Chester Lodge Care Home

Chester Lodge is a care home providing personal and nursing care for up to 40 older people in one adapted building. At the time of our inspection there were 37 people using the service.

People’s experience of using this service and what we found

People were supported by kind and caring staff who had been safely recruited. Staff had received training for their roles and had their competency assessed.

People were protected from the risk of abuse. Staff had received training and understood how to keep people safe. They told us they felt confident to raise any concerns and believed they would be promptly acted upon. Safeguarding policies and procedures were in place.

There was a clear and robust procedure in place for the administration of people’s medicines. The management of ‘as required’ medicines was clear and consistent records were in place. The provider had policies, procedures and guidance in place to support staff when administering medicines.

Care plans and risk assessments included sufficient information to reflect people’s individual needs and preferences. They were reviewed regularly and updated each time people’s needs changed.

The staff and management team worked closely with health and social care professionals to ensure the best outcomes for people.

Safety checks of the premises and equipment had been undertaken. All areas of the service were clean and well maintained. People had personal emergency evacuation plans (PEEPs) in place.

Improvements had been made in the governance systems. The management team identified and promptly addressed any areas identified for development and improvement.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 April 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Chester Lodge Care Home accommodates people in one building across three floors, each of which has separate adapted facilities.

People’s experience of using this service and what we found

There had been several changes of management at Chester Lodge Care Home since our last inspection. This meant some areas of ongoing monitoring hadn’t always been consistent. Existing systems in place failed to always identify shortfalls in risk assessments or areas of care plans which needed updating or further detail.

Further improvements were also needed to ensure medicines were safely managed. Records didn't always accurately reflect prescriber instructions regarding prescribed creams and risks relating to thickening agents in drinks hadn’t been fully considered.

Although we found some improvements were needed, we did observe positive and caring interactions between staff and people living at Chester Lodge Care Home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff sought consent before providing care and demonstrated an understanding of people’s preferences.

The communication needs of people were clearly documented, and people had access to appropriate healthcare services.

People spoke positively about the activities available, were supported appropriately to reduce the risk of social isolation and to keep in touch with family and friends.

Checks were in place to ensure people lived in a clean, safe environment which was maintained to a high standard. Ongoing refurbishment and redecoration of the home was planned.

Appropriate checks on temporary (agency) and permanent members of staff were in place to ensure they were suitable for the role before working with people. Staffing levels were safely planned, and were determined by people's assessed needs.

People were protected from the risk of abuse. Systems were in place to monitor and appropriately report accidents and incidents to external agencies.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 April 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of one regulation.

At our last inspection we recommended that the provider considered current guidance on the management of medicines, medication administration record completion and stock control and took action to update their practices. At this inspection we found the provider had made some improvements, however further improvements were needed.

The service remains rated requires improvement. This service has been rated requires improvement or inadequate for the last eight consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe, effective, responsive and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a continued breach in relation to effective auditing and monitoring of the quality and safety of people’s care at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service and what we found

The system for recording people’s individual medicine stock quantities was not effective and reliable, stock balances could not be established, and excessive stock amounts were being held. Staff had access to medicines policies and procedures as well as best practice guidelines.

The care plans and daily records for people were not consistently stored for ease of access. They had recently been transferred on to an electronic care plan system. The system was still being developed and further work was required to ensure care plans were reflective of people’s individual needs, routines and preferences.

Staff told us they had completed training and they demonstrated competence. Records were unclear and training information and supervision records were not readily accessible.

The provider audit processes had not identified the areas for improvement highlighted within the inspection process.

People’s needs had been fully assessed prior to them being supported by the service. They told us they had been involved in the development of their care plans. Risk assessments were in place to ensure people’s needs could be met and risks reduced or mitigated. These were being developed further to ensure they were personalised.

Safe recruitment procedures were in place and people were supported by regular staff. There were enough staff to meet the needs of the people supported. However; we spoke to the provider about the deployment of staff to meet the needs of the people supported and they addressed this immediately.

