About the service: Worcester Lodge is a residential care home. It provides accommodation and personal care for up to 39 older people, some of whom are living with dementia. At the time of the inspection there were 33 people living at the service.

People’s experience of using this service: People were supported by staff who were kind and caring. Staff and managers had good relationships with people and knew them well. Staff were well trained and supported in their role.

Systems to monitor and review the quality of the service were not fully effective. Some areas did not always get identified, risk assessed or reviewed that needed improvement or may pose a risk to people. Such as hot surfaces, the environment, incidents and reducing infection control risks.

Activities were provided which people enjoyed. Positive feedback was received about the food at the service. Visitors were welcomed. People and relatives were involved in the service through meetings and questionnaires to gain feedback.

Care plans were person centred, containing information about people’s past, family and interests. Individualised details showed people’s preferences and routines. People were supported to retain their independence.

Improvements had been made to some areas identified at the last inspection. For example, people’s consent to care was sought in line with legislation and guidance. The service had also developed end of life care plans that were personalised and detailed.

For more details, please see the full report which is on CQC website at www.cqc.org.uk

Rating at last inspection: Requires Improvement (June 2018). This service has been rated as requires improvement at the previous two inspections (January 2017 and June 2018).

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement: We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up: We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

We undertook this inspection on the 15 & 16 March 2018. This inspection was unannounced, which meant that the provider did not know we would be visiting. The service registered to provide a regulated activity with the Care Quality Commission in October 2010.

Worcester 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 service is registered to provide care and support for up to 39 people, some of whom are living with dementia. Nursing care is not provided. At this inspection there were 35 people living at the home.

There was a registered manager in post. 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 the last inspection the service was rated as Requires Improvement. At this inspection we found the service remained Requires Improvement.

Three breaches of legal requirements were found following the last comprehensive inspection. People were receiving care that wasn’t person centred, systems and audits did not identify shortfalls and people receiving unsafe care and treatment. The provider sent us an action plan confirming how they were going to address these shortfalls. At this inspection we found some improvements had been made. People were receiving care that was person centred and their medicines and care safely. However, improvements were still required to quality assurance systems. As they failed to identify shortfalls relating to lack of effective Mental Capacity assessments and best interest decisions as well as Deprivation of Liberty Safeguards (DoLS).

People could be at risk of cross infection, due to lack of liquid hand soap and paper towels at the point of care. The registered manager following the inspection confirmed they had actioned this shortfall.

Environmental and individual risks were not always identified through a risk assessment that identified the risk and what measures were in place to reduce those risks. Action was taken following the inspection.

People received their medicines when required and safely.

People’s care plans contained guidelines for staff to following relating to people’s individual needs but no details were recorded of what people’s individual pressure relieving equipment should be set to.

People were support by staff who had suitable checks prior to working with vulnerable people.

People felt safe and were supported by staff who were able to identify abuse. People felt staff were kind and caring and that the management in the home were approachable.

People were supported by staff who had received supervision and an annual appraisal and training to ensure they were competent in their role.

Staff demonstrated how they provided people with privacy and dignity. Staff prompted people’s independence encouraging them to undertake certain aspects of their care.

People felt able to complain.

Care plans had important information relating to people’s individual needs, although more information could be recorded about people’s individual end of life wishes.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the back of this report for the action we took.

This inspection was unannounced and took place on the 20 and 21 September 2016. Worcester Lodge provides accommodation for people who require personal care for up to 39 people. All people living in the home have dementia. The home has a more secure Garden Wing for up to 11 people with more advanced dementia and other complex needs.

During the inspection there were 30 people living at the home. The accommodation is arranged in one building with a lift between floors for the main house and the Garden Wing on one level. There were communal spaces including a conservatory, lounges and dining rooms. People had individual bedrooms and some had an en-suite bathroom. People living at the home had dementia so their ability to verbally communicate with us during the inspection was mixed.

Prior to this inspection the registered manager had resigned following a period of absence, so the deputy manager had been promoted to manager. A registered manager is a person who has been 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 the time of this inspection the manager was completing their application to become the registered manager. During the inspection the manager was supported by a new deputy manager.

People told us they felt safe but there were risks to their safety in relation to falls, risk assessments and medicine administration.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef provided alternative options if people did not want the daily options to ensure their preferences were met. However, there were times when weight loss was not being reported so action could not be taken.

