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Ann Charlton Lodge Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 June 2018

Ann Charlton Lodge 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. Ann Charlton Lodge provides care and accommodation to a maximum number of 25 people who have multiple sclerosis or related conditions of the nervous system. At the time of the inspection there were 24 people who used the service.

At our last inspection, the service was rated as ‘Good’. At this inspection on 23 February and 15 March 2018 we found some deterioration and rated the service as ’Requires Improvement’.

The service had a 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff we spoke with during the inspection told us they felt supported by the registered manager and other staff; however they had not received formal supervision on a regular basis. Supervision is a one to one meeting with the registered manager or other senior staff to identify training needs, areas for development and any support that is needed. People were supported by a regular team of staff who were knowledgeable about people’s likes, dislikes and preferences, however, staff were not up to date with their training.

Care plans were insufficiently detailed to ensure the needs of people would be met.

The registered manager and staff undertook a number of quality assurance checks to monitor and improve the standards within the service. However, some of these checks were ineffective as they did not identify the areas of concern that we found at inspection and for other checks there were gaps when auditing had not taken place.

Fire drills were not happening regularly and not all staff had taken part. A record of the fire practice had not been kept with a reflection on practice and learning. The handyman carried out regular checks of water temperatures in baths, showers and sinks to ensure people were safe and did not come to harm. However, we found some of these to be too high. The registered manager contacted us after the inspection and confirmed action had been taken to reduce the temperatures to safe levels.

For people who did not always have capacity, staff had not completed mental capacity assessments or best interests for areas such as choices about healthcare, personal care, medicines and equipment to be used.

Staff understood the procedure they needed to follow if they suspected abuse might be taking place.

Risks to people were identified and plans were put in place to help manage the risk and minimise them occurring. Medicines were managed safely with an effective system in place.

Checks of the building and maintenance systems were undertaken to ensure health and safety was maintained.

People and relatives told us there were suitable numbers of staff on duty to ensure people’s needs were met. Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with people.

The registered manager had systems in place for reporting, recording, and monitoring significant events, incidents and accidents. The registered manager told us that lessons were learnt when they reviewed all accidents and incidents to determine any themes or trends.

People were supported with eating and drinking and feedback about the quality of meals was positive. Special diets were catered for and alternative choices were offered to people if they did not like any of the menu choices. Nutritional assessments were carried out and action was taken if people were at risk of malnutrition.

The premises were clean and tidy and people and their relatives told us they liked the homely atmosphere. The service was well maintained with appropriate furniture throughout.

We observed numerous examples when staff were kind, caring and courteous. Privacy and dignity of people was promoted and maintained by staff.

Staff encouraged people to actively participate in meaningful leisure and recreational activities that reflected their social interests and wishes and maintain relationships with people that mattered to them. The service had a clear process for handling complaints.

The registered manager was aware of the Accessible Information Standard that was introduced in 2016. The Accessible Information Standard is a law which aims to make sure people with a disability or sensory loss are given information they can understand, and the communication support they need. They told us they provided and accessed information for people that was understandable to them.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.

Inspection areas


Requires improvement

Updated 1 June 2018

The service had deteriorated and was not always safe.

Staff had not taken part in regular fire drills. Some temperatures of water were too high and no action had been taken to rectify this until our inspection visit.

Appropriate recruitment checks were carried out to ensure suitable new staff were employed.

Staff understood their roles and responsibilities in safeguarding people.


Requires improvement

Updated 1 June 2018

The service had deteriorated and was not always effective.

Staff had not received formal supervision and training was not up to date.

Mental capacity assessments and best interests were not recorded for those people who were lacking in capacity.

People were provided with food they enjoyed.

People had access to healthcare professionals when needed.



Updated 1 June 2018

The service remained caring.


Requires improvement

Updated 1 June 2018

The service had deteriorated and was not always responsive.

The service had deteriorated and was not always responsive.

Care plans for people were insufficiently detailed to ensure people’s needs were met.

People were involved in a range of activities and outings.

People and relatives were aware of how to make a complaint or raise a concern. They were confident their concerns would be dealt with effectively and in a timely way


Requires improvement

Updated 1 June 2018

The service had deteriorated and was not always well led.

Effective auditing was not taking place.

People and staff were supported by the registered manager and felt able to have open and transparent discussions with them.

The registered manager had regular meetings with staff. Staff confirmed they were encouraged to share their views