People were protected from the risk of harm and abuse. Staff felt confident to raise any concerns they had. Staff understood how to minimise the risk of infection being spread and clearly described the procedures they followed.

People received care and support from staff that knew them well and were kind and caring. People’s privacy and dignity was respected, and their independence promoted. People and their relatives spoke positively about the management and staff team.

People were supported to eat and drink in accordance with their assessed needs and personal preferences. People spoke positively about the food and drink at the service.

People participated in activities and were supported and encouraged to maintain contact with relatives. Staff communicated with people in ways that were meaningful to them.

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

Feedback from people and their relatives was regularly sought. People spoke positively about the service and many compliments had been received.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 5 March 2019) The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

We have identified breaches in relation to regulation 17 due to records not being readily accessible and information being unclear at this inspection.

Follow-up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider to find out what they will do to achieve the rating of good. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chester Lodge is a residential care home that provides personal and nursing care for up to 40 people. Some people also live with dementia. At the time of the inspection 33 people lived in the service.

What life is like for people using this service:

Whilst improvements had been made, we identified a continued breach of regulation in relation to records.

The registered providers system for checking on the quality and safety of the service were not fully effective as they did not identify risks associated with people’s safety and a lack of records. Hot water outlets were not checked at the required intervals to make sure the water temperature was at a safe level for people to use. Records were not completed with details of fire drills carried out and the fire risk assessment for the environment was out of date. Although the registered provider had safe recruitment procedure, it was not followed for a senior member of staff. Care records for some people did not fully reflect their assessed needs and how they were to be met. Records for monitoring aspects of people’s care did not include information about their needs and had not been consistently completed to evidence the care they were given. Monitoring records had not been evaluated at the end of each day as required. The manager took prompt action during the inspection to make the improvements.

The management of medication had improved since the last inspection. Medication was safety stored and medication administration records (MARs) were kept up to date. People received their medicines safely and on time.

People who were able consented to their care and support. Decisions made on behalf of people who lacked capacity to make their own decisions were made in line with the Mental Capacity Act. These decisions had been better recorded since the last inspection.

People were protected from abuse and the risk of abuse because staff understood their role and responsibilities for keeping people safe from harm. People told us they felt safe and family members were confident that their relative was kept safe. The premises were kept clean and hygienic and staff followed good infection control practices to minimise the spread of infection. People’s needs were met by the right amount of suitably skilled staff.

People told us they received all the right care and support from staff who were well trained and competent at what they did. People received the right care and support to maintain good nutrition and hydration and their healthcare needs were understood and met.

People were treated with kindness, compassion and respect. People told us that staff were kind and respectful of their privacy and dignity and encouraged their independence. Staff had formed positive relationships with people and their family members. Visitors people received were made to feel welcome.

People received personalised care and support. People, family members and others knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly.

The leadership of the service promoted a positive culture that was person centred and inclusive. People, family members and staff were confident in the management of the service. They described the manager as supportive and approachable. They told us many improvements had been made to the service since the last inspection and that they were fully engaged and involved in the running and development of the service. The manager and staff worked in partnership with others in the best interest of people using the service.

More information is in Detailed Findings below

Rating at last inspection: Requires Improvement (report published 08 August 2018)

Why we inspected:

This was a planned inspection based on the rating at the last inspection. We saw improvements had been made since our last inspection, however further improvements where required for the service to achieve a rating of Good.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. We will meet with the registered provider to discuss how they plan to address the issues identified during this inspection.

At the last inspection we found multiple repeated breaches of legal requirements in regards to safe care and treatment, nutrition and hydration, dignity in care, record keeping and overall governance.

Following the last inspection, we asked the registered provider to confirm what they would do and by when to improve its rating from Inadequate to Good.

On this inspection we found that a number of improvements had been made but further work was required to ensure full and sustained compliance with the regulations.

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

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Chester Lodge is ‘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 care home accommodates 40 people in one purpose built building which is spread over 3 floors. At the time of the inspection 24 people were living at the service.

