Archived: Cary Lodge

People’s experience of using this service:

• People were put at risk of receiving care and treatment that was unsafe. Risks relating to health concerns and behaviours that challenged were not fully assessed. The service had not taken action to reasonably mitigate these risks. Some risks had not been escalated to health care professionals for advice.

• Infection control practises needed improving and the laundry was disorganised which heightened the risk of cross contamination. People’s clothes sometimes went missing or were worn by other people.

• Medicines were not always well managed, or administered at the correct times. Staff had not all received training in how to support a person that needed oxygen to help them to breathe.

• There were not enough staff in key communal areas to ensure people were safe and to meet their social needs.

• Activity provision was poor. People told us they felt bored. We saw some interactions between staff and people that were not respectful or dignified. Other interactions were caring and kind.

• Oversight of the running of the service was inadequate. Quality control had not picked up on some of the issues we found on this inspection and some issues were repeated from our last inspection.

• However, we did see some improvements. Consent documents had been more thoroughly completed, and the service had made efforts to improve care planning.

• Understanding of safeguarding people had improved and recording of falls was more detailed and showed a level of analysis the service could learn from to prevent reoccurrence.

Rating at last inspection:

At our last inspection on 12 and 18 June 2018 we rated the service Inadequate. The report was published on 10 September 2018.

Why we inspected:

This was a scheduled inspection based on the previous rating. When a service is rated Inadequate it is inspected again within six months to see if improvements have been made.

Enforcement:

Enforcement action will be published at the end of this report once the provider has had adequate time according to our enforcement process to respond to our proposals.

Follow up:

The overall rating for this service is Inadequate. This means that it remains in special measures.

The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

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. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

During this inspection in June 2018 we found the provider had not met our recommendation and identified a number of concerns relating to people’s safety, staffing levels, people’s needs not being met, people not always being treated with dignity and respect, and poor leadership.

Cary 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. Cary Lodge is registered to accommodate up to 40 older people, some of whom are living with dementia.

The home is set over three floors with bedrooms on each floor. There is a lounge/dining room on the ground floor and the basement floor. On the basement floor is an area separated from the rest of the building by a keypad which leads to four rooms being used by people on intermediate care packages. These are care provided by the home when people are well enough to leave hospital but not yet well enough to go home. On the first day of our inspection there were 26 people living in the home and on the second day there were 25 (this was due to some changes in people receiving intermediate care and one person passing away).

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

The people who lived in Cary Lodge were not always safe. Although we saw a number of good examples of risks to people being identified and well managed, we also identified a number of instances where risks had not been adequately assessed or mitigated. People were not adequately protected from others who posed risks relating to their behaviours. People had experienced being victims of assaults and inappropriate behaviours from others due to staff not being able to properly monitor or support people.

There were not enough staff to meet people’s needs or keep them safe from harm. Staff were unable to properly monitor people or give people the time they needed to distract and otherwise occupy them. For example, on the day of our inspection one person had walked into another person’s bedroom and had been physically assaulted.

Along with staffing numbers not being sufficient to protect people from risks, staff did not always have the guidance needed to ensure people were protected. For example, one person who posed a significant risk to people because of their behaviours did not have a risk assessment or care support plan relating to these behaviours. When we spoke with staff we found some were not aware of the risks this person presented or how they should act to ensure people were protected.

People had been placed at risk in relation to medicine management practices. Night staff had not been adequately trained to administer medicines and therefore day staff had been pre-dispensing medicines. This is an unsafe practice and action was taken by the provider to stop this following our inspection.

People did not always have their individual needs met. People’s needs relating to their mental health had not always been identified, planned for or appropriately responded to. There were not enough staff to allow them to spend time meeting people’s needs when they were experiencing distress or anxiety. Therefore people spent very long periods of time in these states.

People’s care plans did not contain detailed information about people’s lives and interests to help staff understand ways to support them positively. People did not have access to adequate stimulation or activities to meet their social needs. Although there were some organised activities which took place at the home, these were not sufficient to engage people and provide stimulation. Creative measures had not been taken to ensure people had access to activities which met their individual preferences or their needs.

