This inspection took place on the 17, 22 and 23 January 2018. The inspection was unannounced on day one and we returned to complete a night time visit which was also unannounced. The registered manager was aware we were returning on the third day.

The last inspection took place on the 9 and 22 December 2016 and The Lodge was rated as requires improvement in all domains except caring which was rated good. The home was in continued breach of Regulation 17 Good Governance. Concerns related to poor record keeping. In addition to this a recommendation was made about staffing levels and activities.

The 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. The Lodge accommodates 28 people in one building. There are 22 bedrooms downstairs with a further six upstairs.

The service had a registered 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 cleanliness of the home and laundry systems were not meeting expected standards. People and their relatives expressed concerns about bedrooms not being kept clean and clothing had gone missing.

Risk assessments were in place. However, for some people with complex needs in respect of their dementia and behaviours which posed a risk of harm to themselves or others there was a need to provide more direction for staff about how to manage these risks.

This was a breach of Regulation 12 (2) (a) (b) (c) 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 the report.

There had been a number of incidents after 8pm whereby people had become distressed and caused harm to themselves or others. Concerns were raised about the complexity of people's needs and the impact this had on other people as staff were providing one to one care.

In the main, safeguarding referrals had been appropriately made. Staff understood how to recognise and protect people from avoidable harm or abuse and they felt confident that any concerns they raised would be investigated thoroughly. Despite this we found one safeguarding issue which had not been appropriately reported by the registered manager. We have made a recommendation about this.

Systems had been set up to assess the quality of care people received and where improvements were required there was a robust action plan to work through these.

Whilst it was evident a significant number of improvements had taken place under the leadership of the new registered manager and operations manager, further work was required to ensure people received care which was consistently good. We were assured the management team and staff team were committed to driving the required improvement but required further time to do this.

Despite the improvement still required, everyone we spoke with described the service as homely. Due to the relatively small size of the home staff had the opportunity to get to know people well. Staff were kind, compassionate and respected people’s diversity.

Staff were provided with the support, training and supervision they needed to deliver effective care. More specialist training on how to support people with behaviours which posed a risk of harm to themselves or others was due to be provided to staff.

The service followed the principles of the Mental Capacity Act (2005). Detailed mental capacity assessments were completed and we saw evidence the service had taken all practical steps to support people to make their own decisions. Where people were

The Lodge is a residential care home in Heslington, a village on the outskirts of York. The service provides personal care and accommodation for up to 30 older people who may also be living with dementia. The Lodge has 26 single bedrooms, two double bedrooms and communal facilities spread across two floors.

We inspected this service on 9 and 22 December 2016. This inspection was unannounced. This meant the registered provider and staff did not know we were visiting. One of our visits began at 5:30am so we could speak with night staff. At the time of our inspection, there were 27 people using this service.

At our last inspection of the service in January 2016, we found breaches of regulation in relation to staffing, safe care and treatment, person centred care and the governance of the service. During this inspection, we identified that the registered provider was now meeting the regulations relating to safe care and treatment and person-centre care. However, we identified continued concerns regarding the registered provider's governance of the service.

We identified concerns regarding how people’s weights and food and fluid intake were monitored. Care plans were not consistently updated, where people had lost weight, to provide additional guidance to staff on how to manage the risks. We received information raising concerns about the support staff provided with personal care. We found that care records did not evidence that staff had regularly supported people to have a bath or shower. These concerns showed us that the registered provider had not maintained complete, accurate and contemporaneous records. This was a continued breach of the regulation relating to the governance of the service. You can see what action we have told the registered provider to take in response to our concerns at the back of our report.

The registered provider is required to have a registered manager as a condition of their registration for this service. 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. On the first day of our inspection, we were told the registered manager was no longer managing the service. An application to deregister them had been received by the Care Quality Commission and the process was completed on 15 December 2016 after which time the service did not have a registered manager. The service was being managed by an acting manager who was supported by the area operations manager in the management of the service. We were told the acting manager was in the process of applying to become the service's registered manager.

At our last inspection, we identified a breach of regulation regarding staffing levels. At this inspection rotas showed examples where only two staff were on duty at night. We continued to receive mixed feedback regarding staffing levels. We have made a recommendation about staffing levels in the body of our report.

The registered provider completed recruitment checks and new staff received an induction and training to support them to provide effective care. However, we identified gaps in staff training which needed to be addressed. We have made a recommendation about this in the body of our report.

