Fern Gardens Care Home

Fern Gardens Care Home is a nursing home for up to 92 older people. At the time of our inspection, 60 people were living at the service.

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

People were happy living at the service. They were able to make choices about their care and felt these were respected. People were supported to see healthcare professionals when they needed. They received their medicines in a safe way and as prescribed. People were able to participate in a range of different social and leisure activities.

The staff were kind, caring and had the knowledge and skills needed to care for people in a safe way. They felt well supported and enjoyed working at the service. There were systems to make sure staff were safely recruited and provided with the training and supervision they needed.

The environment was well maintained and safe. People had the equipment they needed and there were good systems for keeping the service clean and minimising the risks of infection.

There were suitable systems for monitoring and improving the quality of the service. These included investigating and learning from things that went wrong, asking stakeholders for their views and undertaking regular checks on the service. The registered manager was suitably qualified and people were able to approach them to discuss their care. There was a positive culture at the service, where people living there, their relatives and staff felt valued.

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 information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating of the service was Good (published 12 March 2022).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

Follow up

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

Fern Gardens Care Home is a care home with nursing for up to 92 older people. At the time of our inspection 11 people were living at the service. The service is managed by Bondcare (London) Limited, a private company.

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

People received their medicines safely and as prescribed. However, improvements were needed to make sure records were accurate to avoid risks.

We have made a recommendation in relation to this.

People using the service were happy living there. They received personalised care which had been planned. They liked the staff and had good relationships with them. People were given choices and felt respected and valued. There was a wide range of social activities which people participated in. People had access to health care services and had enough to eat and drink.

There were suitable systems for recruiting, training and supporting staff. The staff told us they enjoyed working at the service. There was good communication between staff to help make sure people received consistent care and support.

The registered manager was suitably qualified and experienced. They had introduced new systems for monitoring the service and improving quality. They involved staff in this work and helped to make sure all staff took responsibility for monitoring care. There were systems for investigating and responding to complaints, accidents, safeguarding alerts and other adverse events. These included learning from these. People using the service and other stakeholders were asked for their views on the service.

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 inadequate (Published 10 September 2021) and there were breaches of Regulations. 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.

This service has been in Special Measures since 9 September 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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

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. This included checking the provider was meeting COVID-19 vaccination requirements.

Follow up

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

Fern Gardens Care Home is a nursing home for up to 92 older people. The service was previously called Coniston Lodge Nursing Home. The service is managed by Bondcare (London) Limited. At the time of our inspection 50 people were using the service. Some people were living with the experience of dementia and some were being cared for at the end of their lives.

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

People were not safely cared for. The provider had not always assessed, monitored or managed risks. The staff had not always responded appropriately to accidents and incidents and there were not always investigations or analysis to find out what happened and learn from these.

Medicines were not always safely managed. There had been recent improvements to medicines management following serious concerns raised by a visiting healthcare professional and safeguarding investigations. However, these improvements were not enough to ensure this was safe.

There had been multiple safeguarding concerns in 2021 with some recurring themes of poor care, poor medicines management and avoidable falls. The investigations into these by the local safeguarding authority found that, in many cases, the provider had not protected people from abuse and had sometimes failed to follow their own safeguarding procedures.

There was a poor culture at the service, where people using the service, their representatives and staff expressed concerns about management, care and support. Some staff had raised concerns which had not been responded to and they felt unsupported. The staff teams did not always communicate well with each other and this had a detrimental impact on people's care.

People were not always treated with respect and their needs were not always assessed, planned for or met. For example, care plans were incomplete and did not always give guidance on how to meet people's needs in a personalised way. Additionally, records of care provided indicated gaps in people's care. This was confirmed by some relatives, who explained people's basic needs were not always met.

However, some people were happy with the service and explained that some of the staff were kind and caring.

The provider had identified widespread concerns about the service and had developed plans to try and address some of these. The manager was absent from the service, and the acting manager, who had been in post for a few weeks, had started to make changes. Staff spoke positively about these changes and the acting manager.

