We undertook an unannounced inspection of Chalfont Lodge on 13, 14 and 19 March 2018.

The previous inspection carried in April 2017 found a breach of Regulation 17 of the Health and Social Care Act 2008. The provider did not have robust quality assurance systems in place to effectively monitor the safety and quality of people’s care.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question(s) safe, responsive and well led to at least good. At this inspection we found the provider had made improvements and was now meeting the regulation.

Chalfont 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.

Chalfont Lodge accommodates 119 people across five separate units, each of which have separate adapted facilities. Three of the units specialises in providing care to people living with dementia. Sunningdale Unit supported people with general nursing needs and Turnberry Unit provides complex care nursing. At the time of our inspection there were 98 people using the service. The home is purpose built, with all bedrooms having an en-suite shower room and shared communal dining and lounge facilities.

The service is required to 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 2008 and associated Regulations about how the service is run. At the time of our inspection a registered manager was not in post. The service was being managed by a senior general manager from another location until a new registered manager was recruited.

We received mixed views from people and relatives we spoke with about the quality of the service. One relative told us, “I was apprehensive at first about [family member] coming anywhere. She came here and from the minute she arrived she has been as happy as you like.” Another relative told us, “Staff here are lovely and really pleasant. They keep my relative clean.”

The overriding theme which emerged was there was insufficient staff available to meet the complex needs of people using the service. We were given examples of staff being rushed and not available. Some relatives told us they come in every day to make sure their family member is cared for. One relative said, “I come in every day I have to make sure [he] is cared for but I do worry for people here who do not have visitors able to come in everyday, who is looking out for them?”

Medicines were managed effectively. People received their medicines as the prescriber intended.

Staff were competent in the administration of medicines.

Risk assessments had been completed for people with an identified risk. These were reviewed regularly or as needs changed.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice.

Safeguarding adults’ procedures were in place and staff understood how to protect people from the risk of abuse. There was a whistle blowing procedure available and staff said they would not hesitate to use it.

The providers recruitment process ensured only suitable staff were appointed. Files we viewed contained relevant documentation to support this.

Staff sought consent from people in line with the relevant legislation. Applications to deprive people of their liberty had been submitted to the local authority.

The service ensured people had access to healthcare professionals when required. The GP carried out routine visits and advice was sought from other professionals

We undertook an unannounced inspection of Chalfont Lodge on 6 and 7 April 2017.

Chalfont Lodge provides care and nursing for up to 119 people. The home is divided into five units over two floors. Three units are dementia care units, known as Memory Lane. Sunningdale unit provides general nursing care and Turnberry unit is for people with physical disabilities. During our inspection there were 99 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.

Although some staff felt there were not sufficient staff we found staff rotas showed the number of staff were over complement of the required number as per the dependency tool. However it was accepted by the manager that staff deployment could be improved.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role.

People and their families told us they felt safe at Chalfont Lodge.

On the day of inspection, staff understood their responsibilities in relation to safeguarding people. Staff received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the authorities where concerns were identified. We had received information which showed staff’s understanding on when to report incidents needed improvement. The manager and area manager were working with the staff to ensure responsibility of reporting was further embedded.

People benefitted from caring relationships with the staff. People and their relatives were sometimes involved in their care and people’s independence was actively promoted. Relatives and staff told us people’s dignity was promoted.

Where risks to people had been identified, risk assessments were in place and action had been taken to manage these risks but these were not always effective. Staff sought people’s consent and involved them in their care where possible.

People and their families told us people had enough to eat and drink. People were given a choice of meals and their preferences were respected. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

People told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided, but these were not always effective to ensure people were protected against the risks of unsafe or inappropriate care.

We had mixed feedback from staff about the support they received from the manager and the deputy manager. Staff supervision and other meetings were scheduled as were annual appraisals. People, their relatives and staff told us all of the management team were approachable and there was a good level of communication within the service. However, meetings, for example staff meetings were not always frequent.

People and relatives told us the team at Chalfont Lodge were very friendly, responsive and overall well managed. The service sought people’s views and opinions and were in the process of acting on this feedback.

We found one 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 this report.

This inspection was unannounced on the first day and took place on the 31 March and 1 April 2016.

