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.

The inspection took place on 21 and 22 November 2018 and was unannounced. At our last inspection on 25, 27, 29 September and 9 October 2017, the service was found not to be meeting the required standards in the areas we looked at. There were breaches against regulations of the Health and Social Care Act (Regulated Activities) 2014.

The breaches included regulation 9. Care and treatment of service users did not always meet their nutritional needs.

Regulation 12. The provider had not ensured people’s changing needs were reviewed and actions put in place to mitigate risks.

Regulation 13. The provider had not ensured all incidents had been reviewed and investigated to ensure people were safe.

Regulation 17. The provider had not ensured effective systems to monitor and improve the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in safe, effective, caring, responsive and well-led to at least good. At this inspection we found that the provider had made the improvements required.

There was a manager in post who had registered with the Care Quality Commission (CQC). 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 and associated Regulations about how the service is run.

The service was safe. Staff received training in safeguarding and understood how to report concerns. Recruitment practices ensured that suitable staff were employed. Accidents and incidents were monitored to identify any trends or patterns to ensure appropriate actions could be taken. Identified risks to people were reviewed regularly to ensure people’s changing needs and risks were managed. Medicines were managed safely by staff that received appropriate training. People were protected from the risk of infections by staff who followed correct infection control procedures.

The service was effective. People’s nutritional needs were managed appropriately. Staff received training to meet people’s needs effectively. Staff had inductions and supervisions and were supported to do their job. Staff worked in line with the principles of the mental capacity act. People’s care was reviewed regularly.

The service was caring. Staff knew people well and staff cared for them in a compassionate way. Staff respected people’s privacy and dignity and supported people to maintain relationships. Staff delivered care that was supportive, kind and caring. People were involved in deciding how their care was provided and staff promoted their choice.

The service was responsive. People received person-centred care. People`s needs were assessed to ensure they received the support they required. People were involved with their care plan reviews. People were given the opportunity to think about what was important to them regarding end of life care. People had a voice and the opportunity to discuss and raise concerns.

The service was well-led. The registered manager was very clear about their vision regarding the purpose of the home. Staff understood their roles and responsibilities and worked well as a team. There was an open culture and staff felt they could approach the management team at any time. There were effective systems to monitor the quality of the service, identified issues were actioned and lessons learned. People, relatives and staff were positive about how the home was run.

Further information is in the detailed findings below.

Monread Lodge is a modern purpose built home that provides accommodation and nursing care for up to 62 older people, some of whom live with dementia. At the time of this inspection 51 people were living in the home.

This inspection took place on 25, 27, 29 September and 09 October 2017 and was unannounced.

When we last inspected the service on 11, 12, 15 and 24 May 2017 the provider was not meeting the required standards in all of the areas we looked at. We found breaches of the regulations in relation to providing safe care and treatment, staffing levels across the home, and ensuring governance systems were effectively operated to monitor the quality of the service provided.

At this inspection we found that some improvements had been made, however there were areas that continued to require improvement, particularly in relation to the safety and wellbeing of people using the service and the service being well led. Following this inspection we referred our concerns to the local authority commissioning and safeguarding teams, and told the provider they must improve the quality of care people receive.

A registered manager was not 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 service at the time of inspection was supported by three interim managers, the regional manager and a senior manager.

People felt safe living at Monread Lodge. Staff were knowledgeable in relation to keeping people safe from harm and reporting incidents to management, however some incidents were not consistently reported and investigated. Staff awareness of people's current needs had improved however we found this was at times conflicting due to incomplete care records. People were supported by sufficient numbers of staff. People's medicines were managed safely and medicines were administered to people as the prescriber intended.

People told us they enjoyed the food provided, however, those people with specific dietary needs did not always have their needs met. Staff sought people’s consent prior to supporting them, however records did not always accurately record people’s consent to care and treatment. Staff told us they felt supported by the management team, and were receiving training and supervision in key areas. People were supported by a range of health professionals when their needs changed.

The consistency of involving people in their care was variable; however staff supported people in a kind and compassionate way. Staff were observed to have developed positive and caring relationships with people who lived at the home. When personal care was provided, this was carried out in a respectful way that promoted people's dignity but did not always take account of their needs and wishes.

People did not consistently receive support that met their changing needs and took account of their preferences and personal circumstances. People were able to pursue their individual interests; however there were not always sufficient opportunities for people to take part in meaningful activities. People and their relatives knew how to raise concerns and were kept informed regarding changes within the running of the service.

