The inspection took place on 2 and 4 October 2018 and was unannounced.

At our last inspection on 14 and16 February 2018 we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found one breach of registration regulations.

Following the last inspection, we took enforcement action to impose conditions on the providers registration. These conditions mean the provider has to inform us of actions which have or are being taken to mitigate identified risks. We also met with the provider and registered manager to discuss our expectations going forward.

At this inspection on 2 and 4 October 2018, we found that although some improvements had been made, the service remains in breach of four regulations in relation to safe care and treatment, staffing, governance, and person centred care. We also found a new breach in relation to nutritional and hydration needs. The service had informed us of serious injuries which had occurred in the service, and is therefore no longer in breach of this associated registration regulation.

Clarence 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.

Clarence Lodge accommodates 28 people in one adapted building. At the time of our inspection there were 16 people using the service.

There was not a registered manager in post. The previous registered manager had left the service in July 2018. 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. An acting manager had been appointed in the service, though they were not registered with the CQC.

Some new auditing processes had been implemented. However, these had failed to identify all of the concerns that we found during this inspection. People's health and safety were at risk because the provider had failed to identify where safety was being compromised in the environment.

Risks in relation to falls, malnutrition, and pressure area care were not being adequately reviewed or monitored to ensure people were cared for in a safe way. There was not always accurate guidance in place for staff about how to manage or reduce risk.

Staff knew how to recognise abuse or potential abuse and how to respond and report these concerns appropriately. However, the acting manager had not reported an incident to the local authority safeguarding team which should have been.

Medicine administration was not always observed as safe. Stock levels were not always accurately recorded to determine if people had received their medicines as prescribed.

The re-organisation of care plans meant that people’s health needs were included in some care plans, and subsequent input from health professionals. However, further work was needed in this area to ensure records were accurate and person-centred. Records were not always completed consistently.

End of life care plans were not in place. Staff had still not received training in this area.

Food and fluid charts were not always completed fully or totalled to ensure people were receiving adequate nutrition and hydration. Feedback from people and relatives indicated that the quality of the food provided had not improved.

The acting manager and staff were not receiving regular supervision, and some staff had not received training updates. The acting manager had started to introduce observed practice of staff, however, their time was limited due to other on-going priorities.

The previous registered manager had applied for Deprivation of Liberty Safeguards when people who lacked capacity to consent, had their

This inspection took place on 14 and 16 February 2018 and was unannounced. At our previous inspection of 26 and 27 October 2016, we found the service was no longer in breach of regulations, but was rated as ‘Requires Improvement’.

At this inspection of 14 and 16 February 2018, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to staffing, governance, safe care and treatment, and person centred care. We also found a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, for not informing us of a serious injury which had occurred in the service.

We took enforcement action to impose conditions on the providers

registration. This condition means the provider has to inform us of actions which have or are being taken to mitigate identified risks. We decided to impose these conditions on the providers registration because people may be exposed to the risk of harm.

Clarence 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.

Clarence Lodge accommodates 28 people in one adapted building. At the time of our inspection there were 24 people living in 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.

There were gaps in how the service assessed and monitored the quality of its provision. While there were some quality assurance mechanisms in place, these had proved ineffective at identifying areas for improvement, and not all aspects of the service were being effectively monitored. The registered manager had not notified us of a serious injury which had occurred in the service, which is required by law.

People's health, safety and well-being were at risk because the registered manager and provider had failed to identify where safety was being compromised. Infection prevention and control procedures were ineffective and we found that hygiene in the service was poor in some areas. This included in areas where food was prepared.

People did not always receive timely healthcare support. The organisation of care records meant that it was not always possible to case track people’s medical history and subsequent input from health professionals.

Staffing levels were not sufficient to ensure people’s safety at all times. Staff were not always able to be responsive to people’s needs. Staff were not receiving regular supervision, and some staff had not received training updates.

The registered manager had applied for Deprivation of Liberty Safeguards when people who lacked capacity to consent, had their liberty restricted. However, we did not see that a capacity assessment had been carried out in advance to determine that this was required, or how any restrictions would be managed. Additionally we saw some capacity assessments that had been carried out were generic in nature and not decision specific.

