This inspection took place on the 26 and 27 November 2018. The inspection was unannounced.

Carey 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 at during this inspection.

The service provides care for up to 75 older people, including people with dementia. The home is made up of six individual houses and set over three floors. Each house has its own sitting and dining room. The large reception/ entrance area to the home is used for activities. Three of the houses are for people with dementia and the other houses provide residential care. At the time of our inspection there were 73 people living at the service.

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 our previous comprehensive inspection in February 2016 the service was rated as good overall, with a requires improvement rating in the safe domain. At that inspection the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A focused inspection was carried out in March 2017 to check compliance with breach of Regulation 12. At that inspection the service was compliant with Regulation 12 but in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the previous inspections, we asked the provider to complete an action plan to show what they would do and by when to improve the key question safe to at least good. At this inspection we found there was a repeated breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and other Regulations were not complied with. The service achieved an overall “Requires Improvement” rating.

Relatives were happy with the care provided and felt confident their family members were well cared for. They commented “All of the staff are kind, caring, encourage appropriately and go above and beyond what is expected of them. I really appreciate all that they do. My mum is very happy here and sees it as her home.” “The care staff are excellent, they show such understanding to my wife and the whole family.” “The carers are wonderful, they treat [family member’s name] as a good friend and that is comforting to see.”

Staff were not always appropriately deployed and rotas were not always suitably managed. The staffing levels were not always adjusted to take account of the support a person required and there were periods of the day where there was a reduction in staffing levels. Some people told us there was a lack of continuity of care for them. They told us staff were rushed and did not have time to talk with them.

Risks to people were identified but not always appropriately managed. Systems were in place to ensure medicines were safely managed. However, medicines were not always kept secure and no protocols were in place for a person’s “As required” medicines, which were administered regularly and not as required.

People had care plans in place. The care plans lacked specific detail and guidance on the support people required. Records relating to people and the running of the service were not always accurate, up to date and suitably maintained.

People were consulted on their day to day care. However, for some people the records showed the principles of the Mental Capacity Act 2005 were not followed. A recommendation has been made to address issues of consent.

Care plans made reference to people’s communication needs but appropriate measures and guidance were not put

We undertook an announced inspection of Carey Lodge on 18 March 2017. We let the manager know we were coming so that they could be in attendance.

Carey Lodge provides care for up to 75 older people, some of whom may have dementia. On the day of our visit there were 70 people using the service.

At the last inspection on 16 and 22 February 2016 the provider was in breach of one regulation of the Health and Social Care Act 2008, (Regulated Activities) Regulations 2014.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements within the Safe domain. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Carey Lodge on our website at ‘www.cqc.org.uk’.

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 l Care Act 2008 and associated Regulations about how the service is run.

People, families and staff told us that at times there were not enough staff to meet people’s needs. Staff rotas confirmed that the planned staffing levels were not always maintained. Comments were “Three staff are not always maintained on the floors” and “I know one lady needs two people to assist her, but there is not always enough to do this”.

People and their families told us they felt safe at Carey Lodge. Staff understood their responsibilities in relation to safeguarding people. The service had systems in place to notify the authorities when concerns were identified. People received their medicines as prescribed.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role. Where risks to people were identified, risk assessments were mainly in place. We found some reviews of these risks had not clearly been recorded.

Accidents and incidents were well managed. We found there were checks in place to ensure people were safe.

We found a breach 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.

This inspection took place on 16 and 22 February 2016. It was an unannounced visit to the service.

We previously inspected the service on 13 June 2013. The service was meeting the requirements of the regulations at that time.

Carey Lodge provides care for up to 75 older people, some of whom may have dementia. Seventy people were being cared for at the time of our visit.

The service 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 received positive feedback about the service. Comments from people included “Everything’s fine,” “I’m lovely and comfortable,” “They look after us well” and that staff were “So attentive, helpful and treat you with respect.”

There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Risk was managed well at the service so that people could be as independent as possible. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care.

We found there were sufficient staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a wide range of social activities. Staff supported people to attend healthcare appointments to keep healthy and well.

