Filsham Lodge

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The registered manager told us that the service accommodated a maximum of 51 people as double bedrooms were no longer used. The home has 2 separate units, Ash and Beech. There were 41 people living at Filsham Lodge at time of our inspection, all of whom were in receipt of nursing care and most were living with dementia.

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

The governance of the service had not supported the service to consistently improve management and sustain improvement. Whilst there were systems and processes to assess and manage risks to people, they had not identified some of the shortfalls we found. The action plan from the last inspection had not been fully actioned. For example, individual records to monitor people’s well-being and safety were not all up to date or accurate. We also found shortfalls in the documentation regarding peoples’ mental health status, continence and positioning.

Risk management was an area identified as needing improvement to ensure peoples’ health and well-being was protected and promoted. We identified shortfalls in respect of the management of risk specifically regarding people who lived with emotions that distress and the management of specific health problems.

People received care and support by enough numbers of staff who had been appropriately recruited and trained to recognise signs of abuse or risk. Medicines were stored, administered and disposed of safely.

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.

However, we have made a recommendation regarding the decision making of the use of recline and tilt chairs and the decision making.

The registered manager and staff team were committed to continuously improve and had plans to develop the service and improve their care delivery to a good standard. Feedback from visitors about the leadership was positive. A visitor commented “Really good and makes herself available when I visit.” Staff said, “A good place to work, we are happy.”

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 06 July 2022). 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 regulations.

Why we inspected

We received concerns in relation to staffing, risk management and the safety of people. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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.

The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance.

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.

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The registered manager told us that the service accommodated a maximum of 51 people as double bedrooms were no longer used. The home has two separate units, Ash and Beech. There were 49 people living at Filsham Lodge at time of our inspection, all of whom were in receipt of nursing care and most were living with dementia.

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

There were systems and processes to assess and manage risks to people, however these had not sustained the service through management changes and had not identified some of the shortfalls we found in the management of risk. For example, fire exits were not all clear to evacuate safely in the event of a fire and the sluice areas were not fit for use. Records for people’s well-being and safety were not all up to date or accurate, for example, peoples changed mental health and related mental capacity to make decisions, oral health and nutritional well-being. The cleaning of the premises needed to improve to ensure all areas of the home were clean and hygienic for people.

There were some good examples of risk management but this was not consistent for all people.

People received care and support by enough numbers of staff who had been appropriately recruited and trained to recognise signs of abuse or risk. Medicines were stored, administered and disposed of safely.

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.

The manager and staff team were committed to continuously improve and had plans to develop the service and improve their care delivery to a good standard. Feedback from staff about the leadership was positive, “Really good,” and “A good place to work we are well supported and feel valued.”

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 good (published 23 August 2021)

Why we inspected

We received concerns in relation to staffing, risk management and the safety of people As a result, we undertook a focused inspection to review the key questions of safe 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.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

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 breach in relation to good governance.

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

Follow up

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

Quality systems continued to be established and embedded into daily practice to support quality care and record keeping in all areas. Whilst we identified some areas in record keeping for improvement this had already been identified by the management team through audits and an action plan had been developed and risk therefore was mitigated.

Staffing arrangements were safe at this time and ensured people’s needs were met in a timely way. Staff had received training and regular updates on safeguarding people. They understood how to respond to any suspicion or allegation of abuse or discrimination. Staff were recruited safely. People's medicines were handled safely. There were suitable arrangements in place to assess and respond to any risk to people. The communal areas were clean and there was on-going refurbishment.

Visitors were welcomed at the home. People were able to receive visits from their named visitors. Visiting took place in the sensory lounge which had been converted to a visiting room. Dependant on people’s needs, some visits took place in the person’s room. Throughout the pandemic, where people were receiving support with end of life care, they had been able to receive regular visits from family in their bedrooms. Visiting was on an appointment system to allow time for appropriate cleaning between visits and keep the home safe from the risk of infection. All visitors were required to have a rapid lateral flow COVID-19 test before the visit. If a rapid test has not been done, there were processes in place to do one at the service. During the visit visitors wore the appropriate personal protective equipment (PPE).

The management knew people and staff well and we were told they promoted an open culture where people and staff felt they could share their views. They understood their responsibilities and were committed to delivering safe care.