People received their medicines safely, however, improvements were required in relation to recording of some documentation and the security of medicines.

Risks in relation to falls, malnutrition and pressure area care were not being adequately assessed or monitored to ensure people were cared for in a safe way. There was not always guidance in place for staff about how to manage or reduce risk.

Food and fluid charts were not always completed fully or totalled to ensure people were receiving adequate nutrition and hydration.

Care plans for people were not always reflective of people's current needs. Information h

This inspection took place on 26 and 27 October 2016 and was unannounced. Our previous inspection in July 2015 found three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. We checked whether improvements had been made in these areas and found that sufficient improvement had been made so the service was no longer in breach of these Regulations. However, improvements were still needed in some areas.

Clarence Lodge provides accommodation and care for a maximum of 28 people. At the time of our inspection there were 23 people living in home, 13 of whom were living with dementia.

A registered manager was 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.

Medicines were not always managed in a safe way. There were errors in the records of administration and in stock levels. This meant that we could not determine if people had been administered their medicines as the prescriber had intended.

Risks to people’s health and welfare were being identified and assessed. Action plans were put in place to mitigate these risks. Staff knew how to reduce the risk of harm and what to do if they had concerns about a person’s safety and welfare.

Care was delivered by sufficient numbers of staff who were subject to robust recruitment procedures and provided with training to carry out the duties of their role. Supervision and team meetings were not held as frequently as staff would have liked.

Staff had received training in the Mental Capacity Act 2005, including the Deprivation of Liberty Safeguards. They understood how to support people who lacked capacity to consent to their care and acted correctly when they identified that a person may be deprived of their liberty.

People were being supported with their nutritional needs and were provided with a choice of good home cooked food. Sufficient fluids were provided and people’s fluid and food intake was monitored to ensure that they were eating and drinking enough.

People told us that staff were caring and treated them well. However, there were times when staff did not always treat people with respect or give them the attention that they needed.

Visitors to the home were welcomed by staff and made to feel comfortable. They were invited to stay for meals and encouraged to spend time with their loved ones.

People were involved in planning and reviewing their care to ensure that it remained centred on their needs. However, care records were not always complete and kept up to date when needs changed. The service supported people to stay well and to access community health professionals when needed.

There was good information about people’s interests and hobbies. However, there was a lack of meaningful activity for people. Staff did not spend time engaging with people in a way that promoted their psychological wellbeing.

The service had a complaints procedure that was accessible within the home. People knew who to talk to if they had a complaint. Complaints were handled in accordance with the procedures and the manager analysed the complaints to check for any common themes or trends.

The service had quality assurance systems in place and carried out audits to check the quality of care in specific areas. However, the systems in place were not always effective as they had not identified and made improvements in some of the areas highlighted in this report.

People were asked for their feedback about the quality of the service provided and involved in discussions about how the service could be improved.

We carried out an unannounced comprehensive inspection of this service on 15 January 2015. A breach of legal requirements in relation to cleanliness and infection control was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to the breach.

We undertook this unannounced focused inspection on 15 July 2015 to check that the provider had followed their plan and to check whether they met legal requirements. This report only covers our findings in relation to this requirement and other areas that were found to require improvement at the last inspection. These areas were under the relevant key questions of; is the service safe, effective, responsive and well-led. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Clarence Lodge on our website at www.cqc.org.uk.

Clarence Lodge is a service that provides accommodation and care to older people and people living with dementia. It is registered to care for up to 28 people. At the time of this inspection, there were 23 people living at Clarence Lodge.

This service requires a registered manager to be in place. 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. There is a registered manager in place at Clarence Lodge.

Some areas of the home and some equipment that people used remained unclean. These included the food storage area, the laundry and the communal lounge and toilets. Some chairs that people were sitting in were worn and stained. Equipment such as hoists, standaids and walking frames were not clean.