Staff we spoke with demonstrated that they understood their responsibilities to safeguard vulnerable adults from abuse. People’s needs were assessed and care plans put in place to guide staff on how best to meet their needs. However, some care plans had not been updated as people’s needs had changed. Accidents and incidents were analysed to identify any patterns or trends or where further action could be taken to reduce risks. Health and safety risks were managed through appropriate checks of the building and any equipment used

The Lodge is a residential care home in Heslington, a village on the outskirts of York. The home provides personal care and accommodation for up to 30 older people who may also be living with dementia. The Lodge has thirty single bedrooms and communal facilities spread across two floors. There is limited car parking on site.

We inspected this service on 26 January and 2 February 2016. This inspection was unannounced. One of our visits was carried out between 5:30am and 11:30am so we could speak with night staff. At the time of our inspection there were 28 people using this service.

The service was last inspected in June 2014 at which time it was compliant with all the regulations we assessed.

The registered provider is required to have a registered manager in post and on the day of the inspection there was a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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.

During this inspection we found that the home was not safe. We identified concerns around the systems in place to ensure that shifts were covered in the event of sicknesses and absences and concerns around unsafe staffing levels at night.

This was a breach of Regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Night staff did not receive training on medication management despite being responsible for administering medication when needed. We identified concerns that tablets were not always stored in their original packaging and this increased the risk of medication errors occurring.

This was a breach of Regulation 12 (2) (c) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People had care plans to guide staff on how best to meet their needs. However, we found these were often task orientated and contained limited person centred information. Staffing levels impacted on staff’s ability to provide person centred care.

This was a breach of Regulation 9 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We identified that records were not always well maintained and the systems in place to monitor the quality and safety of the home were not robust enough.

This was a breach of Regulation 17 (2) (a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take in respect of these breaches at the back of the full version of this report.

Risks around fire safety were not effectively assessed and the registered provider did not have a business continuity plan to ensure people’s needs would continue to be met in the event of an emergency. There was not a robust system in place to identify and respond to risks following accidents and incidents and this placed people at increased risk of avoidable harm.

This was a breach of Regulation 12 (2) (a) (b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We had other concerns about how risks were being managed at The Lodge and are carrying out further enquiries in relation to this. We will report on our findings at a later date.

Despite these concerns people we spoke with were generally positive about the home, staff and the management of the service.

Staff had training and supervision to support them in their role. Staff sought consent before providing care and support and there were systems in place to assess people’s capacity to make decisions.

People were supported to eat and drink enough and access healthcare services where necessary.

People were generally positive about the kind and caring nature of staff. We observed that staff supported people to make decisions and respected people’s

We carried out this inspection to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We also wanted to check that the provider had taken action to improve one area that we found non-compliant at our last inspection of the service.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People felt safe because their rights and dignity were respected and they were able to make some decisions about how they spent their day to day lives.

People were safe because staff knew what to do when safeguarding concerns were raised.

When people displayed distressed behaviours and responses then staff dealt with these effectively and respected people’s dignity.

The service kept the home clean and hygienic to minimise the risk of people getting a healthcare associated infection.

People and their belongings were safe because the service assessed and managed the risks to people and the environment.

Is the service effective?

People’s needs, wishes and choices were known and respected.

People’s health and well-being was monitored and healthcare advice was promptly sought when people’s health changed.

Is the service caring?

People were treated with kindness and compassion and their dignity was respected. People told us “I like it here. The staff are very good to everybody.” One relative wrote in the survey about the home ‘my relative always speaks well of the staff.’

Staff responded in a caring way to people’s needs when they need it. People’s independence was promoted.

Is the service responsive?

People received care and support in accordance with their preferences and interests.

People had their individual needs regularly assessed and met.

Is the service well-led?

There was a clear management structure and staff understood their roles and responsibilities.

People said the manager was approachable and available. Visitors spoken with were confident that any concerns would be looked into properly.

New systems were in place to monitor how the service was operating. These needed to be sustained and built on, to demonstrate good leadership and an open culture that was always looking to improve.

We did not talk in detail with people living at the service during this visit. At previous visits to the service people and visitors had been satisfied with the care. One person on this visit said the staff were nice and kind, and they were quite happy living there.

We walked around the home, looking in many of the rooms, and found the service overall was much cleaner and new furniture and furnishings had been bought. This made it a more pleasant environment for the people living there.

The service had better hand-washing facilities, and other improvements had been made, to help minimise the risk of a spread of infection. However, more robust and regular monitoring arrangements needed to be introduced to ensure this improvement is sustained.

Whilst people overall were getting their medication safely and at the times they needed them, some records required closer monitoring to ensure they were an accurate record of medication administered.

The staffing arrangements in place ensured there were sufficient staff to meet people’s needs, although the staff rota could more accurately reflect which staff are working each day.

There are not effective quality monitoring arrangements in place to ensure that improvements made in recent months can be built on and sustained.

