Westbury Lodge

Westbury Lodge is a residential care home providing personal care to 8 people at the time of the inspection. The service can support up to 8 people with a learning disability or support needs relating to their mental health. The service is located in a residential area of Westbury, with access to local services and train station.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support

Medicines were not managed safely, and staff did not keep accurate records relating medicines. This meant the provider could not be sure whether people were supported to take their prescribed medicines.

The service did not make sure people received support in a safe and hygienic environment. The home was not clean. Cleaning schedules were in place, but staff had not completed them. This increased the risk that people would be harmed as a result of poor infection control practices.

There were enough staff to meet people’s needs. The provider had taken action to address staff shortages through use of temporary agency staff. The agency staff had been working at the service on a long-term basis and provided consistent support for people.

Most staff demonstrated a good understanding of the risk management plans and the actions they needed to take to keep people safe. We identified one member of staff who was unclear of the support a person needed to manage the risk of choking. The staff member was provided with additional guidance from senior staff on the day of the inspection and further training was planned.

Feedback from health and social care professionals highlighted staff having a good understanding of people’s needs and actions to keep people safe.

Right Care

We used the ‘Talking Mats’ communication system with 1 person, who indicated they were happy living at Westbury Lodge. Another person told us they felt safe at Westbury Lodge and staff treated them well. The person said they knew how to raise concerns with the registered manager and were confident concerns would be addressed.

We observed people interacting with staff in a confident and comfortable way. People appeared at ease in the presence of staff.

People were supported to maintain contact with their family and friends. Relatives reported they could visit without restrictions, and staff supported people to keep in contact with them through phone calls.

Right culture

The provider had systems to assess and monitor the quality of the service being provided. However, where shortfalls were identified, actions to improve the service were not always maintained and embedded in practice.

We observed staff working in ways that responded to what people were communicating to them.

Health and social care professionals who had contact with the service told us the service promoted a person-centred culture, and worked with them to meet people’s needs.

Staff told us they felt listened to and valued by the registered manager.

People were supported to be active members of their community and participate in local activities.

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 good (published 1 May 2021).

Why we inspected

We received concerns in relation to the way people were treated and the culture of the staff team. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches of regulations in relation to safe care and treatment and premises and equipment at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Westbury Lodge is a care home which accommodates eight people in one adapted building. Accommodation is over two floors which are accessed by stairs. There is a small garden which people can access from the ground floor. At the time of the inspection there were eight people living at the service. People had their own rooms and access to communal areas such as a lounge and dining room.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

This service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People were supported to live as independently as possible. People were able to access local amenities and carry out activities of daily living such as light domestic tasks. The leadership and management of the service supported staff to promote people’s dignity and uphold people’s human rights.

People were able to attend regular ‘house meetings’ to share their views or raise general concerns. People also had regular care reviews with healthcare professionals and where people had limited family members, they had advocates to speak up for them.

Staff received safeguarding training and understood how to report any concerns. Staff were confident the management would take appropriate action. People were supported by sufficient numbers of staff who had been recruited safely.

Medicines were managed safely, and people had their medicines as prescribed. Staff had been trained in medicines administration and had assessments to check for competence. Where appropriate and safe people were supported to manage their own medicines. People’s risks had been identified and care management plans were in place.

Staff had access to personal protective equipment (PPE) and had been trained on how to use it safely. There was an area of the home where staff could put on and remove their PPE safely. The home was clean throughout and staff cleaned high contact areas such as door handles regularly. Posters reminded people and staff on how to wash their hands safely.

Guidance on COVID-19 had been shared with people in a format appropriate for them. This included easy read information and pictorial guidance. Staff encouraged people to be tested for COVID-19 and have the vaccination but people’s right to choose was respected. Staff were testing weekly and had been offered vaccinations for COVID-19.

Any visitors to the home were screened prior to admission and asked to wear PPE. The home had started using the lateral flow tests for visitors which gave COVID-19 results within 30 minutes. Any person returning to the home from hospital was asked to isolate in their rooms for 14 days as per government guidance. The home knew where to go for infection prevention and control advice and support locally and nationally.

Quality monitoring was in place and used to identify improvements and develop the service. Incidents and accidents were reviewed, and the registered manager took action to prevent reoccurrence. Systems were in place to make sure action was taken and the provider had good oversight of action plans.

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 good (published 21 September 2017).