Following our inspection, the provider supplied us with further information about improvements they intended to make.

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 inspection of the service was a targeted inspection where we looked at a specific area and did not assess any key questions. Therefore, a rating was not awarded.

The last rating we awarded was Requires Improvement (published 4 February 2021). From January 2020 until January 2021 the service had been in special measures. We found improvements at our inspection of November 2020 and special measures were removed following that inspection. However, at this inspection we identified multiple breaches of regulations and found the improvements had not been sustained.

Why we inspected

The inspection was prompted in part due to concerns received from a high number of safeguarding alerts where the provider was found to have neglected people and put them at risk. Some of these concerns included medicines errors, falls, unexplained injuries and care needs not being met.

We also received concerns from whistle blowers, relatives and visiting professionals. These concerns included failure to report concerns to others, respond to these and about poor care.

A decision was made for us to inspect and examine those risks.

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

We reviewed the information we held about the service. No areas of concern were identified in the key question of effective. We therefore did not inspect this key question. Ratings from previous comprehensive inspections for this key question was used in calculating the overall rating at this inspection.

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 changed from requires improvement to inadequate. This is based on the findings at this inspection.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person-centred care, dignity and respect, safe care and treatment, safeguarding people from abuse and improper treatment and good governance at this inspection.

Follow up

We will meet with the provider 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Fern Gardens Care Home (previously known as Coniston Lodge Nursing Home) is a care home with nursing for up to 92 older people. Some people were living with the experience of dementia. The service offers care and support to some people at the end of their lives. The home was also providing a ‘designated care setting’ service in a separate unit, set up in January 2021. This is a service the Local Authority and local Clinical Commissioning Group has identified as suitable to care for people discharged from hospital with a positive COVID-19 status. People only stay on this unit for a short time to pass their isolation period before moving on to their home or another care setting. We only visited this setting at this inspection, which 11 people were using at the time of our inspection.

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

The provider had infection control and protection processes in place in the designated setting and they monitored and ensured that these were implemented.

Staff assessed, recorded and monitored people’s eating and drinking needs.

The provider completed pre-admission assessments and risk management plans to assess and reduce risks to people's health, safety and well-being.

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 4 February October 2021). The service had been identified for use by the Local Authority and local Clinical Commissioning Group as a designated care setting, so we carried out a focused inspection on 12 January 2021 to ensure the service was compliant with infection prevention and control measures. We also checked the provider had followed their action plan to improve the service's ratings of the effective, caring and well-led key questions and to check whether a breach of regulation in relation to privacy and dignity (Regulation 10) had been met.

Since January 2020, the provider has been required to send us action plans each month to show us what they are doing to improve the service. This is because we had imposed conditions on their registration telling them they must do this.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the designated setting service supporting people’s safety, nutrition and hydration needs. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe, effective and well-led sections of this report.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. As a result, this report only covers our findings in relation to the safe, effective, and well-led key questions.

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 coronavirus and other infection outbreaks.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Fern Gardens Care Home (Previously known as Coniston Lodge Nursing Home) is a care home with nursing for up to 92 older people. At the time of our inspection, 33 people were using the service, some of whom were living with the experience of dementia.

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

Overall, people were positive about the service and told us they were well cared for. However, during lunchtime, we observed people were not always treated with care and dignity and their choices not always respected.

People’s healthcare needs were recorded and met. However, some records were not completed in line with people’s care plans, and we could not be sure if this was a recording error or if people had not received their care as planned.

Overall people received personal care and looked well cared for. However, some aspects of their personal care were not always met. The provider told us they would address this without delay.

There were systems to monitor the quality of the service and these were mostly effective. However, further improvements were required as the provider’s audits had not identified issues we found during our inspection, including the issues we found in relation to the care and dignity of people who used the service and the management of care records.

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.

