We carried out this inspection on 9 March 2017. When the service was last inspected in February 2016 there were two breaches of the legal requirements in relation to safe care and treatment and good governance. Following the inspection in February 2016 the provider wrote to us to say what they would do to meet the legal requirements. At this inspection we checked that the provider had made sufficient improvements; we found that they were meeting the legal requirements.

The service is a care home without nursing and provides care and support for up to 40 older people who are living with dementia. On the day of our inspection there were 35 people living at the service.

The service has a 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 provider had quality monitoring systems in place which were used to bring about improvements to the service.

The staff had received training regarding how to keep people safe and they were aware of the service safeguarding and whistle-blowing policy and procedures. Staffing was arranged in a flexible way to respond to people’s individual needs.

People’s needs were regularly assessed and care plans provided guidance to staff on how people were to be supported. People’s care, treatment and support was personalised to reflect people’s preferences.

The staff had a clear knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely. Meetings had been arranged in order to enable people’s best interest to be assessed when it had been identified that they lacked the capacity to consent to their care and treatment.

There was a robust staff recruitment process in operation designed to employ staff that would have or be able to develop the skills to keep people safe and support people to meet their needs.

Staff demonstrated a detailed knowledge of people’s needs and had received training to support people to be safe and respond to their support needs.

The service maintained daily records of how peoples support needs were meet and this included information about medical appointments for example with GP’s and dentists.

Staff respected people’s privacy and we saw staff working with people in a kind and compassionate way responding to their needs. There was a complaints procedure for people, families and friends to use and compliments could also be recorded.

We saw that the service took time to work with and understand people’s individual way of communicating in order that the service staff could respond appropriately to the person.

This inspection took place on 15 February and was unannounced. The last comprehensive inspection took place on 15 January 2015 and at that time one breach of the Health and Social Care Act 2008 was found in relation to respecting and involving people who use services. This breach was followed up as part of our inspection.

Redfield Lodge is a care home operated by Bristol City Council and is registered to provide personal care and accommodation for up to 40 people living with dementia. There were 29 people living in the home on the day of the inspection.

In January 2015 we found people who used the service were not always treated in a manner that was dignified or respectful. At this inspection the provider had made sufficient improvements.

The provider had quality monitoring systems in place which were used to identify required improvements to the service. Some improvements had yet to be embedded by the service.

Staff demonstrated a detailed knowledge of people’s needs and had received training to support people to be safe and respond to their care needs. However bank staff training had not been effectively monitored and recorded.

There were not suitable arrangements in place for the safe administration of people’s medicines.

Care provided to people met their needs. However some care records provided basic information and did not provide personalised information about how to support people.

People were involved in regular activities.

The staff had a clear knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely. Meetings had been arranged in order to enable people’s best interest to be assessed when it had been identified that they lacked the capacity to consent to their care and treatment.

There was a robust staff recruitment process in operation designed to employ staff that would have or be able to develop the skills to keep people safe and support individuals to meet their needs.

People had their physical and mental health needs monitored. The service maintained daily records of how people’s needs were meet and this included information about medical appointments with GP’s and dentists for example.

There were positive and caring relationships between staff and people at the service. People praised the staff that provided their care. We received positive feedback from people’s relatives and visitors to the service. Staff respected people’s privacy and we saw staff working with people in a kind and compassionate way when responding to their needs.

There was a complaints procedure for people, families and friends to use and compliments were also recorded.

We found two breaches of regulations at 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 on 15 January 2015 and was unannounced. The previous inspection of Redfield Lodge was on 04 June 2014 There were three breaches of the legal requirements at that time. These related to;

• Respecting and involving people who use services
• Consent to care and treatment
• Assessing and monitoring the quality of service provision

Improvements had been made in some areas but further improvements were needed to meet the regulations.

Redfield Lodge provides personal care and accommodation for up to 40 people living with dementia.

There was a registered manager for the service. 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.