Risks to people’s safety had not always been assessed or the actions deemed necessary by the provider to protect people from a risk had not always been implemented. These included risks in relation to the safety of the premises, evacuating people from the building in the event of an emergency and monitoring people’s risk of not eating.

The quality systems that were in place to assess people’s safety in respect of the premises and some risks to their health and safety were not effective, placing people at risk of poor care.

This meant that there were some breaches of the legal regulations and you can see what action we told the provider to take at the back of the report.

We found that the provider had made some progress to other areas we identified as requiring improvement at our last comprehensive inspection in January 2015, although further improvements were required. These were in relation to staff knowledge of the Mental Capacity Act and associated training, the development of the premises into a more suitable environment for people living with dementia and the provision of activities for people that complemented their interests and hobbies. We will check these areas in detail at our next comprehensive inspection.

We have recommended that the provider considers current guidance on adapting their environment to assist people living with dementia.

The inspection took place on 15 January 2015. The inspection was unannounced.

At the last inspection on 9 July 2014, we found that the service was not meeting three Regulations in respect of safeguarding people, the safety of the premises and the monitoring of the quality of the service provided. We asked the provider to take action to make improvements in these areas. During this inspection we found that sufficient improvements had been made and that therefore the provider was no longer in breach of these Regulations.

Clarence Lodge is a service that provides accommodation and care to older people and people living with dementia. It is registered to care for up to 28 people. At the time of our inspection, there were 25 people living at Clarence Lodge.

This service requires a registered manager to be in place. 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. There is a registered manager in place at Clarence Lodge.

People told us that they felt safe and staff demonstrated that they knew how to reduce the risk of people experiencing abuse. Risks to people’s safety had been assessed. However, some equipment people used was not well maintained and some areas of the service were unclean, both of which increased the risk of people being exposed to infections.

Lifting equipment that people used had been regularly serviced to make sure that it was safe and risks in relation to the safety of the premises had been conducted to make sure it was safe to live in. There was a secure outside space but this was not accessible to all of the people who lived at the service and was not currently a pleasant environment for people to spend time in. The interior of the premises was not suitably decorated to assist people who lived with dementia to find their way around the building easily. The provider had a plan in place to improve the environment for the people who lived at the service.

People received their medicines when they needed them and they saw outside healthcare professionals such as a GP when they became unwell.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that the service was meeting the requirements of DoLS as they had recently requested authorisation from the Local Authority to deprive people of their liberty in their best interests. The staff demonstrated that they understood the principles of the MCA. This protected the rights of people who lacked capacity to make their own decisions.

People received enough food and drink to meet their needs and were given choice about what they wanted to eat, drink and how they spent their time. Staff supported people to make decisions for themselves. However, people did not always have access to activities that were of interest to them. The provider was aware of this and was actively trying to improve the activities that were offered to people.

Staff were kind, compassionate and caring. They respected people and treated them as individuals. Staff had received enough training to give them the skills to support the people they cared for and they were supported by the management team to perform their role.

The provider monitored the quality of the care they provided by asking people’s opinions, analysing incidents and accidents and conducting audits. People’s opinions were acted on and the provider learnt from incidents and accidents occurred. However, the monitoring of the cleanliness of the service and equipment used by people needed improving.

There was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We have made recommendations about: calculating staffing levels based on people’s individual needs, adapting the environment for people living with dementia and supporting people effectively to pursue their interests and hobbies.

An adult social care inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we spoke with six people who used the service, the manager, and two members of staff. We reviewed records relating to the management of the home which included, four care plans, daily care records, training records, support/supervision records of staff and quality information.

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

Is the service safe?

The six people who used the service told us that they were happy with the care and support provided. Three people told us that they felt safe, and one person said, “I would shout very loudly and then tell (the manager).” They went on to tell us about a recent incident that they had reported to the manager and was currently under investigation. Appropriate action had been taken to ensure the safety of the person concerned although the incident was not reported to the Care Quality Commission in accordance with the regulations.

We looked at four sets of care records. These included risk assessments to minimise risks to people’s health such as malnutrition and to people’s well-being for example road safety. Care plans detailed the support required by people and how this was safely delivered.

