This inspection took place on 4 December 2018 and was unannounced. Buxton Lodge Care Home 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. At the time of our inspection there were 32 people living at the home.

Buxton Lodge Care Home is registered to provide accommodation, care support and nursing care for up to 44 older people some of whom may have specific needs and/ or are living with dementia. At the time of our inspection there was an experienced 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 our last inspection of the service on 28 June 2016 we rated the service overall as ‘Good’ and 'Requires Improvement' in Responsive. This was because guidance from healthcare professionals was not always being followed, daily notes and charts were not always being completed accurately and people's care records did not contain information of their medical conditions. Records were stored in multiple places and some staff did not have access to them. Following the inspection, the provider submitted a plan in which they told us that they would audit all files and change the way files are stored making them accessible to all staff. At this inspection we found improvements had been made and the service was meeting the regulations.

Risks to people were assessed and managed safely by staff. Medicines were managed, administered and stored safely. People were protected from the risk of abuse and staff knew what action to take to ensure people’s safety and well-being. There were systems in place to ensure people were protected from the risk of infection and the home environment was clean and well maintained. The home environment was suitably adapted to meet people’s needs. Accidents and incidents were recorded, monitored and acted on appropriately. There were safe staff recruitment practices in place and appropriate numbers of staff to meet people’s needs in a timely manner.

There were systems in place to ensure staff were inducted into the service appropriately. Staff received training, supervision and appraisals. There were systems in place which ensured the service complied with the Mental Capacity Act 2005 (MCA 2005). This provides protection for people who do not have capacity to make decisions for themselves. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People’s nutritional needs and preferences were met. People had access to health and social care professionals when required and staff worked well with health and social care professionals to meet their needs.

People were treated with kindness and staff respected their privacy and dignity. People’s diverse needs were met and staff were committed to supporting people to meet their needs with regards to their disability, race, religion, sexual orientation and gender. People were involved in making decisions about their care. There was a range of activities available to meet people’s interests and needs. The service provided care and support to people at the end of their lives. People’s needs were reviewed and monitored on a regular basis.

There were systems in place to monitor the quality of the service provided. People’s views about the service were sought and considered. The provider worked in partnership with other professionals and agencies and in line with best practice to ensure people received appropriate levels of care

The inspection took place on 28 June 2016 and was unannounced. This was a comprehensive inspection.

Buxton Lodge Care Home is registered to provide accommodation and nursing care for up to 44 older people, many of whom were living with dementia. On the day of our inspection there were 32 people living at the home.

The home did not have 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 and associated Regulations about how the service is run. The interim manager assisted us with our inspection on the day.

During this inspection we followed up on seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which we found at our inspection in July 2015. At that time there were not enough staff working to respond to people’s needs, medicines were not being managed safely. Staff did not have the required training to be effective in their roles. Staff did not always seek appropriate consent from people and follow current legislation. Staff did not always respect people’s privacy and dignity. People’s care plans were not always person centred and important information was not always accessible to staff. Following that inspection we had received an action plan from the provider telling us what they planned to do in order to address the breaches of regulations. We found during this inspection the provider had taken the necessary action in relation to these breaches.

People were cared for by sufficient numbers of staff at day and night. This both ensured safety and ensured staff had more time to spend with people.

Medicines were administered safely. Recording was up to date but there was a discrepancy about how PRN (as required) medicines were recorded. The manager is speaking to the provider about this.

Staff understood their role in safeguarding people and we saw that incidents were being reported where appropriate. Staff routinely carried out risk assessments and created plans to minimise known hazards whilst encouraging people’s independence. We found that policies and procedures were in place to keep people safe in the event of emergencies. Fire drills and fire alarm tests were carried out along with regular audits of emergency and contingency planning.

Staff had appropriate training and support to meet the needs of people living at the home. Staff told us that they were well supported by management and had regular supervision.

People’s legal rights were protected as staff provided care in line with the Mental Capacity Act (2005). Correct procedures were followed when depriving people of their liberty.

Staff followed the guidance of healthcare professionals where appropriate and we saw evidence of staff working alongside healthcare professionals to achieve outcomes for people.

People told us that they enjoyed the food and we saw evidence of people being provided with choice and also being involved in writing menus.

