Archived: Carey Lodge

Carey Lodge is a residential care home providing personal care and support for up to 75 older people some of whom are living with dementia. At the time of the inspection 52 people lived at the home. People's accommodation is located in six separate areas referred to as 'houses', located over three floors. Each house has individual bedrooms and communal dinning and lounge areas. The home had many seating options on each floor.

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

People were not routinely and consistently supported by a service that was well-led. People were placed at ongoing risk of harm as systems and processes were not in place to assess, mitigate and manage risk.

On day one of the inspection we had major concerns about people’s safety if a fire or emergency occurred. We found the manager and other staff could not be confident about how many people were in the building. We found records ranged from 45 to 56. An inspector was escorted around the building to carry out a physical head count of people so we could be confident who was in the building. Equipment which should be used in the event of a fire was stored inappropriately by the front door, not where is was needed on first and second floors. We found the service was ill equipped to deal with a fire, no fire grab bags were readily available. Due to the level of concern we had we made an urgent referral to Buckinghamshire Fire and Rescue Service. The fire service visited the care home following our referral. We have since been informed 11 immediate actions were identified and the fire service will be re-visiting to ensure those actions have been carried out.

People were not protected from the risk of infection. We found the home had many areas which needed cleaning or correct storage of hazardous waste. We routinely observed staff not following government guidance on the use of face masks, which put people at risk of contracting COVID-19.

We found people at risk of malnutrition and dehydration were not routinely supported to ensure their health did not deteriorate. We found people had routinely gone in excess of 12 hours without being offered any fluids. One person’s records showed they had gone 17 hours and 10 mins with no offer of a drink.

Risk assessments were completed by staff who had not received training on how to do this accurately. We found risk assessments were incomplete and failed to assess the level of harm to people. One person who was at risk of choking needed a soft diet and struggled to swallow a tablet had a risk assessment in place dated 23 July 2020. This had not been updated to reflect their current needs. One person had a sore on their back, there was no accurate risk assessment in place to prevent further deterioration in their skin.

People were not consistently supported with their prescribed medicines. Staff did not routinely have access to additional guidance on when, how and why they should administer medicine for occasional use. This put people at risk of receiving more or less than was needed to support them safely.

Records relating to people’s care and treatment were not routinely stored securely or accurate and did not always represent a complete and contemporaneous record of support provided. On day one we found confidential notes were laying on a table in a communal area. This could have been read by any unauthorised person.

People were supported by staff who had been recruited safely, but they had not always been offered or undertaken training suitable to their role. People and staff told us, and we observed the deployment of staff could have been improved. We found times when no staff member was present, and people were observed to be sitting alone in a lounge area.

The service had received complaints, these had not always been handled in line with the provider’s policy and we found some had not been acknowledged or responded to.

People were not routinely supported by staff who respected their dignity, we found staff routinely entered people’s rooms without knocking.

Systems either were not in place or were ineffective to ensure action was taken to improve people’s experience as a result of feedback. The provider had failed to ensure improvements had been made since our last inspection.

People were not routinely supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. We have made a recommendation in the report to ensure people were routinely supported in line with the Mental Capacity Act 2005.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 February 2020) and there were multiple breaches of regulations. The provider completed an action plan after the last comprehensive inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 8 and 9 January 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, compliance with the Mental Capacity Act 2005 and good governance. We issued a warning notice to ensure improvements were made. We carried out a targeted inspection on 28 and 29 October to check if the warning notice had been met. We found the provider was still in breach of regulations in the areas of safe care and treatment and good governance. Following the targeted inspection, a decision was made not to escalate any enforcement. We took into account the impact of the COVID 19 pandemic.

We undertook this focused inspection to check what action had been made since the targeted inspection and to confirm the service now met legal requirements. This report only covers our findings in relation to the key questions Safe, Effective and Well-led.

The inspection was prompted in part due to concerns received about how well-led the service was and risks posed to people.