Improvements had been made to monitor and improve the quality of care people received by reviewing the systems used. However, these were not always consistent in identifying areas for improvement or maintaining these. We saw action plans were developed to support and drive improvement across the home, however at the time of inspection it was too early to measure their effectiveness and this will be further reviewed. People’s care records, although being reviewed continued to require additional work to ensure these were accurate.

Monread Lodge is a purpose built care home and is registered to provide accommodation and nursing care for up 62 older people some of whom live with dementia. At the time of our inspection 56 people were living at the home.

The home had a registered manager in post. 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.

The inspection took place on 11, 12, 15 and 25 May 2017. This inspection was in response to concerns we received regarding low staffing levels in the home. The inspectors arrived early in the morning of 11 May 2017 to inspect the service unannounced. On 12 and 15 May 2017 we contacted people’s relatives by telephone, and on 25 May 2017 we met with the provider to seek assurances due to the nature of the concerns identified at this inspection.

At our previous inspection on 18 October 2016 we found a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people were not supported by sufficient numbers of suitably trained and skilled staff.

At this inspection we found improvements had not been made in areas relating to safe care and treatment, staffing levels, and governance systems to ensure the service provided was safe and of good quality. At this inspection we found a continued breach of Regulation 18, and new breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to safe care and treatment, because people were not supported by sufficient numbers of staff deployed, and ineffective governance systems were in place to identify and improve the quality of care people received.

Following this inspection we referred our concerns to the local authority commissioning and safeguarding teams, and told the provider they must improve the quality of care people receive.

People were not supported by sufficient numbers of staff. Staff did not respond promptly when people required assistance. Staff were knowledgeable in relation to keeping people safe from harm and reporting incidents to management, however patterns were not always robustly investigated and responded to quickly. Staff were not consistently aware of people's current needs and how to keep people safe from the risk of harm. People's medicines were not consistently managed safely and we found an incident where one person had not received their medicines as intended by the prescriber.

Relatives and staff told us the registered manager was not responsive to concerns raised with them and was not visible around the home. People’s relatives told us they did not raise issues or concerns with the registered manager for fear of repercussions and previous lack of action from them. Governance systems were available to the registered manager to use to monitor the quality of care provided, however they were not effectively used. Continual concerns regarding staffing levels raised at the previous inspection and subsequently by staff, people and relatives had not been addressed. People’s records were not reflective of their current change of needs.

This inspection was carried out on 18 October 2016 and was unannounced. At their last inspection on 15 September 2015, they were found to not be meeting all the standards we inspected. This was in relation to infection control and management of medicines. We requested an action plan to set out how they would make the necessary improvements, however we did not receive this. At this inspection we found that they had made the required improvements. However, we also found that staffing at the service was an issue.

Monread Lodge is registered to provide accommodation for up to 62 people. The home provides support with personal care and nursing care for older people, some of whom live with dementia. At the time of the inspection there were 60 people living there.

The service had a manager who was registered with the Care Quality Commission (CQC). 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 and associated Regulations about how the service is run.

People received care that met their needs. However, people, relatives and staff all told us that staffing was an issue. On the day of our inspection we noted people had their needs met in a timely fashion in the main part of the house, however, in the smaller unit there was a delay in people receiving support. People were supported by staff who had undergone a robust recruitment process and were sufficiently trained and supervised. .

People’s medicines were managed safely and individual risks were assessed and monitored. People were supported in accordance with MCA and DoLS, were given choice and involved in the planning of their care. People had a choice of healthy food and received support to eat as needed.

There was regular access to health and social care professionals and communication in the service was effective. People were treated with dignity and respect. They told us staff were kind. Confidentiality was promoted.

People had their own care plans which gave staff clear guidance. Activities on offer supported hobbies and interests.

People, their relatives and staff were positive about the management of the service. Staff enjoyed working at the service and people liked living there. There were systems in place to identify and address any issues and the registered manager was enthusiastic about looking for ways to improve the service. Complaints were investigated and responded to and people's feedback was listened to.

Monread Lodge provides accommodation and nursing care for up to 62 older people. There were 60 people accommodated at the home at the time of this inspection.

The inspection took place on 15 September 2015 and was unannounced. At our last inspection on 18 July 2013 we found the service was meeting the required standards at that time.

The home had a registered manager in post who had been registered since June 2013. 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.

CQC is required to monitor the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection we found that applications had been made to the local authority in relation to people who lived at Monread Lodge and a number of these were pending an outcome.

