Archived: Amberdene Lodge

Updated 12 June 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection of Amberdene Lodge took place on 17 and 27 April 2018 and was unannounced. One Adult Social Care inspector carried out the inspection. Information had been gathered before the inspection from notifications that had been sent to the Care Quality Commission (CQC). Notifications are when registered providers send us information about certain changes, events or incidents that occur. We also received feedback from local authorities that contracted services with Amberdene Lodge and reviewed information from people who had contacted CQC to make their views known about the service. We had also received a ‘provider information return’ (PIR) from the registered provider. A PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We spoke with five people that used the service, two relatives and the registered manager. We spoke with four staff that worked at Amberdene Lodge. We looked at care files belonging to three people that used the service and at recruitment files and training records for three staff. We viewed records and documentation relating to the running of the service, including those in relation to the quality assurance and monitoring, medication management and premises safety systems. We also looked at equipment maintenance records and records held in respect of complaints and compliments.

We observed staff providing support to people in communal areas of the premises and we observed the interactions between people that used the service and staff. We looked around the premises and saw communal areas and people’s bedrooms.

Updated 12 June 2018

The inspection of Amberdene Lodge took place on 17 and 27 April 2018 and was unannounced. At the last inspection in November 2015 the service was rated ‘Good’ in all five key questions. At this inspection we found the service had deteriorated in respect of maintenance of the environment and so the question ‘Is the service effective?’ was rated as ‘Requires Improvement’. However, this has not changed the overall rating of ‘Good’.

Amberdene 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.

Amberdene Lodge is registered to provide care and accommodation for a maximum of 25 older people who may have dementia. It is close to the city centre and local amenities and facilities are within walking distance. It is also close to public transport routes. At the time of this inspection there were 15 people using the service.

The provider was required to have a registered manager in post. At the time of this inspection there was a manager that had been registered and in post for the last 16 years. 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.

We found that the premises were not sufficiently suitable for providing care to older people and measures had not been taken when developing the service to include features which ensured the environment was ‘friendly towards’ those living with dementia. We made a recommendation about following the NICE guidance on dementia friendly environments and general upkeep of the décor and furnishings.

People were protected from the risk of harm. The premises were safely maintained. Accidents and incidents were appropriately managed and risk assessed. Equipment was safely used. Recruitment policies, procedures and practices were robust. Staffing numbers were sufficient to meet people’s needs. The management of medicines was safe and practices were audited to protect people from harm. The risks of infection were reduced by good infection control management and practices. Systems showed that when things went wrong, lessons were learnt.

People’s mental capacity was appropriately assessed and their rights were protected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff were qualified, competent, regularly supervised and received annual appraisals of their personal performance. Staff respected the diversity that people presented. People’s nutrition and hydration needs were met to support their health and wellbeing. The provider worked well with other health and social care professionals. They supported people well with health care.

People received compassionate care from kind staff that knew about their needs and preferences. People were involved in their care and exercised a right to express their views. Wellbeing, privacy, dignity and independence were monitored and respected.

Person-centred care plans reflected people’s needs and were regularly reviewed. People engaged in pastimes and activities and maintained family connections and support networks. Communication needs were assessed and met. An effective complaint procedure was in place and used successfully. People’s needs with regard to end of life preferences, wishes and care were sensitively managed.

Quality assurance systems were effective. Audits, satisfaction surveys, meetings and handovers ensured there was effective monitoring of service delivery. Culture was person-centred, friendly and caring. The registered manager understood their responsibilities with regard to good governance and practiced a management style that was open, inclusive and approachable. Engagement and involvement of people, public and staff was effective. The registered manager looked for continuous learning and updated their practice wherever possible. Good partnerships with other agencies and organisations was fostered.

Further information is in the detailed findings below.