at this service at the time of the inspection. They have since made an application to have their registration removed and no longer work 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 2008 and associated Regulations about how the service is run. The service had employed a second manager for the Orchard unit. This person had started work at the service following their induction several weeks prior to the inspection. The registered manager was not available for this inspection and so the manager of Orchard and the regional manager made themselves available throughout the two days.

The risk of infection was minimised for people who used the service because staff were using appropriate measures to monitor and clean the service.

Safe recruitment procedures were in place to ensure suitable staff were employed to work with people at the service. There were not sufficient staff to meet people's needs. The registered provider has already reviewed this and was making changes to meet the needs of people at those times.

Accidents and incidents were recorded, analysed and trends identified.

Medicines were managed safely.

The service had only minimal signage in place to encourage people to find their way around. Although some people's bedroom doors were personalised the service had more to do in order to make the service fully dementia friendly.

Staff knew the people they cared for and were well trained. They worked within the principles of the Mental Capacity Act 2005. Deprivation of Liberty Safeguard (DoLS) authorisations had to be resubmitted in order to ensure that people were not being detained without authorisation.

People's nutritional needs were met.

The service was caring. From our observations during the day, we saw that staff knew people well and saw that staff approached and spoke with people kindly and with respect. Staff lacked expertise and confidence when caring for one person because of their very complex needs. Staff were supported by the community mental health team and the care coordinator from the local authority was aware of this person.

People received compassionate care at the end of their life.

Care plans were person centred and were regularly reviewed. Activities were provided. A new activity person was joining the team which would allow more time to be spent providing activities for people and reduce the risk of social isolation.

There was a complaints policy and procedure and people knew how to make complaints.

The

This inspection took place on 16 April 2015 and was unannounced. We last inspected this service over two days on 22 July and 17 September 2014 where we found breaches of Regulations 9, 10, 12, 13 and 22. This was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to take action to make improvements to the care and welfare of people who used the service, medication management, infection control, the environment and quality assurance and the provider sent us an action plan telling us that all the actions would be completed by 28 February 2015.

Lake and Orchard Care Centre offers accommodation for up to 99 older people living with dementia and/or with a physical disability requiring nursing or rehabilitation services. The centre is divided into two units named Lake and Orchard. There were 54 people resident on the day of our inspection: 36 people in Orchard and 18 in Lake.

There was no registered manager at this service but there was a manager in post who had started the process of application to be a registered manager with the Care Quality Commission (CQC). The service had also decided to recruit a second manager so that each unit had its own registered manager. 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.

Staff understood what it meant to keep people safe and we saw that they had been trained in safeguarding adults. Staff had been recruited safely.

The risk of infection was minimised for people who used the service because staff were using appropriate measures to monitor and clean the service.

Although some areas of medicine management still required improvements staff administered medicines safely. The service had made major improvements in this area and was clear about what they needed to do.

The service was beginning to make the appropriate changes needed to the environment in order to support people living with dementia to be able to be as independent as possible but further work was necessary. There were plans in place for those improvements to be made.

Staff knew the people they cared for and were well trained in areas that related to the people they cared for. Staff worked within the principles of the Mental Capacity Act 2005.

The service was caring. From our observations during the day we saw that staff knew people well and saw that staff approached and spoke with people kindly and with respect. Staff were at times task orientated but the majority of interactions we witnessed were friendly and supportive.

Although some people were offered and enjoyed activities throughout the day others were not stimulated by any activity which meant that there was a risk of social isolation for some people.

There was a quality assurance system in place which used audits in each area of the service so that there was a consistent approach to improvement.

We carried out this inspection as a follow up to our visit on 17 and 18 June 2013 when we found the provider to be non-compliant with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We looked at the areas of care and welfare of people who use the services and medication

People we spoke with told us they were satisfied with their care and treatment. We looked at their care records and found they accurately outlined the support people needed.

We spoke with staff and they were knowledgeable about the people they were supporting. We observed interactions and saw that people were treated with dignity and respect on every occassion.

We spoke with several people who used the service and they told us that staff always helped them when they needed assistance. One person said “The girls can be cheeky but I like that”. Another person told us “They look after me ok”.

We looked at the systems in place for the safe handling of the medicines and found that people were receiving their medication in line with the prescriber's instructions.

We found that people were involved in decisions about their care and treatment and information regarding advocacy services was available to people who used the service.

Although people we spoke with told us they were satisfied with their care and treatment we found inconsistencies between some people’s care plans and the care and support that they received.

People we spoke with told us they felt safe at the service. We saw that where there were any concerns regarding the safeguarding of adults appropriate referrals had been made to the local safeguarding authority.

