This comprehensive inspection took place on 12 and 18 June 2018 and the first day was unannounced. We last inspected this service in June 2016 where it was rated ‘Good’ overall and ‘Requires Improvement’ in the Responsive key question. We recommended the provider find ways to improve the level of social interaction and meaningful activities within the home. During this inspection in June 2018 we found the provider had not met our recommendation and identified a number of concerns relating to people’s safety, staffing levels, people’s needs not being met, people not always being treated with dignity and respect, and poor leadership.
Cary Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Cary Lodge is registered to accommodate up to 40 older people, some of whom are living with dementia.
The home is set over three floors with bedrooms on each floor. There is a lounge/dining room on the ground floor and the basement floor. On the basement floor is an area separated from the rest of the building by a keypad which leads to four rooms being used by people on intermediate care packages. These are care provided by the home when people are well enough to leave hospital but not yet well enough to go home. On the first day of our inspection there were 26 people living in the home and on the second day there were 25 (this was due to some changes in people receiving intermediate care and one person passing away).
The service had a 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.’
The people who lived in Cary Lodge were not always safe. Although we saw a number of good examples of risks to people being identified and well managed, we also identified a number of instances where risks had not been adequately assessed or mitigated. People were not adequately protected from others who posed risks relating to their behaviours. People had experienced being victims of assaults and inappropriate behaviours from others due to staff not being able to properly monitor or support people.
There were not enough staff to meet people’s needs or keep them safe from harm. Staff were unable to properly monitor people or give people the time they needed to distract and otherwise occupy them. For example, on the day of our inspection one person had walked into another person’s bedroom and had been physically assaulted.
Along with staffing numbers not being sufficient to protect people from risks, staff did not always have the guidance needed to ensure people were protected. For example, one person who posed a significant risk to people because of their behaviours did not have a risk assessment or care support plan relating to these behaviours. When we spoke with staff we found some were not aware of the risks this person presented or how they should act to ensure people were protected.
People had been placed at risk in relation to medicine management practices. Night staff had not been adequately trained to administer medicines and therefore day staff had been pre-dispensing medicines. This is an unsafe practice and action was taken by the provider to stop this following our inspection.
People did not always have their individual needs met. People’s needs relating to their mental health had not always been identified, planned for or appropriately responded to. There were not enough staff to allow them to spend time meeting people’s needs when they were experiencing distress or anxiety. Therefore people spent very long periods of time in these states.
People’s care plans did not contain detailed information about people’s lives and interests to help staff understand ways to support them positively. People did not have access to adequate stimulation or activities to meet their social needs. Although there were some organised activities which took place at the home, these were not sufficient to engage people and provide stimulation. Creative measures had not been taken to ensure people had access to activities which met their individual preferences or their needs.
Sufficient action was not taken to safeguard people from the actions of others. Incidents were not always reported to the safeguarding authorities as they should be to help protect people from harm. Processes in place were not effective in protecting people from abuse or ensuring incidents were reported and appropriately investigated.
We found a lack of understanding in relation to the Mental Capacity Act 2005 (MCA) and the five statutory principles of the MCA by the registered manager. Blanket decisions and restrictions had been applied to people without consideration of whether individuals might lack the capacity to make the decision. For example, each bedroom had been fitted with a sensor mat by the bed. This had been put in place without understanding that this restricted people’s freedom to move around without being monitored. Whilst for some people this was appropriate, this was not the case for everyone.
People were not always treated with kindness and respect. We saw people were hardly spoken to by staff when being supported to eat and one person was not shown respect for their privacy and dignity when sitting in an exposed position. Although we found staff were individually caring, the culture at the service and the staffing arrangements did not ensure people were treated respectfully as they should be. We found the registered manager did not always demonstrate an understanding or a respect for people’s need for contact and sexual expression as they grew older.
People enjoyed the food on offer at Cary Lodge. However, we found that people had to wait for long periods of time to be served their food. People were supported to sit at the dining tables or had their cutlery placed in front of them at their chairs up to 40 minutes before their meal was served. This caused some people living with dementia undue distress.
The culture at Cary Lodge did not put people first. People’s needs were not being met and staff were task focused. Although the provider told us they had strong values and worked towards ensuring people were at the heart of the service, this was not demonstrated at the time of our inspection.
Improvements were being made to the service at the time of our inspection. People’s care plans were being reviewed, staff were receiving training and there were plans to improve the environment. Cary Lodge was a well maintained home with a well-tended garden and pleasant rooms. Staff spoke about people with respect and admiration for their individual personalities.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.
We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people’s individual needs not being met, people’s rights under the MCA not being protected, people not always being safe from risks, safeguarding incidents not always being identified and reported, staff numbers not being adequate to meet people’s needs, and ineffective quality assurance systems. You can see what action we told the provider to take at the back of the full version of the report.