Background to this inspection
Updated
6 May 2017
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.
We visited Ado Lodge on 23 February and 1 March 2017. The inspection was unannounced on the first day. We announced when we were to be inspecting on the second day, however staff were not informed of this and there was no provider’s representative present.
Before the inspection, we checked the information that we held about the service and the service provider, including any notifications we received from the service. A notification is information about important events which the provider is required to tell us about by law. We also contacted a person responsible for commissioning services from the provider.
None of the people who used the service were able to communicate verbally with us. We spent time observing how staff provided cared for people to help us better understand their experiences of the care and support they received. We spoke with the home manager and six members of the care staff team, an interim manager and one of the directors. Following the inspection visit we contacted two relatives who provided us with feedback about the service.
We looked at available documents and written records including people’s care records, risk assessments and medication charts. We also looked at information regarding the arrangements for managing complaints and monitoring the quality of the service provided within the home.
Updated
6 May 2017
This inspection took place on 23 February and 1 March 2017. The inspection was carried out as a result of concerns received about the service.
Ado Lodge is a care home service without nursing, which provides personal care and accommodation for up to four younger adults with learning disabilities or autistic spectrum disorder.
There were three people using the service at the time of this inspection.
The service had a registered manager in post. A registered manager is a person who has registered with 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.
Although there was a registered manager in post they were currently absent from the service. The provider had put in interim management arrangements. The home also employed a home manager. This role was intended to have a lead role in day to day management within the home.
Experienced staff were not always deployed in sufficient numbers to keep people safe.
People were not fully protected from the risk of avoidable harm and abuse that may breach their human rights because staff did not always receive appropriate training in a timely manner.
The system for checking staff’s suitability for their role before they started working at the home was not robust.
Medicines were not all stored, administered and managed safely.
People were not always supported by staff who had received appropriate training, professional development and supervision to enable them to meet people’s individual needs. There were not always enough qualified and experienced staff to respond to and meet people’s needs.
A regular team of staff had developed positive caring relationships with people, knew people well and respected their privacy and dignity.
People's care needs had not been reassessed regularly and this had put them at risk of inconsistent care or not receiving the care and support they needed.
The systems used for recording people’s care and support had changed frequently and had not supported staff to provide individualised or person centred care.
The complaints system was unclear and had been managed inconsistently.
Management systems were not effective in ensuring the quality and safety of the service. Incident reporting systems were not robust.
The registered manager had not promoted a positive, open and inclusive culture at the service. Staff did not receive appropriate support and did not feel well informed.
Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in relation to the service. The provider had not informed the CQC of a number of significant events.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach under the Health and Social Care Act 2008 (Registration) Regulations 2009.