The registered manager had been absent from the service since April 2018 and we were informed that they were unlikely to return . A registered 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. In the interim period, the Clinical Lead Nurse had taken on the manager role.

The quality assurance systems in place had been reviewed and the registered provider now acknowledged that it previous monitoring of the quality and safety of care had been ineffective. They had made use of external consultants as well as commissioners to assist them in identifying shortfalls and making improvements. People and staff confirmed that the registered provider had been open and honest with them about the issues regarding the service and what they intended to do to put things right.

People received their medication as prescribed. However, topical medication was not always stored in a safe and secure way. An accurate record was not kept of its application nor that of prescribed thickener. Risk assessments were not always in place where medication posed a specific risk to a person’s health and wellbeing such as from fire or excessive bleeding.

New staff employed at the service had an induction and worked with more experienced staff to ensure they were confident and had the required skills. Recruitment checks had been undertaken prior to employment but references were not always taken from the last employer. This meant that there was no assurance in place of a person’s suitability for the post. We made a recommendation in regards to this.

Accident and incidents were effectively monitored. Review of these included identifying causation, on-going risk and trends. Steps were taken to reduce the reoccurrence of accidents and there was evidence of their effectiveness. Risk management plans did not fully outline for staff what was required to keep a person safe.

Care plans were being reviewed in order to record people's needs accurately but some improvements were still required to ensure they were complete and accurate. Records were better personalised to reflect people's individual preferences about how they would like their care and support to be provided.

Staff practice showed that people's consent was considered before care or support was provided. Staff showed a better understanding of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards but supporting documentation still required improvement. We made a recommendation that this was reviewed to reflect how specific decisions for people who may lack capacity had been reached and made in their best interest.

A number of people were at risk of malnutrition or dehydration. Staff monitored this and food and fluid charts were completed in detail to reflect what people had eaten and drunk over a 24 period. This helped to inform a further assessment of the person's nutritional status. Referrals to health professionals were made when concerns regarding people's health were identified and advice provided by health professionals was implemented to ensure that risks to people's health and wellbeing were minimised.

People said that they felt safe at the home and were very pleased with the care that they received. People and their relatives felt that staff did their outmost to support people and protect them from harm. Staff were aware of their responsibility under Safeguarding to keep people safe and were confident in how and when to highlight concerns .

The premises were cleaner but some aspects still required refurbishment and repair. We were informed that there was a plan in place to do this once finances were available to support this. Some checks on the safety of the service had not been carried out with the required frequency but steps were taken to correct this. We made a recommendation in regards to ensuring that checks were carried out in a timely manner.

Staff respected people's opinions and choices in how they wanted their support to be provided. People were kept comfortable and treated with dignity and respect. People informed us that the staff were caring and always did their best to look after them.

Staff attended annual training sessions in areas such as moving and handling, first aid and safeguarding adults to update their knowledge and skills. Improvements were planned to the quality and frequency of staff supervisions.

Meetings were held with people who used the service, relatives and staff to discuss the future direction of the service and to seek their opinion. Staff were positive about the staff team and reflected on the changes made to the service, this included improved communication and documentation. Staff were found to be more organised and had a clearer understanding of their role and responsibilities.

People and or their relatives received opportunities to be involved in review meetings to discuss the care and treatment provided. People received opportunities to participate in a variety of activities and staff had time to spend with people. The registered provider’s compliant procedure had been made available and used satisfactorily.

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.

At the last inspection December 2016, we asked the provider to take action to make improvements in regards to safe care and treatment, capacity and consent and overall governance. These actions had not been completed.

During our visit we found a number of new and repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. 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.

People we spoke with said that they felt safe at the home and relatives felt that staff did their outmost to support people and protect them from harm. However, we found that the risks to people’s health and safety were not always identified, assessed or managed.

There was a safeguarding concern prior to the inspection in relation to the management and assessment of pressure ulcers. Care plans did not always include accurate information for the prevention and management of pressure ulcers.