People told us they felt safe living at Monread Lodge. Staff were aware of how to keep people safe and risks to people’s safety and well-being were identified and managed. However not all care plans robustly informed staff of how to support people, particularly those with behaviours that may challenge.

People and staff told us there were not always sufficient staff available to support people’s needs. We observed at busy periods such as morning and lunchtimes that people had to wait lengthy periods to receive support.

People’s medicines were stored safely, however not always administered or stored and managed safely.

Staff had the skills and knowledge skills necessary to provide people with safe and effective care and support. Staff received regular support from management which made them feel supported and valued.

People were supported to make their own decisions as much as possible, however, staff had completed mental capacity and best interest assessments for people without the required knowledge.

People did not always receive appropriate support or encouragement to eat and drink sufficient quantities.

People had access to a range of healthcare professionals when they needed them.

We had mixed views from people about their involvement with the care and support they received.

There were activities in place for people, however those confined to their rooms told us that they did not receive sufficient activities or time socially with staff or people. Visitors were however encouraged to visit at any time of the day.

We observed throughout that people’s privacy was promoted.

There were arrangements in place to obtain feedback from people who used the service, their relatives, and staff members about the services provided.

People told us they felt confident to raise anything that concerned them with staff or management.

People’s care records did not always contain sufficient detail to provide a comprehensive account of people’s care needs.

There was an open culture in the home and relatives and staff were comfortable to speak with the manager if they had a concern.

The provider had arrangements in place to regularly monitor health and safety and the quality of the care and support provided for people who used the service; however actions were not always acted upon or prioritised in a timely manner.

We inspected Monread Lodge on 18 July 2013 because we had received a number of concerns that low staffing levels had led to poor quality care. These concerns related to people being given poor quality food, to there being a lack of meaningful interaction with staff and to there being poor management of the risk of people developing pressure ulcers. When we inspected the home we found no evidence of poor quality care.

People were provided with food and drink prepared according to their individual needs. People also experienced kind and stimulating interaction with staff members. The risk of people developing pressure ulcers was assessed and care plans were in place that were followed by staff in order to manage this risk. One person who was being nursed in bed told us, “They change my position every now and again when I feel uncomfortable.” Another person said, "There is nothing I am unhappy about, they are always accommodating."

The number of staff on duty at all times was in accordance with the provider's guidance on staffing requirements. There were sufficient staff on duty during lunchtime to ensure people's nutritional needs were met. Call bells were answered on time showing that there were enough staff to respond to people if they summoned help.

We looked at people's food and fluid monitoring charts and found they were accurate and fit for purpose. One person said, "The nurses write down everything I drink."

When we visited Monread Lodge on 12 April 2013 we saw that people consented to their care and treatment. We noted that people's capacity to make decisions about their end of life arrangements was appropriately assessed. Where people did not have capacity to make such decisions they were properly made in their best interests according to the law and good practice.

We saw that people's care and treatment was planned according to their specific needs. We also saw that care in the dementia unit promoted people's cognitive abilities and orientation.

People had plenty to eat and drink and their dietary choices and needs were respected. Nutritional risk assessments were effective.

Medicines were appropriately stored and administered. Staff at the home were utilising a new, simplified and effective medication system.

There were arrangements in place to ensure that there were sufficient skilled and experienced staff employed throughout the day and night.

People's records were stored securely and accessible to staff that needed them. People's records were generally completed diligently and were fit for purpose.

When we visited Monread Lodge on 23 October we found that people were supported to make decisions and their independence and community involvement was promoted. One person said, “They are very good with choice here, I can always have whatever I fancy.” Another person said, “They don’t let you get grumpy. They encourage you to get involved.”

People's care and treatment was delivered in accordance with a care plan that arose from an assessment of need. One person said, “I get everything I need here, never want for anything.” Another person said, "I am lucky to be here."

The care of people living on the dementia unit reflected research and guidance and the environment and treatment enhanced people's cognitive abilities and orientation.

People's rights in relation to their capacity to make decisions about resuscitation were not protected because the assessment and documentation used to make 'best interests' decisions was not robust or in line with good practice.

People were otherwise safe because staff at the home could identify abuse and could respond if abuse was suspected or alleged.

Staff were supported by an ongoing training schedule and an effective supervision process. However, there was insufficient qualified nursing staff to meet people's needs.

People were able to provide feedback to the provider about the service and there was an effective system to regularly assess and monitor the quality of service.