Elizabeth Lodge

Elizabeth Lodge is a residential care home providing nursing and personal care to older people, some of whom were also living with dementia. The service is registered to accommodate 87 people. At the time of the inspection there were 53 people living in the home.

Elizabeth Lodge is a purpose built care home consisting of five separate units with their own lounges, kitchenettes and bathrooms. In addition the home has a number of large communal rooms for activities and visitors. The home is one of many homes run by Care UK, a large care provider in the UK.

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

People told us they felt safe living at Elizabeth Lodge. Risks to people’s safety and wellbeing had been assessed and action taken to help keep people safe from harm.

The home followed appropriate procedures for reporting any accidents or safeguarding concerns. All incidents were analysed to see if any improvements were needed to avoid further incidents. People were protected from the risks associated with the spread of infection. The service was clean and action was being taken to prevent a new outbreak of COVID-19.

There were enough staff deployed to meet people's needs and ensure their safety. The home followed the provider’s recruitment procedure but this was not sufficiently robust in checking applicants’ conduct in previous employment and we have made a recommendation to improve the recruitment process. This is being discussed by CQC with the provider at a national level.

Medicines were managed and administered safely.

People told us they were happy with the care and support they received. Staff said they were happy working at Elizabeth Lodge and felt well supported by the management team. They received appropriate training for their roles. 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.

Relatives of people living in the home told us they were generally happy with the service.

Staff were caring and kind in their interactions with people. Staff knew people’s individual needs and likes/dislikes well. Care plans showed good detail about people’s needs and preferences. Staff supported people to meet their health and nutritional needs.

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 17/07/2019) 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 improvements had been made and the provider was no longer in breach of those regulations. At this inspection the rating has improved to good.

Why we inspected

We undertook this comprehensive inspection to check they had followed their action plan and to confirm they now met legal requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor 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.

Elizabeth Lodge is a nursing and residential care home providing personal and nursing care to people aged 65 and over. At the time of the inspection the service was supporting 75 people.

Elizabeth Lodge can accommodate up to 87 people across five separate units called Windsor, Tudor, Hanover, Stuart and York. Each unit has separate adapted facilities. The units specialise in providing nursing and residential care to people including those living with dementia.

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

People were not always receiving care that respected and promoted their dignity.

Care was seen to be task focused with minimal interaction and stimulation taking place especially between people and the staff supporting them.

The lack of activities, interaction and stimulation for people on individual units, especially those who did not join in with group activities was not person centred and did not promote people’s well-being.

We have made a recommendation about the appropriate deployment of staff to ensure people’s safety at all times.

Despite management audits and checks that monitored the quality of care people received identifying these issues, sufficient improvements and changes had not been made to improve people’s experiences.

People and relatives were overall happy with the care and support that they received at Elizabeth Lodge. However, negative comments were made around staffing deployment, provision of activities and the level of personal care that people received.

Risks associated with people’s health, care and social care needs had been assessed to enable the safe delivery of care for each individual.

Processes in place for medicines management and administration were appropriately followed to ensure people received their medicines safely and as prescribed.

Care plans were person centred and gave information about people’s lives, their likes, dislikes and preferences.

People and their relatives told us that they felt safe and secure living at Elizabeth Lodge. Care staff understood their responsibilities around safeguarding people and the steps they would take to report their concerns.

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.

Care staff were appropriately supported through training, supervision and annual appraisals.

People were observed enjoying their meals and were given a choice of what they would like to eat and drink. Snacks and drinks were readily available and offered to people throughout the day.

People and their relatives knew who to speak with if they had a complaint or concern to raise and were generally confident that their concerns would be appropriately addressed.

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

Rating at last inspection and update

The last rating for this service was Good (published 15 December 2016). However the key question Responsive was rated as requires improvement. There were no regulatory breaches identified but improvements were required. At this inspection sufficient improvements had not been made and the provider was now found to be in breach of regulations in relation to person centred care, dignity and respect and good governance.

Why we inspected

This was a planned inspection based on the previous rating.

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.