A number of people were at risk of malnutrition or dehydration. However, food and fluid charts were not always completed in detail to reflect what people had eaten and drunk over a 24 period and to inform assessment of the person’s nutritional status.

Referrals to health professionals were made when concerns regarding people’s health were identified, but this was not always done in a timely manner. We found that advice and guidance provided by health professionals was not always implemented to ensure that risks to people’s health and wellbeing were minimised

People did not always receive their medication as prescribed as there were delays in administration. Medication was not always stored in a safe and secure way.

Accident and incidents were not effectively monitored. Review of these did not always identify causation, risk or patterns. Management plans to reduce the occurrence of accidents were not always followed or their effectiveness reviewed.

Some call bells were out of reach and inaccessible. When people were unable to use a call bell, robust plans had been put in place to ensure the person received the attention they needed.

The premises were not clean and we detected unpleasant smells in parts of the building. The management of infection control required improvement .

Staff showed limited understanding of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Supporting documentation did not reflect how specific decisions for people who may lack capacity had been made in their best interest. Decisions were made by people without any legal delegation to do so. However, staff practice showed that people’s consent was considered before care or support was provided.

Staff did not always respect people’s opinions and choices in regards to how they wanted their support to be provided. People were not always kept comfortable and were not always treated with dignity and respect. People informed us that the staff were caring and did the best that they could to look after them.

Care plans did not always record people’s needs accurately. Records were not personalised to reflect people’s individual preferences about how they would like their care and support to be provided.

The quality assurance system in place was not effective and did not monitor the quality and safety of care. The service has now been non-compliant with the regulations since October 2015. Improvements had not been made or sustained.

Staff attended annual training sessions in areas such as moving and handling, first aid and safeguarding adults to update their knowledge and skills. There was adequate fire safety management and evidence to support effective evacuation in the event of a fire.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

During a focussed inspection of the service on17th August 2016, the service was rated as inadequate. This visit took place to assess any improvements that had been made in response to this change of rating.

Chester Lodge is a nursing home that is owned by Heathbrock Limited. It is a modern three-storey building close to Chester city centre. There is car parking space next to the building. The home provides personal and nursing care for up to 40 people. Thirty people were living at Chester Lodge at the time of our visit.

A registered manager was in place and was present during our visit. 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 last inspection of the service in August 2016 had focused on how safe and well led the service was. We found during that inspection that there were a number of breaches of regulations which meant that people were not safe from risks of harm and did not receive care from a well led service.

The registered provider was served with a Notice of Decision in August 2016. This meant that a condition had been placed on the registered provider in respect of restricting admissions. This meant that all proposed admissions need to be agreed by CQC prior to admission. This is still in place.

These breaches included a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people who lived at Chester Lodge did not always receive safe care and treatment.

On this inspection, although we found some improvements had been made, we found repeated breaches of regulation 11 and regulation 17.

Staff understood the principles of the Mental Capacity Act and applications had been made by the registered provider to the Local Authority for authorisations to carry out such restrictions and safeguards. .Evidence of best interest meetings and how consent was gained from people lacking capacity was not present. This was a repeated breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 gaining consent.

Our last visit showed that care plans were not personal to the needs of the people who used the service. Care plans were available for all people. Evaluations were brief and did not include how care plans had been evaluated and who had been involved in this process. In care plans we looked at, evaluations included the outcome and care plans changed as a result. Care plans were still not person centred. This was a repeated breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Our last visit noted that there were deficiencies in the auditing process and the reporting of adverse incidents to CQC. This has resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) regulation s 2014. Improvements had been made to audits of falls and associated actions. While notifications to CQC had improved, there had been a significant delay in notifying CQC of one allegation of abuse incident since our last visit in August 2016.

We also found that some of the audits did not identify the issues raised at this inspection in particular lack of personalised care plans as well as the lack of robust evaluation of care plans. These were issues we raised at the last inspection but have not been actioned.

