Our last comprehensive inspection of Newcombe Lodge was on the 23 June 2016. At this inspection we rated the service as good overall. We rated effective, caring, responsive and well led as good. However, we rated safe as requires improvement because we saw breaches in regulation surrounding how medicines were managed at the service.

The purpose of this inspection was to follow up on the actions the service had taken following the requirement notice we issued at the last inspection (23 June 2016).

At this inspection we rated safe as good.

At our last inspection on 23 June 2016, we issued a requirement notice against Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment because we had a number of concerns with how the service was managing medicines. The service did not have an ‘as required’ medicines treatment protocols in place. The medicines stock recording system did not accurately record the quantity of medicines held by the service and the medicine cupboard contained some medicines that were not documented on patients’ medicine administration records (MARs). We also saw that staff did not always follow the process for recording medicines for destruction. This meant that people with access to the medicines may have been able to obtain medicines that should have been destroyed.

The medicine policy did not detail the process to follow to risk assess someone for self-administration or the responsibilities for assuring self-administration was being conducted safely.

On the 8 July 2016 the service supplied us with an action plan on how they would meet the requirement notice we had issued. This action plan included implementing new policies for ‘as required’ medicines, self-administration of medicines procedures, and updated procedures for medicines disposal. The action plan also included the service putting training for staff in place for these new policies and displaying the ‘as required’ medicines policy on the wall of the clinic room.

On 29 March 2017 we undertook an unannounced, focussed inspection to look at whether the service had addressed all of the concerns identified in the requirement notice. We looked at the systems in place for managing and administering medicines. We spoke to staff involved in the administration of medicines, and reviewed seven patient’s medicines charts. We found that systems in place had improved since the last inspection and medicines were being managed safely and that the service now addressed all the concerns set out in the requirement notice.

The therapeutic care workers (unregistered healthcare workers) administered medicines to patients. The care workers received training on the safe use of medicines and senior staff assessed their competence before they were signed off to administer medicines to patients. Since the 26 June 2016 inspection, they had undergone further training in the administration of ’as required’ medicines and individual risk assessments.

Arrangements for ordering and receiving patients’ medicines from both the GP and pharmacy were appropriate. Medicines were supplied against prescriptions for named patients from a local pharmacy. The pharmacy supplied medicines, individually labelled for each patient, with printed medicines administration records (MARs). The care workers had completed the MARs once they had administered the medicines and we could clearly see when patients had taken their medicines. Staff double signed handwritten additions or amendments on the MARs and wrote notes when medicines were omitted, which is good practice. Processes were now in place for ensuring waste medicines were recorded and disposed of correctly.

Staff supported patients to take their medicines correctly and there were clear written instructions on how patients liked to take their medicines. Care records also identified any allergies or particular areas of risk for each patient.

We checked a sample of medicines which had been supplied, against the MARs. Staff kept a running balance of stock which meant it was easier to identify if the medicines had actually been given and that there was enough stock for patients.

Some patients were prescribed medicines to be given ‘as required’. We saw that comprehensive protocols were now in place for these medicines. However, in two records we saw that there was no guidance to staff to decide if it was appropriate to give a dose of the medicine. Each patient could also be administered ’homely remedies’ (non-prescription medicines that allow staff to respond to patient’s minor symptoms appropriately) but we did not see a protocol, developed with the GP, to provide guidance to staff on what medicines could be given and when to give the medicines. While there was little written guidance for staff to follow, we observed that staff knew the patients well and were able to make decisions with them about whether a medicine was needed or not.

None of the patients were self-administering medicines when we inspected. The medicines policy had been amended to provide better guidance on the process to follow to risk assess someone for self-administration, and training had been delivered to support the amended policy. However, the medicines policy available in the clinic room was not the most up to date version.

As a result of the improvements made by the service, we lifted the requirement notice that we issued following the last inspection and re rated ‘safe’ as ‘good’.

We rated Newcombe Lodge as good because:

• The home had good indoor facilities and had a good garden. The home involved young people in decorating the home and they were encouraged to decorate their room and to personalise it. Young people were admitted from around the country. They were given the chance to visit the home and stay overnight to see if they liked the placement.

• Staffing levels had improved over the six months before this inspection. Staff said they felt supported by managers through this time and that moral was now better and the home was calmer. Governance systems had helped to address the gaps in staffing and in mandatory training.

• The care plans we reviewed covered the individual needs for the young people in the home. Staff could arrange external therapy if it would be helpful for the young person. Staff helped young people to build life skills to prepare them for discharge.

• Young people had access to a number of experienced staff with different professional backgrounds. They met weekly. We saw that staff were kind and respectful when speaking with young people. They clearly knew the needs of the young people living at the home. Young people were involved in staff meetings and said they felt listened too. In house chefs made meals to meet the needs of the young people.

• The provider responded quickly to the issues highlighted by this inspection and put measures in place to address them

However,

• Systems were not always either in place, or robust enough when it came to managing medicines safely, notifying the Care Quality Commission about safeguarding concerns, and ensuring audits were completed in staff absence. We raised these concerns with the provider and they acted quickly to address them. The provider introduced policies to address the shortfalls and trained their staff on the new procedures.

People we spoke with told us they felt safe and understood the rules and boundaries of the home. Staff we talked with demonstrated a clear understanding of the young women's needs and the therapeutic ethos of the home. The home had a clear therapeutic aim and staff were supported to understand this and to apply the rules and boundaries consistently. Whilst young people were asked for their consent we noted that the home did not always take into account the difference in consent between people who were legally adults rather than children.

The home worked with other providers to deliver care and we saw that the young people's social workers were regularly informed of their progress.

Staff had a clear understanding of safeguarding and the importance of reporting concerns. Restraint was recorded and the restraint log contained evidence of appropriate use of restraint.

Staff received regular supervision and training and the provider had a system in place to monitor the quality of the service.