Medicines people needed for their health and wellbeing were not always being managed safely. This was because the system for recording what medicines people were to be given was not always fully safe. Secondly the system for checking the amount of medicines stock people had was not always effective. This meant it was not always clear whether people had been given the right amount of medicines or not. We have made a recommendation about the management of medicines.

People felt safe with the staff who supported them The staff were aware of how to recognise and respond to abuse in a way which would protect them.

Peoples needs were met by enough staff to provide the assistance they needed. The number of staff on duty to meet people’s needs was based on how much support and care each person required. However, it was not always clear who was the staff member responsible for meeting individuals care needs. This meant peoples care may be overlooked if there was uncertainty about who among the staff team was responsible for assisting each particular person who needed support with their care.

We found that there were caring relationships between staff and people who lived in the home. However it was also evident that people’s dignity was not being maintained at all times by the staff who supported them. People were consistently called terms that may be disrespectful and infantilising such as ‘sweet pea’, darling and sweetheart. Some of the people who were consistently called these names were not able to say if they wanted to be referred to in this way. Nor was there information in care plans to confirm these endearments were what these people wanted to be called.

The system of staff supervision while they provided care to people was not always effective. There was a risk that senior staff may not be fully aware of how staff were providing people with the care and support they needed. This could lead to people receiving unsafe care if staff are not appropriately supervised.

People were assisted by staff who were trained in their work to improve and develop their skills. Staff went on training courses to help them understand how to provide people with effective care and assistance.

The overall care, and service was monitored and improved where needed. The registered manager was aware of shortfalls in the service and improvements that were required.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which now corresponds to a breach of the Health and Social Care Act 2008 (Regulated Activities ) Regulations 2014.  

On the day of our inspection there were 38 people living at the home. We spoke with two people living at the home. We were unable to speak to people in detail about their experience of living at Redfield Lodge as they were living with dementia and had complex needs. We used observations and spoke with staff to gain an understanding of their experience.

We carried out this inspection to check that the provider had improved the service. At a previous inspection conducted on the 13 August 2013 we found that the provider was not meeting two of the essential standards. We found that the home was now meeting these essential standards.

The home currently has no registered manager. However, the acting manager who has been in post since 1st July 2014 is in the process of applying to be registered with the Care Quality Commission.

Interactions between staff and people living in the home were appropriate and respectful. Staff took time not to rush people and listened to what they had to say.

People were involved in the planning and delivery of their care and support. We found people and relatives were consulted and involved in the running of the home.

We saw that care plans had been reviewed regularly were person centred and reflected the current needs of the people living at the home.

We saw that regular activities were planned to take place at the home and in the community. The home actively invited the local community into the home to take part in activities.

On the day of our inspection there were 37 people living at the home. We spoke with five people living at the home. We were unable to speak to people in detail about their experience of living at Redfield Lodge as they were living with dementia and had complex needs. We used observations and spoke with staff to gain an understanding of their experience.

Interactions between staff and people living in the home were appropriate and respectful. Staff took time not to rush people and listened to what they had to say. However, it was not clear how people or their representatives were involved in their care and support.

We saw that care plans had not been reviewed regularly and care plans did not always reflect the current needs of the people living at the home.

Risk assessments in people’s care plans referred to previous homes that they lived in. This meant that they did not take account of the environment people were currently living in.

We saw that regular activities were planned to take place at the home and in the community.

We found that the staffing levels at the home were based on the needs of people. Staff we spoke with felt that there were enough staff working at the home.

We found there were effective systems in place to monitor the quality of the service provided. A new management team had been put in place and had implemented a robust action plan to ensure that improvements were made at the service.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service were living with dementia which meant they were not able to tell us their experiences. We observed care practices, spoke with staff working at the home, looked at care records and spoke to the relative of one person who lived at the home. 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.

