Archived: Garlinge Lodge Residential Home

Garlinge Lodge Residential Home is a small residential care home providing personal care to eight older people. The service can support up to 14 people.

People’s experience of using this service and what we found

Relatives we spoke with felt staff knew people well and understood their care and support needs. People appeared happy and content. They smiled and interacted well with staff and each other. People had formed friendships and saw the service as their home.

Risks to people’s health and welfare had not been assessed. People were at risk or harm because the provider had not adequately maintained the building to ensure it was fit for purpose. The fire alarm system, emergency lights, the lift, electrical equipment and gas equipment had not been serviced and monitored. The lift was faulty which increased the risks to people and staff. People were at risk of developing Legionnaires disease because the systems and processes in place to reduce the risks were not suitable.

Systems in place to check the quality of the service were not robust. The provider had not identified the concerns we raised in relation to risk management, the environment, mental capacity assessments, dignity and respect and providing care and treatment to meet people’s needs and preferences.

Not all accidents and incidents were recorded. Processes and systems to analyse incidents and accidents for trends or lessons learned had not been developed.

People liked the staff. Staff knew people well and treated them with kindness, dignity and respect. The provider had not always treated people with dignity and respect as they had failed to improve the service.

People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; however, the policies and systems in the service did not always support this practice. Mental capacity assessments were inconsistent and did not always follow the Mental Capacity Act 2005. Assessments made were not decision specific.

Although care plans were in place to describe the care and support people needed, they did not always include some important information individual to the person and failed to provide guidance to staff on how to meet their emotional needs. Activities offered to people were minimal; activities took place for one hour four days a week.

There were not enough staff deployed on shift at all times to ensure people’s care needs were met.

Staff had not always received appropriate training, induction and supervision. No new staff had been recruited since our last inspection.

Infection control practice within the service required improvement. We made a recommendation about this.

Medicines were stored, managed and administered safely. PRN (as and when required medicines) protocols were not in place to detail how people communicated pain, why they needed the medicine and what the maximum dosages were. This is an area for improvement.

Assessments were in people’s care records for various areas such as medicine, dependency, and nutrition. However, the provider was unable to tell us how assessments had translated to the care provided. This was an area for improvement.

People were not always given information in a way they could understand. We made a recommendation about this. People told us that they did not feel confident to raise concerns. A complaints policy was in place which was displayed in the service. The policy was not displayed at a height where it would be visible, and it was not in an accessible format.

Staff and the registered manager understood their responsibility to protect people from abuse. Staff spoken with could explain how any suspected abuse would be reported.

People received access to healthcare professionals.

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 at a comprehensive inspection which was carried out on 20 November 2018 (published 31 January 2019). The service received a focused, shorter, inspection on 20 February 2019 (published 19 March 2019) which showed there had been an improvement to the Safe domain but the overall rating remained as requires improvement.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. They told us they would make the improvements by 21 May 2019.

At this inspection we found improvements had not been made, the service had deteriorated and the provider was still in breach of multiple regulations. This service has not reached a rating of good for the last five consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about people’s safety because of the staffing levels at the service and training provided to staff. A decision was made for us to inspect and examine those risks.

We found evidence that the provider needs to make improvements to the whole service. You can see what action we have asked the provider to take at the end of this full report. The overall rating for the service has deteriorated to Inadequate. This is based on the findings at this inspection.

Enforcement

At this inspection we have identified seven breaches in relation to; person centred care, dignity and respect, need for consent, safe care and treatment, premises and equipment, good governance and staffing.

Please see the action we have told the provider to take at the end of this report. 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.

Follow up

We planned to meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We also planned to work with the local authority to monitor progress and return to visit as per our re-inspection programme. However, the provider has closed the service and applied to cancel their registration.

Special Measures:

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 and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. 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.

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.

For more details, please read the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

• The home was safe but it was not well managed as there was not good oversight of the quality and safety of the home.

• Following the last inspection, we issued three warning notices. These were in relation to risks in the premises, staffing levels and governance systems failing to identify shortfalls in the quality and safety of the service. We met with and asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe and well-led to at least good.

• The provider had made improvements and had become compliant with two of the warning notices around risks in the premises and staffing levels. They now met the characteristics of Good in the key question of safe.

