About the service: Epsom Lodge is a care home providing accommodation and personal care for up to 13 older people, some of whom may also be living with dementia. At the time of our inspection there were 7 people living at the service.

People’s experience of using this service: At our previous 6 inspections in April and September 2016, March and October 2017 and March and October 2018 we have identified breaches of regulations of the of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following enforcement action, our inspection on 15 March 2018 found that improvements had been made regarding some aspects of how the service was managed. However, at our inspection on 17 October 2018 we found these improvements had not consistently been sustained. This demonstrated a continued lack of management oversight and failure to sustain improvements within the service.

At this inspection we found the service had made improvements in all areas identified within our last inspection. However, a number of these improvements had been made recently by the new manager in post. This demonstrated the provider had not ensured all required improvements were actioned in a timely manner. Quality assurance processes had improved although continued development of auditing systems was required to ensure any shortfalls in the service were identified and addressed.

People were supported take part in activities in-line with their hobbies and interests although an increase in the variety of activities available and community trips would be of benefit to people. We have made a recommendation regarding this.

People told us they liked living at Epsom Lodge and there was a relaxed and pleasant atmosphere. People were supported by staff who knew them well and understood their needs and preferences. People told us they felt safe in the care of staff and risks to people’s safety and well-being had been identified and addressed. The environment was comfortable and adapted to meet people’s mobility needs. The manager was exploring different ways to ensure the environment fully met the needs of people living with dementia.

People had access to a range of healthcare professionals. Prompt referrals were made where healthcare concerns were identified which had led to positive outcomes for people. Medicines were managed safely. Staff received the training they required to support them in their roles. This included training specific to supporting people with their healthcare needs.

People told us the provider and manager were approachable and felt that any concerns would be addressed promptly.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Rating at last inspection: At the last inspection the service was rated Requires Improvement with the area of Well-led rated as Inadequate (report published on 7 December 2018)

Why we inspected: This was a planned inspection based on the previous rating of the service.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. We will check that the provider has made the improvements we identified as necessary through further inspections.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Epsom 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. Epsom Lodge is registered to provide accommodation and personal care for up to 13 people. There were seven people living at the service at the time of our inspection.

This inspection took place on 17 October 2018 and was unannounced.

There was no registered manager in post on the day of the inspection. 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 were supported by the two Providers during our inspection.

At our previous 5 inspections in April and September 2016, March and October 2017 and March 2018 we have identified breaches of regulations of the of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following enforcement action, our inspection on 15 March 2018 found that improvements had been made regarding some aspects of how the service was managed. However, four breaches of regulations were identified in relation to the training and supervision of staff, responding to complaints, safe recruitment processes and the overall governance of the service. At this inspection we found that although improvements had been made in a number of areas additional concerns were identified. This demonstrated a continued lack of management oversight and failure to sustain improvements within the service.

The provider was not meeting the conditions of their registration as there was no registered manager in post. Additional conditions regarding providing regular action plans to CQC had not been fully complied with. The provider had failed to display the ratings of their previous inspection on their website and within the service. Audits were not robustly completed to ensure that any areas which required improvement were identified and action taken. Systems implemented by the consultant employed by the provider and past managers had not been sustained.

Risks to people’s safety were assessed although for some people we found that guidance to mitigate these risks were not always followed. Personal emergency evacuation plans were not in place for everyone living at Epsom Lodge. In other areas we found that risk management plans were followed in order to keep people safe. Safe medicines practices were not followed in some areas and staff competency to administer medicines had not been assessed. Infection control processes did not always identify where improvements were required although staff were aware of the correct equipment to use. The premises were not always safely maintained as there was no periodic electrical installation certificate available and the annual gas safety check was out of date at the time of our inspection. A contingency plan was in place although this was not accessible to staff during our inspection.

The provider was unable to provide evidence that full assessments of people’s needs were completed prior to them receiving care. Care records were completed in detail for the majority of people living at the service although some people who had moved into Epsom Lodge required additional information. People’s needs were not always met in line with their care plans, particularly with regards to their personal care needs. Plans to meet people’s end of life care wishes had not been completed as recommended following our last inspection.

People told us that they enjoyed the food provided and we saw people were offered drinks throughout the day. However, people were not always offered a choice of meal options. The principles of the Mental Capacity Ac

Epsom 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. Epsom Lodge is registered to provide accommodation and personal care for up to 13 people. There were six people living at the service at the time of our inspection.

This inspection site visit took place on 15 March 2018 and was unannounced.

There was no registered manager in post on the day of the inspection. 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. Instead we were supported by the two Providers.

