We undertook a comprehensive inspection over two days on 20 and 21 August 2018. The first day of the inspection was unannounced. On the 01 June 2018 we received information from the local authority which related to safeguarding incidents which the Care Quality Commission (CQC) had not been notified of. We contacted the provider who identified further incidents which we should have been notified of. In response to these concerns we undertook this inspection.

The White Lodge is registered to provide accommodation for persons who require nursing or personal care for up to 80 older people, some of who may be living with dementia. At the time of our visit 63 people were using the service. The home is situated over three floors. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. 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.

There was no registered manager in post at the time of our inspection. The last registered manager left the service in December 2017. 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 the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected the service in June 2017. The service was rated Good in each domain and Good overall.

At this inspection we have found the service was not always safe, responsive or well-led. Therefore, the service has been rated as Requires Improvement in these three domains. The service remained Good in effective and caring domains. As a result, The White Lodge has been rated overall as Requires Improvement.

The registered provider failed to suitably assess risks to the health and safety of people who received care and treatment. Additionally, the service did not always do all that was reasonably practical to reduce such risks. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered provider failed to deploy sufficient numbers of staff to make sure that people’s care and treatment needs are met. This is a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered provider failed to operate an effective and accessible system for identifying, receiving, recording, handling and responding to complaints. This was a breach of Regulation 16 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Ineffective quality assurance systems meant that the provider could not always continuously learn, improve and innovate. Ineffective audits put people at risk of potential harm, as areas for improvement had not been addressed to mitigate risk. The provider did not always actively encourage feedback about the quality of care and overall involvement with people who use the service. This is a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The provider had not always notified CQC of other incidents within a reasonable time frame. This meant we could not check that appropriate action had been taken to ensure people were safe. The provider is in breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

The registered provider did not always ensure that people’s mental capacity assessments were in line with the Mental Capacity Act Code of Practice. We made a recommendation that the provider seeks guidance to ensure they are meeting these standards.

Staff were trained and understood their responsibilities in regard to the safeguarding of vulnerable adults and were able to identify sig

The White Lodge is registered to provide accommodation which includes nursing and personal care for up to 80 older people, some of who are living with dementia. At the time of our visit 54 people were using the service. Bedrooms are situated over three floors. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. The White Lodge is part of Barchester Healthcare Homes Limited.

We undertook a full comprehensive inspection on the 31 May and 01 June 2017. The first day of the inspection was unannounced. At our last inspection at The White Lodge in June 2016 we found the provider did not meet some of the legal requirements in the areas we looked at. After the previous inspection the provider wrote to us with an action plan of improvements that would be made to meet the legal requirements in relation to the law. We found on this inspection the provider had taken all the steps to make the necessary improvements.

A registered manager was employed by the service and was present throughout our inspection. 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.

People told us that staff worked really hard to keep them safe. Relatives felt reassured that their loved ones were safe because staff kept them well informed should any problems arise. Safeguarding training had been completed and staff were aware of how to raise any concerns about people’s wellbeing to ensure they were safe.

Risks were assessed and reviewed regularly and control measures were put in place to minimise the risks to people.

There were safe medicine administration systems in place and people received their medicines when required. Medicines were stored securely and disposed of safely.

People told us they enjoyed the food and had plenty of choice. They were supported to eat and drink sufficient amounts and maintain a balanced diet. People could choose where they wished to eat their meal and received appropriate support when required.

People said that the staff were kind and caring and that nothing was too much trouble for them. Relatives were complimentary when telling us about the care and support their loved ones received. During our visit we saw that people were relaxed and comfortable in the presence of staff. Staff were observed speaking in a kind and friendly manner with people, taking time to allow them to express their needs.

Care plans were in place which detailed how each person would like to receive their care and support. People were occupied and encouraged to socialise through a programme of engagement and activities.

The service acted in line with current legislation and guidance where people lacked the mental capacity to make certain decisions about their support needs. We saw that people were supported with making decisions around their care. Staff sought people’s consent before providing them with care and support.

There were sufficient numbers of suitably trained staff to keep people safe and meet their individual care and support needs. People were supported by staff who were skilled in meeting people’s needs and received on-going training and support to enable them to deliver effective care.

Quality assurance systems were in place to monitor the quality of service being delivered and the running of the home. Staff said they felt supported by the manager and could raise concerns. They felt appropriate action would be taken by the manager where required.

The White Lodge provides accommodation which includes nursing and personal care for up to 80 older people, some of who are living with dementia. At the time of our visit 58 people were using the service. The home has three floors, with the top floor being divided into two units. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. The White Lodge is part of Barchester Healthcare Homes Limited.

The inspection took place on the 28 and 29 June 2016. The first day of the inspection was unannounced. At our last inspection at The White Lodge in February 2015 we found the provider did not meet some of the legal requirements in the areas we looked at. The provider wrote to us with a plan of what actions they would take to make the necessary improvements. We found during this inspection that the provider had not undertaken all the necessary improvements required to fully meet people’s needs.

The service had 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.’

People using the service, their relatives and staff did not always feel there were enough staff available to meet the needs of people using the service. Staff told us they felt “rushed” and that people only received the correct care and support because staff were “Going above and beyond their duties”.

People’s medicines were managed and administered safely. However during our inspection we found that three resident’s medicines had not been received from the pharmacy when expected. Medicines were securely stored in line with current regulations and guidance.

There was a general activity programme in place. However, there were not enough meaningful activities for people to access in groups or as individuals to avoid social isolation.

We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. Where people were still awaiting a best interest assessment to authorise their deprivation of liberty, we found that best interest decisions had not always been recorded, for example where people were refusing personal care.

Whilst most people spoke positively about the care and support they received there were some differences between how people felt about support they received during the day and night. Staff were genuinely concerned about people’s well-being. Staff knew the people they were caring for including their preferences and personal histories. People were supported to follow their preferred routines.

