Archived: Cleveland Lodge

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for on Cleveland Lodge our website at www.cqc.org.uk”

We undertook an unannounced focused inspection of Cleveland Lodge on 29 November 2017. We inspected the service against three of the five questions we ask about services: is the service well led, is the service safe and is the service effective. This is because the service was not meeting some legal requirements.

Cleveland Lodge is a care home which provides accommodation and personal care for up to 18 older people who are living with dementia. At the time of our inspection 13 people were living at Cleveland Lodge.

The service had 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.

Medicine administration systems were not safe. Procedures were not in place for medicines to be taken "when required" (PRN). Medicine Administration Records (MAR) showed people were receiving PRN medicines. We also found missing signatures on peoples MAR’s and not all staff who administered medicines were competent to do so. An audit completed by the provider had identified shortfalls, but sufficient action was not taken to address these issues.

The service was not consistently meeting the requirements of the Mental Capacity Act 2005 (MCA). The service was liaising with Wiltshire Quality Assurance team and had received advice on the implementation of the MCA.

We found lessons were not always learnt and the registered manager had no action plan in place on how they were making improvements to the service and monitoring the outcome of accidents and safeguarding incidents.

Where people were losing weight or was at risk of dehydration, food and fluid intake was monitored and consumption was recorded daily. However, we found the monitoring forms had no information about the target the person should reach each day and the actual total of their food and fluid intake. This meant staff would not be able to identify if there were any concerns about a person’s food and fluid intake.

We found where people had been losing weight, options such as a fortified diet had not been considered.

Where people had specific dietary requirements, for example coeliac disease, there were clear instructions regarding the need for a gluten free diet both within the care plan and a record kept in the kitchen.

The registered manager worked alongside staff, which gave them an insight into staff practice. However, that left no time for the registered manager to manage the service. The registered manager told us “residents” had to come first.

Staffing levels had improved and staff were more visible and available to people. A new senior carer was due to start soon and the registered manager told us they would be able to step back and spend more time managing the service.

The registered manager observed staff performance; however staff had not received formal supervisions or appraisal. Staff felt supported by the registered manager. Staff told us they had received the necessary training to complete their role. However, they felt they could benefit from further training about the management of behaviours that could be seen as challenging.

People who were able to tell us, said they felt safe living at Cleveland Lodge.

Staff told us they knew the processes they needed to follow should they suspect abuse had taken place. Staff said they would report abuse if they were concerned and were confident the registered manager would act on their concerns.

The building was easily accessible for people living with dementia. There were coloured walls, pictorial signage on bathroom and toilet areas and clearly named room doors to help people find their way around independently.

People, relatives, staff and visiting professionals spoke positively about the registered manager. The registered manager and owner told us they were continuously looking at improving the service. New ideas from staff were encouraged.

We found two repeated breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. The Notice of decision, imposing conditions on the provider's registration remains and they continue to send us monthly updates. 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.

This inspection took place on 1 February 2017 and was unannounced. We returned on 10 February 2017 to complete the inspection.

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 comprehensive inspection in November 2014 we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. This was because people were not protected against the risks associated with the unsafe use and management of medicines because of inaccurate records of medicines held in the service. In response to that inspection we issued a requirement notice. The provider developed an action plan to address the shortfalls, which they submitted to us following the inspection.

At this inspection we found the provider had taken action to address the issues highlighted in the action plan. However, we still found some unsafe medicines management due to lack of recording. For example people's photographs were attached to their MAR sheets to aid identification, however we found medicine allergies and people’s date of birth were not always recorded.

There were sufficient staff to meet people’s basic care needs. However staff were not always deployed in a way that kept people safe. People had limited opportunities to take part in activities or hobbies and interests of their choice. There was lack of social interaction. People didn’t have opportunities to go out into the community, which meant people were at risk of social isolation. Relatives told us they had been concerned about the staffing levels for some time.