Staff were aware of their responsibility to protect people from avoidable harm or abuse and staff had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. However, there were limited systems in place to ensure all incidents were investigated and measures were put in place to reduce the risks to people.

The recruitment process did not always follow the provider’s own policies and procedures, which meant people were cared for by staff whose prior conduct including from previous employment had not always been checked.

The manager and staff had some understanding about making decisions for people when the lacked capacity to do so themselves. However, processes had not always been documented to demonstrate the required legislation had been followed. Where people had been prevented from leaving the home, the correct processes has been followed.

The manager and provider had followed their legal obligations to notify CQC. The provider regularly met with the manager to provide additional support.

Staff were receiving regular supervisions and appraisals and they received appropriate training to care for people and meet their needs.

There were some completed audits but the systems were not identifying all shortfalls in the home. This meant there was a risk actions would not be taken to improve care for people when there were concerns.

The provider and manager thought all care plans were personalised and contained enough information to inform staff how to meet people’s needs. However, people were not always central to their care and care plans lacked detailed guidance for some people. This meant there was a risk staff would not provide appropriate care in line with their needs.

Staff supported people to see a range of health and social care professionals. Staff supported and respected people’s choices and they knew how important this was.

People and visitors thought staff were kind and caring. We observed positive interactions between people and the staff. The privacy and dignity of pe

This inspection was part of a themed inspection programme specifically looking at the quality of care provided to support people living with dementia to maintain their physical and mental health and wellbeing. The programme looked at how providers worked together to provide care and at people's experiences of moving between care homes and hospital.

At the time of the inspection there were 34 people living at Worcester Lodge. The person in charge on the day of the inspection told us that the majority of people had a diagnosis of dementia.

We spoke with six members of staff, the person in charge, relatives, a visiting health care professional and the provider.

People’s health was monitored and they had access to community health resources as required.

People’s needs were assessed and regularly reviewed to ensure they were receiving care that met their needs.

We saw that if someone needed to go to hospital information was sent with them to enable them to be supported appropriately.

We left comments cards at the home to enable people to tell us about the care at Worcester Lodge. We received 16 completed comments cards after the inspection all of which were overwhelmingly positive. For example “The home provides excellent dementia care” and “I cannot fault them in any way”.

We spoke with two relatives on the day of our visit and four people who lived at the home. Feedback that we received was very positive. One person told us that their relative was very calm since being in the home and they felt that this was due to staff understanding their needs. Other comments included "staff are brilliant" and "everyone is very kind". People told us they had enough food to eat and were given choices.

We saw that care plans were detailed and provided information that allowed staff to care for people in a person centred way. We observed a meal time and saw that people enjoyed their food and that where necessary people were gently encouraged.

We found that there were systems in place to monitor the quality of service provided. This was achieved through a programme of audits and feedback from people using the service and relatives.

During our visit we found occasional lapses in recordings which meant that there was a risk that staff would not be aware of the most appropriate ways to support people and meet their needs.

We visited Worcester Lodge on 25 October 2011 and spent the day at the service. We were accompanied by an expert by experience. The expert by experience was someone who has personal experience of working with and caring and supporting a person with dementia. The purpose of involving an expert by experience is to increase the voice of the people using the service.

Worcester Lodge is registered to accommodate up to 39 people for personal care. At the time of our visit, the service was looking after 36 people. We met and talked with some of the people at the service, although most people have dementia in different stages, some advanced, and therefore some were not able to tell us their views.

We met and talked with several members of staff and also the director from the provider organisation. The manager was away on the day of our visit and we were accompanied and assisted by the deputy manager and the staff team.

We found that people were cared for with kindness and patience. When we arrived, people were up and about and mostly sat or sleeping in one of the three lounges in the home. People told us that "staff are very kind", and "it's lovely here, I am very happy". We also spoke with several visitors to the home during our visit. We were told "I know that mum is safe here" and "the staff always tell me if they are worried about anything".

The concerns that we have with Worcester Lodge, and the improvements we are asking them to make, relate to the physical and mental wellbeing of people. People do not have sufficient levels of stimulation from activities and events. A visitor we talked with said "staff are all very kind, but not much else". One person said "there is nothing to do here. I was always on the go".