This inspection took place on the 8 May 2018 and was unannounced.

Following the last inspection in January 2017, the provider wrote to us to show what they would do and by when to improve the key question of ‘Safe’ to at least good. We found that the provider was now compliant with the previously identified breach of Regulation 12 (medicines) of the Health and Social Care Act 2008 (regulated Activities) 2014. Despite these improvements we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The Lodge is a ‘care home’ which accommodates a maximum occupancy of 44 people. At the time of this inspection visit, 8 May 2018, 32 people were living at the home. Most of these people were living with dementia. 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.

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 registered manager was present throughout our visit.

Systems and processes were not always used effectively to monitor the quality and safety of the service. You can read more about this under the ‘Safe’ and ‘Well-Led’ sections of this report. Quality monitoring systems in place had failed to identify that hot water presented a scald hazard and that windows above ground level were not restricted safely. These were immediately made safe once brought to the attention of the registered people. However, the lack of systems to identify potential hazards and risks was not effective. The provider lacked oversight of their provision of service.

People told us they were happy living at this service and that they felt safe with the care provided. People were protected from the risks of abuse. Staff received appropriate training and knew how to raise concerns if they felt people were at risk of being abused or mistreated.

People’s individual needs, choices and preferences were assessed and known by a caring, consistent, well trained staff team who knew people well. People and their representatives, as appropriate, were involved in their care plans and reviews of their plans of care by staff who were well trained to meet their individual needs. No external agency staff were used at this service at the time of this inspection. Individual risks for people were assessed and managed. Medicines were given to people safely and infection control procedures including correct use of protective equipment and cleaning schedules kept the home clean and free from any unpleasant odours.

People received care from staff who had undertaken training to be able to meet their individual needs and preferences, which included having enough to eat and drink. Snacks and drinks were available whenever people wished to have them. Meals were home cooked in line with people’s choice, preferences and needs, by trained kitchen staff. Specialist diets were catered for appropriately for people.

Staff were recruited safely. Checks were completed by senior staff which ensured staff performance and competence was closely monitored. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible. The policies and systems in the service supported this practice.

People told us that staff were caring and kind in their approach and that staff treated them with dignity and respect. Staff were aware of how to protect people's privacy which ensured this was ma

This inspection took place on 12 January 2017; the inspection was unannounced. Our last inspection took place on 21 July 2016. An overall rating of Requires Improvement was made at the 2016 inspection. On that occasion we had concerns relating to staffing and issued a warning notice to lever improvements. On this occasion we found that matters had improved and people’s needs were being met with the staff provided. There had been progress overall and this is reflected within this report.

The Lodge is registered to provide care and support to up to 44 people, some of whom were living with dementia. On this visit 31 people resided at this residential home. This service is required to have a residential 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. The registered manager had recently left and a replacement was actively being sought. At this inspection the deputy manager had become the acting manager and was present, participated fully in this inspection as did the provider.

The numbers of staff were sufficient to meet the needs of people living at the service. This was because the numbers of people resident had decreased and staff had been better deployed at key times, such as lunchtime. The acting manager was continuously assessing the needs and dependency of people at the service and had allocated staffing as a result. People and staff consistently said there was sufficient staff to meet the needs. Staff were trained and supported by the acting manager.

We have identified a breach in regulation. This is because people were placed at unnecessary risk of developing sore skin as risks were not adequately mitigated through clear instruction and actions of staff. In addition medicines were not consistently managed safely and we identified areas to improve safety. A medicine trolley was left locked with the key in it and unobserved by staff. Crushed and covert medicines were not as safely managed as should have been. Medicines prescribed as a cream were not safely managed. Records did not protect people and staff as would be expected.

Staff had undertaken training in The Mental Capacity Act 2005 (MCA). They were consistently offering choices and respected peoples decisions. However, they along with managers were not clear on more complex decisions and how to go about making ‘Best Interest’ decisions.

Staff were attentive, visible, kind and demonstrating meaningful relationships with people. Relatives were positive about the care their relatives received. Privacy, dignity and respect were afforded to people. People enjoyed good nutritious food, with the lunchtime experience being positive for most people. We have fedback further minor developments to ensure everyone has a positive mealtime.