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 Good (published 02 September 2019). We also undertook an Infection Control Inspection (IPC) (published 02 March 2021)

Why we inspected

This inspection was prompted due to information of risk and concern. The CQC had received concerns in respect of communication, end of life care and cleanliness, which had impacted on care delivery. The concerns raised were looked at during this inspection and have been reflected in the report.

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.

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.

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The home has two separate units, Ash and Beech. There were 52 people living at Filsham Lodge at time of our inspection, all of whom were in receipt of nursing care and a majority of whom were living with dementia.

We found the following examples of good practice.

The premises was clean and hygienic and there was a designated housekeeping team. The cleaning schedule included cleaning of frequently touched surfaces and there were infection control posters throughout the premises to promote good practice.

Staff were provided with adequate supplies of PPE and were seen to be wearing this appropriately. Staff had received specific COVID-19 training from the provider, and this included guidance for staff about how to put on and take off PPE safely. Updates and refresher training took place to ensure all staff followed the latest good practice guidance. They were seen to be following correct infection prevention and control practices (IPC). Hand sanitiser was readily available throughout the home. The deputy manager and clinical lead were the infection control leads for the home and undertook spot checks on staff practice. The registered manager also did daily walk rounds to observe practice and support staff and people.

The service have not to have had an outbreak of COVID-19 and have continued to accept admissions to the home. All new arrivals to the home are only accepted with a negative polymerase chain reaction (PCR) test and isolate for 14 days once arrived.

Staff supported people to remain in contact with their families by phone and video calls during the pandemic. There was a visiting policy to support safe visiting that reflected the latest government guidance. This included individual risk assessments for each designated visitor along with a lateral flow devise test (LFT) before each visit, and the wearing of appropriate PPE. The sensory room was now being used as a meeting room if and when required.

Regular testing for people and staff was taking place. There had been changes to testing following their outbreak of COVID-19 as staff who tested positive were not tested for 90 days as per government guidance. Routinely all staff have a weekly PCR and twice weekly lateral flow test (LFT). In addition, they have their temperatures taken daily. People have a monthly PCR test with daily temperatures.

The premises has good sized communal rooms and people who chose to visit the dining areas or communal areas were supported by staff to maintain social distancing. For example, chairs and tables had been re-arranged to allow more space between people. We were assured that there was always a member of staff in the communal areas to assist people in maintaining a safe distance.

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The registered manager told us that the service accommodated a maximum of 51 people as double bedrooms were no longer used. The home has two separate units, Ash and Beech. There were 47 people living at Filsham Lodge at time of our inspection, all of whom were in receipt of nursing care and a majority of whom were living with dementia.

At the last comprehensive inspection in June 2018, we told the provider they needed to improve the oversight and governance of the service. This was because systems had not been effective in identifying shortfalls in safe care delivery and in ensuring people were treated with dignity and respect. We issued warning notices following that inspection. A focused inspection in January 2019 found that improvements had been made and the warning notices had been met. This inspection, we found the provider had made the improvements necessary to meet all the legal requirements.

Changes had been made to systems that assessed the quality of the service and planned improvements.

The management team were making regular checks of all aspects of the service. This was used to develop a

comprehensive service improvement plan, which was regularly reviewed. Further time was needed to

ensure that systems in place routinely identified areas for development and encouraged continuous

improvement.

Although regular quality audits were completed to manage oversight of the service, we found improvements were needed in some areas to guide staff in delivering safe care. For example, aspects of medicine management such as medicines given covertly and those medicines for people in pain at the end of their life needed clear guidance for staff to follow.

People told us they experienced safe care. People told us, “I am comfortable here, it’s clean and I love the garden.” Another person said, “The staff are all very caring, very polite and respectful.” A relative said, “All the staff are very approachable and will always make time to talk to us.” We observed, and people told us that staff met their needs with care and kindness.

Training, policy guidance and safe systems of work minimised the risk of people being exposed to harm. Staff understood how to safeguard people at risk and how to report any concerns they may have. People’s needs and the individual risks they may face were assessed and recorded. Incidents and accidents were recorded and checked or investigated by the manager to see what steps could be taken to prevent these happening again. This ensured lessons were learnt.

There were policies and procedures in place for the safe administration of medicines. Registered nurses and senior care staff followed these policies and had been trained to give medicines safely.

