This inspection took place on 11 and 12 October 2018 and our first day of inspection was unannounced. At our previous inspection in February 2016 we found the provider was meeting the fundamental standards. We rated the service Good overall and Outstanding in the key question ‘Is the service Well-led?’ At this inspection we found the service had improved significantly and we rated it Outstanding overall.

Amberley Lodge - Purley is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Amberley Lodge – Purley provides nursing care. CQC regulates both the premises and the care provided and both were looked at during this inspection. The care home specialises in dementia care and end of life care. The service provides care for up to 59 older people requiring residential or nursing care. There were 49 people using the service at the time of our inspection.

The home had 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.

The service was outstandingly caring. Staff were exceptionally kind and caring and demonstrated a real empathy and understanding of people with dementia. Staff knew people well and staff helped people reflect on their past creatively. People received compassionate care in line with best practice for people with dementia. The service had a strong, visible person-centred culture and the registered manager set up a successful ‘wish tree’ project to fulfil people’s wishes, despite their advancing age, dementia and medical conditions. People were supported to maintain relationships and social contacts. People were given the privacy and dignity they needed.

The service was outstandingly responsive and the service was innovative in relation to end of life care. Staff were encouraged to talk about death and dying openly and sensitively with people and the service helped people plan the end of their lives with dignity. Staff had an excellent understanding of the best ways to deliver end of life care following best practice guidelines including ‘Namaste’ care for people with advanced dementia. Staff also followed the personal wishes of people and their relatives when people were at the end of their lives. The service responded rapidly to people’s changing care needs so people experienced a comfortable, dignified and pain-free death. Staff were very able to meet people and relative’s emotional and practical needs when people reached the end of their lives.

Arrangements for social activities showed innovation with a weekly fruit market for people at the home. Activities met people’s needs and helped them lead a full life. Relatives and professionals agreed the service was excellent at providing person-centred care.

The service was outstandingly well-led by the registered manager and management team. Managers developed their leadership skills and those of others and the registered manager created a positive atmosphere to work where staff felt well supported. Staff were motivated by and proud of the service with award systems in place to recognise their achievements. Staff had high levels of satisfaction levels relating to equality and inclusion at work. The registered manager and other managers kept their knowledge current attending forums and completing specialist training in leading services for people with dementia. The registered manager developed the values of the service through involving people and staff and the values placed people centrally. Governance was well-embedded in the service with a strong framework of performance monitoring and the service was involved in an internal ‘good to great’ scheme to achieve excellent

This inspection took place on 3 and 4 February 2016 and our first day of inspection was unannounced. At our previous inspection in July 2014, we found the provider was meeting the regulations we inspected.

Amberley Lodge Purley provides care for up to 60 older people requiring residential or nursing care, some of whom may be living with dementia.

The home had 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.

We found there was outstanding leadership at Amberley Lodge Purley. The registered manager communicated a strong ethos focusing on striving for excellence, leading by example and always trying to ensure a good quality of life for the people living there. The home had made sustained improvements since 2014 and this was recognised by people using the service, their relatives and other professionals.

People and their relatives were positive about the care and support provided. Staff knew people well and treated them in a kind and dignified manner. We observed positive relationships between staff and people at the service and their relatives throughout our visits.

Any risks to people were identified and they were supported to maintain their welfare and safety. Staff were knowledgeable about safeguarding adult’s procedures and said they would report any concerns they had to the registered manager and other senior staff.

People were supported to have their health needs met. Staff worked well with other healthcare professionals and obtained specialist advice as appropriate to help make sure individual health needs were met. We saw that people’s prescribed medicines were being stored securely and managed safely.

Staff told us they felt valued and appreciated for the work they did by the management team. Staff attended regular training which gave them the knowledge and skills to support people effectively.

Staff had received training in the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). Where people no longer had the capacity to consent to aspects of their care, staff worked in people’s best interests and looked to use the least restrictive option.

People and their relatives felt able to speak to the registered manager or other staff to raise any issues or concerns. There were effective systems to monitor the quality of the service and obtain feedback from people and their representatives.

We undertook this inspection because at our previous inspection, in October 2013, we had raised concerns about staff training. There had also been minor deficiencies noted with regard to medication.

At this inspection we judged that those concerns we had previously raised had been addressed. The majority of the people using the service were not able to contribute to the inspection process due to their complex health needs. However we saw that they were comfortable and engaged with the staff and their surroundings. Many of the staff had worked in the service for some years and we saw that they were very kind and sensitive to people’s needs.

We did judge that there might not always be sufficient staff on duty to meet people’s needs. This was particularly on the ground floor. We also raised concerns that one person was being deprived of their liberty to move around freely. There was a lack of documentary evidence to show how this decision had been made.

Amberley Lodge provides care and support for up to 59 people. Almost all of the people who used this service had a degree of cognitive impairment. However, some of them were able to talk to us and we also met some visitors and relatives.

All of the people we spoke with were very happy with the care and support that they received. They told us that the staff were “kind”, “obliging” and “couldn’t do enough for you”. They said that they were free to spend their days as they wished and there were activities arranged for them if they wanted to join in. The service worked closely with other healthcare professionals in order to meet people’s needs. People’s relatives confirmed that they were involved in planning people’s care and always kept informed of any changes.

