We carried out a comprehensive inspection on 15 and 16 March 2017. At our last inspection in February 2016, we found two breaches of the legal requirements. These related to the safe management of medicines and management of people’s specific hydration needs. The provider sent us an action plan following the inspection. At this inspection we found sufficient actions had been taken to address the breaches.

The inspection was unannounced. Horfield Lodge provides nursing and personal care for up to 75 people. At the time of our inspection there were 68 people living in the home.

There was a registered manager in place at the time of our inspection. 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.

People told us they felt safe in the home. They were cared for by staff that had been trained and understood their responsibilities with regard to keeping people safe from avoidable harm and abuse. Risk assessments were completed and risk management plans were in place.

People‘s healthcare needs were met. People were supported to make decisions on a day to day basis. Staff identified when people’s needs changed and they obtained support and guidance from external health care professionals.

Staff demonstrated a kind and caring approach and they treated people with dignity and respect. Staff knew people well and were able to tell us about people’s likes, dislikes and preferred routines which were reflected in their care records.

There was a range of activities that people could participate in and people were enjoying group and one to one activities on the days of our visit. A team of volunteers provided additional support.

People, staff and relatives told us the home was well-managed. People and relatives told us the registered manager was readily accessible and available to them. Staff told us they were well-supported and that the home was a good place to work.

The inspection took place on 9 February 2016 and was unannounced. We undertook a focused inspection in May 2015 and, at that time, one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was found in relation to record keeping.

Horfield Lodge is a care home with nursing for up to 75 people. Care is provided for older people, some of whom are living with dementia. There were 71 people living in the home on the day of our visit.

There was no registered manager in post. A manager was in post and had submitted their application to the Care Quality Commission to be the 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 our last inspection in May 2015 we found that records relating to people’s care and support were not always accurate or complete. At this inspection we found that sufficient improvements had been made with regard to record keeping.

Medicines were not always managed in accordance with the provider’s policy. For one person, specialist advice was not followed in relation to their hydration requirements.

There were enough staff to meet people’s needs. People felt safe and supported by staff.

People were cared for in a safe, clean and well maintained environment.

People told us they liked the food served at Horfield Lodge. Food choices were offered and drinks were readily available. A coffee shop provided an additional option for people to purchase drinks and snacks.

The management team and staff were aware of their responsibilities with regard to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS).

Staff were kind, compassionate and attentive when attending to peoples’ needs. People were provided with person centred care which encouraged choice and independence.

Activities provided were varied and responsive to individual needs and abilities.

People and their relatives were positive about the leadership and management of the home.

People felt they could raise concerns and were confident actions would be taken to address issues identified.

We found two 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.

We carried out a comprehensive inspection of Horfield Lodge on 16 December 2014. Three breaches of the legal requirements were found at that time. These related to safeguarding, the Mental Capacity Act 2005 and record keeping. After the inspection, the provider sent us a report of the actions they would take to meet the legal requirements.

We undertook a focused inspection on 28 May 2015. This was to check the provider had followed their plan and to confirm they now met the legal requirements.

This report only covers our findings in relation to these specific areas. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for ‘Horfield Lodge’ on our website at www.cqc.org.uk.

Horfield Lodge is a care home with nursing for up to 75 people. Care is provided for older people, some of whom are living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our focused inspection on 28 May 2015, we found some good practice in relation to record keeping; however more needed to be done to ensure consistency and enable effective monitoring of the support that people received. This was particularly in relation to the support provided to people to reposition when they were at risk of developing pressure damage to the skin.

There was good practice in relation to the monitoring of some wounds to the skin, with photographs being used to document how the wound was progressing. We also found good recording in relation to the monitoring of people’s weight and the action taken when concerns were identified.

Progress had been made in ensuring that appropriate action was taken to safeguard people from potential abuse. When unexplained marks or bruises were found on a person, these were reported to the safeguarding team accordingly. There was also evidence that when a person returned from another establishment with unexplained marks on their body, then enquiries were made in order to establish how the marks occurred. This would help ensure that people were safe and action taken to protect them when necessary.