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 last inspection on September 2015, we found that some aspects of medicines management were not safe. The service could not demonstrate that staff members had received an appraisal. These resulted in breaches of Regulation 12, and 18 of the Health and Social Care Act 2008.

During this inspection we found that appropriate actions had been taken and improvement had been made to ensure the safe management of medicines. The registered manager had also completed appraisals for the last year for all staff employed.

Although the home had organised activities which took place centrally within the home, we found very little activity or stimulation on the individual units especially involving those people who were unable to leave the unit due to mobility or health conditions.

People and relatives that we spoke with highlighted concerns around the low staffing levels within the home. Appropriate level of need assessments had been completed, which determined the staffing levels. We observed there to be sufficient staff available to support people. However, due to the way staff were deployed and allocated to work on the units, there were occasions where staff were not visible on the units and people were left on their own for a certain period of time.

People were provided with a healthy and balanced diet which allowed for choice and preference. However, some people, on particular units, who were supported in their own bedrooms had to wait up to 30 minutes before a staff member assisted them with their meal.

Risks associated with people’s care and support needs had been identified and these had been assessed giving staff instructions and directions on how to safely manage those risks. However, where people had been diagnosed with a specific health condition that would potentially affect their mobility, this had not been risk assessed or linked into their moving and handling assessment to ensure that care staff had the appropriate guidance on how to support the person and ensure their safety especially when mobilising.

The registered manager, senior managers and care staff demonstrated a good level of understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered manager had submitted applications to the local safeguarding authority for each person who required an authorisation to ensure that people were legally being deprived of their liberty which was in their best interest. However, where an authorisation had been granted with conditions that the service had to adhere to, these had not been reflected within people’s care plans to ensure staff were aware of the actions that needed to be taken to meet those conditions.

Mental capacity assessments and best interest decisions had been completed for people depending on the specific decisions that needed to be made. However, these were not consistently available in all care plans that we looked at especially where decisions had been made for people to have a valid ‘do not attempt cardio pulmonary resuscitation’ (DNACPR).

All staff that we spoke with confirmed that they felt supported within their role and received regular supervision. Staff also confirmed that they had received an annual appraisal which discussed their performance and development plans. However, staff files that we looked at did not confirm that supervisions were taking place at the frequency stated within the provider’s supervision policy.

Care plans were detailed, person centred and specific to each person and their needs. People’s likes, dislikes and care preferences had been noted.

On both days of the inspections we observed some caring and person-centred interactions between staff and people living at the home. We especially noted the positive interactions between the chef at the home with people and their relatives.

Systems were in place which monitored the quality of service provision with a view to making improvements. This including regulatory governance audits and quality surveys completed by people using the service and their relatives. Improvement plans were in place which detailed the issues, the actions to be taken and a date by which these actions needed to be completed. This ensured that lessons were learnt and steps had been taken to minimise re-occurrence.

People told us that they felt safe and were happy with the care that they received at Elizabeth Lodge. Care staff were aware of what constituted abuse and the actions they would take if abuse was suspected.

Safe and appropriate recruitment processes had been followed by the home. This included obtaining criminal record checks from the disclosure and barring service, previous employment history and references from previous employment confirming past conduct especially when working with vulnerable adults.

Most people and relatives knew who the manager was and felt comfortable in approaching the manager if they had any concerns or issues that they needed to raise. Care staff told us that they enjoyed working at the service and that their priority and focus was that of the people they supported.

A complaints policy was available and procedures on how to complain were on display at various points around the home. People and relatives that we spoke with were clear about who to complain to.

During this inspection we focused on gathering evidence to answer five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

As part of our inspection we spoke with six people who used the service and eight relatives of people who used the service. We also spoke with seventeen members of staff including the Registered Manager.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who used the service and relatives we spoke with told us that they felt safe in the home and that staff treated people with respect and dignity. One person said, 'Staff are very good' and one relative said, 'My dad is safe'.

Since our inspection in February 2014, we found that the provider had taken appropriate steps to ensure that people using the service were protected against the risk of receiving care that may be inappropriate or unsafe as care plans, risk assessments and care records were on the whole up to date and they were available when needed.