We found that the environment did present some risks to people’s safety and improvements were needed.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. The new manager of the service was aware of the procedures and explained a recent occasion where such an application had been considered. We were satisfied that people who used services would only be deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards.

We discussed staffing rotas which showed that there were sufficient numbers of trained and competent members of staff employed to provide people with safe and appropriate care as identified in their assessment and care plans.

Is the service effective?

During our inspection we saw that people who used the service were treated with dignity and respect. We observed staff as they carried out day to day duties and saw that they spoke appropriately at all times.

Quality assurance measures were in place to identify the quality of the service offered. However some improvements were needed to ensure they were effective and identified potential risks to people’s safety.

Is the service caring?

We saw that people were cared for in an appropriate manner. People we spoke with told us that, “We are well cared for, there is always someone to talk to. They (the staff) have time to sit with us and make sure we are alright."

We looked at four sets of care records. These detailed how the care should be provided and the planned outcomes.

Is the service responsive?

The four sets of care records we looked at showed that people's needs, choices and personal preferences had been assessed and planned for. There was information about the person’s life and on three of the four records. This was detailed and provided staff with information about people’s likes and dislikes and this information was used to plan activities.

We saw that the service had responded quickly to an allegation of abuse although not reported it to all parties as required by the regulations.

Is the service well-led?

There were monitoring and reviewing systems in place to measure the quality of the care and support provided but these were not always effective. Audits of the premises were not in place to identify and rectify potential risks to people who used the service.

Records showed that staff had received support and supervision and staff we spoke with confirmed this. Training was monitored by the registered manager to ensure all staff were suitably equipped to meet the needs of people they supported.

During our inspection of the 4 July 2013, we found that the provider was not meeting two of the sixteen standards of quality and safety. We received an action plan from the provider telling us how they were going to meet these standards. We returned to see if improvements had been made.

We found that improvements had been made.

Risks to people’s safety had been assessed and actions for staff to take to reduce these risks were recorded and were being implemented. This meant that the service had taken steps to keep people safe.

We had received a concern that there was not enough food for people to eat at the service and that the fridge was often poorly stocked. We found that there was sufficient food available to meet people’s needs and that they had a choice of food and drink. The people we spoke with told us that they were happy with the food.

The service was clean and hygienic and there were no unpleasant odours. This meant that people lived in a clean environment to protect them from the risk of the spread of infection.

During our inspection we spoke with ten people who used the service, two of their relatives, three staff members and the registered manager. We looked at six people’s care plans and four staff records.

The majority of people told us that they were happy living at Clarence Lodge. One person said, “I like living here, it’s good.” Another person told us, “I’m well satisfied.” A further person said, “I would recommend this place, the food is very good.”

An assessment of people’s needs had been made prior to them using the service and plans of care were in place to assist staff in providing care to people on an individual basis. Risks to people’s safety had been assessed. However, actions to reduce these risks from occurring had not always been identified or they were not being followed. This meant that the risks to people's safety were not always being managed effectively.

The communal areas of the service were clean on the day of our inspection. However, there were offensive odours in some areas and some equipment was not clean. These presented an infection risk.

Recruitment checks had been conducted before staff started working at the service. There were enough staff to meet people’s needs on the day of our inspection.

People told us that they did not have any complaints. The complaints procedure had been brought to the attention of people who used the service. There was a system in place to respond and manage complaints effectively.

People using the service told us that they were comfortable living in Clarence Lodge. People told us about choices they made, for example about their preferences for food. One said, "They know I don't like onions so they make sure there is an alternative for me. It is written up in the kitchen." Another person said, "They always ask you if you want more food." People's needs were carefully assessed before admission or re-admission to ensure the service could meet their needs.

Care plans identified how people should be supported and cared for. A visitor told us, "They look after my relative very well. They cared for them during a recent illness."

The service was clean and the staff followed the correct procedures for ensuring that people using the service were protected from the risk of infection.

Staff were well trained and undertook annual refresher sessions to maintain their knowledge and skills.

