Lound Hall

We found the following examples of good practice.

The management team we spoke with during our inspection, were knowledgeable about their roles and responsibilities relating to infection control. There were systems in place which supported good infection control procedures.

The service was visibly clean and well ventilated.

People were being supported to receive visits from their relatives.

Staff and people using the service received regular COVID-19 testing in line with current government guidelines.

There was a robust system in place to record vaccinations received by people using the service and staff. Where visiting professionals attended the service, their vaccination status was checked and records maintained to show this was undertaken, in line with government guidance.

In November 2017, January 2018 and May 2018 the service was rated inadequate following inspection visits. The service was found to be in breach of multiple regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was placed into special measures and we placed conditions on their registration. This included a condition which prevented them from admitting further people to the service. The service implemented a new management team, with a new manager starting in January 2018.

At this inspection we found that the service had made the significant improvements which were required to comply with the regulations. This meant people were protected from the risks of receiving care which was unsafe, inappropriate or not in their best interests.

The service was meeting the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) 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.

People and their relatives told us they felt safe living in the service and that staff made them feel safe. Staff demonstrated a good understanding of keeping people safe in discussions with us. Risks to people were appropriately planned for and managed. Medicines were stored, managed and administered safely.

Checks were carried out to ensure that the environment and equipment remained safe. Improvements had been made to the safety of the premises to reduce the risk of people coming to harm. The service was clean and measures were in place to limit the risk of and spread of infection.

People and their relatives told us there were enough suitably knowledgeable staff to provide people with the care they required and our observations supported this. Staff had received appropriate training and support to carry out their role effectively.

People received appropriate support to maintain healthy nutrition and hydration. Care planning now provided staff with the information they required to protect people from the risks of malnutrition or dehydration.

People and their relatives told us the staff were kind, caring and considerate. Relatives told us staff respected their family member’s right to privacy and that staff supported people to remain independent. Our observations supported this.

People and their relatives were encouraged to feed back on the service in a number of different ways and participate in meetings to shape the future of the service. People and their relatives told us they knew how to complain, and complaints had been investigated and responded to appropriately.

People received personalised care that met their individual needs and preferences. Some improvements are still required to further personalise care records to include people’s preferences and to include life histories for those living with dementia.

People and their relatives were actively involved in the planning of their care. People were supported to access meaningful activities and follow their individual interests.

The registered manager, clinical lead and provider created a culture of openness and transparency within the service. Staff told us that the registered manager, clinical lead and provider were visible in the service and led by example. Our observations supported this.

Improvements had been made to the quality assurance system in place and this was reflected in the significant improvements that had been made to the service.

Further information is in the detailed findings below.

Lound Hall is registered to provide nursing and personal care to a maximum of 43 older people, some of whom may be living with dementia. At the time of our visit there were 24 people using the service.

The inspection was unannounced and took place on 30 and 31 May and 5 June 2018.

At our previous inspection on 31 October and 1 November 2017, we identified shortfalls in the service which meant people did not always receive the care and support they required. We found that the service was in breach of regulations and needed to make improvements to staffing levels, the management of medicines, care planning, risk management, activities, the support people received to eat and drink, practices around the Mental Capacity Act 2005 (MCA) and the governance system in place. We rated the service Inadequate overall and asked them to provide us with an action plan stating how they would make improvements to the service.

At this inspection we identified continued failings which put people at risk of harm. The service continued to breach regulations and had not made all of the improvements they were required to make following the previous inspection.

The service had a registered manager in place. 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.

People were put at the risk of significant harm in the absence of clear records and assessments which reflected all current areas of risk and how these should be managed to protect the person from harm.

There were limited care plans available to guide staff on how to meet people's needs. Some people’s care plans had been updated to a newer format. However the care plans for some, including those with identified risks, had not been updated. Staff did not always know information that senior staff told us about people.

