Archived: St Andrews Lodge

The home had a registered manager who was also one of the registered providers. 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.

At the last inspection in October 2016 we identified continued breaches of the regulations in three areas and one new breach of regulations. We took enforcement action against the provider. We issued four warning notices in relation to good governance, the safe care and treatment of service users, standards of hygiene at the premises and staffing. We undertook a comprehensive inspection on 21 February 2017 to check whether the required actions had been taken to address the breaches we previously identified. This report covers our findings in relation to these requirements.

The overall rating for St Andrews Lodge 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 providers’ 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.

The registered manager had failed to make and sustain all the improvements needed to address the requirements detailed in the warning notices. Whilst some improvements had been made, there remained continued breaches of the regulations.

Risks to people were not consistently identified and managed to protect people. Staff did not always have clear guidance in how to support people and measures to reduce risks were not always effective. Environmental risks were not consistently assessed and managed. This was identified as a continued breach.

Standards of hygiene had improved and the registered manager had implemented systems to ensure that regular infection control procedures were maintained in most areas of the home. However some areas remained in poor decorative state and hygiene remained an issue in these areas of the home. This was identified as a continued breach.

The registered manager was aware of areas requiring improvement identified at the previous inspection, and that they were required to comply with the regulations by 31 January 2017. However they had not addressed all aspects of the warning notices and therefore breaches of the regulations remained. The continued failure to improve through a lack of effective systems and poor planning demonstrates inadequate management and leadership.

There continued to be a lack of effective systems in place to manage risks, for example a fire risk assessment had not been completed for the home. Policies and procedures had not been updated, this meant that staff did not have the guidance they needed to provide a safe and effective service. Records were not always up to date, complete and accurate. The registered manager had made some improvements and introduced systems and processes to improve standards of care and to provide better oversight. However not all systems were imbedded and improvements were not yet sustained. The continued failure to improve standards means that there remained a breach.

People’s care plans were not well personalised, for example there was little detail about individual’s personal history, their preferences, views, interests and aspirations. This meant that the care plans lacked a sense of the person and were task focussed. Staff had little information to guide them in providing care that was personalised or responsive to the needs of the person. We identified this as a breach.

Failure to maintain adequate standards of hygiene and maintenance in some areas of the home had a negative impact on the dignity of people. There was a significant impact for one person whose needs were not always effectively supported. This was identified as an area of practice that needed to improve.

Staff had received some training and support and people told us they were confident that staff had the skills to support them. One person said, “I’m sure the staff know what they are doing.” However people’s needs were not met consistently because staff did not always have the training and support they needed . This was identified as an area of practice that needed to improve.

People told us they felt safe living at St Andrew’s Lodge, one person said, “I think I am much safer here then living on my own.” People’s medicines were managed safely by staff who had been trained and assessed as competent. Staff understood their responsibilities with regard to protecting people from abuse and knew how to report concerns. There was a safe recruitment process in place to ensure that staff were suitable to work with people.

People told us they enjoyed the food at St Andrews Lodge and that they had enough to eat and drink. One person enjoyed cooking and usually made the main meal for people. One person told us “I like the food its very, very good.”

People were supported to access the health care services they needed and they told us they were supported to make and attend appointments. Staff were working within the principles of the Mental Capacity Act 2005 (MCA) and understood the importance of seeking consent from people before providing support.

People spoke highly of the staff, one person said “The staff are always kind,” another told us, “I can’t think of anything that they could do better.” They told us that staff knew them well and understood their needs. People were supported to retain their independence. One person told us about trips to the local swimming pool, they said, “I think I have grown in confidence and I could go on my own now if I wanted too.” People were encouraged to express their views. One person told us that they had all been consulted about the colour scheme for recent refurbishment in some areas of the home.

People were supported to follow their interests and they told us they enjoyed the activities that were provided at the home. People knew how to complain and said they would feel comfortable to do so. People spoke highly of the staff, one person said of the registered manager, “They are very, very nice and kind. They know me very well. I get all the help I need.” Some management systems were in place to support planning and people were asked for their views on the service and planned developments.

You can see what action we told the provider to take at the back of the full version of the report.

The building was a large detached house arranged over two floors, with a large garden at the back of the property. The home is situated in a residential area of Burgess Hill and local shops and services are within walking distance. The home had a registered manager who was also one of the registered providers. 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.

At the last inspection in December 2015 we identified six breaches of the regulations. The provider sent us an action plan in March 2016 to confirm the actions they would take to address these breaches. At the inspection of October 2016, we checked whether the provider had made the necessary improvements to address these breaches. We found that whilst some improvements had been made, there remained continued breaches in three areas and one new breach of regulations. You can see what action we told the provider to take at the back of the full version of the report.