Safe recruitment practices had been followed before staff started working at the service. Sufficient staff were deployed and who had received the correct training, skills and experience to meet people’s needs. Nursing staff received clinical supervision and training. The premises were clean and infection control measures followed. People told us the home was clean and tidy. Relatives spoken with had no concerns about the cleanliness of the service.

Care plans had been developed to assist staff to meet people’s needs in an effective way. Staff applied best practice principles, which led to effective outcomes for people and supported a good quality of life. The care plans were consistently reviewed and updated. Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SaLT).

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The care offered was inclusive and based on policies about Equality, Diversity and Human Rights.

People’s nutritional needs were monitored and reviewed. People had a choice of meals provided and staff knew people’s likes and dislikes.

Staff always treated people with respect and kindness and were passionate about providing a quality service that was person centred.

The care was designed to ensure people's independence was encouraged and maintained. Staff supported people with their mobility and encouraged them to remain active. Activities were provided and were under review as it was known that improvements were needed. People were involved in their care planning. End of life care planning and documentation guided staff in providing care at this important stage of people’s lives. End of life care was delivered professionally and with compassion.

People, their relatives and health care professionals had the opportunity to share their views about the service. Complaints made by people or their relatives were taken seriously and thoroughly investigated.

Rating at last inspection:

Requires Improvement. (Report published on 28 February 2019.)

Why we inspected:

This inspection took place as part of our planned programme of inspections.

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.

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The manager told us that the service accommodated a maximum of 51 people as double bedrooms were no longer used. There were 38 people using the service at the time of our inspection, all of whom were in receipt of nursing care and a majority of whom were living with dementia.

People’s experience of using this service:

A registered manager was not in post. However the manager had submitted an application that was in progress. Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included ensuring all equipment used by people was clean and hygienic and that care delivery was consistently delivered in a way that ensured people had a choice. Recruitment processes needed improvement and these were attended to immediately during the inspection process.

The service had made improvements to the safety of people's care. People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made. Risk assessments included falls, skin damage, behaviours that challenge or cause distress, swallowing problems and risk of choking, and mobility. The care plans also highlighted health risks such as diabetes. People said they felt comfortable and at ease with staff and relatives felt people were safe. Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns.

The service had made improvements that ensured people were consistently treated with respect and dignity. Staff were kind and caring, they had developed good relationships with people. They treated them with kindness, compassion and understanding. Staff supported people to enable them to remain as independent as possible. They communicated clearly with people in a caring and supportive manner. We received positive feedback from relatives and visiting professionals about the care provided. One visitor told us, “I have no complaints at all, the staff are all kind and very good,” and “The staff keep us informed and my relative is content here.”

The service had started to improve communication with allied health professionals and were working alongside them to consistently drive improvement. A number of audits had been developed, including those for accidents and incidents, care plans, medicines and cleaning schedules. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Staff said they were encouraged to suggest improvements to the service.

The organisation had displayed the latest rating at the home and on the website. When required notifications had been completed to inform us of events and incidents, this helped us the monitor the action the provider had taken.

More information is in Detailed Findings below.

Rating at last inspection:

The rating of this service at our last inspection was "Requires Improvement.” (Report published 14 September 2018).

At our last inspection, there were three breaches of the regulations. We also took enforcement action at that time.

Why we inspected:

This was a planned focussed inspection to follow up on our enforcement action.

Follow up:

The overall rating of the service remains Requires Improvement. The service had met the breaches of Regulation and the Safe and Caring questions had improved to Good. However further time was needed to ensure the improvements were continued and sustained.

As the service remains rated as Requires Improvement, we will request an action plan from the registered provider about how they plan to improve the rating to good. In addition, we will monitor all information received about the service to understand any risks that may arise and to ensure the next planned inspection is scheduled accordingly.

Filsham Lodge is a 'care home'. People in care homes receive accommodation and nursing or 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.

Filsham Lodge is situated on the outskirts of Hailsham. The service provides nursing care and support for up to 53 older people, some of whom are living with dementia. The registered manager told us that the service accommodated a maximum of 51 people as double bedrooms were no longer used. There were 48 people using the service at the time of our inspection, all of whom were in receipt of nursing care and a majority of whom were living with dementia.

A registered manager was not in post. 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 manager took up their post in January 2018 and has not yet submitted their application to register.