The support people needed to reduce the risk of malnutrition was not always care planned or updates to care planning had not been made where their needs changed significantly. Food charts did not evidence that people were supported as far as possible to boost their nutritional intake with extra foods outside of structured meal times.

Clear action was not always taken where people had unexplained bruising that required investigation.

Whilst the provider had identified and taken action to reduce some environmental risks, other risks in the environment such as uncovered radiators and unsecured substances which may be harmful if ingested had not been identified by the service.

Whilst some improvements had been made to the cleanliness of the service, improvements were required to ensure that the service was consistently clean and free of unpleasant odours.

People had access to other healthcare professionals. Whilst some records were kept of the contact people had with health professionals, where advice was given this was not always transferred into care planning which meant it was unclear how staff could consistently follow this advice.

Medicines were not managed and administered safely. There were discrepancies in Medicine Administration Records (MAR) where it was unclear if medicines had been administered and some tablets remained in blister packs.

People were not supported by staff to have maximum choice and control of their lives. Some people had not had an assessment of their capacity. Care plans demonstrated a poor knowledge of the formal process of making a best interest decision and care plans did not always reflect where people had a power of attorney who should be involved in all decision making. Staff did not always support people to make decisions independently.

Whilst activities provision had improved with the addition of two new activities staff, people did not consistently have access to activities that were meaningful and engaging in line with their individual needs. The activities provision in the service required further development and structure and the activities team required further training to develop their knowledge. People who were nursed in bed or preferred to stay in their bedrooms had inconsistent access to engagement and activity.

People’s care plans required further personalisation to ensure they were individualised. Care plans did not always reflect the views of the person or their relatives.

Whilst some areas of the service had benefitted from redecoration, improvements were required to the décor, adaption and design of the service to ensure it was suitably orientating for people living with dementia.

Improvements were required to the knowledge of the staff team. Staff we spoke with and observations of staff practice did not demonstrate a good knowledge of subjects they had received training in, such as nutrition, MCA and Medicines.

On 31 October and 1 November 2017 we rated the service inadequate following the identification of significant widespread shortfalls which meant people did not always receive the care they required to protect them from harm. The report resulting from the inspection made clear the areas of particular concern. Despite this, timely enough improvements had not been made in some areas identified at the previous inspection. For example, clear care plans had not been implemented for people at risk of choking.

There was a failure of the management team to ensure that systems in place to monitor the quality of the service were effective in identifying continuing shortfalls and areas for improvement. Improvements, particularly around risk management and care planning, had not been made in a timely way. The management team had not prioritised the updating of care plans for people who had been identified as at risk. This meant people had been placed at continual risk of receiving poor care.

Progress had been made in improving the culture in the service. We observed staff were caring and kind. However, they were still failing to identify the poor practice of themselves and others.

The registered manager and provider were honest, open and transparent with people and their relatives about improvements that needed to be made. People and their relatives told us they felt more listened to and were more positive that issues they raised would be taken seriously. Regular meetings had been organised where people had the opportunity to feedback their views.

The staffing level in the service had been much improved, with a new structure in place to ensure staff had set responsibilities. A review of call bell records demonstrated that response times were much more prompt. People and their relatives told us they were happy with the staffing level and that staff were prompt when support was requested.

The overall rating for this service is 'Inadequate' and the service therefore is 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.

You can see what action we told the provider to take at the back of the full version of the report.

The inspection was unannounced and took place on 8 January 2018. We carried out this urgent focussed inspection following concerns about people’s safety and welfare from Suffolk County Council and the Clinical Commissioning Group (CCG).

On 31 October and 1 November 2017 we carried out an urgent comprehensive inspection in response to concerns about people’s safety and welfare. We were so concerned about what we found we took urgent action to stop the service admitting people. We also placed conditions on the registration of the service which requires them to send us regular information about the improvements being made. In January 2018 we received further concerns about a lack of improvement in the service and continuing risks to people’s safety and welfare. As a result we undertook an urgent focused inspection to look into those concerns. This report only covers our findings in relation to those topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Lound Hall on our website at www.cqc.org.uk

The service had a registered manager in place. 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.