• Some improvements had been made in relation to the warning notice around good governance. Care records had improved and risks to people were understood and mitigated. However, further improvements were needed to ensure good oversight of the quality and safety of the home. A system needs to be established to analyse trends and promote learning from incidents, audits and feedback received to support continuous improvements.

• Sustainability of the home was not ensured as the leadership was heavily reliant on the registered manager consistently working long hours and there was no emergency plan in place should they become absent for any reason.

• The home had not become fully compliant with the warning notice around good governance in the key question of well-led. There continued to be a breach of regulations with this and therefore the home remains as Requires Improvement in well-led and overall.

• Systems were in place to protect people from abuse and avoidable harm, risks to people were mitigated, medicines were managed safely and there were enough suitable staff deployed to keep people safe and meet their needs.

• There was a relaxed and caring culture in the home. All feedback from people, relatives, visitors and staff was positive. The registered manager was a visible presence in the home and knew people well.

• More information is in the full report.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (report published on 31 January 2019). This service has been rated Requires Improvement at this and the last three inspections.

Why we inspected: This was a focused inspection to check their progress and if they had now met the regulations.

Follow up: We have asked the provider to complete an action plan and to provide us with regular updates. We will follow-up on the improvements needed in well-led and all key questions at our next inspection.

Garlinge Lodge is a privately owned residential care home for older people and people who are living with dementia or physical health needs. The service is registered to accommodate up to 14 people in one adapted building. The care is provided over three floors and people with the highest levels of dependency were on the ground floor. People had access to a toilet on each floor and a bathroom on the ground and upper floors. There was a dining room, lounge and conservatory on the ground floor with a lift for people to access from all floors.

People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Over the course of the inspection 13 people were provided with accommodation and personal care.

There was a registered manager in post. 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 our last inspection on 21 September 2017, the service was rated ‘Requires Improvement’ overall and in all the key areas. There were eight breaches of the Health and Social Care Act (2008) (Regulated Activities) Regulations 2014. The provider had failed to ensure that people had personalised care plans that addressed all their individual needs; people’s rights to privacy and dignity were not always upheld; the principles of the Mental Capacity Act 2005 (MCA) were not consistently followed when seeking consent from people to care and treatment; risks within the premises had not been assessed and managed to ensure people’s and staff safety; medicines were not always managed safely; premises were not properly maintained and suitable for the needs of people living with dementia; there were not always effective systems in place to monitor and improve the quality and safety of the service and there were not enough staff to ensure staff could work in a safe way when caring for people.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve all the key questions to at least good. At this inspection although there had been some improvements, there were three continued breaches of regulations and one new breach of regulations. This is the third consecutive time therefore that the service has been rated as Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

Since the previous inspection the registered manager had ensured staff no longer routinely worked long hours and had made some changes to improve staffing levels. However, there continued to be insufficient staff to ensure people’s needs were met and they were kept safe, as people were at higher risk of falls when staffing levels dropped. People and relatives thought they were kept safe. One person said, “I felt anxious living alone, I am happy here…I feel safe, I have had no falls…there is always someone about.”

Action had been taken around the concerns we raised at our last inspection for risk management within the premises. However, there were further instances where people were not kept safe from environmental risks, to include cleaning chemicals not stored safely and no risk assessments for portable electric radiators. Other environmental risks such as fire, legionella and food hygiene had been managed and all the expected health and safety certificates were in place. Some refurbishment had been completed to improve the environment for people with dementia although further improvements were needed.

Assessments were person centred and included the needs of people. However, people’s needs were not always assessed in detail before moving into the home. Risk assessments had not always been completed in a timely manner and were not in place for all risks identified. These were missing for people around their risk history of epilepsy and urine infections.

There had been some improvements to the providers systems to manage quality and safety. However, the registered manager did not always have good oversight of the quality and safety of the home. Risks were not always clearly understood and managed and accurate records were not always maintained. Care records were disorganised and not always legible. Some records were not always complete or kept up to date and some records held conflicting information. Internal audits were completed to check compliance, however continuous learning was not always evident. There were missed learning opportunities from accidents and incidents analysis. Falls analysis had not identified trends and patterns and audits had failed to identify the concerns we found. Relatives and staff thought the home was well led. One relative said, “They are very on the ball, it’s reassuring. I think (name) is really good as a manager.”

Medicines were now managed safely and people continued to be safeguarded from the risk of abuse. Safe recruitment processes were carried out by the provider. People were protected from the risk of infection and were cared for in a clean environment.

