This inspection took place on 13 and 14 March 2018 and was unannounced. This was the first inspection of Russley Lodge since it had been re-registered with the Care Quality Commission in February 2017. The re-registration had taken place as the provider changed the company name. This did not create any changes to the management or the overall registration of the home. The home, under its previous legal entity, was inspected in June 2017.

Russley 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.

Russley Lodge is registered to provide care to up to 17 older people, including people who may be

living with dementia. Accommodation is based over two floors and there is a passenger lift between the floors. At the time of our inspection there were 16 people living at the home.

There was a registered manager at Russley Lodge. 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.

At this inspection we found breaches in the regulations for consent, good governance and not notifying the CQC of an incident at the home. The Deprivation of Liberty Safeguards (DoLS) for two people had expired and not been re-applied for and a DoLS application had not been made for one person who was restricted from leaving the home. A formal assessment of people’s capacity to consent to their care and support was not completed, although people signed their consent to their care plans when deemed to have capacity.

Care plans and risk assessments were in place. Not all risk assessments had been updated in a timely manner and so were not reflective of people’s current needs. Individual daily logs were not kept. A system of audits was in place but these were not completed on a regular planned basis and were not sufficiently robust to identify concerns identified during this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Medicines were administered as prescribed; however the medicine administration records did not clearly identify when people self-administered their medication or creams and staff had not signed to record they had applied all prescribed creams. We have made a recommendation that guidelines are written as to when ‘as required’ medicines are to be administered and for the quantity of controlled drugs held at the service to be regularly checked.

We were shown copies of people’s life story books which contained details of people’s families, previous jobs, hobbies and interests. We have made a recommendation that these are made readily available for care staff so they have the information to build meaningful relationships with people living at the home. People’s person centred care plans and care files contained information about people’s likes, dislikes and preferences. Staff knew the people living at the home well.

People said they felt safe living at Russley Lodge and that staff were kind, caring and treated them with dignity and respect. People said they were supported to maintain their independence by completing the tasks they were able to do themselves.

Staff received the training and support they needed to undertake their role. Regular supervisions and team meetings were held.

A safe recruitment system was in place to recruit staff who were suitable to work with vulnerable people. There were sufficient staff on duty to meet people's assessed care and support needs.

People were supported to maintain their health and nutrition. Culturally appropriate food was prepared for those people who wanted it. V