People had access to healthcare to maintain their health. Visiting health professionals spoke positively about what they saw at the service. People had access to a variety of activities and interests that they were able to participate in.

The acting manager had made improvements in a short space of time and relatives and staff spoke positively about the changes they had seen. The culture was set to improve with developments being planned. Since our visit we have been sent information and evidence that shows that mangers and the provider continue to develop and monitor the service to ensure the safety of people living here.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on 21 July 2016 and was unannounced. The last inspection of this service took place on 15 June 2015 when we rated the service as requiring improvement overall and inadequate in safety with a number of breaches of regulations. The manager of the service sent us an action plan within the laid down timeframe explaining how the service was going to improve.

At this inspection we found that many of those improvements had been put into place. However we were concerned that the staff were not receiving training in the Mental Capacity Act 2005 or receiving organised supervision as the action plan stated would be put in place. Furthermore, at this inspection we found there were insufficient staff on duty to provide the care and support required by the people using the service to keep them safe. The management staff were frequently providing direct care themselves which would also account for the difficulties involving training and supervision.

The Lodge can provide care and accommodation for up to 44 people older people including people living with dementia. At the time of our inspection there were 36 people using the service

There was 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.

People who used the service did not feel safe and secure because there were insufficient staff working throughout the service. At times senior staff and the manager were required to support the care staff with the delivery of care. This impacted on the manager’s time which meant that other aspects of their work were detrimentally affected. We discussed our concerns with the manager and informed the provider. Action was taken and the staffing numbers were increased.

People had their mental health and physical needs monitored. Staff had received training in how to recognise and report abuse. Staff spoken with, were all confident that any allegations made would be fully investigated to ensure people were protected. However, the staff considered for the service to be safe additional staff were needed on all shifts.

The service had made referrals and worked with the Local authority to support people who used the service with regard to Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, the service had not provided training with regard to (MCA) and (DoLS). This was something we had specifically required the service to do as a result of our last inspection.

The staff did receive some training such as first aid and safeguarding people of which they were pleased with the content. The manager had arranged an annual appraisal for the staff but the planned regular supervision as we required being in place was not arranged, although the action plan informed this would happen. However we did see that the management team offered day to day support to staff, on the day of our inspection we saw the care manager providing on the spot support and advice for a member of staff.

Most people who used the service were content with the meals and staff supported people with their food and fluid intake. We saw that risk assessments and resulting plans of care had been recorded in the individuals care record. However, due to the lack of staff to organise the meal we found the mealtime somewhat taxing for people. The meal was served over two sittings and people and staff’s view was that this was better than one sitting. However, people had to wait, sometimes over 40 minutes, from being seated to their meal arriving. We were concerned that while one staff supported one person with their meal for over 25 minutes, another person in the same lounge had to wait for their meal. This was due to the time it

This unannounced inspection took place on 15 June 2015. This was a comprehensive inspection.

The service had a registered manager who had been at the service several years. 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 Lodge is registered for 44 people living with dementia. When we inspected on 15 June 2015 there were 38 people living in the service.

We found that the staff were generally caring and observed some compassionate interactions between staff and people who lived at this service. We also found room for improvement with regards to dignity and respect. People who live at the Lodge were satisfied with their choice of home. Relatives had mixed feedback about the experience they received for their family member. One raising concerns that we asked the manager to address directly with the family.

This service was not clear about their vision and purpose. They did not have a model of dementia care that they subscribed to. The environment was not specifically designed for people living with dementia and staff had not received enhanced training about supporting people with dementia based upon a chosen model.

Assessments were completed before people came to the service. The service used an assessment and care plan that is based upon a nursing model that does not readily take account of behaviour that may be present in stress situations for a person living with dementia.

We found that staffing levels were satisfactory but staff were not as well organised and designated as efficiently as they may be. This was particularly noticeable at lunch time, which was disordered and confusing for people.

There was a high incidence of falls, accidents and urinary tract infections noted from the service’s own records. We also found that people at the service may be at risk from other people’s distress reactions to situations that arise. Recording of incidents were not routinely used to develop a strategy of management and prevention of further incidents. Individual risk assessments were in place but these were not informative and effective.

