Osborne Lodge is a care home without nursing. It is a family run care home offering accommodation for up to 34 older people living with a range of health and social care needs. A small number of people were living with dementia. People in care homes receive accommodation and their care as a 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. This inspection took place on 21 and 23 January 2019 when there were 25 people using the service.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this care home at the time of the inspection. Their name appears because they were still registered as manager on our register. A new manager had been appointed in November 2018 and has applied to the Care Quality Commission to become registered. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

At our last inspection we rated the service as overall 'Requires improvement’. This was because staff had not been consistently deployed in such a way as to ensure that people received their care safely and in a timely way. Some further improvements were needed to the records relating to people’s care and support and to embed robust management arrangements. At this inspection, our findings continued to support a rating of ‘Requires improvement’.

Some records relating to people’s care continued to be incomplete or inaccurate and were not stored securely. Whilst there were systems in place to monitor and assess the quality of service, these were still not being fully effective in delivering all the improvements needed to achieve a rating of ‘Good’.

Whilst people received their medicines as prescribed, there were shortfalls in relation to how some medicines were stored and some medicines records were incomplete or inaccurate.

We were not consistently able to ascertain what action had been taken to mitigate new or developing risks or in response to incidents or accidents.

The provider had made improvements which ensured that there were now consistently sufficient staff deployed to meet people’s needs.

Overall, staff had received the training and support they required to meet people's individual needs. A number of staff did not have up to date safeguarding training, but they were able to demonstrate an understanding of how to identify abuse and to explain the actions they would take if they identified any concerns. The manager is arranging for this training to take place.

Staff felt well supported by the leadership team and had been receiving periodic supervision and an appraisal to check to they understood how to perform their role and responsibilities effectively.

People were supported to maintain their health and well-being and had access to a range of healthcare services when they needed them.

People were treated with dignity and respect and staff were kind and caring in their interactions with people. People received care that was centred on them as an individual.

Friends and family could visit their family members at any time. They were confident they could raise concerns or complaints and these would be dealt with.

People were positive about the activities provided. Plans were in place to develop these further, including in the wider community.

Families told us that people were supported to have a dignified and pain free death. We have made a recommendation about further developing end of life support planning.

Staff were positive about the new manager. They told us morale was improving and that they felt more positive about their role.

The service work

Osborne Lodge offers accommodation for up to 24 people who require personal care, including those who are living with dementia. We carried out an unannounced inspection on 25 & 30 August and 1 September 2017.

At our inspection in August 2016 we identified the provider was not meeting four regulations. Risk assessments were not always completed and regularly reviewed and actions were not taken to mitigate risks. Staff recruitment procedures were not established and operated effectively to ensure safe recruitment decisions. Records in respect of service users, persons employed and the management of the regulated activity were not accurately maintained. Notifications were not submitted to the Commission when required. The provider had not maintained appropriate oversight of the service.

At our inspection in August and September 2017 we found improvements had been made and the providers now met the requirements of the regulations. Although there was still some work to do to ensure the effectiveness of record keeping which we found was sometimes conflicting or incomplete.

A registered manager was in place at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

The registered manager managed two homes owned by the provider. They spent two and a half days each week at Osborne Lodge and were supported by a deputy manager. The deputy manager was unable to fully carry out their role as they were often needed to cover care shifts due to staffing issues.

Safe recruitment practices ensured that only suitable staff were employed. There were sufficient staff deployed to meet people’s needs during the day, however, during a number of evenings in August the staffing levels dropped below assessed requirements.

People were supported by staff, most of whom had received appropriate supervision and appraisal to enable them to meet people’s individual needs. Some training was overdue and plans were in place to ensure training for all staff was brought up to date.

The registered manager had a good understanding of their responsibilities in relation to meeting the Health and Social Care Act 2008 regulations. They had notified us appropriately of events required by law.

People and relatives told us they felt the home was safe. Staff understood how to identify abuse and explained the action they would take if they identified any concerns.

Systems to manage and administer medicines, including controlled drugs, were safe. Staff received training to administer medicines and were assessed for competency.

Individual and environmental risks relating to people’s health and welfare had been reviewed to identify, assess and reduce those risks. Incidents and accidents had been investigated and learning shared with staff.

The registered manager and staff understood and followed the principles of the Mental Capacity Act 2005 designed to protect people’s rights and ensure decisions were made in their best interests.