Why we inspected

The inspection was carried out due to concerns received about medicines management, staff and management approach and allegations of abuse. As a result, we undertook a focused inspection to review the key questions of safe 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 COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe 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 Westbury Lodge 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.

At the last comprehensive inspection in November 2016, we identified the service was still not meeting four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one further breach of the Regulations had been identified. We served a positive condition on the provider’s registration in which the service had to submit monthly reports so we could be assured the concerns were being addressed and monitored. The service remained in special measures. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. The Local Authority placed an embargo on admissions to the home, whilst they made the required improvements and this remains in place.

A registered manager was in post at this service however at this inspection the registered manager was not present and was on a period of planned leave. 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. An acting manager had been recruited and was responsible for running the service during this time. The acting manager was available throughout this inspection.

At this inspection we found the service had made the necessary improvements to be meeting all of the previously identified breaches of Regulations. No further breaches were found at this inspection. The service is no longer in special measures but will continue to be monitored to ensure the improvements are sustained.

At this inspection we found that there were still some areas of improvement needed in the safe management of people’s medicines. People who had been prescribed medicines to take ‘As required’ (PRN) did not always have a protocol in place. We saw that some PRN protocols had not been reviewed monthly as stated. During the time medicines were being administered, staff would interrupt the staff member administrating to ask unrelated questions, which had the potential for errors to be made.

Although the service had sufficient levels of staff in place there was still a high use of agency staff. During our inspection five staff were on duty. In the morning three members of staff were agency. This then dropped to two agency and three permanent staff in the afternoon. The management team had changed the rotas to ensure consistency of permanent staff was maintained across the home including at weekends.

Staff told us they were confident in knowing how to respond if they saw an incident or heard an allegation of abuse and discussed how to identify if someone who could not speak was being abused. One member of staff said they would look for physical signs of abuse such as bruises. Another member of staff said “I know the people here so well, all their quirks and everything, I would notice any slight change in their behaviour and instantly know something was up.”

Mealtimes were a dignified and pleasant experience for people. There was clear teamwork and coordination between the staff to ensure mealtimes ran smoothly and were enjoyable for people. A new way of working had been introduced in order to reduce the time people had to wait to be served and ensure those waiting had company. People were supported to have a meal of their choosing and a suitable alternative was provided if they did not like the choices on offer.

The home had a more relaxed and calm atmosphere during this inspection compared to previous visits. Staff showed concern for people’s wellbeing in a caring and meaningful way, and were responsive to their needs. One person told us “The staff are friendly, they know me too well.” One staff said “I love coming here; I have got to know people really well.” The acting manager commented “The team that are here, are here for the right reasons. We have some passionate staff; they do what they do because they enjoy it.”

Care, treatment and support plans were personalised and the examples seen reflected people’s needs and choices. We saw that staff’s recording in people’s daily records had a more person centred approach. For people that had monitoring charts in place for things including food and fluid monitoring and regular weight checks, we saw a separate folder was in place to document these recordings. Improvements had been made to how people’s food and fluid intake was monitored, however we saw there were two weeks where this had not been checked by senior management.

Senior management had spent time with the registered manager, acting manager and deputy manager to support the service and take steps to address the concerns. Staff spoke positively about the new acting manager saying they were approachable and responsive and felt they were being well supported.

People and their relatives were being encouraged to participate in the development of the service and had the opportunity to provide feedback and attend meetings. The service was now starting to look towards the future and building on the foundations that had been put in place.

We issued one warning notice to the provider and eight requirement notices as a result of the concerns we identified and the service was rated, as inadequate. The service was placed into special measures. Special measures provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. The Local Authority placed an embargo on admissions to the home, whilst they made the required improvements.

We completed a focussed inspection in October 2016 to ensure improvements had been made. We found the provider had taken the immediate action necessary to improve the service. During this inspection in November 2016, we found the provider had sustained some improvements but not all. Due to this, there was not enough evidence to enable the service to be removed from special measures. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. While some improvements were observed at this inspection further developments are required and the improvements made need time to embed in practise. For this reason this service will stay in special measures. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Westbury Lodge is a small home providing accommodation which includes personal care for up to eight people. At the time of our visit, six people were using the service. The service supports people with a range of needs including learning disabilities, mental health, physical disabilities and sensory impairment. The provider Parkcare homes (No.2) Limited is part of the wider Priory group. The home is arranged over two floors and does not have a lift in place. For this reason the home does not accept any placements where the person has mobility difficulties above the ground floor.

