This unannounced inspection was carried out by one inspector and took place on 5 and 8 December 2017.

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.

Heron Lodge is a care home with nursing and is registered to accommodate up to 30 older people in one adapted building. People in care homes receive accommodation and personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At our last inspection on 11 October 2016, we asked the provider to take action and make improvements to ensure that care was focussed on individual needs and preferences. In addition, we asked the provider to make improvements to ensure their systems for monitoring and improving the quality and safety of the service were effective.

The findings from our inspection on 5 and 8 December 2017 confirmed that appropriate action had been taken and significant improvements had been made.

There had been a considerable change to the staff team since our last inspection, which included a new registered manager, deputy manager and activities coordinator. We found that the whole staff team worked cohesively to ensure people living in the home were consistently safe, well cared for and happy. We saw that the care provided was centred around each person as an individual and staff came up with innovative ways to ensure people could be included and involved in meaningful activities and entertainment.

There were enough staff working in the home to help ensure people's safety. Staff worked well together to ensure people's needs were met safely and appropriately. Proper checks were carried out when new staff were recruited, which helped ensure only staff who were suitable to work in care services were employed. Staff knew how to recognise different kinds of possible abuse and understood the importance of reporting any concerns or suspicions that people were at risk of harm appropriately.

Risks to people's safety were identified, recorded and reviewed on a regular basis. There was also written guidance for staff to know how to support people to manage these risks. Staff worked closely with healthcare professionals to promote people's welfare and safety. Staff also took prompt action to seek professional advice, and acted upon it, where there were concerns about people's mental or physical health and wellbeing.

People's medicines were stored and managed safely and administered as the prescriber intended. Staff were appropriately trained and competent to support people with their medicines.

People enjoyed their meals and were provided with sufficient quantities of food and drink. People were also able to choose what they had. If people were identified as possibly being at risk of not eating or drinking enough, staff would follow guidance to help promote people's welfare and input would be sought from relevant healthcare professionals.

Staff were trained well and were competent in meeting people's needs. Staff understood people's backgrounds and preferences and supported people effectively. New staff completed an induction and all staff had frequent one-to-one time with their line manager, during which supervisions and appraisals of their work were undertaken.

Staff understood the importance of helping people to make their own choices regarding their care and support and consistently obtained people’s consent before providing support. Some people did not have the capacity to make all their own decisions but staff understood how to act in people’s best interests, to protect their human rights.

Staff had developed respectful, trusting and

Heron Lodge is registered to provide accommodation, nursing and personal care for up to 30 older people, some of who may be living with dementia. There were 29 people living in the home at the time of our visit.

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.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People did not always receive care that took into account their individual needs and

preferences and how these could be met. Systems for monitoring and improving the quality and safety of the service, having regard to the accuracy of records and for seeking the views of others, were not always operating effectively. You can see what action we told the provider to take at the back of the full version of this report.

Systems were in place, including staff training, to protect people from the risk of abuse. There were risk assessments that staff followed to help mitigate risks to individuals and their environment.

There were enough staff to keep people safe. Although there were enough to keep people safe, there were not always enough at night to respond to people’s needs in a timely manner. There were recruitment procedures in place to ensure that staff deemed suitable to work with people were employed.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that the home was not always working in line with the requirements of the MCA.

People received enough to eat and drink, although not everyone was offered the same choice of meal. People had timely access to healthcare.

People told us staff were compassionate. However, staff did not always interact with people effectively or missed opportunities to do so. Staff did not always interact with understanding of people living with dementia.

The service did not consistently meet people’s social needs and personal preferences. The provision of activities was not always varied according to people’s interests. There was little stimulation for people who stayed in their rooms.

There were several areas where audits or observations had not picked up issues with regard to person centred care and staff competency.

You can see what action we told the provider to take at the back of the full version of the report.

A single inspector carried out this inspection. The focus of the inspection was to answer the five key 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?

Below is a summary of what we found. The summary describes what people using the service, relatives and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports the summary, please read the full report.

Is the service safe?

During our observations throughout the day, we could see that there were sufficient staff on duty to meet the needs of people living at Heron Lodge. At lunchtime, people were supported to eat their meal at their own pace and were enabled to be as independent as possible.

People were cared for in an environment that was safe, clean and hygienic. Regular health and safety audits took place to ensure that all equipment and systems were working safely.

We spoke with staff who demonstrated to us that they had the skills and experience necessary to support people appropriately. Records showed that staff received training that was relevant to their roles and reflected the specific needs of people living at this home. One relative told us, “We are very satisfied with the care now. The home is much improved.”

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to all care services. An application had needed to be submitted by this service and proper policies and procedures were in place so that people who could not make decisions for themselves were protected. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Relatives told us they were happy with their loved ones living at this home. One relative told us, “I am very satisfied. Staff seem nice and there are usually staff about. I am always made welcome.”