Risks to people were not always assessed, reviewed and managed and staff did not always have the guidance they needed to keep people safe from avoidable harm. Risks associated with changes in one person’s needs had not been identified or assessed, and there was no plan in place to reduce the risk.

A system and process for managing infection control issues within the home was not established and operating effectively. This meant that people were exposed to risk of infection through poor practice in infection control procedures and unhygienic conditions within some areas of the home.

Some areas of the home were found to be in a poor decorative state. The provider was taking action to make some improvements at the time of the inspection and there were plans to address some of the issues we had identified. However, there were not appropriate standards of hygiene and maintenance in many communal areas of the home.

Staff were not being effectively supported through formal supervision to identify their development needs and ensure they had the skills and knowledge to support the people they were caring for. Staff told us they were able to speak to the registered manager on the telephone when they needed support. One staff member said, “I can discuss any concerns or questions with the manager at any time. If I need support I only have to contact them.”

The registered manager did not have systems and processes in place to monitor and evaluate the quality and safety of the service provided and to drive improvements. This meant that the registered manager did not have effective overview of the quality of the service.

People were not always involved in decisions about developments within the home. For example people told us that they had not been asked about the redecoration of the hallway that was in progress during the inspection. One person said, “I don’t know what the colour scheme will be, I knew it was going to be redecorated though.” Another person said, “We haven’t been asked about the colour, I expect it will be brown or neutral colours.”

People’s care was not always personalised and responsive to their needs. Care plans did not always contain information about people’s preferences. One person told us they missed spending time outdoors. They said “I have had to adapt to being an indoors person now.”

People told us they felt safe living at St Andrews Lodge and that they had developed positive relationships with the staff. One person said, “They are supportive, kind and friendly,” another person told us, “All the staff are nice, but I have one favourite because they make be smile.” Recruitment procedures showed that staff had received the required checks to ensure they were suitable to work with people. Staff and people told us that there were enough staff to look after people safely.

An activities programme had been introduced and people told us they had more to do since the last inspection. They spoke enthusiastically about the activities on offer. One person said, “I swim regularly now and I enjoy it.” People knew how to complain and said that they would feel comfortable to make a complaint if they needed to. People spoke highly of the staff and of the registered manager saying, “They are a nice person,” and “They are very caring.”

People were happy with the food at St Andrews Lodge and said they had enough to eat and drink. Staff were proactive in supporting people to access health care services and people told us staff accompanied them to appointments if needed. One person said, “I have regular appointments and the manager makes sure I don’t miss them.” People received their prescribed medicines safely.

Staff understood their responsibilities with regard to safeguarding people from abuse. They knew people well and were able to tell us about people’s individual needs and preferences. One staff member said, “There’s a good bond, we know each other really well.”

Staff sought consent from people before providing care in line with the Mental Capacity Act 2005 (MCA). People told us that they felt their privacy and dignity was respected by staff. One person said, “They do understand if I need some space or want to be quiet.”

The registered manager said that they were committed to delivering high quality care and would continue to seek sources of advice and support to improve the service.

The building was a large detached house in a residential area, arranged over two floors. The service had a registered manager who was also the owner of 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. One of the registered providers was also the registered manager. The registered manager informed us that she was on planned leave since in September 2015 and had come in to assist with the inspection.

At the last inspection on 3 February 2015 we checked that the provider had made improvements in respect of the safety and suitability of the premises identified from a previous inspection in May 2014. We the inspection they had failed to make the necessary improvements to address the concerns The provider subsequently sent us an improvement plan in March 2015 to confirm the actions they would take to meet the regulations. At this inspection we found the necessary improvements had been made.

Risks to people were not consistently identified and managed, this meant that staff did not always have sufficient guidance to support the people they were caring for. The care record for one person identified that there was an ongoing risk of financial vulnerability however there was no risk assessment to indicate how significant the risk was and no strategies for staff to follow to support the person and reduce the risk.

The requirements of the Mental Capacity Act 2005 (MCA) were not consistently being met.

Consideration was not consistently given to when a capacity assessment should be considered, for example when someone had fluctuating capacity. Staff had not received MCA training and did not have sufficient knowledge. There were no records of capacity assessments or best interest decisions where needed, particularly in regards to taking medication. Some staff were not aware of Deprivation of Liberty Safeguards (DoLS) and the possible impact for their work. There were no people subject to DoLS at the time of our inspection. Consideration of someone’s capacity and assessment where needed, ensures that their human rights are being respected and decisions about their care and lives are made in accordance with the law.