People were protected by the provider’s arrangements in relation to the prevention and control of infection. The home was clean.

People were supported by staff who were sufficiently trained, supervised and appraised. The service liaised with other services to share ideas of good practice.

People’s health and nutritional needs had been assessed, recorded and were being monitored. People had access to healthcare professionals and the outcome of their visits were recorded. Healthcare professionals were satisfied that people’s health needs were met.

People’s individual needs and wishes were recorded in their care plans and respected, including their religious and cultural needs. Staff received training on end of life care and people’s care plans recorded their wishes in this area.

The provider had taken further steps since our last inspection to develop the design and decoration of the premises to meet the needs of people who used the service, in particular those living with the experience of dementia.

Staff reported that the management team was effective and making improvements at the service. They found them approachable and visible, and felt valued and supported. The manager told us they felt supported by senior managers and were working hard to continue making the necessary improvements.

The provider had good Infection Control and Protection (IPC) processes and they monitored and ensured that these were implemented. We were assured that this service met good IPC guidelines as a designated care setting.

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 8 January 2020). We carried out a focused inspection on 24 November 2020 to review the key questions of safe, responsive and well-led, and found improvements had been made and the provider was no longer in breach of the regulations we assessed.

The service however remained rated requires improvement as it was still rated requires improvement in the effective, caring and well-led key questions and overall and there remained a breach of the regulation in relation to privacy and dignity (Regulation10).

Since January 2020, the provider has been required to send us action plans each month to show us what they are doing to improve the service. This is because we imposed conditions on their registration telling them they must do this.

At this inspection we found improvements had been made and the provider was no longer in breach of the regulations we assessed. It was however still rated requires improvement in the caring and well-led key questions.

Why we inspected

The service had been identified for use by the Local Authority and local Clinical Commissioning Group as a designated setting in response to the Winter Plan for people discharged from hospital with a positive COVID-19 status. This inspection was to ensure that the service was compliant with infection control and prevention measures and we therefore looked at infection control and prevention practices under the safe key question.

In addition we undertook this focused inspection to check the provider has followed their action plan and has improved the service’s ratings of the effective, caring and well-led key questions and to check whether the breach of regulation in relation to privacy and dignity (Regulation 10) has been met.

As a result this report only covers our findings in relation to the effective, caring and well-led key questions and only the part of the safe key questions that covers infection prevention and control.

The ratings from the previous focused inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Coniston Lodge Nursing Home is a care home with nursing for up to 92 older people. At the time of our inspection, 29 people were using the service. Some people were living with the experience of dementia. The service offers care and support to some people at the end of their lives.

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

There had been improvements to the way quality was monitored. However further improvements were needed to make sure all risks were mitigated, and people continued to receive a high quality service. There was no registered manager at the service and there had been a lack of consistent management and approach. A new interim manager had been in post since October 2020.

People were happy with the care they received and had good relationships with familiar staff.

Medicines were managed in a safe way. Risks to people's safety had been assessed and planned for. There had been improvements in the way people were cared for. The number of accidents and falls had reduced. This was partly due to the provider's improved analysis when things went wrong. As a result they had changed their approach and care planning to help prevent accidents.

The provider had suitable procedures for recruiting, training and supporting staff. This helped to make sure they could meet people's needs. The staff felt supported and had a good understanding about the service and the people who they were caring for.

People's needs were recorded in care plans which were regularly reviewed and updated. These were personalised and took account of people's preferences. People were supported to take part in a range of different activities which reflected their interests.

There were suitable systems for dealing with complaints, accidents, incidents and other adverse events. The provider worked with others and gathered feedback from stakeholders to help them plan and implement improvements.

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 8 January 2020). We carried out an inspection in August 2020, but we did not review the rating because we only looked at specific areas of concern.

Since January 2020, the provider has been required to send us action plans each month to show us what they are doing to improve the service. This is because we imposed conditions on their registration telling them they must do this.