Progress had also been made in ensuring the people’s rights were protected in line with the Mental Capacity Act 2005. Where a person was found to lack capacity to consent to the use of bedrails, a specific capacity assessment was in place and a best interests decision documented.

As a result of the findings of this inspection, the rating for the key question ‘is the service safe’, has been changed from ‘requires improvement’ to ‘good’. Overall the rating for the service remains as ‘requires improvement’. We found one breach of regulation at this inspection. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 16 December 2014 and was unannounced. The home was previously inspected in October 2013 and breaches of regulation were found; a warning notice was issued in relation to records and compliance actions were issued for staffing levels and care and welfare. Further visits to the service were made in November 2013 and January 2014 and we found that action had been taken to address the breaches of regulation.

The service provides nursing care and accommodation for up to 75 people. The home is split in in to three areas. There is a floor for people with nursing needs, a floor for people with personal care needs and an area for people with living with dementia. There is a registered manager in place. 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 service was not always safe. Staff received training in safeguarding adults; however we found that potential concerns about an individual had not been followed up, when they had returned to the home from a stay in hospital.

Applications had been made to the relevant authorities to deprive people of their liberty when it was appropriate to do so to keep them safe. However people’s rights weren’t always protected fully in line with the Mental Capacity Act 2005 because procedures weren’t always followed when gaining people’s consent for the use of bed rails.

There were adequate numbers of suitably trained staff available to support people in the home. Staff received training in a range of subjects relevant to their role. We viewed staffing rotas as evidence of this and spoke with staff.

People were protected because there were arrangements in place to ensure that people’s medicines were stored and administered safely. There were risk assessments in place to guide staff in providing support in a safe way.

There were arrangements in place to protect people from the risks of malnutrition because people’s weight was monitored and action taken when concerns were identified. However not everyone was positive about the quality of the food in the home and reported that they would prefer more fresh vegetables. People were supported to see other healthcare professionals such as GPs and specialist nurses when necessary.

People were supported by staff who were kind and caring and we saw positive relationships between staff and people in the home. People and their relatives had opportunity to be involved in their care planning.

People had opportunity to take part in a range of activities and there were records of these in people’s files. People were also supported by a chaplain and could attend prayer meetings and receive communion if they chose to do so.

People’s support was reviewed regularly. A new system was being introduced so that relatives knew in advance on which day their relative’s support plans would be reviewed so that they could attend if they wished to. Relatives also had opportunity to raise concerns at meetings and ‘relative clinics’ with the registered manager. There was a formal complaints procedure in place and we saw examples of complaints that had been responded to appropriately.

The home was well led and staff told us they felt well supported and could raise any issues or concerns. This showed that an open and transparent culture was encouraged in the home. There were systems in place to monitor the quality and safety of the service. This included a programme of audit to review aspects of the service such as medicines and people’s support plans.

We found three breaches of regulation during this inspection. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place to check on the improvements made since our last inspection in October 2013, when we found that regulations were not being met in relation to care and welfare and staffing. Following this inspection we received an action plan setting out the steps that would be taken to achieve compliance. When we returned to the service in January 2014, we found that improvements had been made.

During our visit, we saw that people were receiving support with their meals and drinks. Records relating to their care demonstrated that support was being provided in accordance with their needs. Care was provided in a calm atmosphere and people that we spoke with told us that they received support when they needed it and were well cared for.

Due to some staffing issues, the activities programme wasn't yet operating in the way that the manager had hoped. However, recruitment of a second activity coordinator had just taken place at the time of our inspection.

We found that action had been taken to address concerns raised at our last inspection. This meant that medicines were looked after safely. People's medicines were available for them to take as prescribed. One person told us that staff always brought their pain relieving medicine three times a day. Another person told us that they were able to order and look after their own medicines and that this helped them keep some independence. Records showed that people were given their medicines correctly.