The service was managed well. The provider regularly checked quality of care at the service through visits and audits. These showed the service was performing well. The registered manager was skilled and experienced and was assisted by a team of senior staff. There were clear visions and values for how the service should operate and staff promoted these. For example, people told us they were treated with dignity and respect and we saw they were given choices. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

Medicines were not always managed in line with safe practices. We found maximum and minimum temperatures of medicines refrigerators were not recorded to ensure medicines which needed to be stored between 2 and 8°C were safe to use. This meant they may not be kept in line with the manufacturer’s instructions. Controlled drugs waiting to be returned to the pharmacy for destruction were not recorded in a controlled drugs record book. This meant they could potentially be misappropriated.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to safe medicines practice. You can see what action we told the provider to take at the back of the full version of this report.

People we spoke with during the visit expressed positive views about the home. We talked with three relatives. Each was pleased with the standards of care. Comments included “We’re very impressed,” “Can’t fault it,” “We’re made to feel welcome,” and “We’ve got peace of mind.” We heard another relative speaking with the manager. They thanked her for the support she had given the family. A resident told us “I think this place is marvellous.”

We found care plans were in place for each person. These documented people’s needs and how they were to be met. Risk assessments had been written to reduce the likelihood of injury to people. We saw people had access to healthcare professionals such as GPs and district nurses.

People’s medicines were managed safely. Staff who handled medication had undertaken training. Medicines were stored securely and accurate records were maintained.

We saw there were effective staff recruitment practices at the home. These included obtaining written references from previous employers and carrying out checks for criminal convictions.

We spoke with nine people using the service. They told us they were happy living at Carey Lodge. One said ''Staff are kind and helpful.'' They said staff were around when they needed assistance. The person told us they felt listened to and had been made very welcome at the service. They said they had been able to keep their independence and had no complaints about their care.

Six people we spoke with told us the same group of staff looked after them. One said a named member of staff ''Is like a friend.'' Another said ''It is good care, they look after everyone.'' The people we spoke with said they enjoyed the meals at the service. They told us they had choices of meals and could eat in their rooms if they wished.

People said they had access to healthcare professionals when they needed them, such as opticians and foot care specialists. One person told us they had enjoyed activities such as a pub lunch, reading a play and listening to a visiting harpist. They said a visit from farm animals had also been popular with people.

We spoke with three relatives. All were happy with standards of care. One told us their relative had received care and attention following an infection. Another said they were always made to feel welcome. They told us staff kept them informed of their relative's condition, so they were aware of any ill health or other concerns.

We spoke to five people using the service. One person told us they were aware of their care plan and that it had been explained to them. Four people were not aware of what was in their care plan and one person told us they did not know what a care plan was.

We were told that the staff were wonderful and had helped people settle into the home. We spoke to a married couple using the service. They said that staff went out of their way to help them and to make sure they could spend time together. They had every faith in the manager and they could already see the progress the manager had made.

One person said they had no complaints and felt very lucky to be living in the home and another person using the service informed us that they felt able to talk to the staff at any time, who always listened and acted upon their concerns.

People felt able to express their views about the home or talk to staff about any concerns or complaints they might have. One person told us they had been part of the residents committee and this was a good way to bring about changes. They were glad the new manager had started these again.

The people we spoke with were very positive about the standard of their care. 'They spoil me' one person told us. People said they felt safe.

They told us they could choose what they ate and if they did not like what was on the menu they could ask for something else. They told us they could choose when they went to bed and when they got up. People said they could choose whether to take part in organised activities.

Minutes of resident's meetings held in July and August 2012 included comments that care staff were clearing tables whilst people were still eating. Some people found this disrespectful.

One relative told us the standard of care had improved in the past six months. They said the standard of their relative's cleanliness and appearance varied depending upon which care staff were on duty. Another person paid particular tribute to the care provided by the key worker involved with their relative.

People we spoke with did not raise any concerns with us about staffing levels. We asked three people about the availability of staff. They said there were satisfactory staff to meet their care needs. One person said response times were sometimes longer at night than during the day.

People told us they could attend resident's meetings if they wanted to. They said they were regularly asked for their views on the care they received and could complete annual surveys. Two people told us that if they had any concerns they would share them with their key worker or speak with the manager.