The service had systems in place to identify, assess and manage risks related to health welfare and safety of people who used the service. Care records contained risk assessments which provided guidance to staff on actions to take to keep people safe.

Is the service effective?

People we spoke with said that they were satisfied with the care provided in the home and felt that people's needs had been met. People were positive about staff and said that they were helpful and listened to them.

We looked at nine care records and saw that people's care needs had been assessed and care and treatment were planned and delivered in line with their individual care plan. Risk assessments had been carried out where necessary and there was evidence that these were reviewed. Care plans included information about people's preferred routines and healthcare needs.

During our inspection the provider demonstrated that they were ensuring continuity in people's care by communicating with healthcare professionals appropriately.

All the staff we spoke with told us that they were well supported by the registered manager and felt able to ask the registered manager questions.

Staff, family members, healthcare and social care professionals were involved in decisions about people's care and we saw evidence of this. Relatives of people who used the service told us that they were kept informed about people's progress.

Is the service caring?

People we spoke with were positive about the staff at the home. They told us that they had been treated with respect and dignity in the home.

During our inspection, we found that people who used the service approached staff without hesitation and people appeared comfortable around members of staff. There was good interaction between staff and people. People looked well cared for and we saw that the atmosphere was relaxed in the home.

Is the service responsive?

People who used the service and relatives we spoke with told us that if they had any concerns or complaints, they would feel comfortable raising them with the registered manager. One person who used the service said, 'The manager is very good and kind. He looks into all concerns'. One relative we spoke with said, 'I know the manager. He listens and responds if I need to complain'.

We saw that the home had a complaints policy and procedure and we noted that the provider had dealt with complaints received in accordance with their policy and these complaints had been resolved.

Since our last inspection, the provider had introduced an 'open surgery' every Tuesday and Thursday. The aim of this was to enable relatives and people who used the service to speak with the registered manager about any issues and concerns they had about the service. The registered manager explained that these were informal meetings and by having these meetings, they hoped to deal with people's concerns and issues before they escalated further.

The service had implemented a new audit system since our last inspection. This audit system introduced an audit schedule for 2014/2015 which listed various areas that the management would carry out audits on a monthly basis which included a medication management audit and a manager's quality assurance audit.

Is the service well-led?

We found that adequate arrangements were in place for monitoring and reviewing the quality of the service provided to people.

Resident's meetings were held monthly which enabled people to discuss issues regarding the running of the home. This encouraged people to raise queries and concerns with management and members of staff.

Staff meetings were held monthly and we saw evidence to confirm this. We also noted that clinical staff attended a meeting every morning with the registered manager to discuss any concerns and people's progress.

All staff we spoke with told us that they felt able to consult the registered manager if they had concerns or queries and said that they felt supported. Staff were positive about working at the home and said that the home had improved since the last inspection.

At this inspection on the 5 November we saw suitable arrangements were not in place to ensure people using the service were treated with dignity and respect during day to day activities and we found that risk assessments and care plans were not up to date and available. Emergency equipment was not in place or being checked regularly. Effective quality monitoring systems were not in place to protect people who used the service against inappropriate or unsafe care.

Improvement had been made in some areas at this inspection. We saw staff were knocking on people's doors and waiting on a response before entering. People we spoke with confirmed that this was happening. One person said, 'they are always knocking on our door now.' Another said, 'we have a choice, we can get up and go to bed when we want.'

The provider had ensured all five units had first aid kits. We saw from a recent health and safety audit the home did not have named fist aiders. However the manager told us staff had been identified to attend training in February and March 2014 to become qualified fist aiders.

We did not see improvements in all areas however. For example two people's care plans indicted that they needed thickening powder due to the risk of aspiration (food going down the wrong way) to prevent the people choking while drinking. Their care plans did not document how many scoops of the thickener the person should have in each 200mls of fluid. Due to unclear guidance on thickener, people were at risk of receiving inappropriate or unsafe care, which may lead to the risk of aspiration (choking).