Chalfont Lodge provides care and nursing for up to 119 people. The home is divided into five units over two floors. Three units are dementia care units, known as Memory Lane. Sunningdale unit provides general nursing care and Turnberry unit is for people with physical disabilities. During our inspection there were 95 people living at the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

In the most recent inspection of Chalfont Lodge in September 2015 we found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. This was because we found people’s medicines were not being consistently managed safely and there was also inconsistency in the completeness and accuracy of records relating to people’s care and treatment.

The provider submitted an action plan dated 4 December 2015 which set out the action already taken or to be taken to address this. The action plan indicated the necessary action had either already been completed or would be by the 31 December 2015. The current inspection provided an opportunity to assess whether the action plan had been successful.

We found some progress had been made to address the previously identified areas of concern. For example, there had been an improvement in medicines management and care records. Some concerns remained and progress had been inconsistent which has been reflected in the overall rating of requires improvement.

There had been significant turnover of staff since the previous inspection. This had an impact both on the consistency of care provision and the overall balance of the staff team. Changes to local pay and benefits for staff had been put in place and we were told this had improved the recruitment outcomes for the service. The effect of recent high staff turnover had not yet been fully addressed and people commented about the lack of staff consistency.

People were, however, overall positive about the standard of care they received with some specific exceptions. Where concerns had been raised either internally or externally to the service, the registered manager and the senior Barchester management responsible for Chalfont Lodge, had actively co-operated with others to bring about improvements. These had not, in every case, had time to be fully effective.

The report reflects a service in transition, having faced significant issues around staff retention and recruitment. Whilst progress had been made, with significant management and staff commitment, there were still areas identified where further improvement was required to provide consistently high standards of care and support to people.

We have recommended the service follows good practice in relation to care plans, staff supervision and medicines practice.

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the deployment of staff. You can see what action we told the provider to take at the back of the full version of this report.

This inspection was unannounced and took place on the 24 September 2015.

Chalfont Lodge provides care and nursing for up to 119 people. The home is divided into five units over two floors. Three units are dementia care units, known as Memory Lane. Sunningdale unit provides general nursing care and Turnberry unit is for people with physical disabilities. On the day of our inspection there were 102 people living at the service.

At the time of the inspection Chalfont Lodge did not have a registered manager. A registered manager is a person who has registered with The Care Quality Commission (CQC) 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 confirmed that the newly appointed manager had applied to the CQC for registration.

In the most recent inspection of Chalfont Lodge in June 2014 we found there was a lack of clarity about the provision of one to one or enhanced care. This had meant it was not possible to demonstrate that there were, at all times, sufficient numbers of suitably qualified, skilled and experienced persons employed by the service.

The provider submitted an action plan dated 22 August 2014 which set out the action already taken or to be taken to address this. The action plan indicated the necessary action had already been completed. This inspection provided an opportunity to assess whether the action plan had been successful. The staffing position in respect of one to one care had been reviewed with the appropriate authorities. People’s needs had been re-assessed where necessary. We were informed the current arrangements where two people might at times share a ‘one to one’ carer had been agreed with the persons’ care commissioners.

We found different people had significantly different views of the service and the way it operated. The home was in transition following a series of management changes over a period of months. Some of the views expressed therefore were looking back over the recent past, whilst others were focussed on the present and the immediate future. Where it was the former, the levels of satisfaction were much lower than in the latter case.

Where external organisations, associated with the service provided information and assessments, these again varied quite significantly. Overall, recent improvements were acknowledged, whilst some issues from the recent past had still to be fully addressed.

The standard of care people experienced was, overall, assessed by them as good, whilst there were individual cases where satisfaction was much less positive. People continued to express concern and some frustration at problems with understanding some of the staff for whom English was a second language. The management of the service were aware of this issue and gave details of the assessments made of spoken and written English as part of their recruitment process.

Staffing levels were also still the subject of some concern, although at the time of this inspection, overall people told us they were usually about adequate. There had been times recently when the assessed numbers of staff required had not been reached, however, recruitment and retention of staff were said to be improving. This remained an issue within the local care sector where demand for care and nursing staff outstripped the numbers available.

The standard of record keeping we found was variable but improving, however there was further work to be done to maintain an appropriate level of accuracy and completeness. This included the recording and administration of medicines, where the standard was found to be variable.

We found 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.

This visit focused on staffing arrangements in the part of the home providing care to people with dementia, in Memory Lane. We spoke with the manager, deputy manager, clinical care lead, nurses and healthcare assistants. We also met the home's divisional manager.

