King's Lodge Centre for Complex Care

Alum Care Limited is a care home with nursing for up to 64 adults. The service specialises in the care of people with long-term neurological needs, including Huntington’s disease, Parkinson’s disease, motor neuron disease and multiple sclerosis. There were 44 people living at the home at the time of our inspection.

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

People received their care from regular staff with whom they had established positive relationships. Staff were available when people needed them. People told us staff had worked hard to keep them safe during the coronavirus pandemic.

The quality of care plans had improved since our last inspection. People’s care plans were detailed and personalised. They contained clear guidance for staff about how to provide people’s care according to their individual needs and preferences.

Risks to people were effectively identified and mitigated, which had improved outcomes for people. Learning took place if adverse events occurred. Incidents were reviewed to identify any actions that could reduce the risk of a similar incident happening again.

People were protected by the provider’s recruitment procedures. Staff understood their role in protecting people from abuse and knew how to report any concerns they had. People’s medicines were managed safely.

Additional infection control measures had been implemented to protect people and staff during the pandemic. These measures included the use of appropriate personal protective equipment (PPE), more frequent cleaning of the home and ensuring staff were up to date with guidance about infection control.

Staff had the skills and training they needed to provide people’s care. All staff had an induction when they started work and access to regular supervision. The manager and clinical lead helped staff keep up to date with best practice and any changes to guidance about the delivery of care.

People said they enjoyed the food at the home and could make choices about what they ate. The menu was changed regularly and people were asked for suggestions for future menus. People with specific dietary needs were referred to relevant healthcare professionals for assessment and any subsequent guidance followed by staff.

The manager and senior staff team had implemented effective quality monitoring systems. Regular audits helped ensure people received safe and effective care. Communication of important information amongst the staff team had improved. Staff were given daily updates about people’s needs and any changes to their care.

The culture amongst the staff team was positive and mutually supportive. Staff felt valued for the work they did and told us they were well supported by the manager and senior staff team.

People told us they had opportunities to give feedback about the home and the support they received. They said staff listened to and acted upon what they had to say. People told us they could speak with the registered manager or a senior member of staff if they wished.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 4 June 2019).

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 19 April 2019. We rated the key questions Safe, Effective and Well-led required improvement.

We undertook this focused inspection to check they had made the required improvements. This report only covers our findings in relation to the key questions Safe, Effective and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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.

Follow up

We will continue to monitor the service action plan to understand what the provider will do to improve standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Alum Care Limited 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. Alum Care provides nursing care home for 64 people with complex needs over three separate wings, each of which has separate adapted facilities. At the point of our inspection there were 55 people living at the service who had a range of needs such dementia, acquired brain injuries and complex health care needs.

People’s experience of using this service:

People and their relatives told us they felt safe at Alum Care, and staff were aware of their responsibilities in safeguarding people from abuse. However, risks to people were not always appropriately recorded and managed, and some care plans lacked information on people’s specific health conditions. There were a sufficient number of safely recruited staff to meet people’s needs, and medicines were recorded correctly and administrated safely. Accidents and incidents were monitored for trends. We have made a recommendations around health care plans and tracheostomy care at the service.

People’s rights were not always protected in line with the principles of the Mental Capacity Act 2005. Staff received training that was relevant to their role and received supervision on a regular basis. Staff felt that the communication within the service was effective, and people had access to healthcare professionals where required. People were complimentary about the food at the service, and people at risk of dehydration were monitored. The design of the building was suitable for people’s complex needs.

Relatives told us staff were extremely kind and caring, and we observed friendly interactions between people and staff. People were involved in decisions around their care and were encouraged to be independent as much as possible. People’s dignity and privacy was respected, with personal care and conversations taking place behind closed doors.

There were a wide range of internal and external activities available which helped people live fulfilled lives. The service had responded to complaints in line with their policy, and the number of complaints received had dropped over the past few months. People’s personal end of life wishes were recorded in detail.

People, relatives and staff felt supported by various levels of management within the service. Robust quality checks allowed the service to identify and resolve any issues or improvements. People, relatives and staff were now engaged in the running of the service and asked for feedback regularly. Any suggestions made were taken on board and implemented where possible. The service had strong working partnerships with a range of organisations and had plans in place to improve their medicine recording system and the personalised care they delivered. For more details, please see the full report which is on CQC website at www.cqc.org.uk.

Rating at last inspection:

At the last inspection the service was rated Inadequate. The inspection report was published on 27 November 2019.

During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures

Why we inspected:

This was a scheduled comprehensive inspection. We inspect all services rated as ‘Inadequate’ within six months to ensure that we review the quality and safety of the service people receive.

Follow up:

We will follow up on recommendations made and any improvements required at our next inspection.