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

We have found evidence that the provider needs to make improvements. 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 Carey Lodge on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to 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 management of risks, health and safety, deployment and support for staff, meeting people’s nutrition and hydration needs, management of complaints, good governance and meeting the requirements of notifying CQC of certain events.

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

Following the concerns we raised about the poor quality of care provided by The Fremantle Trust at Carey Lodge. The provider, The Fremantle Trust made a decision to close the care home. Carey Lodge has been removed as a registered care home.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will 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.

Carey Lodge is a residential care home providing personal care and support for up to 75 older people some of whom are living with dementia. At the time of the inspection 68 people lived at the home. People’s accommodation is located in five separate areas referred to as ‘houses’, located over three floors. Each house has individual bedrooms, a communal dinning and lounge areas. The houses which catered for people living with dementia were decorated to minimise distress and provide interactive opportunities to people.

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

People were not routinely and consistently protected from risks associated with their medical conditions. Staff were not always aware of people’s medical conditions and had not assessed or mitigated potential risk. We found staff who were supporting people with a diagnosis of Diabetes did not always have additional information available to them on how to maintain their safety.

We found people's records held contradictory, out of date and sometimes inaccurate information. For instance, one person’s file contained contradictions about their type of Epilepsy. One record we looked at referred to another person’s name in it.

We found people's care records were not always completed in full. For instance, we found not all fall risk assessments were completed in full to reflect the risk posed to them, as some sections had been left blank.

Since the last inspection the service has a newly appointed registered manager. The provider had been supporting the service to make the required improvements. However, we found the quality assurance processes both at location and provider level required further improvement. For instance, audits completed did not always identify gaps, inaccuracies or out of date information in people’s records.

Since the last inspection people received a better service in respect of the support they needed with their prescribed medicines. We found some improvements were required to ensure staff had readily available information on why, when and how to administer medicines for occasional use. We have made a recommendation about this in the report.

People told us they felt safe living at the home and protected from the risk of infection. Comments included “I think Carey Lodge has managed the virus very well during this period. The staff all wear masks and gloves. They take my temperature every day and I have swabs every month”, “I have been tested four times and I feel they’re on top of the infections” and “They are very strict on the viruses and they’re all wearing masks”.

People told us they felt staff supported them in a positive way. Comments included “I talk to my carers if I have a problem. I was very down in the dumps this morning and I had a good chat with the carers and they really cheered me up”, "They come at set times with my pill, in the morning, lunch time and night-time and they wait until I have taken them. They are usually pretty good”, “I think this a good place and they’ll listen to you. When I came in here, I sat down with the chef and said exactly how I liked my food and now I get the food that I want” and “I am happy with the way I’m being looked after here. It is clean and the food is good. If I need anything, I just ask the staff. I see more people here than I did at home and I am happy with the home”.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 February 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, however, the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

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

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We had identified concerns about the management of risk, prescribed medicines, records relating to people’s needs and quality systems to drive improvements in the service. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

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 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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service. 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 continued breaches in relation to safe care and treatment and good governance at this inspection.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Carey Lodge is a residential care home providing personal care and support for up to 75 older people some of whom are living with dementia. At the time of the inspection 68 people lived at the home. People’s accommodation is located in six separate areas referred to as ‘houses’, located over three floors. Each house has individual bedrooms, a communal dinning and lounge areas. The home had many seating options on each floor. The houses which catered for people living with dementia were decorated to minimise distress and provide interactive opportunities to people. The home benefitted from a sensory garden which had won the providers ‘best sensory garden’ competition last year.

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

People were not always supported by staff who knew how to minimise the likelihood of harm to them. Risks posed to people as a result of their medical conditions were not routinely managed. Risk assessments were not always completed or updated when changes occurred.

People were not always supported by staff who followed best practice guidance and the provider’s policy when completing records for the administration of medicines. People had been given ‘as required’ medicines with no guidance as to why, how often and when it was required. This placed people at risk of receiving too much or too little medicine.

People were not routinely supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found staff had a lack of understanding of the Mental Capacity Act 2005 and sought consent from third parties when not required.

