South Haven Lodge Care Home

Updated 17 February 2023

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 Health and Social Care Act 2008.

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 undertaken by 1 inspector.

Service and service type

South Haven Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. South Haven Lodge Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 7 December 2022 and ended on 12 January 2023. We visited the home on 7 December 2022, 3 and 4 January 2023.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We reviewed all the information we had received about the service since its last inspection.

We used all this information to plan our inspection.

During the inspection

We observed people’s care and support in the shared areas of the home. We spoke with 3 relatives and a visitor, the registered manager, 2 senior managers, 3 care staff, 2 nurses and 2 housekeepers. We also spoke with an administration staff member, the activities co-ordinator and the staff member responsible for maintenance. We received further feedback from 3 relatives and 4 health and social care professionals.

Updated 17 February 2023

About the service

South Haven Lodge Care Home is a care home providing personal and nursing care for up to 46 people, who tend to be older and may be living with dementia. There were 30 people living at South Haven Lodge Care Home at the time of the inspection. It accommodates people in one adapted building with an enclosed garden.

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

People’s care plans and risk assessments identified individual risks which were used to create care plans, for example, where people were at risk of developing pressure area wounds. However, there were inconsistencies between records regarding how often a person needed to be repositioned. Records showed people were not consistently supported to reposition within the correct time frame which meant their skin may be at risk of injury.

People were supported by staff to take their medicines and records were completed. However, the medication records did not match the medicine stocks held in the home. People did not always have protocols in place for medicines prescribed as, ‘when needed’ for severe pain relief or anxiety. Medicines were stored correctly.

There had been improvements regarding the safety of the environment since the last inspection but we identified concerns on the first day of inspection. The registered manager took action to address these.

People’s wishes had not been appropriately sought or complied with regarding the posting of information on social media. The provider had not sought consent or completed best interests decisions regarding the use of sensor mats.

The provider had a system of auditing in place which included the registered manager completing a monthly quality audit. Whilst the governance systems had improved since the last inspection, these were not robust or fully embedded into good practice. There was not a formal system in place to seek and receive feedback from people or their relatives.

Equipment such as hoists were serviced and maintained appropriately. Where people slept on pressure relieving mattresses, the settings were checked and recorded appropriately. Maintenance and safety checks were completed weekly or monthly, as necessary.

The provider had a recruitment procedure in place which included seeking references and checks through the Disclosure and Barring Service before employing new staff. Feedback from relatives and visitors was positive about the staff team.

The provider had policies and procedures in place designed to protect people from the risk of harm and abuse. In the event of accidents or incidents the registered manager completed an investigation and analysis of events. This included analysing incidents to identify trends, actions and learning.

People, their relatives and staff were positive about the home and the impact the registered manager had on improving the service.

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 13 January 2022).

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 but the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We carried out a focussed inspection of this service on 4 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safety and governance.

We undertook this focused inspection to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements. We have found evidence the provider needs to make improvements.

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 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.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for South Haven Lodge Care Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment and good governance 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.