Staff induction, supervision and appraisals were inconsistent and there was no training or development plan. None of the staff had received training in mental health awareness or any training specific to the needs of the individuals they were supporting. Staff records were not available for all members of staff so we were unable to confirm that the provider was following safe recruitment processes for everyone employed to ensure the safety of people.

People spoke well of the staff, saying they were approachable and friendly and that they liked living in the home. One person said, “The manager is always fussing, she wants us all to be happy, they are nice people,” another person said, “I very much like living here, I’ve got all the things I need and my bed is very comfortable.” Although people spoke positively about staff we found that some care practice did not promote choice and involvement in decision making. Some people told us they were not aware that they had a care plan others didn’t know what a care plan was. Care plans had little information that described what was important to the person from their own perspective or how they would like to spend their day and individual preferences were not included. There did not appear to be a clear strategy in place for ensuring that people were supported to make choices. There was little evidence that people were involved in planning their care and people were not consistently consulted with about issues affecting their lives.

Care plans were not personalised or detailed enough to ensure that staff knew how to provide personalised care and were not thorough enough to reflect peoples’ choices or preferences. There was no indication of how the person perceived their mental health needs or what might indicate a decline in their mental health or any triggers associated with this. Lack of detailed daily recording meant that people’s assessed needs could not be accurately reviewed which included maintaining any mental health needs. Although it had been recorded that some care plans had been reviewed we saw no updates to the detail of the plans and information had remained the same therefore we were not assured that this reflected people’s current needs. Records did not show people’s individual preferences or aspirations nor how these would be met. This meant that people were not being supported to follow their interests and staff were not always responsive to peoples’ needs.

People told us that they were having enough to eat and people’s weight was being monitored. People were not effectively involved in making choices about food and they were unaware that they could access the kitchen during the evening. This is an area of practice that needs to improve in order that people’s preferences are taken into account.

People and staff spoke highly of the registered manager saying that she was kind, caring and approachable. However we found that the service was not consistently well–led. The registered manager had reduced her hours significantly since September 2015. The arrangements to cover for the registered manager’s leave failed to provide adequate managerial oversight and there was insufficient day to day management cover to supervise staff and care delivery. Quality assurance systems were not in place to monitor or analyse the quality of service provided and feedback was not obtained consistently.

People were receiving their medicines consistently and safely however, people were not being supported through a risk assessment process to be as independent as possible in managing their own medicines. Staff were aware of safeguarding procedures however, the policy and procedure in the home had not been updated to reflect the most recent guidance in the pan –Sussex procedure.

People we spoke with were positive about the staff, the registered manager and provider. One person told us, “They are all nice people, they do their best for us.” People also said that they felt safe at St Andrews Lodge and one person said, “I very much like living here, I’ve got all the things I need and my bed is very comfortable.”

People were supported to access health care services and received ongoing healthcare support. A health care professional told us that the service was proactive about ensuring people had regular health checks and blood tests and that any health issues were referred in a timely way. People told us that they were supported to access health services when they needed to, one person said, “I don’t go out on my own but if I need to see the doctor someone comes with me.” Staff we spoke with described the people they supported in a kind and compassionate way,“ I like to make them laugh when we are playing games, I think taking their mind off their illness is important, it makes a difference. “

There was a complaints process but the registered manager said they had not received any complaints and there were none recorded. Similarly there had been no incidents or safeguarding alerts raised in the past year and staff told us that there were never any altercations with people living at the service.

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

Our inspection was undertaken by one inspector.

Below is a summary of what we found. The summary is based on our observations during the inspection and speaking with the provider.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

In our last report, we stated that some areas of the house were in need of redecoration and refurbishment. For example, the state of the smoking room which was dirty, smelly and in need of redecoration. The hallway, landing and stairs were in a state of disrepair. Whilst the smoking room had been redecorated, we found that the hall, landing and stairs was in a worse state of repair than at our previous inspection. The compliance action set at our last inspection has still not been met and we have asked the provider to tell us how they plan to improve.

Our inspections on 15 October 2013 and 22 May 2014 found that the provider was not compliant with record-keeping as records were out of date, incomplete and not fit for purpose. Following our 22 May 2014 inspection we issued a Warning Notice to the provider and required them to achieve compliance by 1 July 2014.

An inspection manager carried out this inspection. We considered all the evidence we had gathered under the outcome we inspected. We also looked at the provider's Statement of Purpose, policies and procedures. We spoke with the registered manager and reviewed the care records of all five people who lived at St Andrews Lodge. We did not speak to people or their representatives at this inspection as their feedback did not relate to the outcome we were reviewing.

