The Lodge

We found the following examples of good practice.

We observed staff following good infection prevention and control practices including appropriate use of personal protective equipment (PPE) in line with government guidance to reduce the risk of infection.

The Lodge was clean throughout. Increased cleaning was taking place across all aspects of the service. This included ensuring all high touch points were regularly sanitised.

Windows and doors were observed to be open to support with ventilation whilst a comfortable temperature was maintained.

Polices, and procedures were in place to assist the registered manager and staff to manage any risks associated with the COVID-19 pandemic.

People living at The Lodge and staff were undertaking COVID-19 testing in line with Government guidance. Appropriate action had been taken if anyone contracted the virus including staff who were supported to self-isolate. Staff absence was being effectively managed where shift cover was required.

People had clear care plans in place in relation to COVID-19, this ensured risks could be mitigated and people could be supported in a personalised way.

The Lodge can accommodate up to 44 people and there were 39 people using the service on the days of our inspection. The service comprises of two houses on one site and supports older people in the larger house and up to five people with mental health needs in the Coach House.

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

At this inspection, we found risk assessments for the environment had been reviewed and actions taken to improve the safety of the service. New window locks had been installed to all upstairs windows which allowed opening for ventilation, but the opening was restricted to prevent people from falling through the gap. The hot water temperate were recorded frequently to a set monitoring plan and any issues identified were resolved.

At this inspection, we found the managerial oversight of the service had improved and the quality assurance checks in place enabled the registered manager and senior staff to pro-actively respond to identified events.

The registered manager and senior staff carried out an assessment of people’s needs before they commenced using the service. The information recorded identified to some degree how the support was to be provided in line with the person’s preferences and choices. However, the information, although known by the staff, was not always recorded or lacked detail regarding what may upset people and the actions people were to take. The service had a complaints process and we saw that complaints were recorded and responded to in line with the recorded procedure.

Each person had a care plan containing a risk assessment. Staff were aware of people’s needs and how to support them. This included recorded information in the care plans regarding people’s prescribed medicines and staff had received training in the administration of medicines. Staff were recruited through a robust recruiting procedure. People informed us that there were sufficient members of staff on duty at all times to support them.

The staff were provided with supervision and on-going support including training. Staff recorded when necessary how they had supported people to have enough to eat and drink of their choice. People’s care plans recorded information about support provided by other professionals and when appointments had been made for them by the staff with their permission.

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 told us that their personal care and support was provided in a way which maintained their privacy and dignity. People spoke positively about the way staff treated them and reported that they received appropriate care. Staff demonstrated a good knowledge and understanding of the people they cared for and supported, such as people with a diagnosis of diabetes or dementia.

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 13 July 2018) and there was a breach of Regulation 17: Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

Although the rating for the key question for responsive has deteriorated from good to requires improvement. The key questions for safe and well-led have improved to good.

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

Why we inspected

This was a planned inspection based on the previous rating.

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.

Following the last inspection in January 2017, the provider wrote to us to show what they would do and by when to improve the key question of ‘Safe’ to at least good. We found that the provider was now compliant with the previously identified breach of Regulation 12 (medicines) of the Health and Social Care Act 2008 (regulated Activities) 2014. Despite these improvements we found breaches 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 this report.

The Lodge is a ‘care home’ which accommodates a maximum occupancy of 44 people. At the time of this inspection visit, 8 May 2018, 32 people were living at the home. Most of these people were living with dementia. 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.

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

Systems and processes were not always used effectively to monitor the quality and safety of the service. You can read more about this under the ‘Safe’ and ‘Well-Led’ sections of this report. Quality monitoring systems in place had failed to identify that hot water presented a scald hazard and that windows above ground level were not restricted safely. These were immediately made safe once brought to the attention of the registered people. However, the lack of systems to identify potential hazards and risks was not effective. The provider lacked oversight of their provision of service.

People told us they were happy living at this service and that they felt safe with the care provided. People were protected from the risks of abuse. Staff received appropriate training and knew how to raise concerns if they felt people were at risk of being abused or mistreated.

