We inspected the service on 19 April 2018. The inspection was unannounced. Annesley Lodge is a care home providing accommodation, and personal care for people who live at the service. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Annesley lodge accommodates up to 51 people. On the day of our inspection 31 people were using the service.

A registered manager was not in post during the inspection. There had been no registered manager working at the service over the previous five months. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service was being managed by an interim manager. The provider had based a regional support manager at the service on a full time basis since February 2018. The provider was aware that once a permanent manager had been appointed this person would be required to register with the Care Quality Commission. We will continue monitor the progress of the appointment and registration of a new manager for this service.

This inspection was planned to follow up on concerns we found at our last inspection. When we previously visited the service we found them to be in breach of three regulations of the Health and Social Care Act 2008 (regulated Activities) Regulations 2014. These related to safeguarding concerns and management of medicines . At this inspection, we found evidence to show they were no longer in breach of these regulations. However ,we found a further breach in the regulations relating to the need for consent, and there were still further improvements to be made at the service. Our overall rating for the service is Requires Improvement this is the second consecutive time the service has been rated as Requires Improvement.

People living at the service were protected from the risk of abuse as the provider had responded to and reported safeguarding concerns relating to the people in their care. Staff had a good knowledge of their responsibilities in relation to safeguarding and they had received recent training to support their knowledge base. The regional support manager dealt with safeguarding issues openly, so lessons could be learnt to prevent future incidents.

The risks to people were assessed, and staff showed a good knowledge of the individual risks to people’s safety. However, the risk assessments sometimes lacked detail. The regional support manager was aware of the need to improve this information and had plans in place to address this.

The management of medicines showed improvements and people were receiving their medicines safely from suitably trained staff. People were protected against the risk of cross infection as the provider had protocols and processes in place, and staff had the knowledge and equipment to manage any infection control issues, and maintain the cleanliness of the service.

Staffing levels met the needs of the people in the service and they were supported by staff who received an induction, were well trained and received regular assessments of their work. People felt staff understood how to support them effectively. Staff used nationally recognised tools to assess the needs of people who lived at the service.

People lived in an environment which met their needs, however the service was in need of refurbishment in places, and there was a lack of perminant storage for some pieces of equipment. People’s health and nutritional needs were well managed and staff acted on advice given to them by health professionals to manage people’s health and nutritional needs.

People were not supported to have maxim

Annesley Lodge Care Home was inspected on the 26 and 27 October 2017. The inspection was unannounced. Annesley Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked during this inspection. The service is registered for 48 people and 41 people were using the service on the day of inspection.

Following this inspection the service was rated as Requires Improvement as we found concerns which led to two breaches of the Health and Social Care Act 2008 Regulations (2014) and one breach of the Care Quality Commission (Registration) Regulations (2009). You can see what action we told the provider to take at the back of the full version of the report.

The service had registered manager in place at the time of our inspection. 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 were not always protected from the risk of abuse as staff did not always recognise when abuse had occurred. The registered manager did not always share information with the local authority when needed and act on concerns when they were raised to them.

Risks to people’s safety were not always properly assessed to give staff the information required to provide suitable care to keep people safe.

People were not always supported by adequate numbers of staff; however the management team continued to address this. People were not always supported to receive their medicines safely. Although the majority of staff received their mandatory training to enable them to complete their role there was a need for further training for staff to support them to understand people’s different health needs

The principles of the Mental Capacity Act (MCA) were not always followed and best interest decisions were not always clearly documented. However some people had been assessed as lacking the capacity to make their own decisions.

The majority of people received a varied and nutritious diet and were supported with any special requirements to ensure they received a suitable diet in a safe way. However, there was evidence to show one person dietary needs had not been assessed to meet their individual needs

People’s health needs were not always managed in a timely way and health professionals’ advice was not always followed.

People were supported by a group of caring and kind staff who understood and accommodated their needs and preferences. Staff supported people to be independent and they worked to ensure people’s privacy and dignity was maintained.