The registered manager has worked at the home since June 2016, and became the registered manager in November 2016. 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 the inspection.

People were at risk of dehydration and poor nutritional intake. One person who was at risk of losing weight had been prescribed supplement drinks and put on a monthly weight recording chart. We saw that during a period of nine months this person had only been weighed four times. Throughout our inspection we saw this person was not offered appropriate choices around food and drink.

People were not receiving care from regular staff that enabled consistency to be maintained. Staff had continued to leave the service since March 2016 and the registered manager told us during this inspection that one member of staff had failed to show up for their shift last week and had not been in contactable since. One person told us “Sometimes I get cross because I’m left unattended. Like when it comes to having a shower or when you need something urgently”. Staff told us they felt under pressure from not having enough staff. Relatives raised their concerns “If they are there they will support him but they keep leaving don’t they. There is a big turnover. He can get agitated with agency staff”.

Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe commenting, “I have no qualms about reporting anything, I would go higher to the regional manager or head office. People we spoke with at Westbury Lodge told us they felt safe living there saying “Yes, I feel very safe”.

Improvements had been made to the safety of people's medicines although some shortfalls were identified. Each person’s medicine record was in a folder with a photograph of the person and information about any allergies they had. Each person’s folder also had information about how they liked to be given their medicines. One person had been prescribed a medicine with advice that it should be given 30 minutes to one hour before food, but staff told us they usually gave it just after breakfast.

For people who lacked capacity to make decisions or consent to their care the home had not acted in their best interests. Decisions around medicines, leaving the home under constant supervision and consenting to living in the home had not been made involving the appropriate health professionals or following the correct procedures. Mental capacity assessments showed that these decisions had not been fully considered on an individual basis, and there was not always evidence to show how the decision had been made.

Monitoring charts were still not been completed correctly. This included fridge temperatures, night checks and fluid charts. Systems in place to monitor the service had identified some of these areas for improvement but action had not yet been taken.

Steps had been taken to improve the opportunities available for people and people were now being engaged more in activities in and out of the home. During our inspection two people were supported to go swimming and other people in the home enjoyed a pamper session from a health and beauty professional.

The home had undertaken an extensive refurbishment including putting in a whole new kitchen, redesigning the dining area, a new medicines room, all new internal doors and adding an en-suite to three rooms. People and their relatives spoke positively of the visual changes including “I like the changes to the house”.

We found four repeated breaches and one new breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and of the Care Quality Commission (Registration) Regulations 2009. We are taking further action in relation to this provider and will report on this when it is completed.

This inspection was carried out to assess whether the provider had taken action to meet the warning notice we issued. We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notices have been sustained, to assess whether action has been taken in relation to the seven requirements and provide an overall quality rating for the service.

This report only covers our findings in relation to the warning notice we issued and we have not changed the ratings since the inspection in March 2016. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Westbury Lodge on our website at www.cqc.org.uk.

At this inspection we found that the provider had taken action to address the issues highlighted in the warning notice.

A new manager had been appointed and had submitted an application to the Care Quality Commission (CQC) to become the registered 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.

Due to the concerns raised and incidents regarding people with mobility concerns being safely accommodated at Westbury Lodge, the provider had decided no future placements would be accepted at Westbury Lodge above the ground level, where the person was not independent in their mobility. Everyone had received an in-house placement review in order to decide if they could continue to be safely accommodated at Westbury Lodge and if the service could effectively meet their needs. In addition placement reviews with the relevant local authorities had been requested for everyone living at Westbury Lodge, to be completed by the end of the year.

People who did not have the capacity to call for help should they require support, had all been risk assessed for the level of supervision needed when in their bedrooms. This meant staff completed regular checks in line with these risk assessments to ensure people were not left unchecked for prolonged periods of time.

Incidents were being reported and responded to appropriately. An incident reporting log was in place which showed what actions must be taken. Incidents were totalled and checked by the manager as part of their quality monitoring of the service. Staff told us they felt confident in reporting incidents and that they would be dealt with appropriately commenting “We talk through incidents when they have happened. We are reporting incidents, it’s not being pushed under the carpet and it’s dealt with quickly”.

