Archived: Carrick Lodge

We carried out a comprehensive inspection on 21 July 2015. Four breaches of the legal requirements were found. This was because the arrangements in place for the administration and management of medicines at the service were not robust. Staff had transcribed medicines for five people, on to the Medicine Administration Record (MAR) following advice from medical staff. These handwritten entries were not signed and had not been witnessed by a second member of staff. Prescribed creams had not been dated when opened. There were gaps in the daily recording of the temperature of the medicine fridge, and the temperature readings recorded were above the recommended safe cold storage for medicines of between 2 and 8 degrees. The pharmacist recommendation that the temperature of the room in which the medicine fridge was stored should be recorded, had not been actioned.

The service did not have robust infection control procedures in place. Toiletries were used communally and there were no paper towels available. People were using communal hand towels which did not protect people from the risk of cross infection.

The provider and deputy manager were not clear on the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards. Legislative guidance had not been followed appropriately.

There was lack of systems or processes which effectively assessed, monitored and mitigated the risks relating to the health, safety and welfare of people and those that work at the service. One fire door was not closing on activation of the fire alarm as it was hooked open to obstruct access for some people to a staircase. Policies and procedures held at the service required review, some were not dated and some held incorrect information. Records held by the registered manager regarding training and supervision was not comprehensive and did not enable the effective monitoring of staff needs. The Care Certificate was not being used by the service for the induction of new staff. Staff recorded food and fluid taken by people and these records were monitored by the registered manager. There was no evidence of monitoring of these records and it was not clear what action had been taken when gaps were found in these records. Care plan reviews were not always carried out regularly and consistently.

Providers have a responsibility to comply with the Health and Social Care Act 2008 regulations and submit statutory notifications to the Care Quality Commission (CQC) when any event which may impact on their service provision occurs, such as death of a service user or any concerns of abuse that may be raised. The CQC had not received any notifications from the service.

After the comprehensive inspection the registered provider wrote to us to say what they would do to meet the legal requirements in relation to the breaches. Prior to this inspection CQC had received some information of concern which mainly related to issues identified at the last inspection. As a result we undertook a focused inspection on the 10 December 2015 to check they had followed their plan and to confirm they now met legal requirements.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Carrick lodge on our website at www.cqc.org.uk

Carrick Lodge is a care home offering nursing care for up to 38 older people who are living with dementia. At the time of the focused inspection on 10 December 2015 there were 23 people living at the service.

There was a registered manager in post. 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.

At this focused inspection we found the registered provider had taken action to help ensure all handwritten entries on to the MAR were signed by two staff. This helped ensure the risk of any errors would be reduced. Some prescribed creams had been dated upon opening however, many remained undated. This meant staff were not aware of the date after which the cream would not be safe to use. The temperature of the medicine fridge was being recorded daily, including the temperature of the room where the fridge was stored. However, the temperature of the fridge had been recorded between 0.4 degrees and 6 degrees centigrade between the 3 November 2015 and 9 December 2015. This did not ensure the safe cold storage of the medicines held in the fridge as the minimum temperature had been below the recommended 2 degrees centigrade for over a month.

The service had taken action to replace communally used hand towels and provided soap and paper towel dispensers in all bathrooms and toilets for people to use. However, the staff toilet and the nurses station/office continued to provide a communally used hand towel for all staff to use when washing their hands. This did not protect staff and people from the risks associated with cross infection.

The registered manager and the deputy manager had applied to undertake training in the Mental Capacity Act 2005 but this had not yet taken place. However, the registered manager was aware of the legal requirements and had arranged for healthcare professionals to review people living at the service with regard to this legislation. Some people required to have applications made for potentially restrictive care plans to be authorised, had been refered to appropriate health and social care professionals.

The fire door which was previously held open with a hook and prevented from closing in a fire was now closing automatically when necessary. The services policies and procedures had not been updated and reviewed at the time of this inspection. However, the service had applied to obtain an electronic system to keep their policies and procedures up to date and was waiting for this to be installed. There had been a considerable delay in this taking place and the registered manager assured us it would be chased up.