The provider asked people using the service and others for their views on improving the service, and made changes based on their suggestions.

People were seen smiling and interacting with staff with gentle banter, encouragement and suitable conversations taking place. One person told us they were not at all worried and that they were happy living there.

The people we spoke with as we toured the home told us they were happy with where they lived and that they liked their bedrooms.

During this visit a number of people who live in this home were unable to communicate fully with us. However we were given smiles, noted people interacting and comments such as “This is nice”, when eating their lunch, was overheard.

We noted that people were interacting with staff by using encouragement and visual clues such as choices of what to eat. These staff members appeared to know the people well. Good eye contact was seen when questions were asked. Choices were offered during any type of task and staff appeared to recognise and act on the signs they observed. One person said “I like it here” with another person saying that “This is fun”, when the staff were including them in the activity.

One person, who was having one to one time, told us how kind the staff team were. They told us that they included them in making decisions about what they would like to do to fill their day.

People with whom we spoke told us that since our last visit improvements had been made in respect of the meals provided at the home. They said that they now get more than one choice of main meal and are offered other alternatives if they don't like what's on the menu. One person said that the quality of the meals could be better and told us that the meat is sometimes tough. They also said that on occasions there was very little meat content in the meal.

For those people who were unable to verbally communicate their views and experiences, we observed the meals they received, the support they were given and looked for non verbal signs of satisfaction or dissatisfaction. We found that the mealtime experience was calm and people appeared to be happy with the food provided. People received appropriate support with their food and drink.

We spoke with people about how their medicines were managed. People told us that they received their medicines when they should and were happy with the way they were managed. One person said that they did not always know why they were taking the medicines they were given. Two people indicated that they had recently seen the doctor about changes in their health needs.

During our visit people who were able to express their views told us that they had all they needed. One person told us that they liked the music that was playing. Another person told us that staff were "Kind. They look after us."

People with whom we spoke told us that they were happy living at Clarence Lodge and that they felt able to raise any concerns they may have with staff. We heard people expressing their choices for how they were supported and for meals.

During our visit people expressed mixed views about the food. Whilst the majority were complimentary about what they were given to eat, some people were unhappy about the size of the portions and whether what they were given matched what they had asked for.

During our visit on 24 June 2011 we spoke with a limited number of people who were able to express their views.

None of the people with whom we spoke were aware of who their key worker was or had seen their care plans. However we observed staff speaking to people and gaining informal consent before undertaking interventions.

People spoke positively about their experience at Clarence Lodge. They told us that they felt able to raise any concerns they may have with staff at the home. They also told us that the hairdresser visits every Wednesday but that other activities are limited.

One person said that they had been in five different homes and “this is the best.” They said that they liked their room and en suite toilet. This person told us that they were able to go out regularly and sometimes travelled by bus. They also told us that they enjoyed working in the garden and that the home had provided them with the equipment and plants to pursue this activity.

People also told us that they can get up and go to bed at a time of their choice, providing staff are free to assist them. They also told us that call bells are answered promptly “unless they are busy”. Another person told us that they were supposed to be encouraged to walk but that the “staff don’t bother. They push me to the bathroom in my chair” This person told us that they stayed in their room most of the time and occasionally went to the dining room for lunch.

One visitor with whom we spoke told us that they were very pleased with how their relative was cared for. “She is always clean and tidy”. They told us that their relative had initially resisted socialising and activities but that staff had enabled them to go out in the garden and to do simple tasks, such as folding napkins.

One person with whom we spoke told us that the quality and quantity of the food was variable depending on who was doing the cooking. They said “It is better this week” and “There is no choice”. Another person told us that the food was “OK” and that the cook was good.

During lunch several people made adverse comments about the food, such as “The chips are terrible”; “The peas are hard” and “I can’t eat that” One person was heard to ask for a banana and was told “We haven’t got any.”

People with whom we spoke were mainly complimentary about the staff. “They are kind”. However one person told us that four or five staff had recently left the home and had been replaced by young staff who “don’t know what they are doing.” Another person told us that staff were “always coming and going. It is a difficult job.”