We spoke to three people who used the service about the support with medicines that they received from staff. One person said “I think they are very good here”. Another person said “They are not bad you know. Sometimes they forget to give my medicines”. A third person said “I get well looked after. I am better than I was”. One person’s relative said, “I have seen them being given tablets. I have seen this regularly.” Overall we found medicines were not always safely handled and improvements were needed.

Staff we spoke with told us they felt supported. The introduction of a new training programme prevented us from making a judgement about the current training completed by staff.

We saw that systems were in place to monitor the quality of service provision.

We visited Lake and Orchard in January 2013 to check that improvements had been made since our last visit in September 2012.

We found that work had started on improving levels of involvement in planning care but this was still underway and was not being monitored. We found that there were improvements in staff interactions and general wellbeing of the people who used the service.

We looked at care plans and various types of assessments and saw that these had been started but were not yet completed.

Previously we had identified some issues with infection control previously and that the home had tackled these issues since the last inspection. They had made improvements in both the cleanliness and hygiene of the home and also in the monitoring and audit of these areas.

We found that there had been limited progress in the general quality assurance undertaken at the home and this still required work.

During our inspection we used a number of different methods to help us understand the experiences of people who used the service, because some of the people who used the service had complex needs which meant they were not able to tell us their experiences.

We observed care to help us understand the experience of people who we could not talk to us directly about their experiences at the home. We spoke with staff and with healthcare professionals about the care and well being of people who used the service. We also gathered evidence of people’s experiences of the service by reviewing care records and quality assurance documentation.

We found that although the home had systems in place these were not effective in promoting people’s safety and welfare.

People living at the home who could tell us about their experience of living there said they were happy that their views were listened to. One person living at the home said ‘The staff are very polite, they listen to what I say and act upon it’. Another person said ‘The staff listen to me’. Some people could not tell us if their view were sought because they had poor memories.

People we spoke with who could tell us how they felt about living at the home said they were happy with the care and support they received. We saw that people were being treated with dignity and respect by the staff. One person said ‘The staff look after me, I have no complaints’. Another person said ‘The staff help me’.

We asked some people whom we spoke with if they were unhappy about anything would they tell the staff. They replied ‘Yes’. One person said ‘I would say if I was not happy with something’. We asked if they felt the issue would be acted upon, they said ‘Yes’. Another person said ‘I feel safe here’.

Some people we spoke with could not tell us if they felt there was enough staff available to help to support them. However, one person said ‘The staff give me help with things I cannot do for myself’. Another person said ‘The staff are nice’. A representative of a person living at the home said ‘There are enough staff. I think they have training to be able to meet people’s needs’.

Some people we spoke with said the manager and staff spent time speaking with them; they said they liked that. One person said ‘The manager speaks to me often and I tell her what I think’.

This inspection took place on 9 and 10 November 2015 and was unannounced.

We last inspected this service on 16 April 2015 and found no breaches of regulation but we had made recommendations that the provider look at good practice guidance about the administration and recording of medicines, dementia friendly environments and meaningful activities that met the needs of everyone at the service.

At this inspection we saw some improvements had been made but there were still some issues with the recording and administration of medicines which was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we asked the provider to take at the end of this report.

Lake and Orchard Care Centre offers accommodation for up to 99 older people living with dementia and/or with a physical disability requiring nursing or rehabilitation services. The centre is divided into two units named Lake and Orchard. There were 61 people resident on the day of our inspection: 43 people in Orchard and 18 in Lake.

There was a registered manager at this 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 2008 and associated Regulations about how the service is run. The service had also employed a second manager for the residential unit, Lake. This person started work on the second day of our inspection.

People were not consistently safe. We saw that recording and documentation relating to the administration of medicines needed improvement. Staff did not have enough information available about why and when they should administer ‘When required’ medicines. In addition medicine administration records were not always completed appropriately.

Staff knew how to recognise and how to report any potential abuse of people who used the service. They had been trained in this subject.

Risks to people individually and within the environment had been identified and risk assessments were in place. The risk of infection was minimised for people who used the service because staff were using appropriate measures to monitor and clean the service.

The service had made changes needed to the environment in order to support people living with dementia to be able to be as independent as possible when accessing areas of the building but further work was necessary. There were plans in place for those improvements to continue to be made.

There were sufficient staff on duty to meet the needs of the people who used the service. They knew the people they cared for and they had received appropriate training in areas that related to the people they cared for. Staff worked within the principles of the Mental Capacity Act 2005. However, the service was not consistently effective because some staff lacked confidence when communicating with people who were distressed which led to poor outcomes for those people.

The service was caring. From our observations during the day we saw that staff knew people well and saw that staff approached and spoke with people kindly and with respect.

There was a quality assurance system in place which used audits in each area of the service so that there was a consistent approach to improvement. We could see that learning from incidents had taken place.