This inspection took place on the 16 and 18 May 2018 and was unannounced on the first day.

During the most recent inspection of Shelburne Lodge in March 2017 we found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. This was because we found management of people’s medicines were not effective. The provider had failed to maintain accurate records in respect of people using the service. Sufficient numbers of staff were not deployed to meet the needs of people using 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, responsive and well led to at least good.

During this inspection we found the provider had made improvements and was now meeting the regulations.

Shelburne Lodge is a ‘care home’. People in care homes receive accommodation and nursing or 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.

Shelburne Lodge accommodates 54 people in one adapted building. At the time of our inspection there were 45 people using the service, 21 on the ground floor and 24 on the upper floor.

The service requires a registered manager to manage the service. At the time of our inspection a registered manager was 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 received mixed views from people we spoke with about the service. Comments included, "I use my buzzer, they don't always come quickly", “Yes I use my buzzer; if you want a shower you can have one, you feel safe, they know how to do it”, “Yes I have three pills a day and it all goes well”. Relatives told us, “My [family member] gets on well with the carers", “I hear call bells going off and they seem to answer them very quickly”, “On the whole they are alright, weekends are usually alright”, “I’ve never regretted [family member] being here”.

Safeguarding adults’ procedures were in place and staff understood how to protect people from the risk of abuse.

The service had safe recruitment procedures in place to ensure only suitable staff were appointed. Sufficient staff were available to meet people’s needs.

Risk assessments were not always completed according to identified risks. Staff sought people’s consent and involved them in the care planning process where possible.

People received their medicines as the prescriber intended. Audits were in place to monitor the administration of people’s medicines.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice.

The service ensued people had access to healthcare professionals when required. The GPs involved in the service carried out routine visits and advice was sought from other professionals when required.

The service had a complaints procedure which was available for people and their families to use as necessary.

Audits were carried out to monitor the quality of the service provided.

We undertook an unannounced inspection of Shelburne Lodge on 8 and 9 March 2017.

Shelburne Lodge provides care and nursing care for up to 54 people. At the time of our inspection there were 44 people living at the service.

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.

There were not sufficient staff to meet people’s needs. Staff rotas confirmed planned staffing levels were not maintained. The management of people’s medicine was not always safe and a number of concerns were identified at our inspection.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role.

People and their families told us they felt safe at Shelburne Lodge.

Staff understood their responsibilities in relation to safeguarding people. Staff received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the authorities where concerns were identified.

People benefitted from caring relationships with the staff. People and their relatives were involved in their care and people’s independence was actively promoted. Relatives and staff told us people’s dignity was promoted.

Where risks to people had been identified, risk assessments were in place and action had been taken to manage these risks. Staff sought people’s consent and involved them in their care where possible.

People and their families told us people had enough to eat and drink. People were given a choice of meals and their preferences were respected. Where people had specific nutritional needs, staff were aware of, and ensured these needs were met.

Relatives told us they were confident they would be listened to and action would be taken if they raised a concern. The service had systems to assess the quality of the service provided, but these were not always effective. Systems were in place that ensured people were protected against the risks of unsafe or inappropriate care.

We had mixed feedback from staff about the support they received from the registered manager and all of the team at the home. Staff supervision and other meetings were scheduled as were annual appraisals. People, their relatives and staff told us all of the management team were approachable and there was a good level of communication within the service.

Relatives told us the team at Shelburne Lodge was very friendly, responsive and overall well managed. The service sought people’s views and opinions and acted on them.

We found three 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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This inspection took place on the 30 June 2016 and was unannounced.

At our most recent comprehensive inspection on 5 March 2015 we found the service was not fully meeting the requirements of the regulations in place at the time. This was because people had not always been provided with prompt care and support when they needed it, particularly at night. People and staff who cared for them told us a series of management changes had meant the service had not always been consistently well-led. There was a newly appointed registered manager in place who had not, at that stage, been registered by the Care Quality Commission (CQC). Following that inspection we received information of concern about medicines administration and carried out an unannounced, responsive inspection on the 30 June 2015 to assess medicines practice and recording. We also monitored progress made by the service in respect of staffing and the standard of care provided. We found people, including staff, were much more positive about the management of the home. Concerns about staffing at night and response times were significantly reduced. However, in respect of medicines management we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service submitted an action plan on the 5 August 2015 which set out the action to be taken by the 15 August 2015 to address those breaches. The current inspection provided an opportunity to assess if this had been achieved.

Shelburne Lodge is registered to provide nursing care for up to 54 people. At the time of our inspection there were 43 people being cared for.

The service had 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.

We found whilst progress had been made to address previously identified issues about medicines management some areas of concern remained.