We observed staff supporting people in a respectful way, offering people choices and giving them appropriate time to respond. We saw that staff adapted their communication when speaking to different people at the home according to their needs.

Staff were aware of the needs of people and provided support when necessary whilst encouraging people to maintain their independence.

All the staff with spoke with said that they enjoyed working at the home and were well supported by the management of the home.

Redfield Lodge is a care home operated by Bristol City council and is registered to provide personal care and accommodation for up to 40 people living with dementia.

The inspection of the care home was undertaken by a CQC inspector over a period of two days. During our inspection we spoke with people living in the home and visiting relatives. We also looked at the records relating to people receiving care in the home and spoke with the care staff on duty and the registered manager.

We were unable to speak to some people who use the service in detail as they were living with dementia and had complex needs. We talked to staff and used observations to gain an insight into how they were involved in their care and support. We also used the Short Observational Framework for Inspection (SOFI) tool. SOFI is a specific way of observing care to help us to understand the experience of people who could not talk to us.

Following the inspection we considered all of the evidence we had gathered under the standards we inspected. We used the information to answer the five 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 we spoke with told us they felt safe living in the home and knew who to tell if they didn’t. One person told us “I’d tell the manager if something upset me”.

People using the service told us that their medication was given as prescribed and appropriately. We found that the home had made arrangements for the safe use and management of medicines because there were systems in place for safe storage, administration and recording of medicines used. Where people needed support with their medicines, this was carried out by staff that had been trained to administer medicines safely.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that a DoLS application had been made in the weeks prior to the inspection and it had been approved by the relevant authority. There is however a requirement to submit a statutory notification to the CQC once a decision has been reached in respect of a DoLS application. We found that the required notification had not been submitted.

People’s personal records were not always completed fully. Therefore it was not clear from the information whether the person had received care in line with their identified need.

Is the service effective?

People who were able to speak with us told us they were happy with the care being delivered and that their needs were being met by kind and attentive staff. It was clear from our observations and from speaking with staff that they had a good understanding of people’s care and support needs.

Most care documentation that we viewed was reflective of people's current level of need. However some recording charts were not completed fully. This meant there was a risk people were not being given the support they required in line with their care plan.

The provider ensured that staff were supported through a series of supervisions. This meant that the provider ensured that staff performance was regularly monitored and reviewed. Staff told us they felt supported by the management; one member of staff said “there is an open door policy here, we can always get help if we need it”.

Is the service caring?

People told us they felt reassured by the staff. One person said “It’s very nice here they look after us very well”, another person said “it’s very good, they treat me kindly”.

Although people that we were able to speak with told us that staff treated them kindly, we found that people were not always treated with dignity, consideration and respect. We observed three separate incidences where staff spoke to people without consideration or respect and made comments about them using inappropriate language. We also observed an incident where a member of staff failed to act in accordance with the consent of the person receiving care. We have reported all of these incidences to the provider and the appropriate safeguarding authority.

The care plans we looked at provided details of people's individual wishes and preferences. We found that the service sought advice from external healthcare professionals where necessary.

Is the service responsive?

People’s needs were assessed prior to them using the service. People and their relatives were involved in the assessments of their needs and planning their care. We saw evidence that demonstrated that people were able to discuss what was important to them with staff. One person told us “I knew what I was getting myself into; they explained it all to me”. We saw that care plans were reviewed monthly or if required as a result of changing needs.

People had access to activities that were important to them. The service was well informed about people’s preferences and therefore responded appropriately.

Is the service well led?

Staff had a good understanding of the role of the service. Staff told us they were clear about their roles and responsibilities. The staff told us that the management listened to them when they made suggestions to improve the service and that they could raise concerns without feeling intimidated.

It was clear from our observations and from speaking with staff that they had a good understanding of people's care and support needs and that they knew them well.

People using the service and their relatives, were asked to provide feedback in the form of an annual survey. We found that the views of people using the service and their representatives were taken into consideration, though the action taken was not necessarily recorded.