Safeguarding procedures had been reviewed in the home and protocols for reporting had been revisited with staff in team meetings. Staff comments included “We have had a refresher of safeguarding training” and “Whenever something is wrong you report, I would feel happy especially now to do this”.

The manager and regional manager had developed a comprehensive action plan to address the warning notice and other requirements in the inspection report where they were found to be in breach of regulations. We saw this plan was being updated and amended to reflect the progress made with improving the service. Feedback was obtained through meetings with people who use the service and staff. The meetings were used to explain the actions they were taking and the improvements they wanted to achieve.

We have not changed the rating for this key question from inadequate because to do so requires a full assessment of all the key lines of enquiry for this question. We will complete this assessment during our next planned comprehensive inspection .

The inspection took place on 8 and 10 March 2016. This was an unannounced inspection. The home was last inspected on 29 January 2015 and received a rating of good. This inspection took place in response to on-going safeguarding investigations and information of concern received.

The registered manager had left the service four days prior to our inspection, which meant there was no registered manager in post at the time of our inspection. 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 home was being overseen by an ‘acting manager’ in this interim period whilst a new manager was being recruited. The regional manager was making weekly visits to the service to provide support during this time and another registered manager from a home within the same company was providing mentor support to the acting manager. The acting manager was accessible and approachable throughout our inspection.

People were not being protected against risks and action had not been taken to protect people from the risk of harm. People who had the most difficulty moving independently and were at risk of potential falls were accommodated on the upper floors of the building and had experienced several falls resulting in injuries. The building was not suitable to safely accommodate people with mobility needs other than on the ground floor. There were not effective methods in place for people to be able to call staff for assistance.

The home's medicine management systems required improvement in order to fully protect people. This was currently under investigation from the local safeguarding team, and being supervised by the regional manager and internal quality team.

Staff understood their responsibilities in protecting people and reporting any instances of abuse and had confidence to recognise potential signs in people that were unable to verbalise concerns.

Staff had not been supported to maintain skills relevant to their role. Staff did not receive regular or effective supervisions to discuss their development.

People were not afforded choices during the lunch meal. One person did not receive a substitute when they were unable to eat the pudding provided.

Staff were knowledgeable about the people they supported and demonstrated kindness and genuine care in their interactions with people. Staff encouraged people to maintain their independence.

We saw one example of undignified care. All other observations showed staff upholding people’s privacy and treating people with respect.

Care plans were in an accessible format and contained information about the person’s background, and preferences. However the recording of information was not always consistent and people’s needs were not always reviewed and plans updated to reflect their current status.

Relatives told us they were kept informed about events affecting their loved ones. They were given the opportunity to provide feedback on the service, and people in the home had attended ‘Your voice’ meetings so they could discuss matters relating to the home.

The home had not been well led and staff lacked clear direction and leadership. The culture had not been positive and the acting manager and regional manager were putting things in place to address this.

Quality audits had not been consistently undertaken and some recordings were not an accurate reflection of events in the home. One audit relating to medicines had been falsely signed. We saw events that are notifiable to CQC, concerning injuries to people had not always been reported.

An action plan had been put in place identifying areas of improvement to be made within the home.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and

work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

One person said 'it's very good. It's open. I feel safe.' Another two people told us 'it's ok! We observed people were relaxed in their home. People were able to participate in a range of activities of their choice. People were supported to maintain their independence.

We observed people were asked for their permission before they were assisted with care. We saw people were supported to have an advocate to help them with decisions. People's capacity with regard to important decisions was assessed and best interest meetings held with people who knew the person.

Staff worked with other healthcare professionals to ensure people's care and treatment was co-ordinated and safe.

We found the provider had a system to ensure medicines were administered safely and effectively.

Staff said they were supported. There was a comprehensive training programme. Staff supervision was provided on a regular basis. There was just enough staff to meet people's needs safely.

People's records were reviewed and updated regularly.

People told us "staff are wonderful". We observed care which was kind and caring and provided in line with care plans which were reviewed and updated regularly.

We were told overall the food was "not bad". There was some choice and people's preferences were regularly included in the menu. People's nutrition and hydration needs were monitored and specialist advice sought if necessary.

People were protected from abuse because staff understood their roles and responsibilities concerning safeguarding. People who used the service were well informed about safeguarding and had access to relevant information.

We found staffing levels were improving and overall there were enough qualified and experienced staff to meet people's needs.

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