Archived: Heath Lodge

We carried out a comprehensive inspection Heath Lodge on 31 January 2017, this was unannounced. At this inspection we found that although they had made some improvements, there were still areas that needed further improvement and some areas that remained in breach of regulation. These were in relation to staffing, consent and dignity. You can see what actions we have asked the provider to take at the back of this report.

Heath Lodge is registered to provide accommodation and personal care for up 67 older people some of whom live with dementia. At the time of our inspection 34 people were living at the service.

Since our last inspection there had been continued changes within the senior management team. The manager who was registered at Heath Lodge had been transferred to another home owned by the provider however had not submitted their application to cancel their registration. A new manager had taken up the post from November 2016, and was in the process of registering. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

People did not experience delays whilst waiting for their care to be provided, however staff were rushed when completing tasks. The manager had recruited a significant number of staff to the home and also performance managed a number of staff out of Heath Lodge as they were not working in a way that ensured people received a satisfactory level of care. They had reduced the number of temporary staff working in the home to negligible levels. People’s care plans had been developed to include more up to date information. However, these records still required work to ensure they included all specific information about people's needs and staff did not always read them prior to carrying out care. People’s medicines were managed safely and people received their medicine as the prescriber intended.

The provider had not ensured there was effective, well trained and supported leadership on each of the floors of the home. Care staff had not all had the training required, and staff had not received regular supervision of their conduct or practise. People's consent was sought however the service did not consistently work in accordance with MCA and DoLS legislation. People were happy with the food and drink provided to them and where people were at risk of weight loss, staff took appropriate actions. People were supported by a range of health professionals.

Individual staff members spoke and interacted with people in a kind and friendly manner, and none of the staff observed lacked a caring approach to people. However staff did not always ensure people's social needs were met. People felt able to raise a concern or complaint with staff who they felt would take appropriate action to resolve these. People were provided with regular opportunities to meet so they could discuss improvements in the home or be kept abreast of developments.

People did not always receive high quality care that was well led. The action plan submitted to us following our previous inspection had not been completed and issues identified following local authority reviews of the care had also not been completed. Care records and records relating to the management of the service were incomplete. Staff felt the manager involved them in discussions about the running of the home; however people felt the manager was not always visible.

The inspection took place on 16 and 25 May and was unannounced.

Since our last inspection there had been changes within the senior management team and new ways of working at senior level were being implemented. The manager who was registered at Heath Lodge had recently been transferred to another home owned by the provider. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Heath Lodge was being managed by an interim management team and a newly appointed manager was due to register with CQC as required.

We previously inspected Heath Lodge on 13, 14 and 16 January 2015 and identified breaches of Regulations 09 Person Centred Care, 11 Need for Consent, 17, Good Governance and 18, Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We rated the home as requiring improvement. The provider sent us an action plan setting out how they would meet the requirements of the regulations. We carried out a comprehensive inspection of Heath Lodge on 16 and 25 May 2016. This inspection was triggered by concerning information we received that related to staffing, communication difficulties, and the care people received in Heath Lodge. At this inspection we found that the provider had not made the required improvements they told us they would implement. We also identified breaches of Regulations 09, 10, 11, 12, 13, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of our report.

The service had staff vacancies and as a result was using high level of agency staff. Some staff recruited by the provider were not able to demonstrate to us a good understanding about their roles and responsibilities regarding the care they delivered to people using the service. People experienced delays in getting assistance and also receiving care when they needed it. We observed examples of people not receiving safe care.

There was a lack of leadership on each of the floors of the home and the permanent senior staff who were responsible were expected to provide leadership with limited support and training. The staffing issues had impacted on care delivery, maintenance of records, the management of medicines and people's access to health care professionals.

At this inspection we found that there were not always sufficient numbers of staff deployed to meet people`s needs at all times. Risks to people’s health and well-being were not consistently identified and responded to positively. People’s medicines were not administered at the times indicated by the prescriber. The environment people lived in was not effectively maintained and cleaned. We found unpleasant odours in people`s bedrooms and communal areas which persisted the whole day of the inspection. People were not supported by staff who had undergone robust recruitment processes to help ensure they were of sufficiently good character to provide care to people.

Staff told us they did not feel supported and many were unaware of who was managing the home. Training had not been provided in a manner that supported staff’s understanding of how to provide care.

People’s nutritional needs were not consistently met and monitored. People were not freely able to choose what they ate and people did not always have access to a range of health professionals and were not always referred when they needed to be. This was confirmed by the professionals we spoke with.

Individual staff members spoke and interacted with people in a kind and friendly manner, and none of the staff observed lacked a caring approach to people. However staff did not always ensure people’s social needs were met and people did not always received care at the time they needed it.

People did not always receive high quality care that was well led. The action plan submitted to us following our previous inspection had not been completed and issues identified following local authority reviews of the care had also not been actioned. The service improvement plan in place was not sufficiently robust and the provider had not sought to constantly monitor and review the quality and safety of care people received. Care records, and records relating to the management of the service were incomplete and in the care of care records at times illegible.

