About the service: Leonard Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. On the day of the inspection the registered manager informed us that 58 people were living at the service.

People’s experience of using this service:

Staff received safeguarding training and understood how to recognise signs of abuse and who to report this to both internally and externally if abuse was suspected. Risk assessments provided staff with information on how to support people safely. The registered manager used information from accidents and incidents as a learning tool to prevent reoccurrence in the future. Whilst we saw robust evidence for analysis of accidents and incidents we noted that ABC charts were not always included as part of this analysis.(ABC chart is an observational tool that allows staff to record information about a particular behaviour. The aim of using an ABC chart is to better understand what the behaviour is communicating). We have made a recommendation about incorporating these records in the overall analysis.

Staffing levels were sufficient to ensure people's safety. Medicines were administered and managed safely by trained and competent staff. Medication audits took place to ensure safety with medicines.

The staff team had the skills and knowledge required to effectively support people. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff monitored people's healthcare needs and people had access to a variety of healthcare professionals.

Staff were kind and caring. People and staff had a good relationship and we saw many examples of staff working with people in a friendly and caring way. People had their privacy and dignity respected.

The provider had effective systems in place that were used to regularly review people's care and support that had been provided. Activities were organised to provide stimulation for people.

The service was well-led, with checks and monitoring arrangements used to maintain the quality of the service provided. Staff were positive about the leadership and skills of the registered manager Required information was very well organised and easily available in the service.

Rating at last inspection: Rated Good (Report published 29 June 2016).

Why we inspected: This was a planned inspection based on the date and the rating of the last inspection. The rating continues to be good overall.

Follow up: We will continue to monitor the service through the information we receive.

We previously carried out an unannounced comprehensive inspection on 28th August and 1st September 2015 at which time five separate breaches of the legal requirements were found. These related to the management of risks in and around the environment to ensure peoples safety; a lack of suitable arrangements in place to support staff with training and supervision, failing to treat people with dignity and respect their privacy, ineffective systems and processes to monitor quality and safety and failing to provide person centred care. Other areas requiring improvement included the recruitment and retention of sufficient numbers of staff to keep people safe.

Following the comprehensive inspection, the provider sent us an action plan, which set out what they would do to meet the legal requirements in relation to the five breaches and to improve the service. Because the breaches affected all areas of the service we undertook a further comprehensive inspection to check that the service had implemented their action plan and to confirm that they now met the legal requirements.

The inspection took place on 7th April 2016 and was unannounced. Leonard Lodge provides accommodation over two floors for up to 60 people who require nursing or personal care. There were 56 people living at the service at the time of our inspection.

The provider's registration required them to have a registered manager. At the previous inspection the service had made an application for a new registered manager and this person was now 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 this inspection we found that the service had followed its action plan to address the previous breaches which meant that the service now met the legal requirements and was no longer in breach of the regulations.

Significant improvements had been made with regard to treating people with dignity and respect however this was an area that still required further improvement. Staff were generally caring and less hurried when providing personalised care. However, people’s dignity was not always maintained and they were not always treated with respect.

Environmental risks were managed safely. Broken doors had been mended, a monitoring system was in place and the external hazards had been removed to improve people's safety when accessing outdoor areas.

There were sufficient numbers of appropriately trained staff in place who knew people well and were aware of their preferences so were able to provide more person centred care.

Staff received regular supervision and support from the management team which improved staff retention and job satisfaction and provided a method of assessing staff competency and promoting learning and development.

The provider had suitable arrangements in place for the management of medicines, and people received their medicines safely.

Staff were recruited safely in line with current legislative requirements, and were aware of their safeguarding responsibilities to protect people from abuse.

People were involved in making decisions about the care and support they received. Where people experienced difficulties with decision-making, they were supported by staff who were aware of their responsibilities under the Mental Capacity Act (2005) legislation. Where appropriate, mental capacity assessments had been completed. This ensured that any decisions taken on behalf of people were in accordance with the legislation.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs), making applications when necessary.

People were supported to maintain their health and had access to wide range of healthcare professionals.

A choice of

During our inspection, we spoke with four of the 57 people who were using the service. We also spoke with seven visiting relatives, six staff members and a visiting professional. We spent time observing care provided to people who had limited verbal communication.

We looked at six people's care records. We also looked at staff training records and records of the checks the provider had completed to monitor the planned improvements and the quality of the service.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure their safety and welfare. The records were regularly reviewed and updated. This meant that staff were provided with up to date information about how people's needs were to be met safely and effectively.

A relative said about the staff, “They come in and check hourly and turn [person], I do feel [person] is safe here without a doubt.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in writing their plans. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

People’s mobility and other needs had been taken into account in relation to signage and building adaptation, enabling people to move around freely and safely.

Is the service caring?

People told us that they received the care they needed. One person who used the service said, “I am cared for very well. They are all so kind to me. I have the activity list, it is word puzzles today and I love all the activities. The staff are very caring to all the people here.”

We noted that staff were kind and caring towards people who used the service. Staff spoke with people by name and interacted with them in a friendly and respectful way. They showed respect for people’s privacy and dignity during their personal care.

A visiting relative said, “I am delighted with the care. Staff are very, very caring.”

Is the service responsive?

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

All of the care records we looked at had been reviewed throughout each month and any changes had been noted. We were told by staff that changes to a person's needs were discussed at each handover meeting to ensure staff were made aware. This meant that people's changing needs were responded to.

Is the service well-led?

The provider had procedures in place to support the deputy manager to lead the service. The provider and the management team at the service had acted to ensure that improvements were made to the service following our inspection in March 2014.

