Saxby Lodge Residential Care Home accommodates up to 19 older people including people who live with Dementia. There were 15 people living at the service at the time of our inspection. The premises are a converted domestic property situated in a residential area.People’s experience of using this service and what we found
People who lived at the service, and who were dependant on staff for their hydration needs, were at risk from dehydration and increased risk of urinary tract infections (UTI). This was because records of their fluid intake were incorrect and misleading. Some people were at risk of potential weight loss as their nutritional needs were not always being met.
Staff were not trained to meet the needs of people who had specific health and support requirements such as Parkinson’s Disease or required support to eat. Some staff were unaware of people’s underlying health conditions and associated risks. This meant there was a risk that staff could miss the signs that a person’s health was deteriorating and the required action to take.
Information in people’s care records and staff knowledge was not enough to ensure safe care. For example, where people had significant terminal health conditions their care plan’s failed to provide any information to guide staff on the care or treatment they required.
Appropriate action was not always taken to mitigate risks to people. There was a failure to assess and mitigate known risks to people such as those associated with respiratory conditions, the risk of catheter induced infections, changes in blood sugar levels and required action for people with diabetes.
Our observations showed there were not enough staff deployed during the day to provide people with personalised care, meaningful occupation and to keep people safe. A relative told us “I am unhappy with the staffing levels and have commented as such to Saxby Lodge. Because I visit regularly, I recognise staff and am concerned since the new ownership longstanding staff have left. There have been, in the past six weeks, at least five new faces. They seem to be very short staffed at weekends and no sign of any managerial support.”
Environmental risks were not always well managed. We observed some poor practice with environmental safety including a failure to safely control substances that are hazardous to health (COSHH), safe storage of medicines and infection prevention and control.
The service was visibly unclean in places and there was a very strong smell of urine in parts. One person told us it was like living in a urinal and visitors to the service described the small of urine to be overwhelming. This did not make for a pleasant and dignified environment in which to live. Relatives described the environment as shabby with equipment and furnishings that were worn and old. One relative said, “My first visit l was quite shocked to see how shabby and run down the interior of the home was and my first thought was to get her out of there”.
People told us they spent most of their time alone in their bedrooms. There was little opportunity for meaningful occupation and stimulation. People told us they did not use the main lounge as it was not very stimulating, one person said, “I get more company from my TV than I do in the lounge”.
Care plans did not always reflect people's individual preferences for how they wished their care and support to be delivered. Care plans did not clearly identify which aspects of their care people could manage themselves or the type of support people required in order to promote independence.
There was a lack of leadership and oversight of the service. People, staff and relatives consistently told us how they had fed-back concerns and suggestions, but these had not been acted upon. A relative told us, “Saxby Lodge is no longer the home it was. Having given the new owners a reasonable period of time to settle in, and I know change is always difficult for staff, residents and relatives alike, I am considering seeking an alternative placement.”
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible, the policies and systems in the service did not support this practice. People’s liberty may have been deprived without the lawful safeguarding in place to protect their rights.
Some people shared their positive experiences of living at the service. One person told us how good it was to know that there were people around if needed, and that made them feel safe. Another told us staff were kind and a relative said, their loved one had recently moved in and they found the service to be ok, staff were friendly, and they would recommend it to others.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This is the first inspection under a new provider since they were registered with CQC in February 2021. The last rating of the service under the previous provider was rated Good ( published in 6 June 2019).
Why we inspected
The inspection was prompted in part due to concerns received about standards of care in relation to insufficient food, drink and insufficient staffing levels and competencies. A decision was made for us to inspect and examine those risks.
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.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to: risk management, medicines management, safe staffing levels, staff training, ensuring adequate nutrition and hydration, maintenance and cleanliness of the premises, ensuring people received person centred care and support, treating people with dignity and respect, the need for consent ensuring, systems and processes are operated effectively to assess, monitor and improve the quality and safety of the service at this inspection.
Please see the action we have told the provider to take at the end of this report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit to review the improvement made. If we receive any concerning information we may inspect sooner.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.