Care plans were not always accurate to reflect people’s current needs. We found care plan records were contradictory in nature and often incomplete or did not detail people’s name.

People were not supported by a service that was well managed. We found ongoing breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Systems the provider and registered manager had in place to monitor the quality of the service provided to people were ineffective and did not have the desired effect to drive improvement.

People were supported by staff who had been recruited safely and received training to update their skills. However not all senior staff who held line management responsibility had received training on how to supervise staff.

People told us they had developed good working relationships with staff. Comments included “There is one excellent carer and we have asked to have her up here, but she has not emerged on this floor for a while” and “There is one other who is lovely, and you can have a giggle with her.”

Relatives told us they were happy with the care their family member received comments included

“Staff here like [person’s name], they are very kind to her”,” I am extremely pleased with the care [Name of person] receives” and “She made the decision to move here and undoubtedly she is much better and healthier since moving here.” Another relative told us “The care she received was fabulous, the staff nothing less than wonderful and the accommodation clean and comfortable.”

People had opportunities to engage in interactive activities suitable to their cognitive function. The home hosted a number of annual social events which were attended by people, their relatives and local residents. The home had good links with the local schools and children often visited the home.

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 10 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found some improvements had been made, however, the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified continued breaches at this inspection in relation to mitigating risks to prevent avoidable harm, ensuring people received appropriate care and support to meet their needs and quality monitoring of the service provided. We have served warning notices in relation to safe care and treatment and good governance.

We have identified a further breach in relation to consent to care.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Carey Lodge is ‘a care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides care for up to 75 older people, including people with dementia. The home is made up of six individual houses and set over three floors. Each house has its own sitting and dining room. The large reception/ entrance area to the home is used for activities. Three of the houses are for people with dementia and the other houses provide residential care. At the time of our inspection there were 73 people living at the service.

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.

At our previous comprehensive inspection in February 2016 the service was rated as good overall, with a requires improvement rating in the safe domain. At that inspection the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A focused inspection was carried out in March 2017 to check compliance with breach of Regulation 12. At that inspection the service was compliant with Regulation 12 but in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the previous inspections, we asked the provider to complete an action plan to show what they would do and by when to improve the key question safe to at least good. At this inspection we found there was a repeated breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and other Regulations were not complied with. The service achieved an overall “Requires Improvement” rating.

Relatives were happy with the care provided and felt confident their family members were well cared for. They commented “All of the staff are kind, caring, encourage appropriately and go above and beyond what is expected of them. I really appreciate all that they do. My mum is very happy here and sees it as her home.” “The care staff are excellent, they show such understanding to my wife and the whole family.” “The carers are wonderful, they treat [family member’s name] as a good friend and that is comforting to see.”

Staff were not always appropriately deployed and rotas were not always suitably managed. The staffing levels were not always adjusted to take account of the support a person required and there were periods of the day where there was a reduction in staffing levels. Some people told us there was a lack of continuity of care for them. They told us staff were rushed and did not have time to talk with them.

Risks to people were identified but not always appropriately managed. Systems were in place to ensure medicines were safely managed. However, medicines were not always kept secure and no protocols were in place for a person’s “As required” medicines, which were administered regularly and not as required.

People had care plans in place. The care plans lacked specific detail and guidance on the support people required. Records relating to people and the running of the service were not always accurate, up to date and suitably maintained.

People were consulted on their day to day care. However, for some people the records showed the principles of the Mental Capacity Act 2005 were not followed. A recommendation has been made to address issues of consent.

Care plans made reference to people’s communication needs but appropriate measures and guidance were not put in place to promote people’s communication. A recommendation has been made to address this so that the service works to the Accessible Information Standard.

Staff were suitably recruited and inducted. They received training the provider considered mandatory. Some staff did not feel they had the required skills and training to carry out aspects of their role. A recommendation has been made to address this.

