Archived: Tosh Lodge

Tosh Lodge is a service which provides accommodation and personal care for up to five people who are living with mental health conditions. There was one person living at the service when we inspected. who was also living with long term health conditions such as epilepsy.

This service is not required to have a registered manager in post. The provider had registered with the Care Quality Commission to manage the service and is therefore a 'registered person'. 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.

Tosh Lodge was last inspected in April 2017 when the service was rated inadequate in the safe, effective, caring and well-led domains and requires improvement in responsive. The service was placed into special measures. We found breaches of regulation relating to protecting people from abuse, management of risks to people and the environment, a lack of person centred care, care plans lacking detail and a lack of understanding about people’s capacity to make decisions. Other breaches related to issues with staff recruitment and training, a lack of oversight of the service and not informing the Care Quality Commission of notifiable incidents.

At this inspection there were continued breaches of regulation and little progress had been made to improve the care and support people received. People continued to be at risk of harm due to a failure to treat people with dignity and respect. Although some staff treated people kindly, people were not always protected from abuse and were spoken to in a derogatory way. Plans to manage risks to people did not give enough detail and placed restrictions on people. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

When people became unwell they were not supported to access health care treatment promptly resulting in people being in pain for periods of time with no access to pain relief. Staff did not have guidance about how to support people with long term health conditions. People were not supported to be independent and there was a culture of doing for people, rather than with them. People’s care plans contained contradictory information and lacked detail about how people liked to be supported and what they could do for themselves. People had limited access to activities and records showed they had long periods of time with no meaningful activity.

Staff were completing some checks relating to the environmental risks. However, water temperatures were not being checked regularly and were found to still be too high. Checks to the fire systems were completed and personal emergency evacuation plans were in place. People were supported by staff who had been recruited safely and who had received additional training. However, there was a lack or training and understanding about how to support people when they were distressed or agitated and staff had not attended fire safety training which was highlighted at the last inspection as a shortfall. Although there were enough staff on the day of the inspection the service did not employ enough staff to meet people’s needs in the event of illness or annual leave.

People told us they enjoyed their food, but that they had limited choice in what they could have to eat. People were not involved in preparing their meals. People’s medicines were managed safely by trained staff. The provider told us they had received no complaints since the last inspection. People had been asked to given feedback on their support via a questionnaire which they were supported to complete by staff. The provider told us no notifiable incidents had occurred since the last inspection. The provider had not completed regular audits to identify areas for improvement. There was continued evidence of restrictive practices and the provider was not always knowledgeable about the guidance they should follow or their responsibilities as a registered person. The provider had not displayed the services rating as required by regulation.

We found a number of continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of the report.

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.

Tosh Lodge is registered to provide personal care and accommodation for up to five people with mental health conditions. There were five people using the service during our inspection; who were living with a range of mental health needs. As well as needing support with their mental health, some people required more care and support related to their physical health.

Tosh Lodge is a large house situated in a residential area of Ashford. There was a communal lounge available with comfortable seating and a TV for people to watch. There was also a kitchen with a dining table and chairs and utility room. The service had a small, secluded garden at the rear. People’s bedrooms were on the first floor, along with shared bathroom and toilet facilities.

This service is not required to have a registered manager in post. The provider had registered with the Care Quality Commission to manage the service and is therefore a ‘registered person’. 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.

Tosh Lodge was last inspected in March 2016, when it was rated as good. At this inspection we found that risks to people had not been properly addressed or minimised in a number of areas. These included risks to people’s health, safety and well-being from a lack of staff knowledge, environmental hazards such as fire and risks associated with medicines. Prior to the inspection we received information from the local safeguarding authority that some people living in the service had raised concerns with them about their experiences of the support provided.

Systems designed to protect people from abuse and harm had not been effectively operated. Recruitment processes were not sufficiently robust to make sure that only suitable staff were employed to work with people.

There were insufficient skilled or trained staff available to meet people’s needs. Staff had received most mandatory training but had not been trained about mental health conditions, epilepsy or diabetes. Supervision by the provider had not picked up on shortfalls in staff knowledge.

Care plan information was not clear about how people gave their consent; taking into account some people’s communication difficulties.

People’s health was generally monitored and they had access to regular appointments with health care professionals. Support for one person had not been sought when their condition changed.

People gave us mixed feedback about food provided in the service. Menus had been improved recently but still required greater input to improve variety and choice.

Staff interaction was not always very engaging but people said they felt supported by staff; who were polite and respectful during the inspection. People’s independence was not consistently promoted and they were unnecessarily restricted in some areas.

Care planning was not person-centred and did not reflect people’s individual personalities and preferences. People could join in with organised activities or pursue their own interests.

The provider said they had received no complaints However, the local safeguarding authority made us aware that before and after our inspection, some people living in the service had told them they were not completely happy with the way it was run and did not always feel able to speak out about their concerns.

There was inadequate oversight by the provider to identify and remedy the issues we found during this inspection. As a result we found a number of breaches of Regulation relating to people’s health, safety and well-being. There was evidence to indicate that a restrictive culture was in place in some areas and that the provider was not always knowledgeable about their responsibilities as a registered person.

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.

Tosh Lodge is registered to provide personal care and accommodation for up to five people with mental health conditions. There were five people using the service during our inspection; who were living with a range of mental health needs. People were largely independent and required only support and prompting in their day to day lives.