The service did not always follow the requirements of the Mental Capacity Act when people lacked the capacity to give consent to care and treatment. We found that where people were not able to consent to living at Cleveland Lodge associated mental capacity assessments to consent to care and treatment at Cleveland Lodge, were not completed.

Staff did not receive sufficient appraisal and supervision to support them to carry out their work, as effectively as possible.

People were supported to have sufficient food and drink and to maintain a balanced diet. However we observed and relatives commented that there was a lack of variety in food.

We found there weren’t any systems in place to monitor people’s experience of care. There was also no evidence to show people’s involvement in their care reviews.

People received care and support from staff who had got to know them well. The relationships between staff and people receiving support demonstrated dignity and respect at all times.

Relatives spoke very highly of the care their family member was receiving. Comments from relatives included “You get excellent treatment here. You can’t improve on excellence”, “Couldn’t fault the carers”, “Carers had got to know [person]. They [person] trust the carers now. They [carers] are really good with [person]” and “The carers go beyond what is needed. Nothing is too hard”.

Staff told us they knew the processes they needed to follow should they suspect abuse had taken place. Staff told us they received training in the safeguarding of vulnerable adults and training records confirmed this.

Risks to people's safety had been assessed and plans were in place to minimise these risks. This included risks in relation to falls, malnutrition and developing pressure ulceration.

Staff told us they had the training and skills they needed to meet the needs of the people they were supporting. New staff were supported to complete an induction programme when they started working at the home and were able to shadow more experienced members of staff before working independently.

People were supported to maintain good health and had access to healthcare and other services to meet their needs.

The provider had some quality monitoring systems in place. Accidents and incidents were investigated and discussed with staff to minimise the risks or reoccurrence. The management operated an on call system to enable staff to seek advice in an emergency.

Staff told us they felt supported and the registered manager was accessible to talk to. The registered manager covered shifts at times, including night shifts. The registered manager told us this gave them an opportunity to observe staff practice, while working alongside them.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 for which we are taking action and will report on this when it is concluded. One of these breaches was repeated from the last inspection as sufficient action had not been taken to address the shortfalls. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A person told us care workers always let them get up when they wanted. We observed a care worker welcoming a person as they walked into a sitting room saying 'hello X, nice to see you'. We saw people always had at least one care worker supporting them in each of the two sitting rooms.

We spoke with a care worker who showed a detailed knowledge of people as individuals. This included how they ensured a person's dignity when they experienced periods of agitation. What the care worker told us was documented in the person's care plan.

People had clear, detailed individual capacity assessments completed. These documented how the home supported the person in their best interests where they did not have capacity. People's records showed they were supported by a next of kin, who advocated for them in planning care.

We saw staff supported people appropriately, including moving and handling people in a safe manner and when giving them their medication.

Staff told us they were trained in their roles. One care worker said 'they're pretty thorough with the mandatory training' and another 'there's loads of courses here.'

We saw full records were maintained, including staff training records, medication records and maintenance records.

People told us there were limited activities in the home. One person said 'I've never seen anything happening.' During our observation we saw staff were not routinely available to support people during the mornings. This meant people who showed complex behaviours associated with their dementia were not appropriately supported to ensure their dignity was maintained.

People's privacy and dignity were maintained. At 6:30am, there were two people up and dressed. People were able to get up in the morning at a time that suited them, One of person told us they had got up about 6 o'clock all their life and did not want to change now. People were cared for by staff who knew and understood how to manage people's agitation associated with their dementia. We did not observe any aggression between people or between people and staff while we were in the home.

Staff confirmed they had been trained in safeguarding people. All of the staff we spoke with understood their responsibilities for reporting any concerns about safeguarding people.

Management had reviewed staffing levels, using a range of different methods and there were sufficient staff on duty to meet people's needs.

The provider maintained certain records. However some information about people and the quality of care provided was not documented to enable the provider to ensure people received the care they needed.