People’s individual needs, choices and preferences were assessed and known by a caring, consistent, well trained staff team who knew people well. People and their representatives, as appropriate, were involved in their care plans and reviews of their plans of care by staff who were well trained to meet their individual needs. No external agency staff were used at this service at the time of this inspection. Individual risks for people were assessed and managed. Medicines were given to people safely and infection control procedures including correct use of protective equipment and cleaning schedules kept the home clean and free from any unpleasant odours.

People received care from staff who had undertaken training to be able to meet their individual needs and preferences, which included having enough to eat and drink. Snacks and drinks were available whenever people wished to have them. Meals were home cooked in line with people’s choice, preferences and needs, by trained kitchen staff. Specialist diets were catered for appropriately for people.

Staff were recruited safely. Checks were completed by senior staff which ensured staff performance and competence was closely monitored. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible. The policies and systems in the service supported this practice.

People told us that staff were caring and kind in their approach and that staff treated them with dignity and respect. Staff were aware of how to protect people's privacy which ensured this was maintained. People were supported to access healthcare in a timely manner and we were told by relatives that the management team were “proactive” and ensured healthcare professionals were contacted without delay when people needed this.

People told us that they didn’t need to make complaints but felt confident that they knew the process should they wish to make a complaint.

This home actively supported people at the end of their lives. The deputy manager was able to tell us how they would support people and their families to receive personalised end of life care. This was achieved by using appropriate care planning and by liaising with appropriate healthcare professionals which ensured people had timely access to anticipatory medicines as required in the last few days or weeks of their lives. Appropriate documentation was seen for those people who did not wish to be resuscitated which ensured that people received the end of life care they wanted or that was required in their best interests.

There was a clear, transparent management team at the service who worked well together with the staff team to provide support as required.

The Lodge is registered to provide care and support to up to 44 people, some of whom were living with dementia. On this visit 31 people resided at this residential home. This service is required to have a residential manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had recently left and a replacement was actively being sought. At this inspection the deputy manager had become the acting manager and was present, participated fully in this inspection as did the provider.

The numbers of staff were sufficient to meet the needs of people living at the service. This was because the numbers of people resident had decreased and staff had been better deployed at key times, such as lunchtime. The acting manager was continuously assessing the needs and dependency of people at the service and had allocated staffing as a result. People and staff consistently said there was sufficient staff to meet the needs. Staff were trained and supported by the acting manager.

We have identified a breach in regulation. This is because people were placed at unnecessary risk of developing sore skin as risks were not adequately mitigated through clear instruction and actions of staff. In addition medicines were not consistently managed safely and we identified areas to improve safety. A medicine trolley was left locked with the key in it and unobserved by staff. Crushed and covert medicines were not as safely managed as should have been. Medicines prescribed as a cream were not safely managed. Records did not protect people and staff as would be expected.

Staff had undertaken training in The Mental Capacity Act 2005 (MCA). They were consistently offering choices and respected peoples decisions. However, they along with managers were not clear on more complex decisions and how to go about making ‘Best Interest’ decisions.

Staff were attentive, visible, kind and demonstrating meaningful relationships with people. Relatives were positive about the care their relatives received. Privacy, dignity and respect were afforded to people. People enjoyed good nutritious food, with the lunchtime experience being positive for most people. We have fedback further minor developments to ensure everyone has a positive mealtime.

People had access to healthcare to maintain their health. Visiting health professionals spoke positively about what they saw at the service. People had access to a variety of activities and interests that they were able to participate in.

The acting manager had made improvements in a short space of time and relatives and staff spoke positively about the changes they had seen. The culture was set to improve with developments being planned. Since our visit we have been sent information and evidence that shows that mangers and the provider continue to develop and monitor the service to ensure the safety of people living here.

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

At this inspection we found that many of those improvements had been put into place. However we were concerned that the staff were not receiving training in the Mental Capacity Act 2005 or receiving organised supervision as the action plan stated would be put in place. Furthermore, at this inspection we found there were insufficient staff on duty to provide the care and support required by the people using the service to keep them safe. The management staff were frequently providing direct care themselves which would also account for the difficulties involving training and supervision.

The Lodge can provide care and accommodation for up to 44 people older people including people living with dementia. At the time of our inspection there were 36 people using the service

There was a registered manager in place. 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 who used the service did not feel safe and secure because there were insufficient staff working throughout the service. At times senior staff and the manager were required to support the care staff with the delivery of care. This impacted on the manager’s time which meant that other aspects of their work were detrimentally affected. We discussed our concerns with the manager and informed the provider. Action was taken and the staffing numbers were increased.