People were put at the risk of significant harm in the absence of clear records and assessments which reflected all current areas of risk and how these should be managed to protect the person from harm. Basic care plans had been implemented for people; however, these did not provide adequate information for staff around meeting people’s specific complex needs.

Information received from the CCG demonstrated that there were continuing failures in the safe management of medicines.

Whilst some training had been carried out since our inspection, action was still needed to ensure that staff had the appropriate training and competencies to meet people’s complex needs safely.

There was a continuing failure of the management team to ensure that effective systems were in place to monitor the quality of the service. Limited progress had been made following our previous inspection and we were concerned that the management team had not identified risks to people and taken action to protect them. This was despite us providing clear information on the areas of risk following our inspection on 31 October and 1 November 2017 and the support provided by Suffolk County Council and CCG.

The service had assessed the dependency of people using the service and increased the staffing level. They did not have enough employed staff to cover all the shifts but had organised for agency staff to cover the deficit.

On the day of this inspection a new member of staff had started work at the service. They had been employed to be part of the management team and to facilitate and oversee improvements at the service.

Following our inspection we liaised with Suffolk County Council and the CCG to ensure that appropriate support was given to the service to keep people safe whilst improvements were made. We continue to work closely with other agencies to monitor the service and identify if there are further risks to people’s health, safety and welfare.

You can see what action we told the provider to take at the back of the full version of the report.

The inspection was unannounced and took place on 31 October 2017 and 1 November 2017. The inspection was brought forward due to concerns raised with us by the Clinical Commissioning Group (CCG) and because of a safeguarding concern shared with us by Suffolk County Council.

At our previous inspection on 25 and 30 January 2017, we identified shortfalls in the service which meant people did not always receive the care and support they required. We found that the service was in breach of regulations and needed to make improvements to staffing levels, the management of medicines, activities, the support people received to eat and drink and practices around the Mental Capacity Act (MCA). We rated the service Requires Improvement overall and asked them to provide us with an action plan stating how they would make improvements to the service. At this inspection we identified significant failings which put people at risk of harm. The service continued to breach regulations and had not made the improvements they were required to make following the previous inspection.

The service had a registered manager in place. 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.

People were put at the risk of significant harm in the absence of clear records and assessments which reflected all current areas of risk and how these should be managed to protect the person from harm. In particular, adequate action was not taken to protect people from the risk of developing a pressure ulcer or to identify and adequately care for pressure ulcers.

There were limited care plans available to guide staff on how to meet people’s needs. For some people, there were no care plans at all and there was confusion from staff about what people’s needs were and how they should be met. Relatives and people using the service raised concerns about staff’s knowledge of their needs and told us they had not been involved in the planning of their care.

People were not supported to maintain good nutrition, and action had not been taken by the service to reduce the risk of people becoming malnourished.

Medicines were not managed and administered safely. Ordering and return procedures for medicines were inadequate and resulted in some people not receiving their prescribed medicines. There were other discrepancies in Medicine Administration Records (MARS) where it was unclear if medicines had been administered.

There were not enough staff to meet people’s needs and provide them with support at the time they needed it. People using the service, relatives, staff and healthcare professionals raised concerns about the staffing level.

The service did not practice safe recruitment procedures. Staff started working for the service before appropriate checks had been carried out to ensure they were safe to work with vulnerable people and had the appropriate character for the role.

People were not supported by staff to have maximum choice and control of their lives. Assessments of people’s capacity had not been completed, and determinations about people’s capacity had been made inappropriately. Improvements were required to the knowledge of the staff and management team around the Mental Capacity Act (MCA).

People were not supported to live full, active lives and to engage in meaningful activity within the service. We observed that some people were socially isolated and disengaged from their surroundings. People who were nursed in bed had little access to engagement or activity.