This inspection took place to follow up concerns found at our previous inspection in October 2013. At our inspection in October 2013 we found that people were not fully protected from the risk of unsafe care because accurate records were not always maintained. We judged that this had a major impact on people living in the home.

We returned to the service in November 2013 and found that improvements had been made. Records relating to people's care and support were being filled in consistently. It was evident that food and fluid charts were being monitored because the amounts of fluids were being totalled so that daily intake could easily be seen. We also noted that a number of support plans had recently been updated and information relating to people's weight was recorded in line with their support plans.

One person who told us that although staff looked after their medicines they were able to take their pain relieving medicines at a time that suited them. We heard staff ask people if they needed medicines prescribed when required for pain relief.

Arrangements in place for ordering medicines were not always adequate to ensure a supply was always available. We saw three examples where someone had been unable to take one of their medicines for more than 2 days because a new supply had not been received.

Some people were prescribed medicines to be given 'when required'. Additional information was not always available to ensure that staff were able to give these medicines appropriately.

We found that improvements were needed to ensure that people were better protected from the risks associated with medicines.

We carried out this inspection to follow up concerns found when we last visited the home in March 2013. During our visit, we found that improvements had been implemented and systems were being developed so that the manager was able to monitor the service provided.

People living in the area of the home for people with dementia were unable to speak with us directly. However, we carried out a structured observation and saw examples of people reacting positively to staff interactions and people enjoying time in the lounge listening to music.

We saw that improvements had been made in relation to the quality and quantity of food provided for people. People were able to make choices about the food they wanted and were able to have more if they wished. Staff told us that there were drinks rounds for people between main meals, with cakes and biscuits on offer.

A pharmacist inspector formed part of our inspection in order to look at the recording and administration of medicines. We found shortcomings in the obtaining, recording and safe administration of some medicines.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an Expert by Experience (people who have experience of using services and who can provide that perspective) and a practising professional.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. During our visit we spoke with seven people who lived at the home.

When we visited the home we were told that the home had been open for almost a year. During that time the number of people living at the home had increased to the 66 people that lived at the home when we visited. Most people told us that they liked living at the home and others told us they were still getting used to living in the home and staff were supporting them with this.

People we spoke with told us that they liked the staff and they understood their support needs. One person told us “The staff work very hard and are very good”. People told us that they felt safe at the home. One relative told us ‘Mum is safe at the home and the worry and stress of caring for her had been lifted since she moved into the home”.

Most of the people we spoke with told us that they liked the food at the home. One person said “the food is excellent most of the time”. The home had introduced a new menu and ordering system. We observed that some people in the home found the process of ordering their food difficult. We saw evidence that the manager was monitoring the system and was in the process of developing it further to ensure that everyone at the home was able to choose their meals effectively.

Throughout the day we observed staff addressing people by their name and knocking on doors before entering people’s rooms. Staff we spoke with were clear about promoting people’s dignity and treating people with respect.

We saw that people were involved in making decisions about their care and support. One person told us that they had an assessment before they moved into the home. However, we found that people’s involvement was sometimes not recorded in their care records.

We received information from a number of sources as part of this inspection and issues of concern were highlighted to us; these were predominantly in relation to the nursing floor of the home. We also received communication from families who wanted us to know about the positive experiences of their family members. We received some comments from people living in the home, such as staff are “alright to me". We met another person in their room who was making their own bed who said that "I don't mind doing it to help them, the staff are ok just not enough of them".

Observations that we made showed that people weren't always supported in a person centred way and that they didn't always receive adequate support. For example, we found evidence that people weren't always supported with their food and drink. At other times, we saw that staff were caring and kind and offered support to people when they were withdrawn or upset. Staff told us that staffing levels were inadequate and that this had an impact on how well they could deliver care. The observations that we made supported this view.

Staff received training to support them in their roles and this included training particular to the needs of people living in the home. We found significant concerns in relation to record keeping. Records relating to personal care and food and fluids were not being consistently completed by staff. This presented a risk that staff would not be able to monitor to care that people received.