People told us they received individualised care, however the information in people’s care plans was variable and as a result staff did not have clear information to enable them to provide consistent and individualised care for people.

People were supported to undertake social activities of their choice and staff worked hard to prevent people from becoming isolated. People felt able to raise concerns and felt they would be listened to.

People felt the registered manager was approachable and visible but the service lacked robust quality assurance processes to ensure standards of care were maintained.

We inspected the service on 22 and 23 August 2016. The inspection was unannounced. The service provides residential and personal care for 51 people On the day of our inspection 36 people were using the service. The service is provided across two floors with a connecting lift.

The service had a registered manager in place at the time of our inspection. 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 and associated Regulations about how the service is run.

People were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The registered manager shared information with the local authority when needed.

The risks to people’s safety were assessed and reviewed on a regular basis. These risks were managed in such a way as to both protect people and allow them to retain their independence.

Staffing levels in the home were sufficient and the recruitment processes were safe. People received their medicines safely from suitably trained staff. Staff had a full understanding of people’s care needs and received regular training and support to give them the skills and knowledge to meet these needs.

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were protected from the risks of inadequate nutrition. Specialist diets were provided if required. Referrals were made to health care professionals when needed.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care, they were treated in a caring and respectful manner. Staff delivered support in a relaxed and considerate manner.

People, who used the service, or their representatives, were encouraged to be involved in decisions about their care and their environment, and systems were in place to monitor the quality of service provision. There were systems in place to ensure that the care provided met people’s needs. People felt they could report any concerns to the management team and would be taken seriously.

During the inspection there were 35 people using the service. We spoke with three people who used the service and four relatives and asked them about the care they or their family member received. We carried out a tour of the building and reviewed records relevant to the running of the service. We observed staff interaction with people throughout the home. We spoke with the manager, care manager, district manager, four team leaders, two care assistants and two district nurses.

At the time of the inspection the manager had applied to become registered with the CQC. We will monitor their application to ensure it is completed in a timely manner.

Throughout this inspection we focused on these five key questions; is the service safe, effective, caring, responsive and well-led?

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

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

Is the service safe?

People received care in an environment that was safe. The communal areas, gardens and bedrooms that we looked at within the home were clean and tidy.

We saw people received their prescribed medication and this was handled and stored safely. We observed staff administer people's medication in a safe manner whilst ensuring they respected their wishes and maintained their dignity at all times.

The CQC monitors the operation of the DOLS which applies to care homes. DOLS are part of the Mental Capacity Act 2005. Correctly applied DOLS make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom. The safeguards should ensure that care homes only deprive someone of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them.

The care manager told us they planned to assess each person who used the service to establish whether they believed a DOLS would be required. If so, they would ensure the assessment was conducted and applications sent to the authorising body in a timely manner.

Staffing levels had been increased since the last inspection. There were now enough qualified, skilled and experienced staff to meet people's needs and to keep them safe.

One person who used the service told us, “I feel safe here, no worries at all. I have no problems. The staff are very caring and very helpful, nothing is too much trouble for them.”

Is the service effective?

We saw improvements had been made since the last inspection. People's capacity to make their own decisions had now been formally assessed where required and the documentation was recorded in their care plan.

Improvements had also been made in relation to the documentation regarding cardiopulmonary resuscitation more commonly known as CPR. However further improvements regarding some of the documentation was required .

People were consulted on decisions relating to their care. People we spoke felt included and relatives we spoke felt their opinions and views on decisions regarding their family member were welcomed.

One person who used the service told us, “I am pretty much free to decide what I want to do and what I want the staff to do. I would give the staff top marks." A relative we spoke with told us, "The staff talk to me each time I’m there, they welcome my input.”

A district nurse we spoke with told us they were confident that advice and guidance they gave staff to effectively manage people's care was implemented. They told us, “I am here every day and have no concerns; people are safe from what I see. The staff seem to know what they are doing. When I have given advice they have followed it.”

Is the service caring?

We spoke with relatives of people who used the service and asked them if they felt their family member was safe and well cared for by the staff. One person told us, “The last six months have seen a vast improvement. The carers are brilliant, they get on really well with people, they do seem to really care.”