This visit confirmed that some improvements had been made to ensure the safety of people who used the service. However, we observed one person being given a drink without the thickener that had been prescribed to them. This meant that they did not receive safe care and treatment.

Improvements had been made to ensure that the front door was secure enabling staff to account for all those who visited the building. The sluice room was secured which meant that people who used the service were not at risk from equipment or other hazards within that area. All cleaning products were found to be stored away safely and appropriately and all external doors including fire doors were kept shut. At our last inspection, an area marked as ‘staff only’ was accessible to people who used the service. This area contained hazards such as stored wheelchairs and unlocked doors which could have posed a risk to people’s safety. This area was still accessible to them but presented no risks. A portable hoist was stored in a vacant bedroom which in turn was unlocked. This presented a potential trip and fall hazard to people who used the service. This was raised with the registered manager. However, she stated that she did not consider this to present a risk to people because the room was located in an area near to bedrooms occupied by people who were unable to mobilise independently.

Our last visit in August 2016 found that appropriate arrangements were not in place in respect of bedrails. This had included the level of comfort afforded to people who used bedrails, the level of protection provided through the use of bedrails and the use of unsuitable covers to prevent bruising from leaning on bedrails. This meant that people did not receive safe care and treatment. At this inspection bedrails in use had protective bumpers on them and appropriate risk assessments had been carried out for their use. These assessments took into account the hazards posed by the use of bedrails such as potential entrapment. Instructions were in place for staff on how to protect people from any associated harm or entrapment.

A complaints procedure was available and had been on display for people to refer to.

People told us that they felt safe. Staff demonstrated an understanding of the types of abuse and how these could be reported. Staff had received safeguarding training and this was on-going.

Staff knowledge and practice in respect of nutrition and measures needed to protect people was not sufficient to keep people safe. Care plans outlined in one case clear guidelines for the nutritional needs of one person but this was not understood and followed by all staff. The person was given a drink without prescribed thickener which put them at high risk of choking and aspiration.

Improvements had also been made in respect of the accessibility of call alarms to people in their own bedrooms. In all cases people had access to call alarms either from their beds or armchairs and these were in easy reach of people. People told us that their calls were responded to in a timely way and this was observed throughout the inspection.

Recruitment practice protected the people who used the service and medicines management promoted the health and people who used the service. The premises were clean and hygienic.

Staff had received training in health and safety topics as well as training specific to the needs of people. The supervision process for staff had been changed and supervisions had commenced.

People told us that they felt cared for by the staff team. Observations of care practice noted that people were dealt with in a caring and respectful manner.

A full programme of activities was on offer to people and these took place during our visit.

People who used the service were aware of who the registered manager was and told us that they maintained a presence within the building. They considered the service to be well run

This visit took place in response to concerns that we had received. These concerns included concerns about the safety of people who used the service as well as the way in which the service was led.

During this visit, we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. We will publish the actions we have taken at a later date.

Chester Lodge is a nursing home that is owned by Heathbrock Limited. It is a modern three-storey building close to Chester city centre. There are car parking spaces next to the building. The service provides personal and nursing care for up to 40 people. At the time of the inspection there were 34 people using the service.

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. The registered manager was not present during our visit.

A comprehensive inspection had taken place at the service in June 2016. At that inspection we found that the registered provider was required to make improvements in all the five key areas that we looked at. The inspection in June 2016 highlighted that there were breaches of regulations 11 and 17. Regulation 11 related to the need for consent to be gained from people in respect of their care. Regulation 17 related to the lack of a care planning in respect of medicines prescribed when needed and the need for person-centred and comprehensive care plans.

On this visit we found that the premises were not safely secured which meant that people who used the service could not have their safety guaranteed at all times. Visitors to the service were not monitored therefore staff had no way of knowing who was in the building, Fire doors were not always closed as required which meant that should a fire occur it could not be contained in one area. Cleaning products hazardous to people’s health were left unsecured in a sluice room which in turn was not locked when not in use. An area designated for staff use only was not secured and contained hazards to people who used the service.