Records held by the registered manager regarding staff training did not enable the effective monitoring of staff needs. The training matrix held a ‘YES’ next to the subject undertaken with no detail of when this took place and when it would require updating. Supervision was being provided to staff regularly.

The action plan provided by the service stated three staff were undertaking the Care Certificate. The registered manager told us new staff were informed of the need for them to complete the Care Certificate as part of their induction. However, there was no evidence of new staff having completed any part of the Care Certificate. Some staff had been employed for several months and their progress had not been monitored at the time of this inspection. The guidance for completing the Care Certificate is 12 weeks.

Two of the three care plans we looked at had been reviewed and updated recently. However, one care plan had not been updated since 6 October 2015 and did not accurately reflect the person’s current needs. Staff recorded some people’s food intake due to concerns with their nutritional needs, however there were some gaps seen in these records. There was no evidence that the registered manager monitored these records.

The service had sent in statutory notifications to CQC since the last inspection regarding any event which may impact on their service provision occurs, such as death of a service user or any concerns of abuse.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them ad looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

During our inspection of Carrick Lodge we saw evidence to support our judgement that this service was safe.

People were treated with dignity and respect by the staff.

People were safe because staff knew what to do when safeguarding concerns were raised and they followed guidance.

When people displayed behaviour, which challenged others, staff dealt with it effectively and respected people's dignity and protected their rights.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped to continually improve the service. Carrick Lodge alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service.

We saw that Carrick Lodge understood the legal requirements laid down by the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards and therefore people were protected.

The registered manager set the staff rotas, they took people's care needs into account when making decisions about the numbers of staff required and their qualifications, skills and experience. This helped to ensure that people's needs were met

Is the service effective?

During our inspection of Carrick Lodge we saw evidence to support our judgement that this service was effective.

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people's needs.

We spoke with two visitors who told us: 'The care here is excellent, I am very happy with how X looks, always clean and well dressed, all the people here look well cared for and are well dressed' and 'X fell the other day and they were on to me immediately, they are very good'. A visiting healthcare professional told us 'I have every confidence in the staff here they always call us appropriately and in a timely way. If they apply a dressing to a person following any skin break I know they will have used the correct product and I will not need to remove it immediately to assess it, they know what they are doing'.

People's views were sought with regards to the care and support experienced at Carrick Lodge.

People who used the service, and their representatives, were involved in their care plan reviews. We saw people, or their representatives, had signed care plan reviews to show they had read and agreed to the content of the care plan.

Care plans reflected people's preferences and choices.

People's health was regularly monitored to identify any changes that may be required. Referrals were quickly made to health services when people's needs changed.

We saw peoples end of life wishes were recorded in their files this ensured staff were aware of the choices made by people who lived at Carrick Lodge.

Newly appointed staff received an induction prior to starting work which included a period of shadowing more experienced staff.

Staff received appropriate training and regular supervision.

Is the service caring?

During our inspection of Carrick Lodge we saw evidence to support our judgement that this service was caring.

People were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people.

People told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. People told us 'I am happy here, I can do as I please' and 'the staff are very approachable and always around if we need them'.

Staff knew the people they were caring for and supporting, including their preferences and personal histories.

People had their dignity and privacy respected. We saw staff knock and wait for a response before entering people's bedrooms.

Is the service responsive?

During our inspection of Carrick Lodge we saw evidence to support our judgement that this service was responsive.

Some people at Carrick Lodge had difficulty remembering things they had been told some time earlier, so we saw some people were given the information they needed to make a decision at the time they needed it. For example, choosing meal options at lunch time rather than making choices much earlier in the day or the day before.

Carrick Lodge had a part-time activities co-ordinator who supported the planning and organisation of activities for people at the home.

