Background to this inspection
Updated
7 May 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by one inspector.
Service and service type
Redcot Lodge Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Redcot Lodge Residential Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We reviewed the information of concern we had received to ensure we focused on the appropriate areas during our inspection.
We used all this information to plan our inspection.
During the inspection
We spoke with four people to gain their views on the quality of care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with the registered manager, and three staff. We reviewed information held in four people's care plans, three staff recruitment files, medication records and other paperwork related to the running of the service.
After the inspection
We continued to seek clarification from the registered manager to validate evidence found. We looked at minutes of meetings, duty rotas and quality assurance information.
Updated
7 May 2022
About the service
Redcot Lodge Residential Home is a residential care home providing accommodation and personal care. The service can accommodate up to 18 people in one adapted building. At the time of the inspection there were 16 people living at the service. Some people were living with dementia and some people had learning disabilities.
People’s experience of using this service and what we found
Quality assurance and governance systems were not effective in making sure risks to people’s safety were managed safely. For the past year the registered manager, had not been managing the service on a day to day basis. They had failed to have continuous oversight or scrutiny about what was happening at the service. They had failed to undertake any checks and audits to identify concerns and shortfalls. When they returned to the service on a more regular basis, they had found some of the issues but were unaware of the extent of the shortfalls and concerns we found at this inspection. Concerns identified at the previous inspection had not been prioritised and improvements had not been made and implemented.
People were not protected from the risk of avoidable harm. When concerns were identified about people's safety, information was not shared with appropriate stakeholders so investigations could be conducted. Risks were not managed. The registered manager had not ensured all risks associated with people and the service had been assessed and action had not been taken to make sure risks were mitigated. The registered manager was ensuring that people were protected from the risk of infection.
The registered managers lacked oversight of the incidents and accidents. Lessons had not been learnt when things went wrong.
Medicines were not always managed safely. Handwritten record had not been doubly signed by staff to reduce the risks of errors occurring. Staff did not have guidance for 'when required' medicines that were prescribed for people when they became distressed. Staff could not find any medicines audits to check that medicines had been given safely and any errors identified.
There was not always enough staff on duty to ensure care was delivered in a safe way. Staff received essential training to complete their role, but not all staff received training about people's specific health conditions.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
Based on our review of Safe and Well Led:
The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.
Right support:
The model of care and setting did not always maximise people’s choice, control and independence. People were not considered and involved in the planning of their care.
Right care:
Care was not always person-centred and did not always promote people’s dignity, privacy and human rights. People did not always have access to meaningful and person-centred activities.
Right culture:
Ethos, values, attitudes and behaviours of leaders and care staff did not always ensure people using services lead confident, inclusive and empowered lives.
People were supported with their health needs. GP’s, district nurses and other specialists were contacted when they were needed. Staff were recruited safely. All safety checks had been completed before new staff started working at the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 24 July 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had not been made and the provider remained in breach of regulations.
Why we inspected
The inspection was prompted in part due to concerns received from the local authority about lack of care planning and risks associated with people’s care. A decision was made for us to inspect and examine those risks and to follow up on action we told the provider to take at the last 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.
We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report. The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Redcot Lodge Residential Care Home on our website at www.cqc.org.uk.
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 take further action if needed.
We have identified breaches in relation to safeguarding, risk, medicines, lack of staff, and leadership, management, scrutiny and oversight of the service.
Please see the action we have told the provider to take at the end of this report.
Follow up
We met with the registered manager following the inspection to discuss how they will make changes to ensure they improve their rating to at least good. They agreed with that they would not admit any new people to the service until improvements were made.
Following the meeting we were informed that the provider had made the decision to close the service and would be cancelling their registration with the CQC. The registered manager and the local authority were working with people and their relatives to make ensure people were moved safely to other services that were able to meet their needs.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review until they are de-registered, if we do not propose to cancel the provider's registration. 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.