We saw five paper care records contained other people's information such as care plans, risk assessments and information from doctors. For example, in one person's paper care record we found six other peoples care plans. Therefore staff and professionals may not have been confident that people's records were accurate and fit for purpose.

The provider had been auditing care records however, we saw that care plans were not person centred and were missing important detail. Therefore important information about people could have been missing and inappropriate or unsafe care could have occurred.

This evidence and observations showed that the provider was still not analysing information gathered through audits to identify risk of non-compliance with the regulations and so was not taking action to improve outcomes for people using the service.

We are considering what further enforcement action to take following evidence of continued non-compliance with the warning notices served and the compliance actions set at the last inspection.

On the 5 November 2013 we saw that the manager had reviewed the four people who received covert medication (medication hidden in food or drink). We saw documents had been completed and had included all people who were involved in the person's care such as a psychiatrist, doctors, relatives, home staff and a pharmacist.

We saw that a new hand over process had been implemented and all staff were now having a full hand over of care before they started each shift. However we saw that people's needs were assessed but care plans still did not always address people's individual needs and staff told us that they were not always clear about how to support individual care needs as a result of this.

We saw that each person had their own lifting sling, staff told us that people did not share slings and that they cleaned them regularly. We checked a number of hoists and slings and saw they were in good repair. One relative said, 'my mum needs a hoist to be moved'. She confirmed that she had her own sling in her room. Although emergency equipment was not always checked in line with manufacturers guidance.

The provider had undertaken a recruitment campaign and had so far employed four unit managers; these are qualified nurses who will be responsible for the day to day running of one unit. The provider had also employed eight care workers and had a plan to employ more.

Staff were receiving regular supervision. Staff we spoke with said they had frequent training; however they also said they were not always able to attend due to cover not being available for them to leave their units.

Quality assurance and monitoring systems were not effective. We saw that the provider had recently undertaken the yearly survey of people who live in the home and their representatives. We saw the results of the survey it showed that the home had 37 below average scores out of a total of 40. People's views on the service varied from 'not bad," "all right," "quite nice," "I love it' Some people believed the service was not as good as it used to be several people said, 'it's changed so much."

Records were not kept up to date. Of the 10 care plans(electronic and paper version) we reviewed we saw that more than half of the care plans were missing from the paper records. Staff said that either these had been given to relatives to review or had not been printed off the electronic system.

People were not always treated and supported with dignity and respect. We saw staff walking into people's room without knocking or introducing themselves throughout the day. In one unit in a room where we knew a person was receiving personal care, we saw a carer walk into the room without knocking.

We looked at care plans, talked to staff and people who used the service and their relatives. Some people told us 'the long term staff are excellent, but the agency care staff are not so good, but I do feel respected by them.' Another said 'we have a laugh here with the staff.'

We spoke with five people who lived at the home. All said that they did not feel there were enough staff on duty to support them. One said 'when its different staff on I often have to remind them to give me my tablets as they forget." We saw that relatives were concerned with the increased use of agency and bank staff.

We spoke with eight staff and looked their records; we saw that all new staff had received a comprehensive induction however staff training was not up to date.

We looked at fluid balance charts, turning charts, sleep charts and peoples care records that live in the home. Turning charts showed people were not being turned often enough therefore people could be at increased risk of tissue damage.

We saw that the home ensured people's complaints were fully investigated and resolved, where possible, to their satisfaction.

We observed staff supporting people in a friendly and professional way and saw that people were being offered choice with regard to menus, activities and care preferences.

People who use the service told us that staff were kind and respected their privacy. They confirmed that staff treated them with respect and dignity. One person commented, 'the staff are really nice and they always knock on my door.' Another person told us, 'they look after me very well.'

Most people were able to express their views and were involved in making decisions about their care and treatment. Where people were unable to express their views, their family or other representatives were involved in the decision making process.

We saw that medication records were being regularly audited so that any issues or problems could be identified in a timely manner.

People told us that they felt safe with the staff who supported them. They said they had no concerns or complaints about their care but would speak with their relatives, the manager or the care worker if they needed to. However, we found that the organisation was not always dealing with complaints about the service in line with its own complaints policy.