At the last inspection on 3 October 2017, we asked the provider to take action to make improvements. This related to the safety of people, how people were being safeguarded against the risk of abuse, staff training, the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), the involvement of people in their care, how people were respected, activities for people, the leadership at the service, the quality assurance and how complaints were being responded to. We found at this inspection that whilst some areas had improved, for example in relation to safety, safeguarding, care planning, MCA and DoLS, there were continued concerns around leadership, staff training, staff supervisions and complaints.

Staff had not always received training and supervision to support them in their role. Staff at the service had not always had robust recruitment checks undertaken before they started work. The business continuity plan contained very little detail around what needed to happen in the event of an emergency. People and their relatives were not supported when making decisions about their preferences for end of life care.

There were not always effective systems in place to assess the quality of care and to make improvements. We identified gaps in recruitment, training, supervisions and complaints that were not picked up in a timely way through audits. Complaints were not always investigated, recorded and responded to appropriately. Other audits were taking place that were used to make improvements. Staff meetings and surveys were undertaken to gain feedback.

There were appropriate levels of care staff to support people when they needed it. However we have made a recommendation about ancillary staff. The management of medicines was safe and completed by staff who had the appropriate training.

There were appropriate plans in place to ensure that risks to people were managed. Staff understood what to do to minimise risks in relation to people. Personal emergency evacuation plans were in place and staff understood what they needed to do to support people. Where people had accidents and incidents, actions were taken to reduce the risk of them reoccurring. People told us that they felt safe with staff. Staff had a good knowledge of what they needed to do if they suspected abuse.

The service was homely. The provider advised that improvements were going to be made in relation to environment to meet the needs of people living with dementia. People enjoyed the meals at the service and said they had sufficient choices. People’s health care needs were monitored including weight loss and any changes in their health. People had access to appropriate health care professionals where needed.

People’s rights were protected because staff acted in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Appropriate assessments had been completed where people’s capacity was in doubt and applications to the Local Authority

This inspection was carried out on the 3 October 2017 to follow up on breaches found on the inspection in March 2017. We found that sufficient improvements had not been made.

Epsom Lodge is a residential care home without nursing for up to 13 people, some of whom may have dementia. On the day of our inspection seven people lived at the service.

There was no registered manager at the service. 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 was a manager that had just started working at the service who supported us on the day of the inspection.

There were aspects to care delivery that remain unsafe and people remain at risk. Where a risk had been identified no assessment had taken place to plan how people could be protected from risks. People at risk of malnutrition and dehydration did not have systems in place to monitor their health or to ensure they had adequate food and fluids. Accidents and incidents were not always investigated or analysed. Staff were not always following best practice in relation to infection control and medicines were not always managed in a safe way. There were aspects to people’s medicines that were being managed in a safe way.

People were not always protected from the risk of abuse as staff were not always reporting incidents to the Local Authority. Staff did not always have the skills and competencies they needed to meet people's needs and ensure their safety. Although training was being provided staff were not always providing the most effective care. Nutritional assessments were not always updated to reflect a changing need and guidance was not always available.

We have recommended that there are always the appropriate numbers of staff available as at times they were lacking. People’s rights were not always protected because the staff did not always act in accordance with the MCA or DoLs. MCA assessments were not taking place particularly when specific decisions needed to be made. For example in relation to people being given medicines covertly and people being kept in their room.

There were some people at the service that were at risk of social isolation and staff did not have sufficient meaningful interactions with them. There were times where people were not always treated with dignity.

Care plans lacked detail around the specific needs of people. Where a need had been identified there was not always detailed guidance for staff. Improvements were still needed around the activities provided when external entertainment was not being provided.

The provider continued to breach regulations from previous inspections. Audits and surveys were not being used as an opportunity to make improvements. Not all staff were attending meetings to discuss best practice. Notifications that were required to be sent to the CQC were not being done. Complaints were not being investigated, recorded and responded to.

Robust recruitment checks were in place that ensured that only suitable staff worked at the service. There were appropriate plans in place in the event of an emergency at the service.

People enjoyed the food at the service and were offered choices of meals. Where health care professionals needed to be contacted this was being done, with the exception of two people who had lost weight.

Staff at the service were observed to be kind, caring and respectful towards people. People that were able could access all areas of the service when they wanted.

We found a number of continued breaches and new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is 'Inadequate' and the service therefore remains in 'Special measures'.

This inspection was carried out on the 8 March 2017. Epsom Lodge is a residential care home without nursing for up to 13 people, most of whom are living with dementia. On the day of our inspection 10 people lived at the service.