We visited The Lodge in May 2013 and found improvements were needed in two areas. People were not protected against the risks associated with the management of medicines. And they were not protected from the risks of unsafe or inappropriate care because some records were not well maintained. We re-visited the service to check these improvements had been made.

Recently the Care Quality Commission (CQC) received concerning information about the cleanliness of the home, and the apparent lack of kitchen staff working there. So we decided to look at these two areas during this visit.

We were not able to speak to people using the service because of their complex care needs. However we noted that overall people looked clean and well cared for.

Whilst the domestic cleaning of the service was mostly satisfactory, other cleanliness and hygiene processes needed improving, so as to protect people from the risk of the spread of infection.

Whilst people mostly were getting their medication safely and appropriately some areas of medication management still needed improving, to minimise the risk of harm.

There were sufficient care staff working at the home, but a lack of kitchen staff meant care staff could not always promptly meet people’s needs because they were working in the kitchen.

People’s records were now better maintained and more accurately reflected the care they needed and wanted.

We were not able to speak with many people using the service because of their mental frailty. However we observed the way staff interacted with people, and spoke with the relatives of three people living there. We also spoke with two visiting healthcare professionals. One person said “The staff are kind and helpful. They’re very busy. There’s not much to do.” Relatives commented “The staff seem very caring. X always looks well cared for” and “My relative’s treated like royalty. Nothing is too much trouble.”

We found people were given, and signed contracts which explained which services would be provided at The Lodge and how much these would cost.

We found people overall received safe appropriate care that met their needs.

The majority of people were given their medicines at the time they needed them and in a safe way. Despite this, we found medication records and systems needed improving.

Staff were supported to attend training but the current staffing levels, or the way staff were deployed did not always support people to have interesting, meaningful lives.

There was a system in place to check the quality of the service provided, but this needed expanding to include other areas of service delivery.

Care records were not always accurate and well maintained. Written information did not always evidence that people were receiving safe and appropriate care.

We did not talk to people in detail about what it was like to live at The Lodge. This visit concentrated on checking whether records kept by the service were better maintained. However we sat for some of the time in the lounge and dining room and saw that some people were sitting relaxed and contented, whilst others were walking around the home as they chose.

We couldn't speak with many people living at The Lodge, because their complex

needs meant they were not able to tell us their experiences. We did speak with three

people who told us that overall they were happy living there. One person told us “The staff are very kind. They’re very helpful and they know what they’re doing.” Another individual told us they were happy and the staff were “Very nice.” One person added “I get more than enough food.”

People looked well-cared for and were tidily dressed. The men were clean-shaven. We found care staff were available in the lounge, though one visitor said that sometimes when they visited the care staff weren’t a visible presence. We also observed that care staff were spending periods helping in the kitchen as the kitchen assistant was on leave. When care staff helped in the kitchen this reduced the time they were available to support and interact with the people living there

We did not speak with people who used the service during this inspection.

Some people were not able to share their views with us about their experiences of living at The Lodge. However, during our observations we judged that peoples’ needs were being met overall. Not everyone felt they could make comments and declined to do so. Those who did comment said, ‘It’s nice here, I don’t have any complaints.’ Another person told us: ‘We are alright here.’ People told us that they felt there were 'enough' staff around, to make sure they were cared for properly. One person said, ‘the staff always come to you when you need help' and 'I don’t go out much but the staff do take people out who want to go.'

People said that their care was explained to them, or discussed with their relatives if appropriate. They said they were invited to reviews and could attend or give their opinions for consideration. People said the staff in the home asked them about many areas of daily life, such as activites, outings, meals and the way personal care was offered. Visitors said they were involved in the care of their relative and that the staff in the home did a good job of making sure they respected and involved their relative as much as possible when delivering care. One person, using the service, said: 'It isn't home, but it is as good as it can be.' Another person said, 'I enjoy the chatter and being looked after, I have no family now, these people are my family.' People told us that the staff understood their individual care needs and that they received the care they needed, in a way which suited them. People said they felt safe and well cared for at the home.

Due to the nature of people's cognitive impairment and the focus of our inspection, people did not make any specific comments regarding the outcomes that we inspected. However we did observe how people were cared for. There was some good practice, but also some that was not so good.

For example we observed that care staff talked in a kind and respectful manner to those people who were more able to respond to them. We also saw that people were offered a choice of two plated meals, so that even if they didn’t understand what the meal was, they could still choose the one that looked most appealing. We also saw that one person, who stayed in bed looked comfortable and well cared for.

However we also saw that care staff did not engage very much with those people with more advanced dementia, who could less easily communicate. And we observed some people had been left sitting in one position for a long time. When people are not encouraged to change their position then they are at increased risk of developing pressure damage to their skin.