People were supported to maintain their health and well-being and had access to a range of healthcare services when they needed them.

People enjoyed a choice of freshly cooked foods, prepared in a way that met their specific dietary needs. People received support from staff, such as prompting or physical assistance to eat their meals, where required.

Staff interacted with people with kindness and care. Staff treated people with dignity and respect and ensured their privacy and independence was promoted.

Friends and family were able to visit their loved ones at any time and felt welcomed by staff.

Initial assessments were carried out before people moved into Osborne Lodge to ensure their needs could be met. The service was responsive to people’

We inspected Osborne Lodge Rest Home on 5, 9 and 12 August 2016. This was an unannounced inspection.

Osborne Lodge Rest Home is a care home for older people, some of whom may live with dementia. The home is registered to provide accommodation and personal care for up to twenty four people. At the time of our inspection there were 22 people living there. The home consists of a main house with a large lounge and separate dining room with the majority of bedrooms on the ground floor. The remaining bedrooms are on the first floor and accessed via the stairs or a lift. At the time of our inspection, extensive building work was taking place to create additional communal space, eight extra bedrooms and to upgrade the utilities.

We inspected Osborne Lodge to check that improvements had been made following the findings at our previous inspection when we found three breaches of regulation. We had also received information of concern in relation to management changes in the home which we had not been notified of. The previous registered manager had left the service in January 2016. The Nominated Individual, who had also been employed to oversee the governance and management of the home, had not been actively present in the service for almost three months and ended their employment the week before our inspection. A Nominated Individual has legal responsibility for the home. The provider had employed the services of an external consultant who they had recently nominated to be their new Nominated Individual.

The service did not have a registered manager in place. 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. The home had recently employed a new manager who was in post and had started their application process to register with the commission.

The provider had not maintained adequate oversight of the governance of the home. Notifications had not always been sent to CQC when required and we found a number of on-going concerns in relation to how the home had been managed since our last inspection.

People had not been protected from possible harm. The areas around the home affected by on-going building work had not been risk assessed and site safety had not been adequately managed by the provider to prevent people from wandering into the building area. This had not been identified by the provider but was addressed once we raised our concerns with them. The provider did not have other relevant environmental risk assessments in place in relation to other areas of the home.

The provider did not always follow robust recruitment practices to ensure that only people suitable to work in social care were employed.

Staff had not all received regular supervision and appraisal in order to provide formal opportunities to discuss performance and personal development. This was outstanding from our previous inspection. However, the new manager had put a schedule in place to address this.

People received personalised care, in line with their needs and preferences. However, people’s care plans and risk assessments were in the process of being re-written . The new manager and key staff were involved in developing these with people and their relatives. This required further work to ensure they were sufficiently detailed and accurately reflected any risks. This was outstanding from our previous inspection.

Some people and relatives did not feel they were kept sufficiently up to date with significant changes in the home.

Records relating to people’s care and the management of the home, such as policies, procedures and ‘do not resuscitate forms’ required review and updating.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liber

We inspected Osborne Lodge Rest Home to check that the provider had met the standards required. We also checked to make sure the provider had made improvements to the way they managed their medicines, as we had identified some concerns at our inspection in August 2013.

Not everyone who lived at the home was able to tell us verbally what they thought about living there. However, we were able to speak with five people who used the service and two people who were visiting on the day of our inspection. We spoke with five members of staff, including the new manager, who told us they had been at the home since April 2014. They told us they had been making improvements in a number of areas, and had prioritised updating people’s care plans and providing staff training. Staff we spoke with confirmed that the new manager had already made improvements within the home and were confident that this would continue.

The home was undergoing building work to extend the dining room and provide an office at the time of our inspection.

We gathered evidence against the outcomes we inspected to help answer our five key questions; 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. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People we spoke with told us that they felt safe. People told us that they were treated well by staff and that they felt listened to and their wishes respected.

Some systems were in place which meant that managers and staff learnt from complaints and concerns. However, systems were not in place to manage the control of infection within the home.

Risk assessments had been completed to guide staff in managing and minimising risks to people. However, we observed a number of occasions when there were no staff present in the lounge for extended periods of time.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These are safeguards that prevent people without mental capacity from being unlawfully restricted within the home. The manager told us that everyone currently living in the home had capacity, so DoLS did not apply. They were aware of the recent changes to legislation and would apply for a DoLS order if they needed to.