Most people enjoyed the food at Amberley Lodge. They told us that there was always a choice and we saw that individual and cultural preferences could be catered for.

We saw that procedures were in place to make sure that people received their medication appropriately and it was managed safely.

There was a programme of staff training in place. There was a process in place to identify any shortfalls and staff were being encouraged to attend training to help them in their roles.Supervision was in place to monitor staff performance.

Records that the service was required to keep as evidence of its commitment to the health and safety of people and staff were in place.

Complaints were responded to appropriately.

The majority of the people living in this home had dementia or associated mental health problems. This limited their ability to contribute to the inspection process. However those who were able to talk with us confirmed that they were quite happy in the home. Comments we received included “its good here”, “the people who look after us are very nice” and “it’s alright here”. They told us that they were able to join in with activities and some said they were able to go out if someone went with them. People told us that they enjoyed the meals and we were able to see that there were choices available to them. Those people who were not able to communicate with us showed signs of positive engagement with staff and their surroundings.

During the course of our review, prior to this inspection, we had been informed of two serious safeguarding matters. This is where one or more person's health, wellbeing or human rights may not have been properly protected and they may have suffered harm, abuse or neglect. Investigations had judged both these issues to be substantiated. There was ongoing monitoring in place by the local authority. We found evidence to show that the provider had taken the appropriate action by immediately informing the relevant authorities and following their own procedures for responding to them. At the time of our visit there was an interim manager in place. There has also been an improved programme of monitoring by senior personnel within the organisation.

We undertook this visit to check the providers progress with meeting the improvement actions and compliance actions that we set after our last review of compliance.

As we walked around the home we spoke with some of the people who live there. Many of them were not able to engage with us due to their dementia and mental health problems however, some of them told us that they were happy living in the home, saying " its nice here" and " I am quite happy here".

Generally they showed signs of positive wellbeing and we saw some good examples of staff engagement with them. Where people displayed more challenging behaviour staff approached them sensitively and addressed them respectfully.

Due to their needs, many people that we met during our visit were unable to share their views about the standards of care. The views of people who were able to comment on their experience can be summarised as follows. “its alright here, I can do things how I want to”,” Its not too bad here, I can get up when I want to, no-one makes me do anything”. A third person said “I’m contented and very well looked after. If I have a problem, X (name of staff) takes care of it for me”

We spoke to visiting relatives and they were generally pleased with the care given and were kept well informed and involved in the care of their family members.

Please refer to each outcome below and within the main report for more detailed comments about specific aspects of the service.

During this inspection visit by one inspector, we spoke with twelve people using the service, four visiting family members or friends, eight members of staff and two managers. We looked at five people’s care plans as well as other records held by the provider including those kept for staff training, supervision and quality assurance.

Following our last inspection visit in February 2014, we asked the provider to take action to make improvements around staffing and record keeping. We found this action had been completed.

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and staff told us.

Is the service safe?

People told us that they liked living at the home and said they felt safe there. Comments included “I think it’s quite nice”, “Fantastic”, “Never known it to be so good” and “It’s handy, as good as anywhere."

We saw the home environment was safe, clean and well maintained. Further work could take place to make the home more ‘dementia friendly’ with improved opportunities for engagement and occupation.

Is the service effective?

We saw people’s changing care needs were being identified and discussed by care staff through their key worker responsibilities, care plan reviews, handovers, team meetings and supervision sessions with their line manager. New systems had been put in place to ensure that an effective management structure was in place on each floor. Staff were initially worried about the changes taking place with some individuals moving to different floors however positive feedback was received during our second visit to the home. Comments included “I love the change” and “I like the results”.

We saw that staff now had access to the training and supervision that helped them do their jobs well.

Is the service caring?

People using the service told us that staff treated them with respect and said they were happy living at the home. Feedback included “I love it here”, “The staff are quite friendly”, “They’re very kind” and “Very nice."

Staff understood the importance of treating people with dignity and respect and they gave us examples of how they upheld these values. A small number of instances were however noted where people were moved without being properly informed beforehand. This should be seen as a priority for on-going work by the dignity champions appointed on each floor of the home.

Is the service responsive?

We had some mixed feedback from people using the service and their family members or friends about the activities provided within the service or out in the community. Some people were very positive about the activities but others would welcome more things to do particularly outside of the home environment. The service does not currently benefit from having its own vehicle to enable more regular or spontaneous trips out.

People said they knew how to make a complaint and felt able to approach the manager or other senior staff. Family members or friends told us “they have listened to me” and “I can go and they do something about it”.

Is the service well-led?

The service had a new manager in post. The turnover of managers at Amberley Lodge Purley has been highlighted in previous inspection reports and remains a key risk for this service.

Family members or friends of people using the service told us “Issues have fallen between different managers” and “I think we have had seven or eight managers come and go”. Some individuals reported that they had stopped going to the relatives meetings saying “There is no point in attending...there is always a new manager and in the end what we suggest is forgotten and is not acted upon."

Staff members spoke about the impact this had on their work saying “It’s not easy to keep changing manager” and “Very unnerving.” They were however positive about the leadership, support and training now being provided which helped them to meet people’s needs. One staff member said “They’re on top of it now” and another said “fingers crossed, we’ve been through a lot here."

The home clearly needs to benefit from having a consistent management team in post for a prolonged period of time.