At this inspection we found improvements had been made and the provider was no longer in breach of the regulations we assessed. We did not have enough evidence to make a judgement about the remaining breach of regulation relating to dignity and respect. However, we found no new concerns in this area. We will assess this when we next inspect.

This service has been in Special Measures since April 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was prompted in part due to our ongoing concerns about the service which has been in special measures since 26 April 2019. There has been no registered manager at the service since December 2019, there have been a high number of safeguarding alerts and incidents in 2020 and we needed to visit to make sure people were safe and well cared for.

We undertook a focused inspection to review the key questions of safe, responsive and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 coronavirus and other infection outbreaks effectively.

The overall rating for the service has not changed. This is based on the findings at this inspection.

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

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Coniston Lodge Nursing Home is a nursing home which can provide personal and nursing care to 92 adults. At the time of our inspection 34 people were living at the service. The majority of people were older adults. Some were living with the experience of dementia and some were being cared for at the end of their lives. The service was managed by Bondcare (London) Limited, a private organisation.

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

There were appropriate procedures for infection prevention and control. However, staff did not always wear face masks correctly and this meant there was an increased risk of infection being spread.

There had been improvements in the way medicines were managed since the concerns raised earlier in 2020. However, staff did not always follow prescribers' instructions when administering nutritional supplements. Protocols describing when PRN (as required) medicines should be administered were not personalised. This meant there was a risk people would not receive medicines when they needed them.

There had been improvements to quality monitoring and responding to accidents, incidents and safeguarding alerts since the time when we were first alerted to concerns. However, there was a lack of proactive measures to identify root causes and plan to prevent these from reoccurring.

The provider had recruited a new manager and feedback from stakeholders indicated the service had made improvements. The relatives of people using the service told us they felt people were safe. Staff felt supported and told us they had the information they needed to carry out their roles.

Following the inspection, we provided feedback to the manager and regional support manager. They assured us they would address the areas of concern regarding the use of PPE (personal protective equipment) and medicines management.

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 8 January 2020). We identified breaches in relation to person centred care, dignity and respect, safe care and treatment and good governance. Following this, we imposed conditions on the provider's registration. These conditions require the provider to update us each month about the service, including any identified concerns and how they are addressing these. The provider completed an action plan after the last inspection to show what they would do and by when to improve. They have updated us each month to tell us the progress they have been making.

This service has been in Special Measures since 26 April 2019.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service and areas of high risk identified following our previous inspection. The inspection was prompted in part, in response to concerns received about safeguarding and medicines management. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. We found no evidence during this inspection that people were at risk of harm from these concerns.

Please see the safe, effective and well-led sections of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Coniston Lodge Nursing Home on our website at www.cqc.org.uk.

Enforcement

At this inspection, we have not looked at all the Regulations which were breached at the previous inspection. Therefore, we were unable to make a judgement about whether these had been fully met.

We have identified some improvements. However, we also found some care and treatment was not always safe. For example, staff did not always correctly wear PPE (Personal protection Equipment) and medicines procedures were not always followed in a safe way.

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 through the conditions we imposed following the last inspection. We have not taken addition action.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures:

We have not changed the rating at this inspection and the service remains in special measures.

This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions 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.

Coniston Lodge Nursing Home is a nursing home providing personal and nursing care to 92 adults. Most people were adults over the age of 65 years, some people were living with dementia and some were being cared for at the end of their lives. At the time of our inspection 48 people were living at the service. The service is managed by Bondcare (London) Limited, a private organisation.

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

People were not always treated with dignity and respect. A small number of staff spoke about people, or behaved in a way which did not respect them. Other staff were kinder and more caring in their approach, but most of the time staff focussed on the tasks they were performing rather than the wishes and perception of the person being cared for. The registered manager had undertaken considerable work to improve this area since the last inspection, however we found there was not a consistent approach from all staff and as a result some people had a negative experience.