People were overall positive about the standard of care they received and the quality of staff. They were less satisfied with the numbers of staff available to meet their care needs at times, when they told us they could experience delays.

Healthcare professionals associated with Shelburne Lodge were positive about progress being made by the service and with the co-operation they received. They in particular felt the management team, led by the registered manager listened to their advice and acted upon it to improve the quality of people’s care.

We have recommended the service follows good practice as it applies to the assessment of people’s ability to manage their own medicines.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the deployment of staff and the management of medicines. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced comprehensive inspection of Shelburne Lodge on the 5 March 2015. We found people had not always been provided with prompt care and support when they needed it, particularly at night. People told us they felt safe and secure and were positive about the standard of care received, more so during the day than at night. There was a newly appointed manager in place who had not at that stage been registered by the Care Quality Commission (CQC), although an application to do so was in progress. People told us they were looking forward to a period of sustained stability in the home’s management following a series of management changes.

Following that inspection we received information of concern about medicines administration and associated care practice. This focussed inspection was carried out to assess medicines practice and recording. We also monitored progress made by the service since our previous inspection in respect of staffing and the standard of care provided. This report only covers our assessment of whether services at this location were safe.

Shelburne Lodge provides residential, nursing, respite, palliative care and accommodation for up to 54 people. The home provides care for older people, including those living with dementia and younger adults, including people with a physical disability or sensory impairment. At the time of our inspection there were 41 people living at the home.

The manager for the home had made an application for registration with the CQC which was still under consideration. They were being supported by a senior Barchester Healthcare Homes manager who was present during this inspection visit.

During this visit we found people, including staff, were much more positive about the management of the home. There were still some concerns about response times, but less than previously. Some staff still felt that at times they were under too much pressure and weren’t always able to provide care in the way they would ideally like to.

In respect of the safe management of medicines we found the service was not consistently safe. Medicines were not appropriately stored, appropriate arrangements were not in place to check the expiry dates of medicines and the effectiveness of medicines were not appropriately monitored. Medicines were kept within their recommended temperature ranges, safely administered and recorded.

We found 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 this report.

You can read the report from our last comprehensive inspection in March 2015 by selecting the, ‘all reports’ link for Shelburne Lodge on our website at www.cqc.org.uk

Shelburne Lodge provides residential, nursing, respite, palliative care and accommodation for up to 54 people. The home provides care for older people, including those living with dementia and younger adults, including people with a physical disability or sensory impairment. At the time of our inspection there were 42 people living at the home.

At the time of our inspection visit there was no registered manager in place. 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. However, a manager for the service had recently been appointed, was in post and present throughout the inspection. They confirmed they had begun the process of registration with the CQC as required.

This unannounced inspection took place on the 5 March 2015. At our last inspection of Shelburne Lodge in May 2014 we found the home met all the regulations assessed.

At the time of this inspection the newly appointed manager had only been in post for a little over a month. This had followed a period when there had been a series of management changes and arrangements. Whilst the provider had attempted during this time to provide a high level of management support, a repeated theme during this inspection, when speaking to people who used the service, their relatives and staff, was the need for a period of sustained consistency and stability.

Some people who received care and some relatives thought staffing levels were not always adequate, whilst others thought staffing had improved and was adequate. The provider used a recognised assessment tool to determine what were appropriate staffing levels taking into account dependency and occupancy levels. This however remained a contested area where different opinions were held as to outcomes achieved. The staffing in place, on the day of our inspection, agreed with the assessment tool.

We found there were systems in place to identify and eliminate or manage risks to people. Staff understood people’s needs and tried to meet them in the way they wanted them. Staff said that sometimes they felt they did not have sufficient time to do so as well as they would like. People recognised staff worked very hard and were appreciative of the standard of care provided by them. They consistently told us staff at night provided a less satisfactory standard of care than staff during the day, although some individual night staff were said to be very caring.

People received their medicines when they needed them. There was a robust system of administration of medicines and people received support from appropriately trained staff.

Staff received training in safeguarding vulnerable people. They were aware of what to do if they saw or suspected abuse had taken place. Staff had the necessary skills and knowledge they needed to meet people’s care needs effectively. However, the way people’s care needs were met at night was said to be less satisfactory than during the day.

People received care from permanent staff that had been subject to a robust recruitment process. This protected people from receiving care from unsuitable people. The service made use of agency staff and tried when doing so to use staff that were familiar with the service, its policies and procedures and the people who received care and support there.

People received care and support from staff that had the necessary skills and knowledge to care for them. Newly recruited staff received induction training and support from more experienced members of staff. There was a programme of on-going training and supervision support for staff to ensure their training remained up to date and that they were supported appropriately in their work.

People expressed contrasting views as to the quality of the food and activities available to them.