Is the service effective?

People’s health care needs were assessed and specialist input, such as occupational health and GP, was provided to support the planning and delivery of people’s care.

Most people’s care plans and risk assessments were updated to reflect people’s changing needs.

Is the service caring?

We spoke with five people being supported by the service and asked their opinions about the staff who supported them. Feedback was positive. One person told us that “Staff are very kind” and another said “They are very, very good.”

We observed that staff spoke to people with kindness and respect. Staff knew people well and responded to them with patience and understanding when supporting them.

Is the service responsive?

People knew how to make a complaint if they were unhappy. One person told us “I would make sure they know if I was unhappy about something.” When asked if they felt confident they would be listened to, they told us “Yes, very.”

We saw that when people’s needs changed, the service responded in a timely way and communicated this to staff and other agencies on a need to know basis.

The service worked well with other agencies and services, such as GPs, to ensure that people received appropriate care and support.

During our visit we noted that there were not always staff present in the lounge. We saw on two occasions that people wanted help but could not get it as the only call bell was positioned on the wall by the door and they were not independently mobile. This meant staff were not always aware that people required assistance.

Is the service well led?

The new manager told us they had recently joined the service and were reviewing people’s care plans as a priority. The service had a quality assurance system but this was out of date and was on the list of actions the manager had identified.

Staff meetings were now taking place which enabled staff to discuss and plan improvements within the service.

The manager had implemented a training review to identify training needs. Staff told us that they were now clearer about their roles and responsibilities. We heard that staff now felt their skills and experience were being utilised and they felt empowered in their roles. Staff told us that they received training which supported them to carry out their roles, and more training was scheduled and booked.

We were assisted by the registered manager throughout the inspection. We spoke with five members of staff and with six people who lived at the home. We also spoke with one visiting relative. Everyone we spoke with had positive things to say about the home and the service provided at Osborne Lodge. A visiting relative we spoke with told us, “I can’t fault anything; I would recommend the home to any one”. A person who lived in the home told us, “I like it here and couldn’t expect anything better”.

People were asked for their consent before care or support was provided to people. They told us that their wishes were respected.

People’s needs had been assessed and care plans developed to inform staff of how to support people.

There were systems in place to manage medication in the home; however, to make sure that medication is managed safely, some improvements were required at this inspection.

Since our last inspection of the home in June 2012 no new members of staff had started working at the home. The home had robust recruitment systems in place should they need to recruit new members of staff.

The home had systems in place to monitor the quality of service provided to people living at Osborne lodge.

The manager assisted us throughout the inspection, at which we spoke with eight people living at the home and with four members of staff.

People told us that their care and welfare needs were met, the food was of a good standard and that there was a long-established staff team who were kind and caring. People said staff knew how to care for them and that activities were arranged everyday, including regular trips out from the home. They told us that there were sufficient numbers of staff to meet needs of people living at the home. They told us that if they needed to summon assistance through their call bell, staff would respond within a reasonable period of time. Overall, we received positive feedback about the standards of care provided at the home.

One person told us, “There is always someone to listen to you”, and another person said, “The carers are lovely; they treat us with respect”.

We inspected Osborne Lodge Rest Home on 11 and 20 February 2015 in response to some concerns we had received. This was an unannounced inspection. We also checked to see if the provider had made improvements necessary to meet the breaches of the regulations we had previously identified.

At our inspection in July 2014 we found the provider to be in breach of regulations relating to care and welfare, staff recruitment and quality monitoring of the service. The provider sent us an action plan and said they would be meeting the regulations by 30 January 2015. At this inspection we found improvements had recently been made following a restructure of the service and the appointment of a new manager and operations manager (The management team) who had already identified concerns and areas for improvement. An action plan had been produced and remedial action was already underway. However, there was still work to do to fully meet the regulations relating to care and welfare.

Osborne Lodge Rest Home is registered to provide accommodation and personal care for up to 24 older people, most of whom were able to communicate with us verbally. The home had communal areas such as a lounge and dining room, as well as the majority of bedrooms, provided on the ground floor. There was a smaller first floor which housed the remaining bedrooms. Several of the bedrooms had access via sliding patio doors to a semi private personal patio area and direct access to the rest of the garden. The home has it’s own minibus which was used regularly to facilitate trips out.