People's needs were not always planned for. Where specific needs had been identified, the staff had not always assessed and planned for risks or the care needed. Some care plans focussed on a list of standard tasks and did not include information about people's preferences. Where people had mental and physical health needs, these were not always recognised as a need, their safety and wellbeing had not always been assessed and there were no plans to support their wellbeing in this area.

People's social and emotional needs were not always being met. People using the service and their relatives told us there was not enough for them to do, with some people expressing loneliness. The provider employed an activities coordinator but they did not have the time or resources to ensure everyone's needs were being met and they were not assisted by other staff who spent their time meeting care needs.

There had been improvements in the way medicines were being managed, but people did not always receive their medicines as prescribed or in the correct way.

The provider's systems for monitoring and improving the quality of the service had not always been operated effectively. There were risks to people's safety and wellbeing which had not been mitigated.

The provider had recruited a new manager to the service since the last inspection and they had registered with CQC. They had started to make improvements at the service. They had introduced a number of systems for improving quality, but these had not been embedded at the time of the inspection.

Complaints, accidents and incidents were investigated and action was taken to learn from these.

There were appropriate systems for the recruitment, training and support of staff to make sure they had the information they needed to care for people.

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 rating at the last inspection was requires improvement (Published 4 June 2019). We issued two warning notices and three requirement notices. We also asked the provider to send us monthly updates about the improvements they were making. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection not enough improvement had been made and the provider was still in breach of regulations.

This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to person-centred care, dignity and respect, safe care and treatment and good governance.

We have imposed conditions on the provider's registration.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. 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.

This service has been in Special Measures since 26 April 2019. As insufficient improvements have been made and there remains a rating of inadequate for the key question of well-led the service therefore remains in special measures.

This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Coniston Lodge Nursing Home is a '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 service provided both nursing and personal care and is registered to care for up to 92 people. At the time of our inspection, 48 people were living at the service. The majority of people were over the age of 65 years and some people were living with the experience of dementia. The service is owned and managed by Bondcare (London) Limited, a private organisation.

People’s experience of using this service:

People living at the service sometimes had to wait for care and support, because there were not enough staff deployed to meet their needs. People had to wait for support with personal care and assistance with meals.

Medicines were not always being managed in a safe way, and some people had not received their medicines as prescribed.

People were not always treated with dignity, respect or kindness. We witnessed interactions which were task based and some which caused people distress and discomfort. The staff supporting these people did not demonstrate an understanding of the person's perspective, nor did they offer comfort or reassurance.

People did not always receive personalised care which met their needs or reflected their preferences. There were not enough social activities or ways for people to spend their time.

The provider's systems for identifying and improving the quality of the service were not always operated effectively. Whilst we found improvements in some areas, these were not sufficient. The provider remains in breach of five Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations relating to person centred care, dignity and respect, safe care and treatment, good governance and staffing. The provider has been in breach of four of these Regulations since we first inspected the service in February 2018.

Notwithstanding the above, people using the service, their visitors and staff spoke positively about their experiences. People told us the staff were kind to them and the staff said they enjoyed working there and caring for people.

There had been improvements at the service, including the introduction of an electronic care planning system which allowed the staff to spend less time on paper work and more time with people using the service.

The provider had shown a commitment to making continuous improvements. Senior managers regularly spent time at the service monitoring this and providing support. There had been increased staff supervision and training, in order to enable them to develop the skills they needed to care for people. The provider's representative contacted us after the inspection visit to let us know about more training they were arranging following the feedback of our findings.

The environment was safely maintained and risks to people's safety and wellbeing had been assessed and planned for. The provider had responded appropriately to safeguarding allegations and worked with other professionals to protect people from the risk of abuse or harm.

People's healthcare needs had been identified and plans described how people should be cared for in respect of these. The staff worked closely with other healthcare professionals and made appropriate referrals when people's needs changed.