Improvements were required to the knowledge of the staff team. Staff we spoke with and observations of staff practice did not demonstrate a good knowledge of subjects they had received training in, such as nutrition, MCA and Medicines. Improvements were required to fully implement consistent supervision and appraisal for care staff and nursing staff.

There was a failure of the management team to ensure that systems in place to monitor the quality of the service were effective in identifying shortfalls and areas for improvement. The management team had not taken appropriate action to make necessary improvements following our previous inspection. This meant people had been placed at continual risk of receiving poor care.

There was not an open, honest and transparent culture in the service. People using the service, relatives, staff, healthcare professionals told us they felt a disconnect between the management team and themselves. Relatives and people using the service told us they did not feel listened to and did not have confidence in the management team to take on board their comments and act on these.

Notifications had not been made to CQC where this was necessary.

Following our inspection we were so concerned that we took urgent action to protect people. We have issued a Notice of Decision to prevent further admissions to the service and a Notice of Decision to require the provider to send us information about how they are meeting people’s individual needs.

The overall rating for this service is 'Inadequate' and the service therefore is 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.

You can see what action we told the provider to take at the back of the full version of the report.

Before the inspection, feedback we had received from people using the service, their relatives, advocates and professionals, which raised concerns over the leadership and governance of the service. They told us the systems in place to monitor the quality of the service people received were not effective enough to independently identify and address shortfalls. Where people told us they felt the service had not effectively listened, and responded to their concerns in a timely manner, it had impacted on their confidence in the ability of the management to address them. This had resulted in the service being required to put in ‘action’ plans to reduce risk to people living in the service, and being given support to improve in areas including care planning and infection control. This had led to improvements in these areas. Work was being undertaken by the provider to gain people’s confidence back. The provider told us they were in the process of recruiting to a new clinical lead to oversee the quality of the nursing being provided. Relatives spoke about feeling more reassured by a more visible presence of the provider’s representative. However, further work was still needed to instil confidence in the daily management of the service, as part of driving continuous improvement.

People told us they felt safe living in Lound Hall, and spoke about the improvements they had seen in the standard of cleanliness within the service.

We found improvements were needed in the management of medicines and staffing levels. This is to ensure people received their medicines as prescribed, and that there were enough staff to monitor, support and respond to people’s individual needs.

Staff received training in core skills to support them providing a safe service. However some infection control and health and safety training needed to be embedded in practice. We found shortfalls in staff’s knowledge of supporting people living with dementia; we have made recommendations around training to support staff in gaining these skills.

People told us they did not have enough access to stimulating activities, linked to their individual interests and needs, to occupy their time. Where people were spending long periods of time without quality interaction, this put people at risk of becoming socially isolated.

People were not always supported to have maximum choice and control of their lives and to ensure staff supported them in the least restrictive way possible; the policies and systems in the service did not always support this practice. There was a lack of forums to support people in voicing their views and experiences, and be influential in driving improvements.

Improvements were required to ensure all staff’s interactions with people were caring and empowering so all people feel valued. This included looking how routines can be changed to support the person, not the other way round; more supportive of person centred care. Systems had been put in place to check the contents of people’s care plans were accurate and reflected their needs and preferences. This needed to be developed further, to ensure the person and all staff involved in their care are aware of the contents, so any missing information / inaccuracies are quickly identified.

People complimented the quality of the food. However, we found people were not always supported to ensure that they had enough food and fluid to support their health needs. Records were incomplete and not assessed to make sure that people had enough to eat and drink. Where people of low weight turned down food, or had a low appetite, this was not always being effectively managed. This included offering nutritious, high caloric snacks in-between meals, or as an alternative where people had declined. This put people at risk of losing, or not maintaining their weight gain. We made a recommendation to support staff in improving people’s meal time experiences, especially for people living with dementia.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of this report