Information in people’s care plans had improved. However, the manager is working to improve these further as they currently lack detail of people’s individuality. People were given the opportunity to provide feedback on the care they received through residents meetings and one to ones with staff. Issues raised by people were responded to by management.

People and relatives told us that they had a positive relationship with the interim manager.

Buxton Lodge Care Home provides nursing and accommodation for up to 44 people who are elderly and frail, having a specific condition such as a learning disability or are living with dementia. At the time of our inspection 39 people were living in the home.

The inspection took place on 29 July 2015 and was unannounced.

There was a registered manager in post 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. The registered manager was present during our inspection.

Staff did not always follow correct and appropriate procedures in relation to medicines to ensure people received their medicines safely. There was little guidance to staff for people who may request ‘as required’ (PRN) medicines.

There were insufficient numbers of staff to meet the needs of the people living at Buxton Lodge. We observed people waiting for long periods in the morning to be assisted to get up. The deployment of staff was not carried out appropriately to meet the needs of the people.

People could be at risk of harm from pressure sores as staff did not ensure they turned or repositioned them as often as they should. Risk assessments for people were not complete and we found two people being barrier nursed for a potentially serious infection, but signage to inform people of this was not clear. Barrier nursing is a procedure used to protect other people from the risks of the infection.

Some staff were behind on their training and we found some qualified staff were unable to demonstrate a good knowledge of medical emergencies.

Staff did not understand their responsibilities in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). Best interest decisions were not made in line with legislation.

People were provided with a varied and nutritious diet and they had a choice of meals. However, people did not always know what was available to eat.

Staff did not always treat people with dignity, respect or consideration.

Care plans were not person-centred and not always accurate. Record keeping was not robust and the records were not suitably organised.

Activities took place and staff were working on developing more individualised, meaningful activities. Although the environment in the home was not currently suitable for people living with dementia we were told work was underway to change this.

Complaint procedures were available to people. People and relatives knew who to speak to should they wish to complain. However we heard that complaints were not always responded to the satisfaction of people.

Quality assurance checks were carried out by staff to help ensure the home was a safe place for people to live and people were provided with a good quality of care.

Staff supported people to access health care professionals, such as the GP or occupational therapist.

Staff knew the procedures to follow should they have any concerns about abuse taking place in the home. In the event of an emergency people’s care would not be interrupted.

The provider had ensured safe recruitment practices to help them employ staff who were suitable to work in the home.

Relatives were made to feel welcome when they visited and were involved in the running of the home.

During the inspection we found some 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 the report.

Our inspection was undertaken by one inspector. We spoke in detail with four people who lived in the home and two people who were visiting relatives. We talked with a registered nurse, five care assistants, the administrator and two activities coordinators. We read a variety of care and staff recruitment records and observed the care people received during the day. The information we obtained helped 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? Below is a summary of what we found. To see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they considered the home provided a safe environment. One person said “Safety is the main thing, this was clearly safer for me than returning to my home.” Another said “The staff make it a safe place.” Safeguarding procedures were robust and staff understood how to safeguard the people they supported. The home had policies and procedures, including staff training, in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards, although no applications had needed to be submitted. Staff we spoke with demonstrated an understanding of working with people’s consent, and following proper procedures where any possible deprivation of liberty was identified.

Recruitment practice was safe and thorough and helped ensure staff were deployed in sufficient numbers and with the qualifications, skills and experience required to meet the needs of people in the home.

Is the service effective?

People were involved in assessment of their health and care needs and in development of their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People told us their plans reflected their current needs and this was confirmed by our observations. One person said, “I get the help I’ve requested. Independence is important to me and they help me maintain what I can. I feel I’m able to live as I did at home.” Another person said, “The care I get is what I’ve agreed.” Staff showed they had a good understanding of people’s care and support needs.

Most people in the home were registered with an individual GP, who visited the home at a fixed time every week. This meant non urgent issues could be listed for their attention during the routine visit. Records showed people got medical attention swiftly when needed.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People told us staff were very respectful of their privacy and dignity needs.

Is the service responsive?

People’s needs had been assessed before they moved into the home. Care plans were reviewed every month, or more often in response to events or needs arising. The home employed two full time activities coordinators, which gave people access to activities that were of interest to them. All care plans considered whether there were communication challenges and, if so, how to address these. We saw examples of interactions where staff were sensitive and patient in establishing mutual understanding with people whose speech was compromised.