The service did not have a registered manager in place. 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 manager had only been in post for a few weeks but had started the process of applying for the relevant checks to be completed prior to their application to the Care Quality Commission (The commission) for their registration.

People were protected from possible harm. Staff were able to identify different types of abuse and what signs to look for. They were knowledgeable about the home’s safeguarding processes and procedures and who to contact if they had any concerns.

There were systems in place to manage, record and administer medicines. However, procedures to manage the disposal of unwanted medicines required improvement. Systems to record changes on people’s medicine administration charts (MAR) were not safe.

There were sufficient staff on duty to meet people’s needs. Call bells were answered in a timely way and people told us they did not have to wait for help when needed. The new manager had reviewed staffing requirements and was in the process of recruiting new staff with experience of supporting people with dementia.

The home was clean and tidy. New cleaning schedules had been implemented and housekeeping staff told us that these had made cleaning the home much easier. Refurbishment of the hallway was underway and carpets were due to be replaced when completed.

Some, but not all staff had received appropriate supervision and training. The new manager had identified what training was outstanding, and was in the process of implementing training and supervisions for remaining staff. A spot check supervision process had been put in place which the manager carried out to assess staff attitudes and approach to providing care.

Care staff understood the importance of gaining consent from people before providing any care or support. However, they were not knowledgeable about the principles of the Mental Capacity Act 2005 in relation to assessments of capacity, or the Deprivation of Liberty Safeguards (DoLS). There were no mental capacity assessments for people. Whilst people living at the home had mental capacity, staff told us two people had been assessed for possible dementia as they sometimes became confused.

People were supported to maintain their health and had access to healthcare when required. However, we noted some concerns in relation to recurring urinary tract infections in four people. Care plans did not include information on how to prevent or manage these infections. Other care records such as risk assessments were not up to date. The new management team had identified that care plans and risk assessments were not fit for purpose and had started to address this.

Not everyone had received an assessment of their needs before moving in to the home. Care plans were not person centred and there was little information about people’s life histories. This was in the process of being addressed.

People’s nutrition care plans did not always include sufficient details about their dietary needs, such as a lack of information to guide staff in how to support people with diabetes.

However, people were supported to eat and drink a variety of food and drink. People ate independently but staff were on hand to help if needed, such as cutting up a person’s meat for them during their lunchtime meal. Food was freshly cooked by the chef and people had opportunities to give feedback about what they would like on the menu. There were jugs of juice or water in the lounge, and people had fresh water in their rooms.

Staff interacted positively with people and were caring and kind. They were reassuring to people when required and supported them at a pace that suited them without rushing. The staff had good natured encounters with people and seemed to know them well. They talked about issues people were clearly interested in. People told us staff treated them with dignity and respect and we observed this throughout our inspection.

A new system had been put in place to monitor and record any complaints that were received. People told us they had no complaints about the service, but if they had, they were confident the new manager would listen to them and respond.

There was a range of activities on offer throughout the week and a programme was given to each person in advance to let them know what these were. Several people went out for lunch and a drive in the home’s minibus and said they had enjoyed the experience. Other activities took place within the home, such as singers, entertainers and quiz games. People were supported to maintain links with their local community including attending church or the local community centre.

The previous manager had not returned a provider information return as requested by the commission. The new management team had implemented significant changes and improvements in the past few weeks such as a restructure of the staff team, audits for medicines, staff training and infection control. People had been consulted about the changes to the home and were asked for suggestions for improvements. For example, about the menus and activities. Care plans and risk assessments for each person were in the process of being re-written to ensure they were person centred and relevant.

Systems had been put in place to monitor and record incidents and accidents and to show if these had been reported to the appropriate authority such as the local safeguarding team or the commission. These systems had only recently been embedded in practice so their effectiveness could not yet be evidenced. As there had not previously been any systems in place, the new manager was unable to show us any historical information in relation to incidents, accidents and complaints.

The culture within the service was open and transparent. Staff told us the new management team was professional and supportive. They were visible and encouraged staff to participate in developing the service. Staff told us managers were approachable and they felt listened to. The new management team had already identified most of the issues we raised with them at the inspection and we could see they were in the process of making the improvements required. They were open with us and were responsive to the feedback we gave them.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have asked the provider to take at the back of this report.