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 are 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.

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.

The home lacked leadership and effective management. There was no permanent manager in post. The home was managed on a part time basis by the manager from another home owned by the provider. This manager had a very basic knowledge of the home and of the people who lived there.

We saw that the home used a high number of agency staff, there were no systems in place to ensure these staff were given the appropriate information on the people who lived at Heath Lodge and how to recognise and meet their needs. One unit was managed by a staff member new to care who had worked in the home for seven weeks.

People were not given the medication in a timely manner and we found that some people had been given their medication covertly without a plan in place to identify if they had the mental capacity to understand the consequences of refusing their medication.

Care plans had not been updated and therefore did not always reflect the current needs of the person. One person was isolated as they did not speak English and no one spoke their language so there was no way of knowing if they were getting the care they needed or wanted.

Assisting people to move using hoists was done in a manner that could cause the person injury and pain. Staff were unaware they were putting the person at risk as they did not have adequate training in assisting people to move safely.

We saw that on the day of our inspection there were not enough staff on duty to respond to the requests of the people. We saw a person waiting for more than 40 minutes to be taken to their room because there was no staff member to assist them.

Senior managers had identified problems in the home but they had not put actions on place to address them.

We saw that while staff were not trained to care for people living with dementia, most of the staff were seen to treat people with respect and kindness and we saw that in the circumstances the staff tried their best to care for and offer comfort to the people.

We were given mixed responses on care delivery by the people and their relatives, some thought it was good, however most of the people we spoke with had some concerns. Generally people told us that they were not involved in the planning of their own care and where appropriate their relative's care.

Among the comments told to us by the people living there and their relatives were,

'Some of the staff are brilliant and do their best, but there is not enough of them', "We can't leave our relatives care to the home, we have to be here'. 'We are looking for a new home as we can't rely on this home to provide good care'. 'They can't even give the medication on time'.

All the concerns we identified at this inspectiion are being followed up by this Commission.

During our inspection we found areas where the cleanliness was not of a satisfactory standard. When we entered the home we noticed that there was an unpleasant odour. We saw that the carpets in all the corridors and lounge areas were dirty and stained.

On the day of our inspection we saw that the morning medicines on all units were not administered at the time shown on the medicines administration records (MAR charts). People were given medicines that should have been taken up to an hour before their meal after they had eaten.

During our inspection we looked at recruitment files for three people who had recently started work at the home and saw that robust procedures were in place to safeguard people who used the service.

We looked at the staff rotas for the period from 10 February 2014. We saw that the service had identified that on each day there should have been at least 10 care workers, including at least three senior care workers, on duty in accordance with their dementia accreditation. However on at least three occasions in the period the number of care workers fell below this level. A recruitment programme was underway for new care workers to work at the home.

We carried out a further inspection on 09 September 2013 and found that people were supported to eat and drink and were provided with food that met their specific dietary requirements. We looked at the care records of four people who lived at the home and saw that care plans were in place for people at risk of inadequate nutrition.

When we carried out our inspection on 03 June 2013 we found that people's records were not kept securely and were not accurate. Falls that people had experienced had not been recorded in the resident's accident log.

When we carried out a further inspection on 09 September 2013 we found that people's records were kept in locked cabinets inside offices which were locked when unoccupied. They were therefore protected from access by any unauthorised persons. We also found that falls experienced by people had been recorded in the care records.

We looked at the action plan for improvement following a provider audit and saw that the manager had signed off the completed actions. This showed that the record was fit for purpose.

We saw that people's care plans identified their specific dietary needs, for example for the control of diabetes, the need for a low sodium diet or the control of diverticular disease. The chef said they were unaware that there were people who had special dietary needs such as a low sodium or high fibre diets.

We looked at the training spreadsheet that showed that all the care workers had received training on the safeguarding of vulnerable adults within the last two months.

On the day of our inspection the home looked clean and smelled fresh. We saw that all the rooms were thoroughly cleaned on a daily basis.

We saw that there were regular quarterly internal provider audits undertaken and action plans were developed to address the areas of improvement identified. The manager had recorded verbal complaints that had been received as well as the written complaints.

We saw that people's records did not contain all the relevant information and were not stored securely which meant that they could be accessed by unauthorised people.

We found that a new manager had started the day before our inspection. For the previous two weeks, the service had been managed by a regional manager.

Some of the provider's systems had not been maintained.

People told us that they were pleased with the care they received. We found that care plans were in place, which gave staff good guidance on the care needed by each person. Some risk assessments were carried out. However, for one person, risk assessments had not been updated effectively following a number of falls, to minimise the person's risk from falling.

There was a sufficient number of staff on duty to meet people's assessed needs.

The provider did not have effective systems in place to ensure that the quality of the service was monitored effectively in all areas. The provider had a complaints procedure in place. However, this had not been followed in a number of instances so people's complaints had not been recorded appropriately.

The provider had not notified the local authority safeguarding team or the Commission of all other incidents that had taken place and had not followed appropriate procedures for the investigation of safeguarding issues.