Sufficient action was not taken to safeguard people from the actions of others. Incidents were not always reported to the safeguarding authorities as they should be to help protect people from harm. Processes in place were not effective in protecting people from abuse or ensuring incidents were reported and appropriately investigated.

We found a lack of understanding in relation to the Mental Capacity Act 2005 (MCA) and the five statutory principles of the MCA by the registered manager. Blanket decisions and restrictions had been applied to people without consideration of whether individuals might lack the capacity to make the decision. For example, each bedroom had been fitted with a sensor mat by the bed. This had been put in place without understanding that this restricted people’s freedom to move around without being monitored. Whilst for some people this was appropriate, this was not the case for everyone.

People were not always treated with kindness and respect. We saw people were hardly spoken to by staff when being supported to eat and one person was not shown respect for their privacy and dignity when sitting in an exposed position. Although we found staff were individually caring, the culture at the service and the staffing arrangements did not ensure people were treated respectfully as they should be. We found the registered manager did not always demonstrate an understanding or a respect for people’s need for contact and sexual expression as they grew older.

People enjoyed the food on offer at Cary Lodge. However, we found that people had to wait for long periods of time to be served their food. People were supported to sit at the dining tables or had their cutlery placed in front of them at their chairs up to 40 minutes before their meal was served. This caused some people living with dementia undue distress.

The culture at Cary Lodge did not put people first. People’s needs were not being met and staff were task focused. Although the provider told us they had strong values and worked towards ensuring people were at the heart of the service, this was not demonstrated at the time of our inspection.

Improvements were being made to the service at the time of our inspection. People’s care plans were being reviewed, staff were receiving training and there were plans to improve the environment. Cary Lodge was a well maintained home with a well-tended garden and pleasant rooms. Staff spoke about people with respect and admiration for their individual personalities.

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

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to people’s individual needs not being met, people’s rights under the MCA not being protected, people not always being safe from risks, safeguarding incidents not always being identified and reported, staff numbers not being adequate to meet people’s needs, and ineffective quality assurance systems. You can see what action we told the provider to take at the back of the full version of the report.

The service was last inspected in July 2013 when it was compliant with the regulations relevant at that time.

A registered manager was employed at the service. 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.

The environment was generally clean and well maintained. However, when we arrived we noted a strong smell of urine in the main lounge. This area was cleaned during the inspection and the smell was removed. Some aspects of the environment were risk assessed. For example, the garden and people’s bedrooms were risks assessed. However, we noted some specific issues relating to potential trip hazards and fire safety. For example, the first floor fire exit doors were not fitted with safety glass or film and one of the lower glass panels was cracked. Following the inspection we wrote to the Devon and Somerset fire service to ask for their advice about these matters. They are due to visit the service on 7 July 2016. These issues had not been identified through the service’s quality assurance systems. We discussed our concerns with the registered manager and provider who agreed to address the matters as a priority. Following the inspection we contacted the registered manager who told us the matters had been rectified. We also received a letter from the provider confirming their commitment to continually improve the environment.

People had care plans that were person-centred and provided staff with sufficient information to meet their personal care needs. Care plans were reviewed regularly and updated when people’s needs changed. However, care plans lacked details about people’s past lives. This meant staff did not always have the information that would help them provide people with meaningful social interaction.

People’s personal care needs were met in a person centred way, by kind and caring staff that knew them well. Staff ensured people’s privacy and dignity was respected and all personal care was provided in private. People said “[Cary Lodge is a] nice place to be, all staff are very pleasant and helpful” and “Staff are wonderful”.

People were protected from the risks of abuse as staff were confident they would recognise if abuse was occurring, and knew how to raise any concerns. There was a robust recruitment procedure that ensured the risks of employing unsuitable staff were minimised. People’s human rights were upheld because staff displayed a good understanding of the principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards (DoLS). Any decisions taken on behalf of people were made in their best interests.