We observed people who used bedrails did not always have their safety and comfort taken into consideration despite this being identified as an issue during our last visit in June 2016.

Sections of care plans designed to take the safety of people in to account were out of date. No falls risk assessments were in place for people when there was evidence that they had experienced numerous falls in a short period of time.

Call alarms were responded to inconsistently. We timed the response to call alarms and found that the response times varied. For example some were responded to promptly and others exceeded 20 minutes. Some people stated that their calls were responded to quickly, however one person told us staff had taken some time to answer their calls or had not responded at all.

Staff demonstrated a limited understanding of the process for reporting any abuse allegations. Staff either had no understanding of whistleblowing or did not have the confidence to raise concerns whilst in employment at the service.

Medication was secure; however, a refrigerator used for the storage of some medications was not secure when not in use.

The registered manager had failed to notify us of many incidents that adversely affected the health of people who used the service. Audits undertaken in respect of falls and medication were not robust. Audits had not been undertaken in respect of many key areas such as care plans, bedrail risk and call alarms.

The registered provider was not able to produce a complaints procedure on request or a supporting record of complaints made. This was despite one comment made to us about a concern reported to staff about call alarms.

The registered provider was not able to produce an accident record of an incident that had resulted in a person attending hospital.

People told us that they felt safe and confident with the manner in which the staff supported them. They told us that they considered the service to be "well run".

Chester Lodge Care Home is a privately owned residential and nursing care service located close to Chester city centre. The service is based over three floors, which provide accommodation and personal care for up to 40 people. Access to the upper floor is via a passenger lift or stairs. Local shops and other amenities are a short distance away from the service. At the time of our inspection there were 35 people living at the service.

There was a registered manager that had oversight of the whole 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. At the time of our visit the registered manager had been away from the service for some time and the deputy manager was responsible for the day to day running of the service.

At the last inspection on 29 October and 3 November 2015 we found that a number of improvements were needed in relation people not being protected from the risk of unsafe care and treatment and poor management of infection control. People were not always supported or treated in a dignified way and consent to care and treatment was not always sought. People were not protected from the risk of inadequate nutrition and hydration and quality assurance systems were not effective. We asked the registered provider to take action to address these areas. The service was placed into special measures by CQC.

After the inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches identified. They informed us they would meet all the relevant legal requirements by the end of January 2016. This inspection found that there was enough improvement to take the provider out of special measures. Whilst we found a number of improvements in most areas, the registered provider had not demonstrated full compliance with the Health and Social care Act 2008 (regulated activities) 2014. You can see what action we have told the provider to take at the end of this report.

People received their medication as prescribed and the deputy manager had completed competency assessments in the safe administration and management of medication with all nursing staff. Medication administration records (MAR) were appropriately signed and coded when medication was given. Care plans relating to PRN (as required) medication were not in place to guide staff. There was no clear written guidance for staff to follow to establish when and how PRN medication would be required to be given.

Staff had an understanding and awareness of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People confirmed and observations showed that staff always asked for consent prior to providing care and support. The registered provider had submitted DoLS applications to the local authority where appropriate. However, people’s care records contained limited information about their mental capacity, and mental capacity assessments and best interests decisions had not been completed as required by the MCA.

The registered provider had introduced a number of quality assurance audits since our last inspection visit. Further improvements were needed to make sure that they were effectively used by staff to evidence what actions had been taken to ensure the quality and safety of the care provided to people. CQC were notified as required about incidents and events which had occurred at the service. We have made a recommendation about the effective use of audits.

Staff were able to describe the care and support people required. Daily records were completed in good detail to reflect what care and support people had received on a daily basis. Care plans had been reviewed since our last visit and contained up to date information relating to the health and care needs of each person supported. We found limited information recorded about how a person preferred their care and support to be delivered. This meant that people could experience care that was not in line with their wishes, needs and preferences if supported by staff less familiar with them.