The inspection took place on 19 September 2018 and was unannounced.

The service did not have 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. A new manager had been employed and they had commenced at the service in July 2018. The new manager (known as the manager in this report) assisted us with our inspection.

People were not always safe as risks to them were not always being managed appropriately, in particular those at risk of developing pressure sores and those at risk of choking. Call bells were not always responded to in a timely way and problems with the call bell system meant there was no clear picture of how long people had to wait for care. There was no monitoring or analysis of accidents and incidents that had taken place to identify trends and reduce further risk. The care received by people did not always reflect what we observed in care plans throughout our inspection.

Safeguarding procedures were not followed and appropriate referrals were not made to local authority. People’s concerns were not being investigated appropriately which left people at risk of abuse. Feedback from people, relatives and staff was that there was not always a sufficient number of staff to meet people’s needs. People told us they felt “Vulnerable” due to this. It was unclear how many staff were needed to safely meet people’s needs. There was a high use of agency staff which impacted on the care people received. Staff recruitment checks required improvement, this is important as the service was recruiting new staff to reduce the reliance on agency.

People had access to a wide range of healthcare professionals. This included General Practitioners, Tissue Viability Nurses and Physiotherapists. We asked the manager to provide us with contact details for healthcare professionals who visit the service following the inspection but we did not receive these.

Medicines were appropriately stored, dispensed and managed. Actions picked up on a recent medicines audit and been resolved. People were being cared for by staff who were aware of and carried out safe infection control processes. Aprons, gloves and hand sanitizers were available throughout the service and staff were aware of infection control procedures.

Staff were not up to date with their mandatory training. There were gaps in all areas of training that meant staff would not be up to date with best practice. We did not see evidence that staff were receiving supervision and appraisals.

People’s rights were not protected. The service did not always follow the Mental Capacity Act principles. Mental capacity assessments for specific decisions had not been completed and correct legal authorisation had not been sought to deprive people of their liberty.

People had a choice of foods, however people told us at times they did not have access to food and drink when they wished it. Staff were not sure of some people’s dietary needs. We have made a recommendation to the registered provider in this respect.

There were detailed pre- admission assessments completed before people moved into the service to ensure they could meet their needs. Multiple meetings involving people, their relatives and professionals involved in their care took place before they moved to the service. The adaptation of the premises was suitable to meet people’s needs effectively. Specialist equipment was in place and corridors were wide enough for people to be able to use specialised wheelchairs.

People did not always feel listened to or have their opinions valued. A residents committee was informed by the manager that they could only discuss activity ideas rather than any concerns or suggestions to improve the service they may have. People were not always treated with kindness, respect or dignity. We observed staff entering people’s rooms without knocking. However, people and relatives were very complimentary about how staff treated them and we saw examples where staff spoke and treated people in a kind manner.

Although people felt staff knew their needs, care plans were not detailed enough and were not always completed fully. People’s end of life wishes were not always recorded.

Complaints were not responded to in line with the providers policy. People and relatives told us that they did not feel able to raise concerns and were not confident action would be taken if they did.

There was a negative culture in the service. Staff were nervous to speak to our inspection team and people, relatives and staff told us they felt they could not approach the manager.

The manager was not accessible and people told us that they had not met her or feel able to speak to her as they felt she did not have an ‘open door’ policy.

Plans for improvement within the service were in place, but people, staff and relatives did not feel confident in the management’s ability to achieve these. The service did not have robust quality assurance systems in place to assess the quality and safety of the service. Internal audits that had taken place had not identified the issues that we had during our inspection

The service had not notified the commission of all reportable incidents. This included people developing pressure sores and safeguarding concerns.

The provider had failed to display the service’s rating on their website.

During this inspection we identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. We also made two recommendations to the registered provider. You can see what action we told the provider to take at the back of the full version of the report.

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.

On the day of inspection we met the 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 inspection was unannounced and took place on 8th September 2016.

The requirements of the Mental Capacity Act were not being fully met. The registered manager had submitted Deprivation of Liberty Safeguard applications but these applications did not include the full range of restrictions being imposed. This could potentially lead to people having their freedom unfairly restricted.

People, relatives and care professionals said that Kings Lodge was a safe place to live. A person with complex health needs had chosen to return to the service for a respite placement because they felt that it was safe.

People were protected from harm. Staff had the training and the ability to understand risk, and reported accidents and incidents in a timely manner. Staff understood how to report suspected abuse so that action could be taken if necessary. Incidents and accidents were investigated and the manager reviewed reports to prevent them from re-occurring. Any potential risks to individual people had been identified and appropriately managed.

Risk assessments had been completed to ensure the home was safe for people to live in and there were arrangements in place should there be an emergency.