At this inspection we found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. As such we found that the provider was now compliant with this area and had complied with the Warning Notice.

Our inspection was undertaken by one inspector. We considered our inspection findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with two people using the service, two staff supporting them and from looking at records.

If you want to see the evidence supporting our summary, please read the full report.

Is the service safe?

People's care plans were regularly reviewed, however, the risk assessments did not always fully assess people's risks or how these could be mitigated. We saw there were gaps in the daily records, for example, daily entries had not been recorded for two people since February 2014 which meant that the monitoring of their needs was not updated. Care staff we spoke with told us that the manager would tell them of any changes that were needed to people's care. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

People were able to leave the premises when they wished, for example, to go into town shopping, but staff told us that they needed to let them know if they were going out to ensure their safety.

In our last report, some areas of the house had not been cleaned efficiently. At this inspection, we saw that some improvements had been made and that cleaning was being undertaken, although there were no audits in place to corroborate how often this was being done. We saw there were some areas of the house that were in need of refurbishment, for example, there were holes in the stair carpet which were a potential trip hazard. There was a downstairs room dedicated to smoking which was dirty and fume filled. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We saw documents relating to the recruitment of staff and saw that all appropriate checks had been undertaken and that staff had received training.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We were told that no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Is the service effective?

People who lived at St Andrew's Lodge were supported by staff who understood their needs. One person had been encouraged to participate in the community and told us how they were involved in voluntary work. We saw that people were encouraged to be as independent as possible.

One person told us that they were, 'Quite happy ' I'm sure it's [the location] in capable hands'.

Is the service caring?

We observed that people were looked after by caring staff who understood their mental health needs and how to support them. One person told us that they liked the home and were, 'Happy with everything'. The manager told us that, 'I look after them like I would expect my own mother to be looked after'.

We were told by the manager that people could have access to advocacy support if they wished. Advocacy is a process that provides support to enable people to express their views and concerns and to make their own decisions.

Is the service responsive?

The majority of people who lived at the service were happy to participate in the local community. However, others preferred to stay at home. We saw that people could choose what they wanted to do and were supported to do so. We saw that activities were offered and the manager told us that, 'Activities are what service users want'. For example, some people liked to play dominoes or watch films.

Residents' or 'house' meetings were held at least quarterly and anything could be discussed. For example, we saw records which showed that menu choices had been discussed and that people could choose what they wanted to eat.

People received regular input from health professionals as needed such as the services of a podiatrist on a regular basis.

Is the service well led?

The staff we spoke with were clear about their role and responsibilities and had received appropriate training.

We saw that satisfaction surveys had been completed by people and their relatives. One person told us, 'Everyone is asked if everything is ok'.

People we spoke with said they were happy with the care, treatment and support they received. One person said of staff 'they would go out of their way to help me.' We saw that other health professionals were involved in the care of people where this was appropriate.

Since the last inspection improvements had been made with regard to the safeguarding of people and protecting them from abuse. Staff had received training, up to date policies and procedures were available and further learning and development was planned. People who lived there said they would 'tell the manager if they weren't happy with anything.'

We saw that people who lived at the home were not protected from the spread of infection due to the level of general cleanliness. We have asked the provider to make some improvements in their practices and procedures to ensure the home is clean and people are protected.

We saw that there was a safe system in place for the receipt, storage, administration and disposal of medication for the people who live there.

People told us they liked the staff describing them as 'kind', 'very nice' and 'good at spending time with me.' We have asked the provider to make some improvements to the procedures for recruiting staff to ensure all information to assess their fitness to work is reviewed.

We found that the views of the people who live there, their representatives and other professionals were sought. We saw that a visiting professional had said 'the home is run in a way that maximises independence and is entirely flexible and responsive to the needs of the residents.'

We have asked the provider to make some improvements to their records in relation to peoples' care and safety.

We found that people's care and treatment was planned and reviewed with them by appropriate healthcare professionals to support their health, safety and wellbeing. People told us they felt safe and comfortable in the home and satisfied with the care and support they received.

We have asked the provider to make some improvements to their policy, procedures and training on safeguarding and preventing abuse, to meet the required standard and ensure people are adequately protected.

People told us that the staffing levels were sufficient to meet their needs. A person told us "staff are respectful and kind and I would talk to staff if I were unhappy".

We found that people, their representatives and other professionals were asked their views on the quality of the service and their responses were complimentary. We saw that a person's relative had said "this is genuinely a home for the people who live here".

We have asked the provider to make some improvements to their records in relation to people's care and safety.