We found staffing levels were appropriate to meet the needs of people using the service. Rotas were maintained to provide cover 24 hours a day. Managers were supernumerary and available to assist staff as necessary. There were arrangements for obtaining cover when staff were sick or on annual leave. For example, bank staff.

Staffing levels had been determined using a dependency assessment tool. This was repeated at regular intervals to make sure staffing levels were still appropriate to meet people's needs. Nurses and healthcare assistants were deployed effectively. However, we noted one short period of time where people in St Andrew's unit were unsupervised. This was when staff were dealing with a person who was agitated. During this time we saw one person walking without their frame. This put them at risk of falling.

Relatives told us the care was "excellent". One person, whose relative had challenging behaviours said "I am lucky to have found this place". Another person said "I am comfortable with the standard of care".

The equipment used in the home was regularly serviced to ensure it was fit for use. All the staff we spoke with said they felt well supported to carry out their duties and were "happy" working at Chalfont Lodge.

The home had an effective complaints procedure. Two relatives said they had raised issues in the past which had been satisfactorily resolved.

People said they were well cared for and the staff were very good.

People told us that staff respected their privacy and dignity while carrying out personal care.

People said they were happy living at the home and felt able to raise concerns with the management team.

We carried out this inspection over two days. The first day included two inspectors and an expert by experience.The second day only one inspector. We spoke with a total of 20 staff at all levels over the two days, including the home's general manager, deputy manager and regional manager. We talked with eight people who lived in Chalfont Lodge and with four relatives. We observed interaction between staff and people who lived in Chalfont Lodge and looked at some key records. We considered the evidence we had gathered under the outcomes we inspected. We used this information to answer the questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

People who lived in Chalfont Lodge and relatives we spoke with were positive about the quality of the staff and the standard of care they received. They had concerns about frequent changes to the staff team and communication with some members of staff which they found difficult because of language difficulties.

CQC monitors the operation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made, and how to submit one. There were 16 Deprivation of Liberty Safeguards in place which had been subject to a formal review. This confirmed there were proper safeguards in place where it was determined people might be deprived of their liberty.

Systems were in place to make sure managers and staff learnt from any accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We looked at seven care plans. We found people's needs were assessed and kept under review. There were assessments of risks to the health, safety and welfare of people in place together with details of how these should be eliminated or managed. This meant care and support was planned and delivered in a way which was intended to ensure people's safety and welfare.

Is the service effective?

We found lack of clarity about the provision of commissioned one to one or enhanced care. This meant it could not be demonstrated there were enough qualified, skilled and experienced staff to meet people’s needs at all times. We have set a compliance action and asked the provider to submit a plan to show how and when they will become compliant.

We found care plans had been audited and subject to review and updating to make them effective. Staff we spoke with told us they were under pressure, however they said they worked together effectively as a team to ensure people's needs were met.

People we spoke with were positive about the care they received or observed. We observed very positive interactions between staff and people who lived in Chalfont Lodge. When we spoke with staff they were well-informed about the care needs of people.

Is the service caring?

We observed the routine of the home throughout the day. We found the staff were respectful and patient although they told us they felt they did not always have as much time as they would like to spend with people they supported.

We saw people were offered choices, for example about what they ate and what activities they took part in.

Is the service responsive?

People who lived in the home and their relatives were offered the opportunity to comment about the standard of care and support they received or observed. We saw minutes of relatives meetings, which we were told were also open to people who lived in Chalfont Lodge. At these meetings any issues or concerns could be raised. People told us they were aware of the service's complaints procedure, however people said they would usually raise any concerns informally as they were confident they would be addressed. This showed the service sought to identify and respond to any concerns about the quality of care provided. We were told there were surveys carried out by an independent external body which identified any areas of good practice or where improvements were required.

Is the service well led?

Several members of staff told us they felt the new management of the home had made a positive impact. The provider carried out regular audits of the service and drew up action plans to address any areas of concern. A recent report had identified staffing and staff turnover as having a significant impact of the home. It had also identified one to one care needed to be better recorded and the needs of people currently assessed as requiring one to one care needed to be clearly established.

A series of routine audits were carried out and additional training and monitoring of medication practice had been put in place to improve the management of medicines. This showed the service was being actively managed to achieve and consistently maintain a good quality of care and support for people who lived in Chalfont Lodge.