This inspection took place on 24 and 25 January 2019 and was unannounced. At the last inspection in June 2018 we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the service was rated ‘Inadequate’. At this inspection, we found that although there were continued breaches of the regulations, improvements had been made and that the service was now rated ‘requires improvement’.

Lofthouse Grange and Lodge 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. There were 45 people living at the care home at the time of the inspection.

The care home accommodates up to 88 people across two separate units. One of the units specialises in providing care to people living with dementia.

The service did not have a registered manager in post at the time of the inspection, however the service had appointed a manager who was in the process of registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with 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, people and their relatives expressed concerns about staffing levels. Staffing dependency tools we reviewed were not always reflective of people’s current needs. Rotas we were shown did not always match actual staffing levels. However, we found that there had been improvements made with regards to staffing continuity. Levels of agency staff had reduced, and staff were able to build more effective relationships with people. People and their relatives told us that there had been improvements since the last inspection, however they were still concerned about staffing levels.

We have made a recommendation around staffing levels.

We found that medicines storage areas were clutter free, and staff used an electronic medicines administration records system which helped reduce errors. However, we found instances where practice could be improved to reduce risks to people.

Governance systems and processes had improved and we saw that they were beginning to have a positive impact on certain aspects of the service such as infections, weight loss and falls. However, these processes were not fully embedded and some of the issues we had previously identified in medicines management and staffing had not been addressed.

People told us they felt safe, and staff knew how to protect vulnerable people from harm. The service was clean and there was sufficient equipment in place to prevent the spread of infection such as personal protective equipment and hand gel dispensers.

Staff told us they received good support in the form of induction, training, ongoing supervisions and appraisals. Staff told us the leadership team at the service were approachable and supportive, and that morale at the service had improved since the last inspection.

People’s health and wellbeing was being monitored effectively by staff. Health professionals we spoke with were confident the service was making appropriate referrals, and any guidance or information from healthcare professionals was cascaded effectively to staff. People’s nutrition and hydration needs and preferences were recorded accurately.

People and their relatives told us staff were kind, caring and compassionate. People told us staff worked to uphold their independence and offer them choices to help empower them. Staff described how they protected people’s privacy and dignity.

People were appropriately assessed before using the service, and care plans contained person-centred information and guidance for staff which was regularly updated.

This inspection took place on 6, 12 and 13 June 2018 and was unannounced. This was the first inspection undertaken since the service was registered in December 2017. The inspection was prompted in part by notifications sent to us that raised concerns about people’s care.

Lofthouse Grange and 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. Lofthouse Grange and Lodge accommodates up to 88 people over two communities, referred to as ‘The Lodge’, which accommodates people living with a dementia related condition and ‘The Grange’, which accommodates people requiring residential care. There were 72 people living in the home when we inspected.

At this inspection we found four breaches of the Regulations of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special

measures.

There was a registered manager in post at the time of the inspection. 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.

There were not enough staff to meet people’s needs effectively. There was a high turnover of staff and staffing levels were impacted due to sickness and absence. People, their relatives and staff told us they had concerns with staffing levels. There was a high number of agency staff used with the service, and people, their relatives and staff told us they had concerns about continuity of care and competence of agency staff.

Systems and processes around medicines management were not safe. Specifically, we found concerns with the safe storage, administration practice and documentation of some medicines.

Safeguarding referrals were not always made appropriately and there were a high level of falls and incidents which had not been managed effectively. This meant appropriate action ha