People were supported by sufficient numbers of staff who were recruited safely and had the skills and knowledge to support people. All nurses had an up to date PIN number to prove they were registered.

Medicines were managed and administrated in a safe way and staff had a good understanding of the medicines they were administrating.

Staff had the knowledge and skills to support people with neurological conditions and physical needs. Specialised training was available to staff, which included training courses related to people’s needs.

People’s nutritional needs were met and people had a varied diet. Staff ensured that people had enough to eat and drink.

Staff ensured people were supported to maintain their health and wellbeing and people received support from specialist healthcare professionals when required.

People were cared for by staff who put them at the centre of all they did. People were not rushed by staff and were treated with dignity and respect. People were encouraged to maintain relationships with their family and those that mattered to them.

People’s care met their needs and wishes. Staff were responsive to the needs and wishes of people. The environment was adapted to support people with physical support needs and neurological conditions. Equipment had been introduced to help people maintain their independence. People were encouraged to be involved in how the home was run and people and relatives felt comfortable in raising a concern or making a complaint.

The home was led by a manager who was a positive role model. Organisational values providing compassionate care by helping, understanding and caring were reflected in the support given by staff and the management team. A new auditing system had recently been started, which mirrored CQC methodology.

People and staff were involved in the running of the service. Feedback was used by the registered manager to improve service delivery.

We carried out this follow up inspection to check that the provider had taken the necessary action to improve the safety of the building. We also checked to make sure that changes to the premises had been carried out as detailed by the provider in the action plan they had sent us.

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

We saw closed circuit television cameras had been fitted around the outside of the home to monitor less well supervised areas. The provider had therefore improved security in the home which meant people were better protected. We saw keypads had been fitted to areas containing hazards, for example, the lift machinery cupboard, the medication room, the chemicals room, and rooms containing access to high voltage.

We noted that windows had been repaired and made secure. We found that some window restrictors had been fitted and the new building's windows had been restricted to protect people. The provider may find it useful to note that some window restrictors had not been fitted.

People who used the service said they liked the home and their rooms which were warm enough. One person told us they had lived in many homes and this one was 'far the best'.

At this inspection we reviewed the actions the provider had taken in response to the compliance actions set.

The last inspection report identified shortfalls under outcome 1 (regulation 17) regarding protecting people's privacy and dignity when using the toilet. At this inspection we found that the shortfalls had been met and the compliance action closed. We therefore found that people who use the service were treated in a way that respects their privacy and dignity.

The last inspection report recorded shortfalls under outcome 10 (regulation 15) regarding the environment and set a compliance action. At this inspection we found that the provider had made some progress but more was required. This compliance action therefore remained open and we found that people who used the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises.

It was seen as responsive that the provider, once they clearly understood what was required, started to take immediate action during the inspection to make improvements in the remaining areas of non-compliance. For example, setting up systems authorising funding and ordering equipment that would assist compliance during the inspection.

We noted that the home was hygienic, clean and fresh.

People told us they had enjoyed their meals, liked the food and got enough to eat. They said they had choices of food and they could have a snack or a drink at any time.

People said they liked their rooms, their taps worked and they were warm enough in winter.

One person told us that they were offered their choice of food, they got enough to eat and the food was good, except sometimes the meat was a bit tough.

We saw that people decided what to eat on the day as opposed to deciding weekly menus. This offered more flexibility and choices.

People were supported to be able to eat and drink sufficient amounts to meet their needs.

We saw that the building and grounds had been made accessible, were well kept and that the home benefited from having its own pets, for example, dogs and chickens.

We found that staff did not always provide care in a way that acknowledged, recognised and protected people's right to privacy, dignity and respect.

We found that the home was not always protecting people against the risks associated with unsafe or unsuitable premises, by not fitting secure restrictors to windows that had been risk assessed as needing these; and leaving a fire door, alarms and three fire exits unable to close securely.

One resident told us that "staff always knock before they enter my room and if I do not want to have a shower at a specific time then they will go away and come back at a time that is suitable for me".

A relative told us that "we like Kings Lodge because they put the need of the residents first. They always ask us for our opinion and they always listen to the residents".

People told us that the staff were "Very good" and "Very kind". We saw on the day of our inspection that staff treated people in a caring and supportive manner. People also told us that they knew about the care and treatment they had and that they were always kept informed about this.

We spoke to three relatives of people who used the service. The told us that they were happy with the care that people received and that they felt that staff do a "Very good job". One relative told us that they felt the staff gave "Very good care" whilst others told us that staff were always "Very kind".

This was confirmed by our observations on the day as we saw that staff spoke to people in a respectful and caring way. We noted that the staff and the people were very relaxed in each others' company