Management of the service did not have a defined overview to use data to improve governance and the safety within the service for people. People told us that the management within the service was friendly and approachable.

We fed back our findings to both the registered manager and the provider at the end of the inspection. Both were keen to develop this service and make significant changes.

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with eight of the 38 people who used the service. We spent some time in the two of the service’s lounges to observe the care and support provided and the interaction between staff and people using the service. We spoke with the registered manager, nine staff members and a visiting health professional. We looked at four people's care records. Other records viewed included staff training and health and safety checks. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a staff member looked at our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made, and how to submit one. We saw that the staff were provided with training in safeguarding vulnerable adults from abuse. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

The service was safe. Records showed that there were regular health and safety checks carried out to make sure the service was well-maintained and met people's needs. This included regular fire safety checks, which meant that people were protected in the event of a fire. The service was clean and hygienic.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

Is the service effective?

People told us that they were happy living in the service. One person said, "I love being here, I would not want to leave." Another person said, “We are really well looked after.”

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

People's dietary needs were met.

We saw the staff rota which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs.

Is the service caring?

The staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with kindness and respect. One person said, “All of them (staff) are kind.”

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and mental health professionals.

We looked at how complaints had been dealt with, and found that the responses had been open, thorough, and timely. People could therefore be assured that complaints were investigated and action where taken as necessary.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities. We reviewed the minutes from staff meetings which showed that the management had consulted with staff before implementing changes in the service. This helped to ensure that people were provided with a good quality service.

The service had an effective quality assurance system and records reviewed by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We spoke with four people who used the service who told us that they were happy with the service they were provided with. One person said, "I am happy here, they (staff) are very good." People told us that they were provided with enough to eat and drink. They were complimentary about their lunch. One person said, "It is very tasty." Another person said, "It is nice thank you, would you like to try some?"

We spoke with a person's relative who told us, "(Person) is very well looked after." We also spoke with a visiting care professional who told us that they were satisfied with the care and support provided to their client and that they had noted an improvement in the person's wellbeing since they had moved into the service.

We spent time sitting in the two lounges in the service and observed the care and support provided to people. We saw that staff were attentive to people's needs and that they interacted with people in a caring, respectful and professional manner.

We looked at the care records of four people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights.

We saw staff training records which showed that staff were trained to meet the needs of the people who used the service.

We saw records which showed that people's comments and complaints were addressed in a timely manner.

We spoke with four people who used the service. We asked two people if they felt that the staff treated them with respect and they both answered, "Yes." Another person pointed to a staff member and said, "(Staff member) is jolly good." We saw that staff interacted with people in a respectful and professional manner. They were attentive to people's needs and responded to requests for assistance promptly.

One person told us that they had enjoyed their lunch and said, "It was gorgeous, I should have saved you some." We saw that people were supported by staff to eat their meal at a pace that suited them.

We found that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. Prior to our inspection we had received a concern about the heating in the service. The registered manager told us that they had identified an issue with the heating and actions had been taken to repair it. All people spoken with said that they were happy in the service and that they were warm enough.

We spoke with six of the 41 people living in the service. We also observed the care and support provided to people during our visit.

Six people told us that they were happy living in the service and with the care and support that they were provided with. They said that the staff treated them with respect and were attentive to their needs. Comments made by people about the service that they were provided with included "Anything you want they get it", "They do a wonderful job" and "They (staff) should be praised for what they do."

People told us that their choices and comments were listened to and acted upon.

We received feedback from people who visited the home. This included social care professionals and relatives. We spoke with two people living in the home who gave us feedback on their care. One person told us they were looked after by “nice people”. People knew who to talk to if they had any concerns. One relative described staff as supportive and helpful “always popping in and asking if you want anything”. Visitors to the home commented on the lack of social interaction and would like to see more going on.

We spent time in the lounge and dining areas observing the routines of the day. This helped us identify the experiences of seven people living in the home with varying levels of dementia. We saw some staff could communicate well and showed more empathy and respect for people living with dementia than others. We saw that when staff engaged people in meaningful conversation and activities it had a positive effect on people’s wellbeing. This included the game of “floor darts” in the lounge during the afternoon.