This inspection took place on 3, 4, 5, 10 and 11 September 2018 and it was unannounced. We undertook this inspection due to a number of concerns raised.

Warren Lodge Care Centre is a care home without nursing. People in care homes receive accommodation and personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service supports people requiring care for reasons of age or frailty, some of whom are living with dementia. The service is registered to accommodate up to 55 people, during the inspection there were 42 people living at the service. The service is divided into two units known as the Main House and the Courtyard. The Courtyard is designed specifically to meet the needs of people living with dementia.

The service did not have a registered manager as required. At the last inspection the registered person had taken immediate action following the resignation of the registered manager to appoint a new manager. However, during this inspection the home manager was still in the process of applying to 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 2008 and associated Regulations about how the service is run. The home manager, four operations managers and the nominated individual assisted us with our inspection.

The registered person did not ensure their safeguarding systems were operated effectively to investigate and follow the provider's procedure after becoming aware of an allegation of abuse. Not all staff were up-to-date with their safeguarding training.

The registered person did not ensure staff kept clear and consistent records when people's care and treatment needs changed. In some cases, this put people at risk. They were not having their individual health and care needs met on time. There was inconsistent and ineffective support for people who became distressed or who were unable to make their needs known. When we raised queries or issues with support or records at our inspection, the evidence was not always available. We gave the provider the opportunity to provide the evidence needed but they were not able to.

We did not receive information to evidence the provider operated safe recruitment and selection processes to ensure suitable staff were employed. Staff training records indicated which training was considered mandatory by the provider. Not all staff were up to date with, or had received, their mandatory training. We saw evidence that learning was not always put into practice when staff supported people. Staff felt some training was missing to help them care for people more effectively. The provider could not be sure staff had the appropriate knowledge and qualifications to meet people's needs. Staff did not have regular support and supervision sessions to review their work and performance. However, staff felt supported to do their job and could ask for help when needed.

People had access to health care professionals. However, staff did not always record and act upon health issues promptly. Therefore, appropriate care and treatment was delayed and did not help people stay as healthy as possible. People had sufficient to eat and drink to meet their nutrition and hydration needs, however support from staff at meal times was not always available.

People's safety was compromised in the service as the premises were not well maintained. People received their prescribed medicine safely and on time. Storage and handling of medicine was managed appropriately. We found some errors with recording and storage which was not picked up by the provider's audit system. There were no specific plans for people receiving medicine covertly and anticoagulants as the prov

This inspection took place on 28 and 30 November and 1 December 2017 and it was unannounced.

Warren Lodge Care Centre is a care home without nursing. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home supports people requiring care for reasons of age or frailty, some of whom are living with dementia. The service is registered to accommodate up to 55 people, during the inspection there were 50 people living at the service. The service is divided into two units known as the Main House and the Courtyard. The Courtyard is designed specifically to meet the needs of people living with dementia.

At the last inspection in October 2015, the service was rated Requires Improvement in the Safe domain. At this inspection we found the service had made improvements and is now rated Good in Safe, Effective, Caring and Well-led, while the Responsive domains has been rated Outstanding.

There was no registered manager in place at the time of the inspection. However, the provider had taken immediate action following the resignation of the registered manager to appoint a new manager. The new manager was experienced and had worked in another of the provider’s services for many years before transferring to Warren Lodge. They were in the process of applying to become registered with the Care Quality Commission (CQC) to manage the service. 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 2008 and associated Regulations about how the service is run.

Warren Lodge Care Centre provides high quality care and support to people who live there. The whole management team with support from the provider had worked towards improving the quality and outcomes for people. Since the previous inspection improvements had been made to help ensure care was provided safely and a number of innovative and creative ideas had been implemented and embedded, resulting in people receiving person centred care that met their individual needs.

Initiatives included “People Like Me", through which people who use the service and the staff team including the chief executive were encouraged to make positive connections with people based on shared interests. This had resulted in meaningful and positive relationships being developed that benefitted people and staff alike. Another initiative reflected the provider’s interest in evidenced based practice. Internal research had resulted in an award and accomplishment framework for all leaders and managers being implemented to encourage and support outstanding practice.

People told us they felt safe at Warren Lodge. Staff were knowledgeable on how to protect people and were confident to report concerns. Where concerns had been identified appropriate action had been taken. People’s needs were assessed before they moved into Warren Lodge. Risks to individuals and the environment were identified and managed. Robust recruitment procedures helped to ensure suitable staff were employed. People received their medicines when they required them and there were procedures in place to manage medicines safely.

Staff were well trained and supported in their role, their contribution was recognised and valued. Initiatives had been developed to support and mentor staff as well as acknowledge their achievements. People were able to access healthcare professionals when necessary and staff supported them to keep as well as possible. People’s nutrition was monitored and any concerns were addressed. The catering department worked with the care team to provide a pleasant dining experience for people and to ensure people’s nutritional needs were met. Staff were aware of the importance

There were enough qualified, skilled and experienced staff to meet people’s needs. The manager explained the actions they had taken to improve staffing levels, for example employing more bank staff and amending the rota system. Staff also told us staffing levels had improved recently. We observed two dining areas over the lunch period. There were sufficient staff to attend to the needs of people in both dining areas. We saw staff engaged with people, encouraging conversation. People appeared relaxed and content with staff.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We looked at the personnel records for eight members of staff. We saw evidence that every staff member was up to date with all of their mandatory training. We reviewed the training records the provider kept for all members of staff. There were 12 training topics that the provider had identified as mandatory for all staff. In five of the subjects 100% of staff were up to date with their training. In four of the subjects 98% of staff were up to with their training and three of the subjects 96% were up to date. One care worker told us “We can ask for training. They [the management] are pretty good at providing what we identify staff need.”