People had their mental health and physical needs monitored. Staff had received training in how to recognise and report abuse. Staff spoken with, were all confident that any allegations made would be fully investigated to ensure people were protected. However, the staff considered for the service to be safe additional staff were needed on all shifts.

The service had made referrals and worked with the Local authority to support people who used the service with regard to Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, the service had not provided training with regard to (MCA) and (DoLS). This was something we had specifically required the service to do as a result of our last inspection.

The staff did receive some training such as first aid and safeguarding people of which they were pleased with the content. The manager had arranged an annual appraisal for the staff but the planned regular supervision as we required being in place was not arranged, although the action plan informed this would happen. However we did see that the management team offered day to day support to staff, on the day of our inspection we saw the care manager providing on the spot support and advice for a member of staff.

Most people who used the service were content with the meals and staff supported people with their food and fluid intake. We saw that risk assessments and resulting plans of care had been recorded in the individuals care record. However, due to the lack of staff to organise the meal we found the mealtime somewhat taxing for people. The meal was served over two sittings and people and staff’s view was that this was better than one sitting. However, people had to wait, sometimes over 40 minutes, from being seated to their meal arriving. We were concerned that while one staff supported one person with their meal for over 25 minutes, another person in the same lounge had to wait for their meal. This was due to the time it took staff to support people to the dining room and then be available to assist them with their meal.

Before moving to the service people took part in an assessment of their needs from which a care plan was written and reviewed.

Staff had worked with people to support them to have access to and be visited by healthcare professionals when they had been unwell and to attend appointments to maintain their well-being when long standing illnesses had been diagnosed.

There were systems in place for replying to people’s concerns. There had been no recorded complaints since our last inspection. We did note there had been a number of compliments from relatives regarding the care provided.

Relatives told us that they had confidence in the manager and senior staff who they saw regularly. People living at the service, staff and visitors described the management of the service as open and approachable.

You can see what actions we have told the provider to take at the back of this report.

This is a summary of what we found;

Is the service safe?

When we arrived at the service a staff member looked at our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made, and how to submit one. We saw that the staff were provided with training in safeguarding vulnerable adults from abuse. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

The service was safe. Records showed that there were regular health and safety checks carried out to make sure the service was well-maintained and met people's needs. This included regular fire safety checks, which meant that people were protected in the event of a fire. The service was clean and hygienic.

Systems were in place to make sure that managers and staff learned 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.

Is the service effective?

People told us that they were happy living in the service. One person said, "I love being here, I would not want to leave." Another person said, 'We are really well looked after.'

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

People's dietary needs were met.

We saw the staff rota which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs.

Is the service caring?

The staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with kindness and respect. One person said, 'All of them (staff) are kind.'

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and mental health professionals.

We looked at how complaints had been dealt with, and found that the responses had been open, thorough, and timely. People could therefore be assured that complaints were investigated and action where taken as necessary.

Is the service well-led?

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities. We reviewed the minutes from staff meetings which showed that the management had consulted with staff before implementing changes in the service. This helped to ensure that people were provided with a good quality service.

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

We spoke with a person's relative who told us, "(Person) is very well looked after." We also spoke with a visiting care professional who told us that they were satisfied with the care and support provided to their client and that they had noted an improvement in the person's wellbeing since they had moved into the service.

We spent time sitting in the two lounges in the service and observed the care and support provided to people. We saw that staff were attentive to people's needs and that they interacted with people in a caring, respectful and professional manner.

We looked at the care records of four people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights.

We saw staff training records which showed that staff were trained to meet the needs of the people who used the service.

We saw records which showed that people's comments and complaints were addressed in a timely manner.

One person told us that they had enjoyed their lunch and said, "It was gorgeous, I should have saved you some." We saw that people were supported by staff to eat their meal at a pace that suited them.

We found that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. Prior to our inspection we had received a concern about the heating in the service. The registered manager told us that they had identified an issue with the heating and actions had been taken to repair it. All people spoken with said that they were happy in the service and that they were warm enough.