Staff and management were readily available to people in the home, and to visitors. People had portable call bell switches, so they could obtain assistance when needed. Staff responded readily to requests to move by people who were not independently mobile. Specialist health, mental health and social care resources were accessed when necessary. Care records showed specialist advice and care directions were incorporated into care plans and followed.

Is the service well-led?

The provider maintained regular contact with the service through visits from an area manager. They had direct contact with people living in the home and visiting family members, and undertook routine audits. Any identified shortfalls were rectified through monitored action plans.

The service had a quality assurance system that included an annual survey conducted by the provider and monthly residents’ and relatives’ meetings. Records showed identified shortfalls were addressed promptly. A visitor told us they did not attend the relatives’ meetings but found the management very approachable. They said minor issues they had raised shortly after their relative’s admission had been attended to. They said the approachability of the registered manager and teamwork approach of the staff group “set the tone for how the home works.”

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and demonstrated they worked as a team. This helped to ensure that people received a good quality service at all times.

People we spoke with told us that they were satisfied with the level of care and support they or their relative received. Comments included “I am happy here, the staff look after me well”, “I get what I need, sometimes it takes a while for staff to come to me when I call them, but I otherwise I am happy”, “They look after my relative really well, I can’t praise the staff highly enough” and “The staff are very accommodating and treat my relative like an individual”.

People told us they felt safe in the home and were treated with respect by the staff. They said staff knew them well enough to provide the care they needed. However, they said sometimes they would have to wait, sometimes for up to half an hour, for staff to come to them when they needed support to move around.

Staff and people who used the service said they were asked for their views about the service on a regular basis and were able to speak with the manager about any concerns they had at any time.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We found that generally people interacted positively with each other and with staff.

People who used the service and their representatives told us that they felt involved in their own or their relatives care planning and treatment.

One representative told us that “you cannot fault the staff and there is a good atmosphere in the home”.

Representatives of people who used the service told us that they were able to express their views and opinions on how the home was run. They could either attend relatives’ committee meetings or record their views in survey/questionnaires sent to them by the provider. Some people said they were able to put their views or comments directly to the manager as she maintained an “open door” policy.

People who used the service and their representatives told us that they felt that Buxton Lodge was a safe and secure environment and that if they had any concerns they would have no hesitation in speaking to the manager.

People who used the service and their representatives told us that they did not feel there were always sufficient numbers of staff on duty. People told us that they or their relative had to sometimes wait for their call bells to be answered. In particular, people told us that on occasions they had waited up to 30 minutes to be assisted by a member of staff to visit the communal lavatory. One relative told us that, “this situation is not helped by the fact that there are only 2 communal toilets on the ground floor”. This relative went onto tell us that “the home also seemed especially short staffed in the afternoons”.

People using the service or their representative told us that staff treated them or their relative with respect and dignity and respected their privacy. However, they also told us that they were sometimes woken up by staff who could be quite noisy.

Staff told us that the current staff team had “a very caring approach”. Staff told us that the manager was, “brilliant and has improved the home a lot”. One member of staff told us that, “we’re here for the residents” and “the care is much better”.

Staff told us that they had regular staff meetings in which they were able to raise any issues or concerns. Staff told us they were aware of the provider’s whistle-blowing policy and had no qualms about raising any concerns either with the manager or other responsible agency.

People who were able to speak with us said they were treated with kindness and respect by the staff and were involved in the way their care was organised. Carers of people using the service spoke of their overall satisfaction with the services offered and most were able to confirm their involvement in deciding if the home could meet their relative’s needs. Some carers spoke about attending reviews of their relatives care plan, where they were asked if they were satisfied or if they felt any changes needed to happen. People using the service said they felt safe and secure. Carers said they had never seen any practices in the home that had concerned them and they were confident that the manager would investigate and act on any issues brought to her attention. A person using the service said that on occasions staff were so busy that they had to wait to receive attention, but staff were generally very responsive and helpful. A person using the service said that some staff could be quieter during the night hours as unnecessary noise could be annoying and disruptive if you were a light sleeper. Another carer said that they felt that some staff needed to communicate better. Some individuals did not always explain what they were going to do clearly enough, which can lead to frustration for the recipient. There was some very positive praise received for the new manager. One person said, ‘very on the ball’ and another, ‘I feel confident that she will put residents first’’