The provider was now working within the principles of the Mental Capacity Act 2005 (MCA) and where needed, people had a DoLS authorised or they had been applied for. People’s needs were met by the homes facilities and people had specialised equipment, for example around their mobility.

Staff were knowledgeable about people’s needs, had the right induction, training and on-going support to do their job. People were supported to eat and drink enough to maintain a balanced diet. One person said, “The cook comes and asks me what I want and gives me a choice, I have water in my room, no complaints…I’m having chicken today and something lemon for pudding which is up my street.” People were supported to access the healthcare they needed. The provider worked with other health professionals to ensure people received the care they needed and that they were supported with various health conditions.

Peoples’ rights to privacy and dignity were now respected by staff. People’s independence was promoted by staff and appropriate systems were in place which ensured information held about people was secure.

The general atmosphere in the home was caring. We observed caring interactions between staff and people enjoyed affection being shown, such as their hand being held. Staff and the registered manager knew people well and interacted with them politely and with respect. People’s bedrooms were personalised and relatives could visit people whenever they wanted and were made to feel welcome. People were involved in their day to day care and developing their care plans where they wished to. Relatives were involved in people’s care reviews. People and relatives told us staff were caring. One relative said; “It’s a miracle, before (name) was so confused and anxious. (They) would call me a lot and not know why. But (name) is so much better.”

People’s needs were met around their communication and they were supported to take part in activities they liked within the home. Care plans included people’s wishes around their end of life care where known.

There had not been any complaints. The complaints procedure was available and people and relatives told us they could complain and would be listened to. One person said, “No complaints whatsoever, the biggest tick you can find.” The registered manager actively sought feedback from people and their relatives and surveys had been completed. The registered manager engaged with people and relatives. Good communication and staff involvement was promoted and staff felt supported by the registered manager and knew their roles. The staff team worked in partnership with other agencies and engaged with their local community.

This inspection was carried out on 21 September 2017 and was unannounced. The inspection team included two inspectors.

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 our last inspection in August 2016 we found that the registered provider was not meeting the regulation relating to the provision of person centred care. This was because they were not ensuring that people had opportunities to engage in social activities that met their needs. At this inspection we found that some improvements had been made and people had access to a weekly programme of activities. However, there were further areas of shortfall in relation to person centred care. People’s needs had been assessed before they first moved to the service, but they did not have a care plan that addressed all their assessed needs. People’s care plans lacked the detail necessary to ensure staff could provide personalised care, particularly in relation to dementia and to supporting people to continue with hobbies. People were not given regular opportunities to go out of the home and engage with their local community.

At this inspection we found that seven other regulations were also being breached.

There were insufficient numbers of staff to ensure that staff could work in a safe way when caring for people. Some staff routinely worked very long hours, which placed the people they cared for at risk.

Risks within the premises had not been assessed and managed. This included ensuring that fire evacuation procedures were correct and practiced. Areas of the home had not been properly maintained. The registered provider had not sought advice on appropriate environments for people living with dementia when planning the decoration of the premises.

People’s medicines were not always managed safely. Staff left medicines unattended which left people living with dementia at risk.

The principles of the Mental Capacity Act 2005 (MCA) had not consistently been followed when obtaining consent from people to care and treatment. This meant that people’s right to make their own decisions had not been promoted and care had been provided without people’s consent.

Staff did not always ensure that people’s right to privacy and dignity were upheld.

The service was not always well led. Systems for monitoring the quality and safety of the service were not always effective in ensuring that shortfalls were identified and improvements made. The registered manager did not monitor patterns of accidents in the home, such as falls, to identify where risks could be reduced. The registered manager had not sought and used resources and best practice guidance to continually improve care at the service.

People’s care records were not completed with sufficient detail to show that they had received the care they needed and to allow the registered manager to review that care.

The risk of infection spreading in the service had been minimised and the premises were kept clean, but we found that two commodes had not been properly cleaned on the underside. We made a recommendation about this.

A person using the service told us during the inspection that it was their birthday. The staff and registered manager were not aware of this, but arranged a cake once we alerted them. We made a recommendation about celebrating key dates.

People were encouraged to do some things for themselves, for example in their mobility and in eating and drinking. However care plans could be improved to ensure that staff considered ways to encourage people to retain and develop their independence in all areas of their lives. We made a recommendation about this.

