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Review carried out on 7 January 2022

During a monthly review of our data

We carried out a review of the data available to us about Imperial Lodge on 7 January 2022. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Imperial Lodge, you can give feedback on this service.

Inspection carried out on 20 February 2018

During a routine inspection

Imperial Lodge is a 'care home'. People in care homes receive accommodation and 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. Imperial Lodge accommodates 10 people in one building. Services are for people with mental health needs and/or people who have experienced substance misuse. The service aims to help people with recovery and some people have been supported to move to places where they need less care and support. At the time of our inspection nine people were living at the service.

Imperial Lodge is run by a small private organisation. The provider owns and manages one other care home. One of the owners is also the registered manager for Imperial Lodge. 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 last inspection on 16 January 2016 we rated the service Good.

At this comprehensive inspection on the 20 February 2018 we found the service remained Good in all key questions and overall. The inspection was unannounced.

People were happy living at the service. They felt well supported and that their needs were being met. People had been involved with planning their own care and had consented to care and treatment. There was evidence that the provider was meeting people's needs and supporting them with their recovery. The staff worked with other professionals to make sure people's physical and mental healthcare needs were being met.

People lived in a safe environment which was appropriately maintained. There were procedures designed to safeguard them from the risk of abuse. People received their medicines in a safe way and as prescribed. The risks to their wellbeing had been assessed and planned for. People knew how to make a complaint and felt that concerns were responded to their satisfaction.

The staff were kind, caring and supportive. The provider ensured that only suitable staff were employed. There were sufficient numbers of staff and they had the training, support and information they needed to care for people. The staff were happy working at the service and felt well supported.

The owners of the company were involved in the day to day running of the home and one was the registered manager. They worked closely with the staff and other stakeholders to monitor how the service was being delivered. There were effective systems for identifying and mitigating risks, as well as making continuous improvements. People using the service, staff and others were asked for their feedback on the service and their views were listened to and valued.

Inspection carried out on 7 January 2016

During a routine inspection

This inspection took place on 7 and 8 January 2016. The first day was unannounced.

The last focused inspection was the 20 and 25 August 2015 where we followed up on previous breaches in the Regulations which had been made during the provider's first rated inspection in October 2014 using the new methodology. We found that these breaches had been met. However, we made a new breach of a regulation at this focused inspection relating to the provider not notifying the Care Quality Commission (CQC) of significant events. Since the August 2015 inspection improvements had been made and CQC had been receiving notifications in a timely way.

Imperial Lodge provides accommodation for up to ten people who have mental health and/or substance misuse needs. The service offered different levels of support depending on people’s individual needs. There were eight people living in the service at the time of the inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us that they were happy living in the service. They said the staff were good and the registered manager approachable. Most people were independent but required different levels of support and encouragement. Staff understood people’s individual needs.

Staff supported people in a caring and professional way, respecting their privacy and dignity. We observed staff interacting in a positive way with people offering them daily choices and encouraging them to take part in activities.

People's choices and wishes were respected by staff and people had been involved in reviewing their care. Care plans outlined people’s needs and the support they required.

People had a range of individualised risk assessments in place to help them maintain their independence and to guide staff in how to support them.

People consistently received their medicines safely and as prescribed. Some people were supported to manage their own medicines and this was monitored by staff.

The staff members we spoke with and records we saw confirmed recruitment procedures were being followed.

The provider had acted in accordance with their legal requirements under the Mental Capacity Act 2005 and the Deprivation of Liberties Safeguards. They ensured people were given choices and the opportunities to make decisions. People we spoke with confirmed that they had choices in their everyday lives and had consented to the support they received.

Staff told us they were supported through regular meetings with the registered or deputy manager. They received ongoing training and met as a staff team to talk through any issues and to receive updates.

People could choose what they ate and staff were available to provide support and assistance with meals.

The health needs of people were being met. Staff had received support from healthcare professionals and worked together with them to ensure people's individual needs were being monitored and met.

People felt confident to express any concerns and make a complaint, so that these could be addressed. The provider asked people for their views about the service.

There were systems in place to monitor the quality of the care being provided and to make improvements as and when necessary.

Inspection carried out on 20 and 25 August 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 22 and 23 October 2014. Breaches of legal requirements were found as there had been a lack of training for staff, clear records had not been kept for when people had attended health appointments and the checks and audits on the quality of the service had not identified that improvements needed to be made in these areas. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Imperial Lodge on our website at www.cqc.org.uk

Imperial Lodge provides accommodation for up to ten people who have mental health and/or substance misuse needs. The service offered different levels of support depending on people’s individual needs. There were nine people living in the service at the time of the inspection.

The provider is a partnership and there was a registered manager in post at Imperial Lodge. 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 our focused inspection on the 20 and 25 August 2015, we found that the provider had followed their plan which they had told us would be completed by 28 May 2015 and legal requirements had been met.

However, the registered manager, who is also the provider, was on holiday at the time of the inspection and we identified that the senior support workers in charge of the service had not been aware that they needed to notify the Care Quality Commission (CQC) about significant events affecting people using the service. They did not have access to the service’s computer or have any paper copies to inform CQC of notifiable events.