There had been improvements with the way in which people's nutrition and hydration needs were monitored and met. The care plans associated with these needs had been improved and the staff recorded people's food and fluid intake. These records could be accessed remotely by senior managers, so they could make sure people were receiving enough to eat and drink. The electronic care planning system alerted the staff if people's weight changed or they did not have enough to eat or drink.

The provider had improved the assessment and recording of people's mental capacity. Where people lacked the mental capacity to make decisions about their care, the provider had acted in their best interests, consulting with their representatives and applying for the correct legal authorisation to impose any restrictions on them.

The provider had suitable systems for dealing with, and learning from, accidents, incidents and complaints.

Rating at last inspection:

The last inspection of the service took place on the 25 and 26 September 2018 (published 1 November 2018). At this inspection we rated the service requires improvement. The key question, 'is the service well-led?' was rated inadequate. We identified breaches of seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, consent to care and treatment, nutrition and hydration, dignity and respect, person centred care, good governance and staffing. We issued warning notices in respect of the breaches of two Regulations relating to person centred care and good governance.

Whilst we found improvements in some of these areas during our inspection of 19 March 2019, the service remains rated requires improvement and has been rated as this for the last three inspections.

Why we inspected:

We inspected the service as part of our scheduled inspections based on the previous rating.

Enforcement:

We are taking action against the provider for failing to meet Regulations. Full information about CQC's regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The key question, 'is the service well-led?' has been rated ‘Inadequate’ at two consecutive inspections 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.

Follow up:

We will continue to monitor the service and will undertake another comprehensive inspection within six months or sooner if needed. We have invited the provider to meet with us to discuss how they plan to improve the rating of the service to at least 'good'. We have also asked them to provide us with a written action plan explaining this.

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

The last inspection of the service was on 23 January 2018 when we rated the service requires improvement. We identified breaches of four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to person centred care, dignity and respect, safe care and treatment and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the service to at least ''good.''

At the inspection of 25 and 26 September 2018, we found that the service continued to be rated requires improvement. None of the previous breaches had been met and we identified breaches of a further three Regulations, relating to the needs for consent, meeting nutritional and hydration needs and staffing. We have rated the key question of, 'Is the service well-led?' as inadequate because we have found the service did not have effective systems to make and sustain improvements.

Coniston Lodge Nursing Home is a '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 service provided both nursing and personal care and is registered to care for up to 92 people. At the time of our inspection, 52 people were living at the service. The majority of people were over the age of 65 years and some people were living with the experience of dementia.

The service is owned and managed by Bondcare (London) Limited, a private organisation.

The registered manager left their post shortly before the inspection. The provider's representatives told us they had successfully recruited a new manager who was due to take up post in November 2018 and who would apply to be registered with the Care Quality Commission. 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 and associated Regulations about how the service is run.

The provider did not ensure the safe and proper management of medicines. In addition, they had not always mitigated the risk of people acquiring pressure sores because they had not helped people, who were at this risk, to change position as often as they needed.

People's needs were not always being met. People did not always have enough to drink to keep them hydrated. The staff had not responded appropriately when people had lost weight to make sure their care was reviewed, and they had the support they needed. Care plans did not always include guidance about how people's individual care needs should be met.

The provider had not always assessed people's mental capacity and ability to consent to their care and treatment. Information about people's mental capacity was not consistently recorded and the provider had not always sought consent in accordance with legislation.

The staff did not always respect people's privacy or treat them in a respectful way.

The provider's systems for mitigating risks, and monitoring and improving the quality of the service were not always effective. Records were not always accurately maintained and this presented a risk of people receiving care and treatment which was inappropriate and did not meet their needs.

People sometimes had to wait for their care because sufficient numbers of staff were not deployed to meet people's needs.

We identified breaches of seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to safe care and treatment, consent to care and treatment, nutrition and hydration, dignity and respect, person centred care, good governance and staffing.