People were safeguarded from the risk of abuse. Staff understood safeguarding procedures and how to report concerns. The registered provider had a policy for equality and diversity which ensured that people were not discriminated against. Risks to individuals’ safety, such as the risk of malnutrition, falls and skin pressure wounds, had been assessed and managed.

The registered provider had ensured robust procedures for the recruitment of new staff.

Applications had been made appropriately for people to deprive them of their liberty under DoLS where this was deemed necessary for their safety.

Staff were provided with the training they needed to meet people's needs. They had opportunities to undertake relevant health and social qualifications. Staff felt supported in their roles and they told us the culture of the service was open enabling them to raise concerns about poor practice if they needed to.

People had care plans in place to meet their health needs and they had access to health and social care professionals. People had enough to eat and drink to meet their needs and told us they enjoyed the meals.

Staff knew people well and had positive relationships with them. Staff knew what was important to individuals and used this information when talking with them. They knew how to communicate with each person individually. People were involved in their day to day care and in the reviews of their care plans when they were able to and when they wished to be.

People could be confident that best practice would be maintained for their end of life care.

Staff were responsive to people’s needs and requests throughout the inspection. People did not have to wait long for staff to attend when they asked for assistance or used their call bell.

People had an opportunity to give their feedback about the quality of the service through reviews of their care plans and an annual quality survey. The registered manager was present in the home on most days and spent time with people. People we spoke with, and their relatives, were aware of how to make a complaint and they felt their views were listened to. The registered manager knew people well and understood their needs.

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

There was a manager in post who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

Staff knew how to raise an alert if they had any concerns about people’s safety. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm. Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

There was a sufficient number of staff deployed to meet people’s needs. Thorough recruitment procedures were in place which included the checking of references.

Medicines were stored, administered and recorded safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

Staff knew each person well and understood how to meet their individual needs. Staff communicated effectively with people and treated them with kindness and respect. They had received all essential training and attended regular one to one supervision sessions.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options had been considered. Staff sought and obtained people’s consent before they helped them.

A system was in place to assess people’s mental capacity when necessary and hold meetings to decide particular decisions in their best interest, as per the requirements of the Mental Capacity Act 2005.

Staff provided meals that were in sufficient quantity and met people’s needs and choices. People told us they enjoyed the food that was provided. Staff knew about and provided for people’s dietary preferences and restrictions.

People’s individual assessments and care plans were reviewed monthly or when their needs changed. Information about the service, the facilities, and how to complain was provided to people and visitors. People and relatives’ feedback was sought during satisfaction surveys.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred routines. Staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People were not involved in the planning of activities that responded to their individual needs. The provider had not ensured that a suitable amount of activities and outings were provided to stimulate people’s interests and meet their social needs. We have requested the provider to take action.

Staff told us they appreciated the registered manager’s style of leadership. The registered manager was open and transparent in their approach.

The registered manager placed emphasis on continuous improvement of the service and carried out monitoring checks and audits to identify any improvements that needed to be made. However the provider had not identified a shortfall in regard to the provision of activities, a lack of outings to combat isolation and a lack of measures to maintain links with the community. We have made a recommendation about this and will check that action has been taken at our next inspection.

At this inspection we found that the provider had addressed all these gaps. This included separating the sluice sink and laundry facilities, carrying out a water and legionella risk assessment, and making changes to cleaning processes in the home. Maintenance issues had been addressed, which included removing uneven flooring, and cleaning rusty and dirty bath hoist seats.

We had concerns about how infection control was managed in the service.

There were adequate process for the safe handling and administration of medication.

The environment was maintained, but there were areas that needed to be addressed as they presented risks to people using the service.

The people we spoke with were positive about the staff. One person told us the 'staff are fine, even the new ones' and another that the 'staff are very good' and 'they respond quickly'. Staff received training, supervision and appraisal to give them the skills to care for people effectively.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. People told us 'I can always ask staff for help and they will take their time' and 'I get help when I need it. I feel very comfortable and looked after'.

We saw that people were relaxed with staff, who listened to their views and concerns. People told us that they would speak with staff if they had a problem or were worried about anything.

At the time of our visit there were enough qualified, skilled and experienced staff to meet people's needs. One person told us 'I have a buzzer in my room and if I use it, I don't have to wait very long for staff to come'. One person told us 'I have no complaints at all. I can talk to the staff and they are very nice'.