We were told best interest meetings were held to support decision making processes regarding their future care, when people were unable to make such decisions themselves. We saw reference to people's capacity in the care files we reviewed.

We saw people's preferences were recorded, for example 'prefers a female carer'.

People we spoke with felt confident their concerns would be heard and dealt with effectively.

Is the service well-led?

During our inspection of Carrick Lodge we saw evidence to support our judgement that this service was well-led.

Prior to this inspection we received information of concern from visiting external healthcare professionals. They were concerned about an interaction which took place, during the assessment of a person who lived at the home, which involved the service provider. These allegations were confirmed to us by staff. Good professional working relationships with visiting healthcare professionals are important and help ensure the best outcomes for people at Carrick Lodge.

Carrick Lodge had regular support from the district nursing team and GP's from the local GP practices. This helped ensure people received appropriate care in a timely way.

People using the service, their relatives, friends and outside professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed. This showed the service was attempting to constantly improve support for people who lived at the service.

Staffing levels and skills were monitored by the registered manager to help ensure the service could meet the needs of the people who lived there.

Staff were motivated, caring, well trained, supported and open.

Carrick lodge worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision and service development.

The management of Carrick Lodge did not have a regular forum, such as staff meetings, to seek staff views and experiences and disseminate information to staff which could affect working practices.

Regular checks were carried out to help ensure the home was operating effectively and safely. Where these identified need for action this was followed up.

In October 2013, the Commission identified breaches of Regulation 9 of the Health and Social Care Act 2008 and issued a warning notice regarding the breach. A Warning Notice is a written notice that the Commission can give to a registered person, i.e. either a service provider or a service manager, where it appears to the Commission that that person has failed to comply with any relevant requirements.

As part of our inspection we spoke with the registered provider, registered manager, care staff, housekeeping staff and catering staff. Since our previous inspections of Carrick Lodge the home had been working to make improvements to become compliant with the Essential Standards of Quality and Safety.

We spoke with people who lived at Carrick Lodge, some of these people had recently moved to Carrick Lodge. People we spoke with were complementary of the staff and of the care and support they received. Comments included, 'the staff are good, it's a nice home, quite happy here', 'it's wonderful, it's a lovely place' and 'I'm perfectly happy here'.

We spoke with people about social engagement, some people told us they would like more opportunities to be able to go out as well as an increase in social activity within the home. One person told us the visiting library service was 'marvellous, you get such a choice'.

We asked people about the standard of food and the choices available. Overall people were complementary of the food; however, some people told us that they would like more choice.

We spoke with a relative who was visiting on the day of our inspection; they confirmed that they were satisfied with the care their relative was receiving and told us, 'I can't fault it at all'.

We found, people who used the service were given appropriate information and support regarding their care or treatment.

Care and treatment was planned and delivered in a way that ensured people's safety and welfare.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

We visited Carrick Lodge in the early hours of the morning, as information had been provided to us that people were being assisted out of bed between the hours of 5am and 8am.

As part of our inspection we spoke with people who lived at Carrick Lodge and observed how staff cared and supported people. We met and spoke with the provider, the registered manager, night and day care staff, housekeeping and catering staff.

We found, people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

People who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Care and treatment was not planned and delivered in a way that ensured people's safety and welfare.

We observed people who lived at Carrick Lodge were cared for and supported by staff in a kind and compassionate manner.

People who lived at Carrick Lodge told us, 'they're (staff) very good' and 'I can't think of a fault at all'.

Relatives were complementary about the staff, comments included, 'friendly and attentive' and 'they're so good here'.

We found people's needs were assessed and their care and treatment was planned and delivered in line with their individual care plan.

There were enough qualified, skilled and experienced staff to meet people's needs.

People who used the service were protected from the risk of infection because appropriate guidance had been followed.

People who used the service were not always given appropriate information and support regarding their care or treatment.

The provider did not have an effective system to regularly assess and monitor the quality of service that people received and did not identify, assess and manage risks to the health, safety and welfare of people using the service and others.