There was no registered manager at the service. The manager that had been working at the service had not submitted an application to the Care Quality Commission (CQC) at the time of the inspection. A registered manager is a person who has registered with the 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 were not always enough staff deployed in the service at night to safely provide care to people. However there were sufficient staff on duty during the day.

Risk assessments for people were missing or incomplete and other assessments were not always detailed. There was not enough information to guide staff in how to reduce the risks to people and protect them from harm. Incidents and accidents were not always recorded or followed up and lacked detail and actions put in place to reduce the risk of incidents.

The safety of the premises and equipment was not well maintained to a safe standard and people were put at risk. People's medicines were not always being managed in a safe way as staff had not received training and had not been competency assessed in medicines management. Other aspects of medicines management was being managed in a safe way.

Personal evacuation plans were not in place for every person who lived at the service and staff had not received fire safety training.

Staff had knowledge of safeguarding adult's procedures and there was a safeguarding adult's policy in place. One person told us they felt safe.

Recruitment practices were not always safe and relevant checks had not always been completed before staff started work.

People's rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not been completed specific to the decision that needed to be made around people's capacity. DoLS applications had not always been submitted to the local authority where it may have been appropriate.

People were not always receiving care from staff that were competent, skilled and experienced. There was a risk that people were receiving care from staff who were had not had training to meet the needs of people living with dementia. Staff competencies were not assessed as they did not have appropriate supervision or appraisals.

The environment did not meet the needs of people living with dementia.

People were not always provided with choices that met their reasonable preferences including at meal times and regarding what care they wanted. People at risk of dehydration or malnutrition did not have systems in place to support them. People had access to health care professionals to support them with their health needs.

We did see times when individual staff were caring and considerate to people. People told us that staff were kind towards them.

The provider was not always responsive to people's needs. There was no detailed information in people's care plans around the support they needed. There was a lack of guidance around care for people living with dementia or those that had challenging behaviours.

There were not enough activities on offer specific to the needs of people. There were periods of time where people had no meaningful engagement with staff.

There were not effective systems in place to assess and monitor the quality of the service. Although an audit had been undertaken this

Epsom Lodge is registered to provide accommodation with care for up to 13 people. At time of our inspection there were nine people living at the home. The majority of the people who live at the home are living with dementia. The accommodation is provided over two floors that are accessible by stairs and a lift.

The inspection of Epsom Lodge took place on 19 September 2016 and was unannounced. This inspection was to follow up on actions we had asked the provider to take to improve the service people received.

At the time of the inspection Epsom Lodge did not have 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 were informed that the manager had commenced the application process to be registered as manager with the CQC.

At our previous inspection on 8 and 11 April 2016 we found breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to take action in relation to infection control, risk management, obtaining consent in accordance with the requirements of the Mental Capacity Act 2005, deployment of staff and assessing and monitoring the quality of the service provided. The provider sent us an action plan and provided timescales by which time the regulations would be met. They stated that the actions would be completed by 2 August 2016.

During this inspection we found that some improvements had been made. However, they were not sufficient enough to meet the requirements of the regulations.

The management of medicines had improved but there were areas that still required further action. Although people got their medicines as prescribed, the conditions medicines were stored in needed improving. Staff had not completed the Medicines Administration Records correctly in line with current guidelines.

People’s risk of infection or cross contamination was reduced due to the improvements made. Although staff followed best practises in infection control and maintained appropriate standards of cleanliness, there were still areas that needed to be addressed.

People were not always safe because there were a number of inconsistencies in the systems and arrangements to protect people from harm. Robust and up to date risk assessments were not in place to identify, assess and manage risk safely and to minimise the risk of harm to people. Although environmental risks around the home had reduced, there were still improvements needed. The management team did not monitor trends or identify patterns in regard to accidents or incidents.

People were not always protected from being cared for by unsuitable staff because although recruitment processes were in place, they were not always followed.

Although additional staff had been employed and people told us they were happy with the staffing level at the home. The employment and deployment of staff still had an impact on the care people received and the range of activities provided.

Staff did not have a clear understanding of their responsibilities regarding the Mental Capacity Act or Deprivation of Liberty Safeguards. Where people lacked capacity they were not fully protected and best practices were not being followed.

Staff received the training and skills they needed to meet people's needs. However they did not receive appropriate support such as supervision and appraisals that promoted their professional development or reviewed their performance.

People were supported to have access to healthcare services and healthcare professionals to support their wellbeing. The service worked effectively with health care professionals and referred people for treatment when necessary. However, where peopl

This was an unannounced inspection that took place on 8 and 11 April 2016.