This is the second time the home has been rated requires improvement. At a comprehensive inspection in May 2017 the overall rating for this service was Requires Improvement with two breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 identified. We asked the provider to complete an action plan to show improvements they would make, what they would do, and by when, to improve the key question in safe to at least good. The provider sent us an action plan stating they would have addressed the breaches by December 2017.

This unannounced inspection took place on 19 and 21 June 2018 to check the provider had made suitable improvements to ensure they had met regulatory requirements. We found that the breach of regulation 11 had been met however we identified there were new breaches of Regulation 10 and 12 and a continued breach of regulation 17. This was because we could not be sure people always received care that was safe, risks to people’s care were not always addressed, for example in relation to moving people safely and people were not consistently treated with dignity and respect. Further improvements were also needed to develop the quality assurance systems.

People told us that they felt safe and visitors were complimentary about the care people received. One person told us, “I feel safe, good care and no problems.” A visitor said, “I can’t praise the staff, it’s a real home here.” However, we found people’s safety was not consistently managed safely. There were not enough suitably qualified or experienced staff at all times to move people safely. Not all areas of the building were clean and some bathroom equipment was not fit for use, which had not ensured that people were protected from the risk of cross infection.

The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Documentation referred to people’s best interests and decisions being made in their best interests, but care tasks were often undertaken without clear consent and discussion.

Whilst the building had been upgraded and met the physical needs of people, there was a lack of visual signage to assist in enabling people to be orientated to time, day and season.

People told us that the staff were caring, however not everyone was treated with dignity and respect. Whilst we saw some caring interactions between staff and the people who lived in Filsham Lodge, there was a lack of interaction when undertaking care tasks. People were assisted by staff with eating but practices were poor as staff did not communicate with them and sat in a position which meant the person could not see the staff assisting them. People’s dignity was not protected when they were moved with lifting equipment in communal areas. We saw that people were not always offered choices in their everyday life.

People, staff and relatives spoke highly of the management team and their leadership style. However, we found areas of care and support which demonstrated that improvements were needed in leading the service forward. The provider’s quality assurance framework had not consistently identified shortfalls and the audit of incidents and accidents needed to be developed to reflect lessons learnt.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. However, the deployment of staff needed to be improved to ensure peoples safety. The provider was actively seeking new staff, nurses and care staff, to ensure there was a sufficient number with the right skills when people moved into the home.

Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking, and moving and handling. For example, pressure relieving mattresses and cushions were in place for those who were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy. There were systems for the management of medicines and people received their medicines in a safe way.

All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns. Staff had a clear understanding of making referrals to the local authority and CQC. Pre-employment checks for staff were completed, which meant only suitable staff were working in the home.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service. This included the care of people with specific health and mental health needs such as diabetes, dementia and Parkinson’s disease. Staff had formal personal development plans, including two monthly supervisions and annual appraisals. People were encouraged and supported to eat and drink well to maintain their health and well-being.

A range of activities were available for people to participate in if they wished and people enjoyed meeting visitors and pets. Activities were provided throughout the day, seven days a week and were developed in line with people's preferences and interests. A sensory room had been introduced since the last inspection. Technology was used to keep families up to date if they lived away via protected internet access. Staff had received training in end of life care supported by the Local Hospice team. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. The service worked well with allied health professionals. Complaint systems were in place and people and visitors could be assured that they were taken seriously and responded to.

Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service. Relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

Staff said the management team was fair and approachable, care meetings were held every morning to discuss people's changing needs and how staff would meet these. Staff meetings were held monthly and staff could contribute to the meetings and make suggestions. Relatives said the management was very good; the manager was always available and they would be happy to talk to them if they had any concerns.

During our inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

Full information about CQC's regulatory response to the breaches of regulations noted above will be added to our report after any representations and appeals have been concluded.

There was a manager in post who was registered with the Care Quality Commission (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.

At the last inspection undertaken on the 2 December 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to the principles of the Mental Capacity Act 2005 not being adhered to. The management and storage of medicines was not safe. Infection control procedures had not been followed, people’s right to privacy was not consistently respected and the provider’s quality assurance framework was not robust. Recommendations were also made in relation to staffing levels, safeguarding and staff’s interaction with people. The provider sent us an action plan stating they would have addressed all of these concerns by February 2017. At this inspection we found the provider had made improvements to the management of medicines, staffing levels, safeguarding, privacy and dignity and staff interaction with people. However, improvements were not yet fully embedded and the provider continued to breach the regulations relating to the other areas.

