Archived: Fallings Park Lodge

Updated 17 June 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 2 March 2015 and was unannounced. The inspection team consisted of an inspector and an expert by experience (ex by ex). The ex by ex had personal experience of caring for someone who experiences dementia.

We looked at the information we held about the service prior to the inspection. We looked at information received from relatives, from the local authority commissioner and the statutory notifications the provider had sent us. A statutory notification is information about important events which the provider is required to send to us by law.

During our inspection we spoke with 14 people who lived at the home and three relatives. We also spoke with the acting manager, three care staff , two senior staff and the cook. We looked at the care records for three people, the medicine management processes and at records maintained by the home about staffing, training, meetings and the monitoring of accidents, falls, complaints and the quality of the service.

Updated 17 June 2015

Fallings Park Lodge is registered to provide accommodation, nursing or personal care for up to 48 people. People using the service have conditions related to old age or dementia.

The Inspection took place on 2 March 2015 and was unannounced. At the time of our inspection 24 people were using the service. The provider told us his plans to reduce the number of registered beds in the home were continuing so that occupancy levels would be reduced from 48 to 30 people.

When we last inspected Fallings Park Lodge in September 2014 the provider was not meeting the regulations inspected. These related to the monitoring of the quality of the service and record keeping. Following that inspection the acting manager sent us an action plan informing us of the action they would take to address the breaches we found. At this inspection we looked to see if these improvements had been made and found that they had been.

The registered manager had left the service in April 2014. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had appointed two acting managers over the period of April 2014 and February 2015. The acting manager told us that they were in the process of applying for registration with us, although no formal application had been received at the time of the inspection.

People we spoke with told us they felt safe in the home and with the staff. Staff we spoke with had received training on how to protect people from abuse and were able to demonstrate the action they would take.

People and staff said there were sufficient numbers of staff available to meet people’s needs. We saw the acting manager used a staffing tool to review the levels of staff needed alongside people’s individual needs to reduce risks to people’s wellbeing.

There were systems in place to ensure all the appropriate checks on new staff’s suitability to work at the home. Staff had received training and support to develop their skills and we saw there were opportunities for them to reflect on their practice. Staff meetings and formal supervision had been utilised to develop staff knowledge and re-enforce good practice.

People received their medicines safely and when they needed them. Arrangements were in place to ensure medicines were stored securely and regularly audited. People had access to healthcare professionals when they needed them.

Staff were receiving training to support them to understand the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). We saw staff were receiving support from the local authority to help them understand and apply the MCA in order to support people’s rights when specific decisions needed to be made. This included ensuring mental capacity assessments were in place so that people’s rights were supported. We saw staff obtained people’s consent before providing them with support by asking for permission and waiting for a response, before assisting them.

People told us they enjoyed the meals provided and the choices available. We saw systems to monitor that people were getting enough to eat and drink were in place. Risks to people’s nutrition were minimised because staff understood the importance of offering meals and involving healthcare professionals when this was required.

People had the support of an activity co-ordinator and told us they regularly enjoyed the activities on offer. Relatives and staff told us because the occupancy level had reduced there was more time to spend time with people and support them in activities.

People who lived at the home, their relatives and staff were encouraged to share their opinions about the quality of the service. The provider’s system for dealing with people’s concerns and complaints needed some improvement to reflect how concerns had been investigated.

People were happy with the improvements in the lounge areas, and staff were happy with the reduced occupancy numbers as this had allowed them to spend more quality time with people. The systems in place to monitor and improve the quality of the service had improved and had been maintained by the acting manager. This had resulted in identifying improvements needed. However the provider had not addressed all of the works identified in the most recent infection control audit carried out by the infection control team.