Epsom Lodge is registered to provide accommodation with care for up to 13 people. At time of our inspection on 8 April there were 10 people living at the home. Upon our return on 11 April 2016 there were 11 people living at the home. The majority of the people who live at the home are living with dementia, some of who may have complex needs. The service also provides end of life care. The accommodation is provided over two floors that were accessible by stairs and a lift.

At the time of the inspection Epsom Lodge did not have 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.

The management of medicines required improvements. Although people got their medicines as prescribed, the conditions the medicines were stored in and how they were secured were ineffective.

People were at risk due to unsafe practices taking place. Although the provider had systems to ensure appropriate standards of cleanliness were maintained, best practices were not always followed for the prevention and control of infection.

There was an insufficient number of qualified staff deployed to meet the needs of all people who required care. Risk assessments were in place, however people were placed at risk of harm as appropriate guidance and best practice was not always followed.

Staff did not have a clear understanding of their responsibilities regarding the Mental Capacity Act or Deprivation of Liberty Safeguards. Where people lacked capacity they were not fully protected and best practices were not being followed in accordance with the Mental Capacity Act.

There were inconsistencies with how the home carried out their own pre assessments before people moved into the home and therefore they were not always robust enough. Pre-assessments assist the home to ascertain information about people’s care and support needs and to assess whether they can meet the person’s current needs. This information was used to develop care and support in accordance to people’s needs to ensure staff had the most up to date information. Care records did not reflect up to date information regarding people’s care or support needs which meant new or agency staff who did not know people might not be working to the most up to date information.

There were inconsistencies with the quality assurance systems in place, to review and monitor the quality of service provided. They did not always identify or take action to improve poor care practices. The management and leadership of the home were ineffective. This meant that whilst there were arrangements in place to manage standards, people were not fully protected against the risks as there was no systematic approach to managing these.

People told us that they felt safe at Epsom Lodge. People told us, “I feel safe and the staff are good to me.” Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from abuse.

Staff told us they had regular meetings with their line manager to discuss their work and performance. However, we reviewed the provider’s records and there was not current information recorded about the discussions to show that staff had discussed their work practices, training and role with their managers. We have made a recommendation that the provider ensures that all support meetings are documented in line with best practice.

People had access to healthcare professionals and social care professionals. People were supported by staff or relatives to attend their health appointments. Although people’

During our visit to Epsom Lodge we were able to speak with five residents, three relatives and four members of staff. We were also able to spend time observing how the residents interacted with staff.

From the observations that we made, we felt that residents seemed comfortable and happy in Epsom Lodge and they were treated by the staff with respect. One resident we spoke with told us “I’m looked after pretty well – no complaints.”

We talked to the chef on the day of our inspection and observed that residents were given a nutritious hot meal for lunch. When we asked people’s opinions on the quality of the food we were told by one person “The food is excellent.”

We looked at the staffing rotas during our inspection and found that the provider ensured that a sufficient number of staff were available during each shift to care for the people who used the service.

The provider did not carry out quality assurance surveys to identify whether or not the residents and their relatives were happy with the care provided. However, none of the people we spoke with were unhappy with the care provided.

During the inspection we spoke with nine people who used the service, the manager and the registered providers, who also worked at the home. We spoke with five relatives by telephone following the inspection.

People who used the service told us that they enjoyed living at the home and that staff provided good care. They said that staff were always polite and treated them with respect. One person said, “I'm very happy here; I can’t fault it” and another told us, “The staff are all nice people. They're very good.” Relatives confirmed that their family members received good care and support. One relative said of their family member, “She’s well cared for and very content” and another told us, “The care she gets is fantastic. She’s really well looked after.”

Whilst the care people received was good, we found that the assessments carried out before people moved into the home did not address all relevant areas. This meant that some people had needs that had not been identified before they moved into the home. We also found that care plans did not provide sufficient detail about people’s individual preferences regarding their care.

Relatives told us that their family members would benefit from more in-house activities and opportunities to go out. One relative said, “My only complaint is a lack of activities” and another told us, “My mother would benefit from more opportunities to socialise or leave the house.”

People told us that they were happy living at Epsom Lodge.

They felt their wishes and expectations were taken into account when making a choice about living there.

A relative told us that they chose the home on behalf of their family member because it was small and homely. They also told us that they were satisfied with the care provided and the communication regarding care and treatment.

There was good feedback regarding the food and people told us that the cook was very accommodating and listens to their views.

People felt that there was sufficient staff employed in the home to meet their needs.