Staff were kind and caring, however some staff practices did not promote people’s dignity and show respect. Staff were trained in safeguarding, but they failed to notice other staff member’s poor practice and interactions which did not safeguard people. A recommendation has been made for staff practices to be monitored.

The service was being audited and these audits had identified improvements were required. The improvements made were not sufficient to demonstrate an overall good rating at this inspection.

People, staff and relatives felt the service was well managed. However, our inspection findings showed a lack of management oversight.

Systems were in place to deal with complaints. Resident meetings took place and relatives were invited to give feedback on the service through reviews of their family member’s care and surveys.

People’s medical and nutritional needs were identified and met. The service had regular input from local GP practices and the community mental health teams. There was mixed feedback on the meals provided, with some people telling us the meals were good, whilst others were less satisfied with them.

People had access to a wide range of activities, which were person centred, innovative and promoted involvement in their local community.

The home was clean and suitably maintained. The dementia care houses were decorated with murals and displays suitable to the needs of people on those houses.

At this inspection the provider was in breach of Regulations 9, 12, 17 and 18 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.

Carey Lodge provides care for up to 75 older people, some of whom may have dementia. On the day of our visit there were 70 people using the service.

At the last inspection on 16 and 22 February 2016 the provider was in breach of one regulation of the Health and Social Care Act 2008, (Regulated Activities) Regulations 2014.

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

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 l Care Act 2008 and associated Regulations about how the service is run.

People, families and staff told us that at times there were not enough staff to meet people’s needs. Staff rotas confirmed that the planned staffing levels were not always maintained. Comments were “Three staff are not always maintained on the floors” and “I know one lady needs two people to assist her, but there is not always enough to do this”.

People and their families told us they felt safe at Carey Lodge. Staff understood their responsibilities in relation to safeguarding people. The service had systems in place to notify the authorities when concerns were identified. People received their medicines as prescribed.

The service had safe recruitment procedures and conducted background checks to ensure staff were suitable to undertake their care role. Where risks to people were identified, risk assessments were mainly in place. We found some reviews of these risks had not clearly been recorded.

Accidents and incidents were well managed. We found there were checks in place to ensure people were safe.

We found a breach 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.

We previously inspected the service on 13 June 2013. The service was meeting the requirements of the regulations at that time.

Carey Lodge provides care for up to 75 older people, some of whom may have dementia. Seventy people were being cared for at the time of our visit.

The service had 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.

We received positive feedback about the service. Comments from people included “Everything’s fine,” “I’m lovely and comfortable,” “They look after us well” and that staff were “So attentive, helpful and treat you with respect.”

There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Risk was managed well at the service so that people could be as independent as possible. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care.

We found there were sufficient staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had been kept up to date to reflect changes in people’s needs. People were supported to take part in a wide range of social activities. Staff supported people to attend healthcare appointments to keep healthy and well.

The service was managed well. The provider regularly checked quality of care at the service through visits and audits. These showed the service was performing well. The registered manager was skilled and experienced and was assisted by a team of senior staff. There were clear visions and values for how the service should operate and staff promoted these. For example, people told us they were treated with dignity and respect and we saw they were given choices. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

Medicines were not always managed in line with safe practices. We found maximum and minimum temperatures of medicines refrigerators were not recorded to ensure medicines which needed to be stored between 2 and 8°C were safe to use. This meant they may not be kept in line with the manufacturer’s instructions. Controlled drugs waiting to be returned to the pharmacy for destruction were not recorded in a controlled drugs record book. This meant they could potentially be misappropriated.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to safe medicines practice. You can see what action we told the provider to take at the back of the full version of this report.

We found care plans were in place for each person. These documented people's needs and how they were to be met. Risk assessments had been written to reduce the likelihood of injury to people. We saw people had access to healthcare professionals such as GPs and district nurses.

People's medicines were managed safely. Staff who handled medication had undertaken training. Medicines were stored securely and accurate records were maintained.

We saw there were effective staff recruitment practices at the home. These included obtaining written references from previous employers and carrying out checks for criminal convictions.