Improvements had been made relation to the management of infection control. Some fixtures and fittings could not be cleaned due to their poor condition and were in need of repair. The director of the service confirmed that refurbishment of the service after 25 years was going to be looked at in the near future.

Staff attended regular training sessions in areas such as moving and handling, first aid, safeguarding adults and tissue viability to update their knowledge and skills. Staff confirmed that they had regular supervisions to ensure their practice was reviewed. Team meetings were held to ensure staff were kept up to date with any changes occurring at the service. We were unable to access induction and supervision records as part of this inspection.

Detailed risk assessments were in place to identify if people were at risk of developing pressure areas. Where people had pressure ulcers robust care plans were in place to monitor their condition alongside relevant health professionals. Appropriate pressure relieving equipment was in situ and regular safety checks had been introduced.

People were supported to access health care professionals to make sure they received appropriate care and treatment for their needs. Robust recording and reviews of dietary and fluid intake was in place at the service. This meant people were protected from the risk of inadequate nutrition and hydration. There had been significant improvements to the management and prevention of pressure ulcers.

People told us that staff always treated them with kindness and respect. They told us that staff were mindful of their privacy and dignity and encouraged them to maintain their independence. People were relaxed and staff offered support in a kind, caring and respectful approach. Family members spoke with compassion about the care and support people received at the end stages of their life.

The mealtime experience was positive and engaging. People were provided with appropriate dietary options and received good levels of support from staff. Staff were patient in their approach and encouraged people to eat and drink in a discreet and respectful manner. Staff respected individual choices and where required alternative meal options were offered and sourced. People made positive comments about the quality of the food available.

Safe and robust recruitment procedures were completed by the registered provider. A range of checks to ensure staff were suitable to work with vulnerable people were completed.

We visited Chester Lodge and undertook a tour of the building, spoke with four people who lived at the home, two staff, the registered manager and owner.

People who lived at Chester lodge confirmed they were happy with their bedrooms and the environment in general. They all agreed the home was clean and odour free. Other comments included: 'I am very happy with my room', 'I have no problems or concerns', 'My room is lovely' and 'The staff work very hard and are good.'

Staff commented: 'This is a lovely home', 'I enjoy working here' and 'The atmosphere here is lovely.'

During a tour of the building we found it clean and odour free and improvements had been made since our last visit.

We spoke with four people who used the service, four relatives, three staff and two professionals involved in the service. People who used the service said: 'The staff are nice' and 'I am well looked after here.'

Relatives commented: 'The home is clean and odour free', 'I am delighted with the home' and 'The staff treat my relative extremely well.'

Staff commented: 'The staff work well as a team', 'The training is good', 'The staff help each other out' and 'I like caring for the people here and sitting and chatting to them.' All the staff said they got good support from the management team.

Other professionals said: 'The home is very nice', 'The staff are great with the residents' and 'We have a good working relationship.' They both said that they had no issues or concerns with the service.

We looked at the rotas and staffing levels at the home and discussed staffing issues with the manager.

We observed interactions between the people who used the service and staff during the day and found there was a relaxed and friendly atmosphere between them.

During a tour of the building we found it was clean and odour free. However concerns were raised regarding some stained carpets, a rip in the corridor carpet, some bedroom furniture and some documentation regarding the home.

We looked at three care records and all these were up to date and reviewed regularly. This meant that the service could demonstrate they could meet people's needs and maintain their health and well being.

We found the provider had robust and effective recruitment procedures in place. We spoke with four staff members. They said "It is a good, friendly staff team here", "The training is good", "The manager will organise other training if you ask", "The manager is highly thought of and is committed totally to the residents here" and "The provider is brilliant and helpful". We spoke with one relative and a GP, commented "The home is clean and doesn't have any odours. I don't have any problems or concerns", "My relative has improved in health since they have been here. The staff are friendly and if I had any concerns I would contact the manager." During our visit the home was clean and odour free.