Archived: Russley Lodge

Updated 18 June 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Russley 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 had a manager registered with CQC. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

We gave the service 24 hours’ notice of the inspection.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with eight people who used the service about their experience of the care provided. We spoke nine members of staff including the registered manager, senior carers, care assistants, and the activities coordinator. We also spoke with a representative of the provider partnership.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included care plans and associated documentation and multiple medication records. A variety of records relating to the management of the service were also reviewed.

After the inspection

In respect of the most serious concerns highlighted in this report, we raised individual safeguarding alerts with the local authority. In addition to this, the CQC, local authority and NHS partners took urgent steps to ensure the health, safety and wellbeing of everyone who used this service.

Updated 18 June 2021

About the service

Russley Lodge is a residential care home. The service provides support with personal care and accommodation for up to 17 people. At the time of our inspection, 17 people used the service.

The service was providing support to people with a wide range of needs, including younger and older adults, people living with dementia and people living with mental health support needs.

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

Medicines were not managed safely. We found serious concerns which placed people at risk of harm. This included concerns around the ordering, storage, administration and disposal of medicines. Risks associated with choking were poorly managed. Standards for preventing and controlling infection had deteriorated. Staff were not always deployed safely and effectively at key times during the day. Staffing levels were reduced in the afternoon which meant there was a risk of people’s needs not being met.

People were not always supported to have maximum choice and control of their lives. We were not assured that care and support was being provided in the least restrictive way possible. Robust pre-admission assessments were not always completed which meant the registered manager could not always be sure of people’s individual needs before they moved into the home.

There was an inconsistent approach to involvement. This included missed opportunities for the involvement of external advocacy services to support people with more complex decision making. There was a lack of a joined-up person-centred approach that took full account of cultural differences, beliefs, and individual identities. This was a missed opportunity to truly celebrate and promote difference within the service. We have made a recommendation about this in the full report.

In response to Covid-19 restrictions on visiting in care homes, a wooden structure had been built in the grounds. The structure was poorly designed, exposed people to the elements and due to its location adjacent to neighbouring houses, did not enable private and dignified visits between people and their family members and friends. Gaps, omissions and errors in records were present throughout people’s care plans. This meant we could not be assured people’s needs and preferences were consistently met.

Systems for audit, quality assurance and questioning of practice were inadequate. There was an absence of meaningful overarching analysis of the governance systems that were in place. There was a failure to identify themes, trends and newly emerging risks, which placed people at an increased risk of harm. Russley Lodge has consistently been rated as requires improvement with continued breaches of regulations since March 2018. This shows the provider has failed to respond adequately to serious concerns raised by the Care Quality Commission (CQC) and has failed to implement a culture of continuous learning.

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 14 January 2020). At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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

Enforcement

We have identified new and continued breaches of regulations in relation to: safe care and treatment; staffing; dignity and respect; meeting nutritional and hydrational needs; premises and equipment; and good governance.

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

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.

Follow up

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.

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.