Tosh Lodge is a detached house situated in a residential area of Ashford. There was a large lounge available with comfortable seating and a TV for people. There was also a well-fitted kitchen with a table at which people could sit to eat. There was an attractive, enclosed garden to the rear of the building.

This service is not required to have a registered manager in post. The provider has registered with the Care Quality Commission to manage the service and is therefore a ‘registered person’. 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.

People told us that they felt safe living in the service. The service was secure and the environment was safe for people. Staff knew how to safeguard people from abuse and to report any concerns to the appropriate authorities. Fire alarms had been tested regularly and there were individual plans to evacuate people if necessary.

There were enough staff to meet people’s needs and training and supervision happened regularly to ensure staff were competent and confident to do their jobs. Recruitment practices were robust and ensured that proper checks were carried out before applicants were employed.

Assessments had been made of any risks to people and actions to minimise these had been followed through in practice. Accident and incidents had been recorded properly and used as a learning opportunity. Medicines had been managed safely and people had received their medicines as prescribed to them.

People had access to a varied diet of healthy foods and the opportunity to enjoy fast food occasionally. The right to make choices had been respected and people were involved in their own care and support decisions. Physical and mental health needs had been addressed and people had regular appointments with health professionals.

Staff were kind and respectful to people and there was a comfortable atmosphere in the service. A wide range of activities were on offer and the provider and staff knew people and their preferences well. Complaints had been managed effectively by the provider and people and relatives had been invited to give their feedback about the service.

There were effective auditing and assurance processes in place to help identify any shortfalls in safety or quality. Staff enjoyed working in the service and felt able to raise any concerns or issues with the provider.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We saw that the premises were clean and well maintained and provided a pleasant environment for people to live in. We looked at safety records as part of our assessment to see how the home was monitored for on-going risks to people's health and safety. We found that there were regular checks for systems such as fire alarms and fire exits; and audits for medication and any changes in people's care needs.

We found that individual risk assessments were in place for people living in the home, and included actions in place to minimise the risks to their health and welfare. For example, some people needed one to one care for their safety when going out into the community.

We found that the provider had comprehensive procedures in place to check that people had consented to the care and treatment provided for them. People were appropriately supported by their family members or advocates, and by health and social care professionals, to help them with decision-making processes. The provider and staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). There were no DoLS authorisations in place, and no applications had been made.

Is the service effective?

We found that care plans had been written according to people's individual needs, and showed the physical health, mental health and social care support that people needed. This meant that people were appropriately supported in regards to their care needs.

We saw that the care plans identified people's individual choices and enabled people to develop their own goals and work towards these with support from the staff.

The home had reliable procedures in place to contact other health and social care professionals to obtain advice and support when people's needs changed. This included people's social workers, and the local community mental health team.

We looked at staff recruitment procedures and found that these were thorough and included all the required checks. Staff were supported through a comprehensive induction process, and through regular supervision and appraisals with the provider.

Is the service caring?

Only one person in the home was willing to talk with us, and for only a few minutes. They said that they liked living in the home, and staff were good to them. We heard staff interacting with people in the home and saw that they knew how to approach people in different ways, according to their mental health difficulties. For example, staff spoke quietly to one person who would be mentally disturbed by loud voices.

People were encouraged to carry out their own interests, and encouraged to mix with others so that they did not become socially isolated. Staff supported people with their daily living needs, and enabled people to go where they wanted to within the limits of their agreed risk assessments.

The provider and staff demonstrated a detailed understanding of people's past histories and their mental health needs. This meant they were able to provide effective and meaningful care for people.

Is the service responsive?

The staff made provision for people to share their views about the home through individual key worker meetings with staff. People's views were also sought using yearly questionnaires, and we saw that action was taken in response to people's comments. This showed that the service sought to obtain people's views and respond to them appropriately.

We saw that the service had leaflets on the home's noticeboard about how to report any concerns of abuse; and a guide for understanding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People living in the home had the phone numbers for their individual social workers and were able to contact them directly if they wished for support with raising any concerns or complaints.

Is the service well-led?

The registered provider was also the manager, and was usually in the home every day or else she was on call. This meant that she took direct responsibility for the day to day running of the home. We saw that she was accessible to the staff and people living in the home, and responded to any requests for support or advice.

The provider had systems in place to ensure there was on-going monitoring of the home. This included care plan reviews, and checks for the environment, health and safety, fire safety, and staff training needs. The provider supported the staff through individual supervision sessions on a regular basis, and by following through with staff on their personal development plans. This showed that there were reliable systems in place to provide oversight for the service, and effective leading by the provider.

People who used the service told us that they were supported with the skills they needed to towards living independently and were involved within the local community. People told us 'I've been into town today and to a day centre.'

Care plans gave staff current guidance about how to support each person with their personal, social and health care needs. People's welfare was promoted by the opportunity for social and recreational activities.

People were protected from the risk of abuse. There was a system in place that supported people with their financial affairs.

There were enough experienced staff to meet people's needs. We saw that people were supported appropriately by staff and in an unrushed manner.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

People who used the service and staff were asked for their views about the service provided and these were acted on.

People told us they received care from a small team of staff and were happy with the care received and had no concerns relating to the home.

All spoken with expressed a great deal of satisfaction from living within the service and did not raise any concerns about the quality of care. All said if they were not happy they would speak to staff or the manager.

Many comments received were complimentary of the service. One person said 'I like living here there are no problems' another said 'I'm quite happy here. Staff treat me well'. Other people were complimentary of the food and had no concerns about the quality of care. Another said 'Staff are very good. They respect us and treat us well'.