Risks to people’s health and welfare were assessed. Where necessary, plans were put in place to minimise the identified risks. For example, risks in relation to choking, nutrition, falls, pressure area care and moving and transferring were assessed and plans put in place to minimise the risks.

Staffing levels were sufficient to ensure people’s needs were met in a timely manner. During the inspection we saw people’s needs being attended to in a prompt manner. One visitor told us there were always enough staff on duty when they visited. Following the inspection one relative sent us an email. They wrote that their relative ‘appreciates the sense of security that the staffing levels give her, especially at night time’. However, we received mixed comments from staff about staffing levels. Two staff we spoke with felt there were not enough staff especially at weekends. Two other staff said they felt there were enough staff and one told us they had time to “Give people the care they need”. We discussed staffing levels with the registered manager and provider who said they felt staffing levels were sufficient to meet people’s needs. They also said there was an ‘on call’ system for senior staff at weekends. For example, the previous weekend a senior member of staff had been called to help care for one person who had been taken ill.

People were supported to maintain a healthy balanced diet and good health. When required, GPs and other healthcare professionals were involved with people’s care. People’s medicines were managed safely. Staff ensured people received their medicines as prescribed by their GP.

People were confident that if they raised concerns these would be dealt with by the registered manager. We received many positive comments from relatives who contacted us following the inspection. For example one relative wrote ‘I am very happy to recommend the home to other relatives and I enjoy my visits to the home as I believe it to be well run, very caring and very effective in its care and respect for everyone concerned’. One visitor told us the service had “Made a hard decision (finding a care home for their relative) easier”.

However, we received mixed comments from staff about how well supported they felt. Some staff told us they felt they were not supported by the manager. We discussed the mixed comments with the registered manager and provider. They said they could not understand how staff felt unsupported as they received regular supervision and were able to raise any concerns. The provider said they were surprised about this as staff at Cary Lodge never ‘by-passed’ the manager to talk to them, as they sometimes did in their other services. They agreed to look into this matter. Other staff members told us they felt well supported, could go to the manager about anything at any time. One staff member said ‘The manager and deputy are really helpful’.

There were effective quality assurance systems in place to monitor care and plan on-going improvements. A series of audits were undertaken by the registered manager and deputy manager. Audits included medicines, care plans, infection control and complaints. We saw that where issues had been identified action was taken to rectify the matters. Records were well maintained and stored securely.

We have made recommendations asking the provider to look at providing a more suitable environment and more suitable activities for people living with dementia.

Improvements had been made related to access to fluids, weight monitoring, personal emergency evacuation plans and recording of hygiene needs. The care plan for a person with diabetes was updated on the day of our inspection.

Responsibility for the safe management of medicines had been allocated to the deputy manager to ensure safe practice.

The management team were positive about the response of the team to making improvements. We were told that the changes made had been underpinned by the supervision of staff. The deputy manager said 'I think we've really moved forward. We've raised the standards.' A relative described the care as 'fabulous'. The people we spoke with made positive comments about their care.

On the day of our inspection 34 people were living at the home and receiving care from the service. We, the Care Quality Commission, (CQC) spoke with two people, one relative, the provider (owner), manager and deputy manager. We looked at four care plans.

The home was last inspected by the CQC in July 2012 and improvements were required relating to the standards of staffing and management. We followed up on the improvements required at this inspection. We found that suitable arrangements were in place to ensure staff received appropriate induction, training, supervision and appraisal. There were systems in place to monitor the quality of the service and manage risk. We also inspected three other standards.

One person said 'I'm really very happy. I like the staff. This is home.' Another person said 'I've been quite happy here.' A relative said 'I feel confident they're looking after X. I don't have to worry.' We saw staff interact with people in a manner that specifically met the needs of those with dementia. Staff were positive about the standard of care provided.

People were not reliably protected against the risks of receiving inappropriate or unsafe care by appropriate assessment, planning and delivery of care. People were not protected against the risks associated with the unsafe use and management of medicines as appropriate arrangements were not in place.