The provider had quality monitoring systems in place. Whilst the registered manager had an action plan in place to address any areas that required improving areas of improvement from the last inspection still remained outstanding.

People were protected from the risk of harm and abuse by trained staff who knew how to recognise abuse and what actions to take to keep people safe.

Staff told us they had received the relevant training to support them in their role. The staff we spoke with were positive about the training and felt it supported them to be able to carry out their duties effectively. Comments from care staff included “I feel I get enough and the training here is good” and “I have access to the right training”.

Arrangements were in place for keeping the home clean and hygienic and to ensure people were protected from the risk of infections. During our visit we observed that bedrooms, bathrooms and communal areas were clean and tidy and free from odours. Regular maintenance of the home was undertaken to ensure the safety and suitability of the premises. A call bell alarm

We visited The White Lodge on 3 February 2015. The White Lodge is a care home supporting up to 80 people with care and nursing needs. This includes people living with dementia. The home has three floors, with the top floor being divided into two units. At the time of our visit there were 63 people living in the home. This was an unannounced inspection.

At our inspection on 17 September 2014 we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We issued the provider with one warning notice and four compliance actions. These related to people's care and welfare, respecting and involving people in their care, safeguarding people, the management of medicines and the assessing and monitoring of the quality of service. Concerns were shared with the local authority safeguarding team and commissioners of 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.

The registered manager showed strong leadership and was clear about the improvements made and those still required. There was a positive culture in the home that promoted personalised care.

People, their relatives and staff recognised that improvements had been made.

At this inspection we found action had been taken to bring the service to the required standard in relation to respecting and involving people, safeguarding people, management of medicines and assessing and monitoring the quality of service. There were continuing issues relating to people's care and welfare. We also found concerns relating to records and staffing.

Since the last inspection an activity co-ordinator had been employed and was developing an activity programme. However, people who remained in their rooms were at risk of social isolation as they spent long periods alone. There were limited activities for people living with dementia.

People's care records did not always contain accurate information. Some care plans contained conflicting information. Where monitoring forms were in place these were not always completed accurately.This put people at risk of receiving inappropriate care or care that did not meet their needs. 

There were not always enough staff to meet people's needs. Some people told us they did not receive support promptly when they needed it.

People in their rooms were left for long periods and were only visited by staff when supporting people with care tasks.

People enjoyed living in the home and felt well cared for. People were positive about the staff and the care they received. There was a culture that promoted dignity and respect. Staff were knowledgeable about people's needs and were kind and caring. Staff felt supported and were positive about the improvements made.

Peoples care and health needs were met. People were supported to make decisions and maintain independence. People had access to a range of heath professionals and were referred promptly when their needs changed.

The registered manager and regional manager had implemented robust auditing processes that identified the issues found during our inspection and action was being take to address them.

Staff understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. The registered manager had made several applications for DoLS.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see the action we took and what action we told the provider to take at the back of the full version of the report.

The White Lodge is registered to provide accommodation for up to 80 older people who require nursing and personal care. The accommodation is arranged over three floors.

On the day of our visit there were 77 people living at the home. We spoke with twelve people who used the service, six of their relatives/friends and twelve staff. We observed care and treatment and looked at ten care records. We also carried out a short observational framework for inspection (SOFI). A SOFI is used to capture the experiences of people who used the service who may not be able to express this for themselves.

The inspection team who carried out this inspection consisted of two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Is the service safe?

The service was not always safe.

We found people who used the service were being put at risk because care was not being provided in line with their care plans. People who used the service were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were not always cared for safely because they were not protected against the risks associated with medicines. The arrangements in place in relation to the management, storage and recording of medicines were not always followed.

Following our inspection we asked the provider to refer two people to the Local Authority Safeguarding Team.

Is the service effective?

The service was not always effective. Staff did not always know how to support people living with dementia. We found that people were not always supported in a way that maintained their health and welfare. Care files did not show that risks had been explained to people in order for them to make an informed choice.

Is the service caring?

People were not always supported in a caring way. Some people were positive about the care they received, but this was not supported by some of our observations and other people’s comments. People were not always treated with dignity and respect. People who were in their rooms received little meaningful interaction.

Is the service responsive?

The home was not always responsive to people’s needs. We saw evidence that people’s changing needs were not always communicated and advice from health care professionals not always sought.

People did not have sufficient time engaged in meaningful activities. People felt bored. People living with dementia received little stimulation.

Is the service well-led?

The service was not well led. People were put at risk because systems for monitoring quality were not effective. We found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service.

People who lived in the home we spoke with told us they were well cared for and treated with respect by the care and nursing staff. We were told the staff were friendly and professional. Relatives we spoke with told us they were kept informed by the home of any concerns and were always made to feel welcome when they visited. We were told they had no concerns about the care that was provided.

We found that people were provided with a good variety of food and that choice was available. People told us they enjoyed the meals.

The home was clean and hygienic and staff received the appropriate training in infection control.

Staff we spoke with said they worked well as a team and were well supported by their colleagues and senior staff. The home had recently appointed a new training manager who was implementing a plan to update the training and supervision that was provided.

We observed staff meeting needs and interacting with people living in the home with a caring and positive approach.

People who lived in the home told us they were treated with respect and well cared for by the staff who were polite and friendly. We were told it was a safe place to live.

People enjoyed the food and variety and choice was catered for.

Relatives said they were made to feel welcome when they visited, that staff communicated well and were available to listen to any concerns.

Staff told us they worked well as team and were well supported by the management of the service.

The management told us they had systems in place to monitor the quality of care and support that was provided. They sought feedback on the quality of care from people living in the home, their relatives, and professionals who had an involvement with the service.