The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Documentation made reference to people’s best interests and decisions being made in their best interests. For example, the use of bed rails or remaining in bed. However, underpinning mental capacity assessments were not in place to demonstrate that people lacked capacity to make these specific decisions.

People, staff and relatives spoke highly of the registered manager and their leadership style. However, despite people’s praise, we found areas of care which were not consistently well-led. The provider’s quality assurance framework had not consistently identified shortfalls and the audit of incidents and accidents was not consistently robust.

Accurate, complete and contemporaneous records had not consistently been maintained. Documentation failed to reflect the support people received to manage and meet their continence needs. Arrangements were in place to provide social activities and reduce the risk of social isolation. However, these arrangements were not yet consistently embedded into practice. We have identified this as an area of practice that needs improvement.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people's freedom had been submitted.

People told us they felt safe living at Filsham Lodge. One person told us, “There are no complaints here.” Another person told us, “The carers look after me well.” Staff worked in accordance with people's wishes and people were treated with respect and dignity. It was apparent that staff knew people's needs and preferences well. Positive relationships had developed amongst people living at the service as well as with staff.

Systems were in place to ensure people were supported to receive their medicines on time by qualified and competent staff. Medicines were ordered and disposed of safely. People were supported to access health services and their health care needs were being met. People were safe and staff knew what actions to take to protect them from abuse

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Staff were knowledgeable about people's behaviours which might challenge and areas of care which might pose a risk to people. A range of risk assessments were in place and people's ability to use the call bell was considered.

People received support from sufficient numbers of suitably vetted and trained staff. Staffing levels reflected people's needs and were flexible to manage people's changing needs. Staff were supported to undergo an induction process to enable them to understand their roles and responsibilities in their job. Staff received training in core mandatory training and told us, this aided them to deliver effective care to people. Staff reflected on their working practices through regular supervisions and appraisals.

The service had care plans in place that detailed people's history, health, medical and physical needs and preferences. Care plans were reviewed regularly to reflect people's changing needs and shared with staff to ensure the delivery of care coincided with the changes.

Staff encouraged people to make decisions about their care and had their decisions respected. People had their dignity and respect maintained by staff that were kind, caring and compassionate. People's confidentiality was maintained by staff and records were kept securely with only those with authorisation having access to them.

During our inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

We last inspected Filsham Lodge in May 2015 when the service was rated ‘Good’. After that inspection we received concerns in relation to the safeguarding of people’s belongings in the service. This was a focussed inspection in response to these concerns. The inspection was carried out on 2 December 2016 and was unannounced. We looked at the three key questions ‘Is the service safe’, ‘Is the service caring’ and ‘Is the service well led’. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Filsham Lodge on our website at www.cqc.org.uk.

There was a manager in post who was registered with the Care Quality Commission (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.

Staff understood how to recognise the signs of abuse, but appropriate action had not always been taken by the registered manager to assess whether alleged abuse required reporting to the local authority safeguarding team under the multi agency safeguarding policy.

People’s medicines were not always stored in a safe way. There were not effective systems in place for ensuring that opened medicines were disposed of within an appropriate timeframe.

The registered provider had not ensured that the premises were clean and hygienic to ensure the risk of the spread of infection was reduced.

People’s right to privacy was not consistently maintained as some bathroom doors did not close properly and did not have a lock. Staff generally sought and obtained people’s consent before they provided care. However we found that people’s mental capacity had not always been assessed before a decision was made in their best interests, following the requirements of the Mental Capacity Act 2005.

There was not an effective system in operation for monitoring the quality and safety of the service to make improvements to the care provided. Where shortfalls in the service were identified appropriate action had not always been taken to make improvements.

There were sufficient numbers of care staff to meet people’s care needs, but the registered provider had not demonstrated that sufficient numbers of nursing staff were deployed in the service to meet people’s nursing needs. We have made a recommendation about this.

The registered provider had not ensured that the service was organised in a way that provided personalised care. Some people had to wait a long time for their meals to be served and staff did not always meet the people’s social needs. We have made a recommendation about this.

Risks to people’s wellbeing were assessed and staff knew what action they needed to take to keep people safe. People had individual evacuation plans outlining the support and equipment they would need to safely evacuate the building.

