This inspection took place on 7 and 13 November 2018 and was unannounced.

We previously inspected this service in October 2017, under a different provider registration name. In October 2018, the provider de-registered the previous company and registered as a sole provider. The same provider is operating this service.

The 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.

The Lodge accommodates up to 20 people in one adapted building. At the time of our inspection there were 16 people using the service, some of whom were 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 this inspection in November 2018, we found four breaches of regulation in relation to safe care and treatment, governance, person-centred care and consent procedures. We also found one breach of registration regulations as the service had not reported a safeguarding incident to the CQC as required by law.

Auditing processes had failed to identify all of the concerns that we found during this inspection. Senior staff’s work had not been checked adequately to ensure they were competent in their role.

Risks in relation to people’s care was not always sufficiently detailed to ensure people were cared for in a safe way. There was not always accurate guidance in place for staff about how to manage or reduce risk.

The management of people’s medicines was not always safe. We found discrepancies which indicated people may not have received their medicines as intended. Some medicines had not been obtained in time and so had not been available to give to people. Audits were in place to enable staff to monitor medicine administration but we considered the audits to be ineffective at identifying and promptly resolving the issues that we identified.

Documentation procedures did not enable staff to have effective oversight of people’s care. This placed people at risk of harm.

Staff knew how to recognise abuse or potential abuse and how to respond and report these concerns appropriately. However, the service had not reported one safeguarding incident to the CQC as required by law.

Staffing levels had been increased by the provider, however, they were unable to demonstrate how they had assessed people’s needs in determining the number of staff needed, as the dependency tool had not been recently completed. Staff did not have defined roles and responsibilities.

Staff received supervision and training relevant to their role, however, training in end of life care and behaviour that may challenge others had not been undertaken to ensure staff had the skills to support people effectively.

Care plans were not always accurately detailed, or sufficient to ensure people’s needs and preferences were documented. End of life care plans were not always detailed.

The previous registered manager had applied for Deprivation of Liberty Safeguards when people who lacked capacity to consent, had their liberty restricted. However, it was not always possible to determine if or how people had consented to their care where they had not been given information in a format they could understand. This did not support the principles of the Mental Capacity Act 2005.

The provider was not aware of the Accessible Information Standard which ensures that people with a disability or sensory loss can access and understand information they are given.

The dining experience was not conducive to an enjoyable mealtime and opportunity for social interactio