Staff explained how they communicated with people who were not always able to understand what was being said because they were living with dementia. Staff were able to tell us about individuals’ preferences, their health requirements and how they effectively supported people to be as independent as possible. Our observations showed that people were supported to make choices as much as possible and staff described various ways they established people’s preferences, including using picture menus.

Is the service caring?

Our observations showed us that people were treated kindly and with respect. Staff were supportive and attentive to people and their needs and preferences. We heard staff speaking to people in a warm and friendly way.

We noted that people were spending their time either in the lounge, their bedroom, or they were walking freely about the home. Where necessary, staff were supporting people to move between various locations. An entertainment during the afternoon meant that many people were in the main lounge. Throughout the day we noted that people appeared calm, relaxed and content.

Is the service responsive?

Relatives and advocates knew how to make a complaint although the complaints process was not displayed in the entrance hall where visitors would be able to see it. Copies of the complaints procedure were included in the service user guide and the statement of purpose. One relative told us they had made a complaint in the past but that they had no concerns at present.

People’s needs were assessed on a monthly basis. Where they changed we found that the service responded promptly and followed the advice given by health professionals. Care records showed that the service worked well with other agencies and services to make sure people received care in a joined up way.

Is the service well led?

The service last sought the views of people in May 2014 to ensure that they were providing a quality service that met people’s expectations. Once they had been returned, the questionnaires would be sent to head office for analysis and the development of an action plan. This was so that the service would continuously improve the quality of the experiences people received.

Staff told us they were clear about their roles and responsibilities. They understood the ethos of the home and had access to relevant training and development that enabled them to provide appropriate care and support.

We looked at the care records for nine people who had been identified as having higher levels of assessed need and saw that these contained consistent audits that had been implemented and regularly updated to ensure each person's health, safety and wellbeing was promoted and maintained.

We acknowledged that significant improvements had been made since the registered manager was appointed in November 2012 and the manager told us that the staff team, as a whole, had worked hard to ensure high standards of care were consistently provided and maintained.

Copies of correspondence from three relatives were all very positive in respect of the care and support being provided since the appointment of the manager. One person thanked the manager and staff and stated that their relative was 'so much better now'.

Correspondence that followed visits from Norfolk County Council's Quality Assurance Officer and a Clinical Quality and Patient Safety Manager from the NHS acknowledged the significant improvements that had been made with regard to people's care and welfare in the home.

During our inspection on 27 September 2012 we identified concerns with regard to information recorded in people's care records. We carried out a follow up inspection on 15 January 2013, to check that improvements had been made.

From a discussion with the nurse on duty, we identified how many people had higher levels of assessed need and looked at the care records for four of these people. However, we noted inconsistencies and found that some important information was lacking. This meant care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare.

During our inspection on 27 September 2012 we identified that people’s complaints were not fully investigated and resolved, where possible, to their satisfaction. We found that improvements had been made in this area when we carried out our inspection on 15 January 2013.

A family member we spoke with told us that most of the issues that they had previously raised had been acknowledged and dealt with appropriately and that communication had improved, since the new manager had been in post.

A family member we spoke with told us that they had raised a number of concerns with the manager during the past few months but had not received any responses. They said that they were unsure whether any action had been taken in respect of the issues they had raised, which included items of their relative's clothing going missing or being worn by other people.

This person also told us that their relative had fallen from their bed but that they did not know why or how this had happened.

People with whom we spoke told us that they the home was a good place to live in. One person commented: “It is wonderful here, they are very kind and help us how we want.” People told us that staff respected them, asked them if they were happy with care and listened to them.

We observed staff swapping responsibilities for the day for a person who did not want their regular carer to support them on this particular day and they told us that they were happy that staff listened to them and made changes how people wanted.

Two people told us that they preferred to sleep with their bedroom door open, but they were not disturbed as the home was quiet. We observed the noise in corridors before seven in the morning and all communal areas and corridors were quiet.

People were satisfied with the quality and the choice of food. One person told us, “We can choose what we want to eat. I did not want cereal this morning and they made me toast, I did not need to say it twice.”

People with whom we spoke told us that they felt safe in the home. The majority of them told us that food was good. Two people commented that they did not have a choice of food, however we saw them choosing toast instead of cereal for breakfast and the menu written on the board in a dining room that showed two meals each day.

People told us that they have pendants to call staff when they needed their help and that staff usually responded in a reasonable time. However, we saw some people who were being cared for in bed and noted that their call bell cords were out of reach and they were unable to call staff if they needed them.

Some people told us that they wanted their bedroom doors kept open and staff respected this, but we noticed that some people who were being cared for in bed also had their bedroom doors open while there was constant noise from a person living with dementia.

People with whom we spoke told us that staff were kind and good to them. One person missed a particular staff member who had left employment, as they were not taken out from the home as regularly since this person had left. The manager explained that there was a plan to designate another staff member to this person who would be able to continue to support the wishes and preferences.

Some people told us that they preferred to stay in their room because they did not feel appropriately stimulated by the activities organised in the home.