At our inspection on 3 October 2013 we found that people’s individual care needs were not being met. We also found that staff were completing charts in advance of checks being carried out and care being delivered. We also found gaps in the recording of care delivery.

At this inspection on 12 March 2014 we found that the necessary improvements in these areas had not been made. People were not receiving the appropriate pressure care and care records were being completed in advance of care delivery.

We received information of concern regarding the care provided during the night to people who lived at the home. We carried out an inspection in response to this information and started our inspection at 10.25pm.

We found that some people who used the service were in bed, asleep. Other people were watching television. One person we spoke with told us, "I'm quite comfortable."

We spoke with four staff members who told us what their night time routine was and how they supported people who lived at the home. However, we found that there were areas that the service needed to improve in relation to meeting people’s needs.

We looked at care records for people who used the service and found that these were not completed accurately.

During our inspection we observed staff members’ approach to people who were living in the home. We saw that people were treated with dignity and respect.

We looked at six people’s care plans and saw that they included thorough assessments of people’s individual needs. We spoke with six people living at the home who were all positive about their experience. One person told us, “Lovely staff. If we need it, they’re here.”

There were systems in place to protect people from the risk of abuse. We spoke with three staff members who were clear on what their role was should they have concerns that a person had been at risk of abuse. We saw that staff had received safeguarding adults from abuse training.

During our inspection we saw that medication was managed appropriately and in accordance with published guidance.

Staff were supported appropriately and given access to training updates which included personal development. Staff told us they felt supported by their manager.

We spoke with six people using the service and two visitors during our visit to the home on 24 August 2012. People using the service told us that they felt well cared for and that their dignity, independence and right to make decisions were respected.

People told us that they enjoyed the social activities and entertainment that were available in the home. One person told us how they had been able to continue their love of gardening and had put in some plants that were doing very well. They were also involved with the activity co-ordinator in a ‘best garden’ competition that was going on with the provider’s other care homes.

People we spoke with told us they felt safe living at the home, that staff were kind and friendly and that they would feel able to speak out if they had any concerns. A visitor said, “I hear the way staff talk to people and it is always nicely. I have no concerns. I have my ear to the ground for such things as I have seen it on television. I have no concerns here.”

People confirmed that there were enough staff to meet their needs and to respond promptly to their requests for assistance. They told us that there were regular staff, who addressed them by their name and took time to talk to them and ask how they were.

People told us that they found the premises clean, comfortable and maintained to a good standard. One person said, “The room is fine, you have everything you need. The place is clean, comfortable and homely. I was able to bring my own pictures.” A visitor told us that they found the home “clean, with no odours”, and to be “a well kept place”.

We were unable to gather the views of some people using the service due to their limited verbal and cognitive ability. We spent time during the inspection visit listening to interactions and communication between people using the service and staff. We also spent some time directly observing everyday routines and practices to help us determine what it was like for people living there. Our observations indicated overall that people were relaxed and comfortable and found their experience at the home to be positive.

People with whom we spoke confirmed that they were respected and involved by staff and if they required any assistance staff would respond promptly.

We spoke with a number of people during our visit to Leonard Lodge. One person told us “It’s nice here.” We spoke with the relatives of a person living at Leonard Lodge who had recently become a resident. They told us that “The staff are very helpful and have taken time to build a good rapport with X. They have made arrangements for all their needs, I feel assured my relative is in a safe comfortable home.” One person we spoke with told us they were happy living at the home and liked their room. They told us “This is my home now and I am happy with my room.”

People with whom we spoke confirmed that they were satisfied with the care and treatment provided by staff. They felt able to approach staff if they had any concerns and were confident that these would be addressed appropriately. People told us that they enjoyed being in this service and that the staff were kind. Two people said that they were always doing something interesting.

The inspection took place on 28 August and 01 September 2015 and it was unannounced.

Leonard Lodge provides accommodation over two floors for up to 60 people who require nursing or personal care. There were 56 people living at the service at the time of our inspection.

The provider’s registration required them to have a registered manager in post. An application was being made at the time of our inspection for a new 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.

The arrangements at Leonard Lodge were insufficient for managing risks appropriately in relation to people's health and safety. There were risks in and around the environment which needed action to be taken.

There were not always enough staff with the skills and experience to care for people in a safe way. People were not provided with the care and attention they needed to keep them safe and well at all times.

No formal system of supervision and appraisal was in place, to make sure that people received care from staff who were skilled and confident in their role and responsibilities.

The provider had suitable arrangements in place for the management of medicines and people received their medicines safely.

Staff were recruited safely in line with the requirements of current legislation.

People were not always treated with respect and their dignity, privacy, choices and independence was not always promoted.

Deprivation of Liberty safeguards (DoLs) had been appropriately applied for. These safeguards protected the rights of adults who used the services and who do not have capacity to make their own decisions. Applications had been made appropriately for people who may require them. Appropriate assessment and authorisation by professionals had been completed, for any best interest decision taken regarding any restriction on their freedom and liberty. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice.

Assessments and care files contained all the necessary information about a person’s health and social care needs for staff to care for them appropriately.

Care based on risk assessments and information about people’s needs, wishes and preferences was not being carried out which meant that people did not receive a service which was consistently responsive to their needs.

A range of quality assurance systems were in place but were not being used effectively to drive improvement to the quality of the service being delivered. Improvement was needed in the areas of governance and leadership of the service to ensure the care and support provided to people was appropriate and was relevant to current best practice and good care.

We found that there were a number of breaches in the Regulations of the Health and Social Care Act 2008 Regulated Activities Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.