Staff treated people with kindness and respect. People told us they liked the staff and that they were caring. Staff knew people well, understood what care they needed and responded to their physical needs. The staff promoted people’s independence and encouraged people to do as much as possible for themselves. People were involved in making decisions about their care.

You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. We spoke with five people who lived at the home, one relative and four members of staff, including the registered manager.

Is the service safe?

People were treated with respect and dignity by the staff. People who used the service told us they felt safe. A relative told us, "It's a real comfort to know that mum is safe and well cared for."

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

The manager compiled the staff rotas, they took people's care needs into account when they made decisions about the numbers, qualifications, skills and experience required. This helped ensure that people's needs were always safely met.

Policies and procedures were in place to make sure that unsafe practices were identified and people were protected.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people were safeguarded as required.

Is the service effective?

People's health and care needs were assessed with them, and, as far as practicable, they were involved in developing and reviewing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

People and their relatives said that they had been involved in reviewing care plans and they reflected their current needs.

People's needs were taken into account with the accessible layout of the service, enabling people to move around freely and safely.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

The home had systems in place to assess and manage risks and to provide safe and effective care. The staff were appropriately trained and training was refreshed and updated regularly. Staff could also take the opportunities provided to study for additional qualifications and to develop their understanding of caring for people with conditions such as dementia and mental health illnesses. We also found evidence of staff seeking advice, where appropriate, from the GP or social services.

Is the service caring?

People were supported by kind and attentive staff. We saw that all staff that had contact with the people who used the service showed patience and empathy.

We spoke with relatives who said they were always made to feel very welcome. They told us 'Whenever I visit there are always staff around and they are kind, friendly and provide good quality care.' We saw that the staff took time with people over lunch and when they were moving about within the home. We observed high levels of respect and people were treated sensitively with consideration and dignity.

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People had the opportunity to take part in a range of activities, reflecting their interests and preferences, both in and outside the service. A care worker told us "We spend time with people and get to know them individually, so we can find out what their interests are and how they like to spend their day.'

People's needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed regularly. This ensured that the care and support provided reflected any identified changes in people's individual care needs. We saw that the staff monitored weight, nutrition and hydration and handover sessions were helpful and informative. However we did find that the care documentation did not reflect the care delivery in respect of monitoring fluid and food intake, safe moving and handling and continence needs. This could impact negatively on people's needs if staff do not respond to poor intake of food and fluids and move people safely.

We were told by the manager that the service had good systems in place to monitor its own standards of service delivery and to gain feedback from people who used the service, their relatives and other stakeholders. As well as satisfaction questionnaires, the deputy manager told us they operated an 'open door policy' so people who used the service and visitors to the home could discuss any issues they may have.

People told us they were asked for their feedback on the service and their feedback was heard and changes were made as a result. People and their relatives, who we spoke with, also knew how to make a complaint or raise any issue or concern that they might have. They were also confident that their concerns would be listened to and acted upon.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up and consistent way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in. They also told us that they felt valued and supported by the management team and were happy and confident in their individual roles.

People who used the service made some positive comments about the care and staff working in the home. A relative told us that they were 'Happy'with the care and support provided within the home. One person told us, 'I like it here.' Another person told us, "The staff are kind and the food tasty."

Care plans and delivery of care for some people was more task orientated than person centred. Not all care plans had been reviewed regularly to reflect people's health and well-being changes.

We examined the home's policy, practice and records in relation to medication. We found that staff were appropriately trained, medication was stored appropriately and administered correctly. We saw that record keeping in relation to medication was accurate and up to date.

We found that the skill mix and experience of staff had impacted on positive outcomes for people who used the service. The provider could not evidence that there were enough qualified, skilled and experienced staff to meet people's needs.

People we were able to speak with who lived in the service told us they liked living at Filsham Lodge care Home. We were told "It's my home, sometimes I grumble but the staff are very good,' "Caring and kind staff,' and "I know I'm safe, staff look after us very well.' We also spoke with relatives/visitors. One visitor told us 'Wonderful place, the staff are very committed.' Both family, visitors and the people who used the service were enjoying an Easter party on the day of the inspection. One visitor said, "This is so lovely for them, they are really enjoying themselves, singing along with the entertainer."

We saw that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We found that care and treatment was planned and delivered in a way that ensured people's safety and welfare. There were effective recruitment and selection processes in place and staff records and other records relevant to the management of the service were accurate and fit for purpose.