We found the numbers of night staff on duty when we visited agreed with the staffing rota and staffing number assessment tool used by the provider to determine staffing levels.

We saw staff were attentive to the care needs of people who lived in the home. We saw call bells were answered promptly and observed unhurried and appropriate care being given to those people who were awake.

Staff told us staffing levels were not, in their opinion, always adequate. They said they were under pressure to complete some additional ancillary tasks like laundry and cleaning. They were also unable to meet the scheduled times for recording checks made on those people living in the home who required them.

People told us they felt able to talk to staff or the manager about their care and the way it was provided. They said staff were very caring and helpful, even when they were busy. People told us they felt safe. Those relatives we spoke with indicated they had no concerns over the safety of their relatives.

People said the home was clean and there were no obvious problems with unpleasant smells. People told us they were very comfortable in the home, they were very positive about the garden seating areas which they said they enjoyed using, weather permitting.

We saw there was a varied programme of activities available and we were told by people how much they enjoyed those. Comments about the quality of food varied. No one said the food was less than satisfactory and three people said it was good. People said they were able to choose what they ate and said if they asked for an alternative one was provided.

We asked people who lived in the home about the numbers of staff available to meet their needs. They told us they understood the staff were always busy which meant they had to wait sometimes. They told us they thought the number of staff was adequate most of the time.

We saw the complaints policy and procedure was clearly displayed and available to people who use the service or who are responsible for them. Complaints were recorded and responded to within a specific time frame.

We carried out three visits, including one at night. We spoke with five people who lived in Shelburne Lodge, with three relatives and with twelve members of staff, the home's manager, administrator and chef together with a regional trainer for the provider. We observed the interaction between staff and people who lived in Shelburne Lodge and looked at some key records. We considered the evidence we had gathered under the outcomes we inspected. We used this information to answer the 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 who lived in Shelburne Lodge and those relatives we spoke with were positive about the quality of the staff and the standard of care they received. They had concerns about the frequent changes to the staff team, which they told us could be unsettling as they had to get used to new staff providing their care and support.

CQC monitors the operation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. The home had proper policies and procedures in relation to this legislation. Relevant staff had been trained to understand when an application to deprive people of their liberty should be made, and how to submit one, although no applications had needed to be submitted. This ensured there were proper safeguards in place.

Systems were in place to make sure that managers and staff learnt from any accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

We looked at three care plans. We found people's needs were assessed and kept under review. There were assessments of risks to the health, safety and welfare of people in place together with details of how these should be eliminated or managed. This meant care and support was planned and delivered in a way which was intended to ensure people's safety and welfare.

Is the service effective?

We found care plans had been audited and subject to review and updating to make them more effective. Staff had received training to gain, update and maintain their skills and knowledge. Staff we spoke with told us they were under pressure, however they said they worked together effectively as a team to ensure people's needs were met.

People we spoke with were in general positive about the care they received or observed. Where one person had contacted us about the effectiveness of care for their relative, their concerns had been acknowledged and were in the process of being addressed.

When we spoke with staff they were well-informed about the care needs of people. They told us that recent reductions in staff, as a result of a reduction in the number of people who received care and support, had been challenging for them. We found staffing numbers were adequate to meet people's needs at the time of our visits.

Is the service caring?

We observed the routine of the home both early in the day and at night. We found the interaction between staff and people who lived in Shelburne Lodge was overall very positive. Staff were respectful and patient although they told us they felt they did not always have as much time as they would like to spend with people they supported.

We saw people were offered choices, for example about what they ate. We spoke with one person who had just chosen their breakfast, they told us they could have, 'More or less what I want."

Is the service responsive?

People who lived in the home and their relatives were offered the opportunity to comment about the standard of care and support they received or observed. We saw minutes of relatives and residents meetings at which any issues or concerns could be raised. People told us they were aware of the service's complaints procedure, and we received details of one complaint being dealt with. People said they would usually raise any concerns informally as they found that worked well. This showed the service sought to identify and respond to any concerns about the quality of care provided

We were told there were surveys carried out by an independent external body which identified any areas of good practice or where improvements were required.

Is the service well led?

Staff told us they felt the management of the home had improved and this was also supported by comments made at the most recent relatives and residents meeting held at the end of January 2014.

The provider carried out regular audits of the service and drew up action plans to address any areas of concern. The latest audit had identified staffing and staff turnover as having a significant impact of the home and detailed the action taken to achieve improvement.

The service manager had identified inconsistencies with the quality of care plan documentation and some care practice and had taken steps to improve the quality and consistency of both. This showed the service was being proactively managed in order to achieve and consistently maintain a good quality of care and support for people who lived in Shelburne Lodge.