The provider was reporting applicable incidents as required by the regulations. This meant we could effectively monitor the quality and safety of care received by people who use the service.

We spoke with the person managing the service on the day of our inspection. Throughout this report, we have referred to this person as the acting manager. The location did not have a registered manager at the time of our inspection.

We spoke with nine people who use the service, three visitors, and seven members of staff. People expressed their views and were involved in making decisions about their care and treatment. People told us staff spent time talking with them and were respectful of the choices they made. When speaking about people who use the service, one member of staff said “I always promote their independence”. This was supported by people we spoke with.

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare. We looked at three people’s care records. They were person centred and contained detailed information about how each individual’s care needs should be met. A relative told us they were “very happy with the care….. received”.

People were provided with a choice of suitable and nutritious food and drink and were supported to be able to eat and drink sufficient amounts to meet their needs. One person said, “The food at the home is good.”

There were not enough qualified, skilled and experienced staff to meet people’s needs. People who use the service and staff told us there were times when there were not enough staff on duty. Some staff did not demonstrate they had the suitable skills to meet the needs of people who use the service at all times.

When we spoke with staff they told us they felt well supported by managers and they had enough training to enable them to meet the needs of the people they support. We looked at the appraisal and supervision records which showed evidence of appraisals and regular supervision. However, other records showed that most of the appropriate mandatory training for staff was not up to date.

The provider had not reported applicable incidents to us which concerned the provision of care and welfare to people who use the service. This meant we could not effectively monitor the safety and quality of services provided to people.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register.

People told us that they were always treated with respect and their privacy and dignity was maintained at all times. They told us that they could make choices about their lifestyle. People said it was ''a lovely place to live''. People used descriptions such as ''phenomenal, excellent and of a very high standard'' to describe the care offered by the home. People told us that they felt very safe in the home.

Relatives of people who used the service and other professionals told us that they had never seen anything of concern and were confident that people who lived in the home were safe and well treated. People told us that staff were kind, patient and knowledgeable. One person said ''they are as near perfect as they can be''. They told us that they could talk to the staff or the manager if they had any concerns or worries and they were confident they would be listened to. A relative of someone who used the service said that the manager always had the best interests of the residents as her priority.

The inspection took place on 5 August and 13 October 2015 and was unannounced.

Warren Lodge Care Centre offers accommodation for up to 55 people requiring support and personal care by reason of age. Some people may have additional needs relating to dementia. The service is divided into two main units. The Courtyard and the Main House. At the time of the inspection 48 people were living at the service.

The service had a registered manager at the time of the inspection. 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.

On the first day of the inspection we found a shed in the garden used to store chemicals, tools and equipment could not be securely locked. This was a potential risk to people’s safety. We raised this with the registered manager and maintenance manager who took immediate action. By the end of the first day of inspection the shed had a new lock and was secure.

Areas of the perimeter fence were in poor condition and uneven outdoor surfaces could present potential risk to people using the service. This had been identified by the service and was being addressed with plans to make the garden area safe, secure and more appealing for people using the service.

Individual risk assessments had been carried out. These included assessing the risks associated with moving and handling, skin integrity and poor nutrition. Risk assessments were reviewed regularly, however, we found recording of these was not always accurate and there was not always sufficient direction for staff to follow. This was reviewed by the registered manager and care manager and by the second day of the inspection improvements in recording and instruction to staff had been made.

Trends in accidents had been identified and the service was working with the Berkshire NHS Home Support Team to complete an action plan to reduce falls in the service.

There were usually sufficient staff to meet people’s needs and keep them safe. People said there were enough staff and their needs were attended to promptly. However, there were times when staff felt stretched if cover was not available when colleagues were off ill.

There was a relaxed and positive atmosphere in the service. People were treated with kindness, compassion and respect. People who use the service and their relatives told us they were happy with the care they received. Staff were aware of how people liked to receive their care and people’s personal preferences were recorded in their care files. Where possible people had been involved in making decisions about their care.

People had the opportunity to engage in a full and varied programme of activities and links were maintained with the local community.

Privacy and dignity was maintained and staff promoted independence whenever possible. People told us they felt safe living at the service. Staff were knowledgeable about their responsibilities to keep people safe and understood how to report safeguarding concerns.

Staff worked with health professionals to ensure any health needs were met. There was a medicine management system in place and people received their medicines from suitably trained staff who had their ability and knowledge monitored. Medicines were stored, administered and disposed of safely.

Staff recruitment processes were robust to ensure those employed were suitable to work in the service and to protect people against the risk of abuse. Training was available to all staff and refreshed regularly. Staff were encouraged to gain recognised qualifications and received regular support from their managers.

People who could not make specific decisions for themselves had their legal rights protected. People’s care files showed that when decisions had been made about their care, where they lacked capacity, these had been made in the person’s best interests.

The provider was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). The DoLS provide legal protection for vulnerable people who are, or may become, deprived of their liberty.

Complaints were investigated and responded to appropriately. The quality of the service was monitored by the provider and audits were conducted regularly by the registered manager. Feedback about the quality of the service was encouraged from people, visitors and stakeholders and used to improve and make changes to the service.