We observed staff interact with people who used the service. They were caring and attentive in their approach and did not rush people. They observed people's dignity and wishes at all times. We observed two activities taking place; a church service in the morning and arts and crafts in the afternoon. During both of these activities people were treated with respect by all staff.

Is the service responsive?

We saw staff respond to people's needs throughout the inspection. We did not see people left for long periods without interaction from staff. When people needed help, staff were there to assist them.

We saw management had responded to a person who had recently started to regularly fall out of bed by requesting a meeting with their relative to discuss the use of bed rails being added to their bed. These were implemented. However, it was noted that an assessment, known as a mental capacity assessment, had not been conducted to assess whether the person could contribute to the decision about the bedrails themselves.

The management welcomed people's views and responded to them. Questionnaires had been issued to people who used the service and their relatives. The responses received were positive. However, when asked, the management could not provide the analysis of these results to show how they planned to use the results to improve the service. We were told these would be forwarded to us.

Is the service well-led?

We asked people who used the service, their relatives and staff whether they felt the service was well led by the management team. A person who used the service told us, “The new manager seems lovely.” A relative we spoke with told us, “I think this is the best care home in the area. I went to see them all before this one. The new care manager is great. If I have any concerns I can raise it with them.”

We saw improvements had been made since the last inspection. We saw there were now regular audits in such areas as care plans, medication and infection control. Regular supervision and observation of staff performance was now conducted and recorded.

Staff spoke positively about the new management team. One staff member told us, “The management are brilliant, you can have a laugh with them, they have fitted in really well.” Another staff member told us, “Since the new manager started we have become more of a unit now. Now we have a settled manager things have settled down and we work as a team.”

We spoke with four people who were using the service. One person told us they were happy living in the service. Another person said, “I’m never afraid, I feel safe here” and, “The dinners are usually very good.” Another person said, “It’s very good here, the staff are respectful.”

We were concerned that consent to care and treatment was not always sought from people who used the service. We were concerned that people’s needs were not always assessed and care and treatment was not always planned and delivered in line with their individual care plan.

We found a number of concerns regarding medication. We found that medication was not always stored within acceptable temperature ranges. We also found gaps on the medication administration record (MAR) charts. We saw the medication trolley was not locked when the staff member moved to different areas of the room to give people their medication.

We saw staff interactions with people who use the service were mainly caring and polite. However, there was not always enough staff available to meet people's individual social needs. We saw some people sitting passively in their chairs in the lounge and dining areas.

We found there was a lack of audits in place to monitor the quality of the service actually being delivered. We found areas of concern in relation to other outcomes of the essential standards of quality and safety. Some of these areas of concern had not been identified by the registered manager or provider.

There were 43 people living at Annesley Lodge Care Home when we visited on 10 January 2013. We spoke with seven people who used the service; two relatives; five staff and others who had regular contact with the home to ask for their comments and observations. We spent time in the company of people who used the service in communal areas and in their private accommodation. We observed people's experience of care and assessed the quality of support they received.

The majority of the comments we received from people who used the service and from visitors were positive. We were told, "It's lovely to live in comfort here," and another person said, "I immediately felt at home, the staff have given me my confidence back."

People said they were consulted and agreed that staff understood their care needs. There was some evidence that although the staff worked hard to meet peoples needs in a timely way, people did sometimes have to wait for prolonged periods of time to have their care needs met and this sometimes impacted on the quality of care provided.

There were 45 people living at Annesley Lodge Care Home when we visited on 17 November 2011. We were able to speak with a significant number of people who used the service. We also spoke with two relatives; three staff and others who have regular contact with the home to ask for their comments and observations. We spent time in the company of people in communal areas, observing their experience of care and assessing the quality of support they received.

We were told that people felt involved in making decisions about their care and support. We were also told that staff were tolerant and treat people with kindness and respect and we saw direct evidence of this.

Overall people were very positive about the care and support provided. We were told, "the care is excellent" and "the treatment is first class."