We are taking action against the provider for failing to meet Regulations. Full information about CQC's regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

People living at the service told us they were happy and felt well cared for. They said they were involved in planning their care and they were given choices about their everyday lives. People told us the staff treated them with kindness and that they had good relationships with them.

The staff felt well supported. They said that they had good communication with the management team and had access to the training they needed. The provider was organising for additional training for the staff in response to identified areas of need.

The environment was clean and appropriately maintained. There were regular environmental checks. The provider made sure equipment was safe to use. The staff followed procedures to minimise the risks of infection.

There were procedures designed to safeguard people from abuse and for people to make complaints. People felt safe and were happy to raise concerns. The provider had learnt from accidents, incidents and complaints to improve the quality of the service.

The inspection took place on 23 January 2018 and was unannounced.

This was the first inspection of the service since it was registered with the provider Bondcare (London) Limited in October 2017. Previous to this the service was owned and managed by another provider.

Coniston Lodge Nursing Home is registered to accommodate up to 92 people who require support with personal care and nursing needs. At the time of our inspection there were 41 people living at the service. The majority of people were over the age of 65 years, although there were some younger adults. People had a range of complex health conditions, some people had physical disabilities, some people were living with the experience of dementia and some people were being cared for at the end of their lives.

Bondcare (London) Limited were part of the Bondcare Group, a national provider of care services in the United Kingdom.

There was a manager who had been employed by Bondcare (London) Limited. They were in the process of applying to be registered with the Care Quality Commission. 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 and associated Regulations about how the service is run.

We have rated the service Requires Improvement overall and in the key questions of Safe, Caring, Responsive and Well-Led. We have rated the key question of Effective as Good.

People liked living at the home and felt their needs were being met. They told us they were cared for by kind staff. People felt they had been involved in planning their care and were given choices. They liked the food they were offered.

The staff felt supported by the manager and told us they had the training and support they needed. Some of the staff did not feel there were enough of them to meet people's needs and keep them safe. The staff told us the manager was approachable and they could discuss their concerns with them. We observed that the staffing levels at the service were sufficient to meet people's basic care and health needs. However, people did not always have access to company and opportunities to spend time with staff other than during practical support tasks. In addition, the staff did not always work efficiently as a team when communicating and meeting people's needs.

We observed some practices where people were being placed at risk. For example, one person who was at risk of choking was not given the support they needed when eating one of their meals. We also found that medicines were not always being safely managed.

The staff did not always care for people in a kind and considerate way. We saw that the staff also tended to focus on the tasks they were performing rather than the feelings of the people they were caring for. However, we also saw examples where individual staff members were kind and thoughtful.

People did not always receive personalised care and support which met their needs. For example, some people had to wait for personal care and they did not always receive the care which had been planned. In addition, whilst some people had opportunities to take part in organised social and leisure activities, others did not have the same level of opportunity for entertainment, leisure and social events. The care plans did not always include clear guidance on meeting people's needs. Although, the provider had recognised this and was taking action to make improvements in this area.

The provider's systems for ensuring people received the support and treatment they needed had not always been operated effectively. The risks of people receiving unsafe care had not always been mitigated.

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

In most cases, the procedures for controlling the spread of infection were appropriate. However, we found that the audits of the service had not identified a damaged and malodourous mattress. The staff had carried out suitable risk assessments for people. The environment was safely maintained and the provider ensured checks on safety and suitability were regularly carried out. The provider had a contingency plan for when things went wrong and there was evidence they learnt from adverse events, such as accidents and incidents.

People's needs had been assessed and planned for. They were able to contribute their ideas and had consented to their care and treatment. People's healthcare needs were monitored and met, with the staff working closely with other healthcare professionals. People had access to a range of nutritious food and drinks.

People being cared for at the end of their lives had the support and care they needed.

The provider had introduced changes to help improve the service. They carried out regular audits and had made changes as a result of these. People using the service and their representatives were able to contribute their views about their experiences. They knew how to make a complaint and felt they had opportunities to meet with the manager.