Regular checks and counts on medicines were taking place. People who self- medicated confirmed support workers checked that they were taking their medicines. Records were kept of the prescribed medicines delivered to the service and carried over from the previous cycle to ensure the amount at any one time in the service was correct. Only support workers who had received medicine training administered medicines to people.

However, the provider did not have systems in place to always record and check with the GP that over the counter medicines bought by people using the service were suitable to be administered.

We have made a recommendation about the recording and management of some medicines.

The four people we spoke with were complimentary about the service and the support they received from the registered manager and support workers. They confirmed they were supported to look after their own medicines and learn daily independent skills, such as cooking and budgeting. Feedback from a healthcare professional on the service was also positive. They commented favourably on the support the registered manager and support workers provided to people with varied and sometimes complex needs.

We found there had been improvements to the training provided to the support workers and we were able to verify what had been completed through viewing a sample of training certificates and talking with support workers. They confirmed that there was ongoing training for their professional development. This included training on subjects such as, emergency first aid and fire safety.

Health appointments were now being clearly recorded along with any outcomes so that staff could monitor people’s individual health needs and be confident these were being met.

The checks on the quality of the service were detailed and audits were carried out on a range of areas, for example we saw, regular health and safety checks, cleaning checks and checks on people’s bedrooms.

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

Inspection carried out on 22 & 23 October 2014

During a routine inspection

Imperial Lodge provides accommodation for up to ten people who have mental health and/or substance misuse needs. The home was full at the time of the inspection. The home offered different levels of support depending on people’s individual needs. Staff assisted people who require help with day to day routines, including, personal care, meal preparation, shopping, budgeting and supporting people to access community resources.

The provider is a partnership and there was a registered manager in post at Imperial Lodge. 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.

This was an unannounced inspection carried out on 22 and 23 October 2014. The previous inspection was carried out on 4 April 2013 and the service met the regulations that we checked at that time.

Although people’s needs had been assessed and care plans developed, health appointments were not recorded to show when people saw a healthcare or social care professional, such as a GP or psychiatrist. Therefore staff could not easily know when people’s health needs were reviewed and what the outcome was from these appointments. This was a breach of the regulation in relation to care and welfare of people using the service. You can see what action we told the provider to take at the back of the full version of the report.

There was a formal induction programme for new staff. They were also offered one to one support and guidance from the registered manager and deputy manager. However, staff were not provided with sufficient regular training to ensure they were able to meet people’s needs effectively. This was a breach of the regulation in relation to supporting staff. You can see what action we told the provider to take at the back of the full version of the report.

There were some systems in place to monitor the quality of the service and people and relatives felt confident to express any concerns, so that these could be addressed. However, the registered manager had not identified that there were areas that needed addressing and improving on to make sure the service was run safely and effectively. This was a breach of the regulation in relation to assessing and monitoring the quality of service provision. You can see what action we told the provider to take at the back of the full version of the report.

There were systems in place to support people to take their medicines. Checks took place to make sure staff recorded when they administered medicines to people, however the medicine audits were not comprehensive to make sure staff knew people were always receiving their prescribed medicines.

People and their relatives were happy with the care provided. Comments from healthcare professionals were also positive and reported to us that the care people received was good and their individual needs were understood and being met.

People told us that they felt safe and staff treated them with dignity and respect. We found the service to be meeting the requirements of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS).

Staff understood safeguarding and whistleblowing procedures and were clear about the process to follow to report concerns. Staff demonstrated an understanding of people’s individual needs and wishes and knew how to meet them. They confirmed they supported people to develop independent living skills.

There was a complaints policy in place so that people and their relatives understood that their complaints would be looked into and they would be told the outcome of their complaints.

Meetings were held with people receiving support and these helped staff to gain people’s views. People using the service, relatives and staff said the registered manager was approachable and supportive.

Inspection carried out on 4 April 2013

During a routine inspection

During our inspection of Imperial Lodge we spoke with three people who use the service, two members of staff and the manager.

People told us the service was excellent. One person said "the staff support us to be independent", another said "the staff are very pleasant and friendly".

People confirmed they were treated with dignity and respect and were supported with their day to day living. We reviewed four care plans and found that people received care and support that met their assessed needs. We found that people had been fully involved in decisions about the way their care was delivered.

People were protected from abuse and staff had a clear understanding of the procedure to take if there were any suspicions of abuse.

Staff members were well trained and given adequate support to carry out their roles effectively.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

Inspection carried out on 23 November 2012

During a routine inspection

During our inspection of Imperial Lodge we spoke with two people using the service, two staff members, the manager and the provider.

People told us that they were happy with the service and support they received at the home. One person said, �I like it here, we are free to go out, all we need to do is to communicate with staff�.

People confirmed that they were treated with respect and were supported to make choices. They could choose food shopping and how they liked to spend their time and they were free to watch TV in their rooms or in the shared living room.

People told us that they felt safe and protected and they were aware of how to make a complaint if they needed to and they told us that they felt listened to by staff.

We found that people that people were protected from abuse and staff were able to demonstrate their knowledge of safeguarding and what action they would take if they had concerns about the welfare of people they were providing care for.

However the provider did not have systems in place to assess and monitor the quality of service provision. For example the provider had not developed policies on the frequency of reviewing peoples care plans and getting feedback on the quality of services that were provided to people.