Archived: Telford Lodge Care Limited

The last comprehensive inspection was in November 2017. The service was rated ‘Requires Improvement’ in the key questions ‘Is the service Safe, Effective, Responsive and Well Led?’ and overall. We found five breaches of regulations relating to person-centred care, safe care and treatment, premises and equipment, good governance and staffing.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the rating of the key questions of ‘Is the service Safe, Effective, Responsive and Well Led?’ to at least good. At this inspection we found the provider had not been able to make sustained and measurable improvements to fully meet the regulations. In addition, we found three additional breaches of regulations

Telford Lodge is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection,43 people were using the service. They were mainly older people and people living with the experience of dementia. This is the only location for Telford Lodge Care Limited which is registered as a charity.

The service did not have a registered manager. 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 registered manager left the service in February 2018 and a member of Telford Lodge’s Committee had made an application to become the registered manager.

During the inspection we found care workers were not deployed effectively to meet the needs of the people using the service to supervise them as they go about their daily lives in the home and to help protect them from harm.

Incident and accident forms were not always completed and risk assessments were not always robust enough to minimise risks to people and others. This meant the provider was not assessing, monitoring and mitigating risks to people to help minimise their exposure to the risk of harm.

We also observed other unsafe practises that could put people at risk including a child regularly visiting the home who might not have had adequate supervision, a person using a wheelchair without the footplates and half full drinks containers that posed a risk of making people ill as it was not possible to ascertain how long they had been left out.

Medicines management was inconsistent and audits did not always identify discrepancies to help ensure people always received their medicines in a safe way.

The environment did not always meet people’s needs and we saw worn furniture in the home, unused equipment sitting on the floor, broken furniture in the garden and CCTV cameras that did not have signs to alert people they were being recorded both visually and with sound. Furthermore, the provider did not follow best practice guidance for dementia friendly environments so that people lived in surroundings suitable to their needs.

Daily fluid charts were not always completed to monitor people’s intake of drinks which meant they could be at risk of dehydration as records were not being maintained. Some weight charts were also incomplete which meant the provider could not effectively monitor people’s weight and nutritional status to identify any risks relating to nutrition so appropriate action could be taken in a timely manner to manage the risks and to meet people’s needs.

Care workers told us they had regular training but the manager did not provide evidence to confirm this. Supervisions and appraisals were not up to date which meant care workers did not always receive the support they required to develop their professional skills and knowledge.

We saw individual acts of kindness from staff, but people were not always treated in a person-centred manner. Mealtimes in particular were task orientated instead of meeting people’s individual needs.

People’s daily files were stored in cabinets in communal areas that were easily accessible and not secure. This indicated a lack of systems to help protect people’s confidentiality and ensure people’s privacy.

Care plans were not always competed in a timely manner or with up to date information. This meant there were risks that people may not have been receiving the care they required.

The home had a number of activities for people to join in, however these were not always meaningful and did not always meet their individual interests and preferences.

The service had systems in place to monitor, manage and improve service delivery and to improve the care and support provided to people. However, these were not always effective. For example, record keeping was not always complete and contemporaneous, and some records were not available during the inspection.

We saw there were procedures for reporting and investigating allegations of abuse and whistle blowing. Staff we spoke with knew how to respond to safeguarding concerns. Safe recruitment procedures were followed to ensure staff were suitable to work with people.

People’s needs had been assessed prior to moving to the service and care plans included people’s likes and dislikes. There were also records of end of life wishes and Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms completed by the GP as appropriate.

The service liaised with other professionals and we saw evidence that people were supported to access healthcare services appropriately.

Care workers did not always have a good understanding of the Mental Capacity Act 2005 but the provider generally followed the principles of the Act.

Relatives were positive about the level of care provided and we saw examples of care workers being kind, patient and reassuring with people using the service.

There was a complaints procedure in place, however the service had not had any complaints since the last inspection.

The manager had submitted an application to CQC to become the registered manager and was attending a number of courses to develop their skills for managing a care home. Feedback from relatives and care workers indicated the manger was approachable and accessible.

We found eight breaches of regulations in relation to person-centred care, safe care and treatment, premises and equipment, good governance, staffing, dignity and respect, safeguarding service uses from abuse and improper treatment and meeting nutritional and hydration needs. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’

On the 13 July 2018 we served a Notice of Proposal to cancel the Registration of the provider Telford Lodge Care Limited so they can no longer provide a care home service at the location Telford Lodge Care Limited. This process has now been completed and Telford Lodge Care Limited has been deregistered and can no longer provide a care home service lawfully.

• Telford Lodge is a residential care home that provides care for up to 45 people, some living with the experience of dementia. The accommodation is provided over two floors divided into six zones. At the time of the inspection 34 people were using the service. This is the only location for Telford Lodge Care Limited which is registered as a charity.

People’s experience of using this service:

• During this inspection we found that incident and accident forms did not always provide effective guidance about what preventive measures to put in place or reflect the cause of the incident. As at the previous inspection, care plans were not always being updated to reflect incidents. Risk management plans were not always robust enough and lacked detail and effective guidance to mitigate risks. They were also reactionary rather than preventative. This meant the provider was not assessing, monitoring and mitigating risks to people to help minimise their exposure to the risk of harm.

• Checks for the environment were not carried out consistently and the home was not dementia friendly with distinctive features to help people with dementia care needs orientate themselves.

• The provider did not ensure medicines were always managed safely, and audits did not always identify discrepancies to help ensure people receive their medicines in a safe way. For example, when people were administered as required medicines regularly there was no evidence that referrals were made to the GP to review these medicines in accordance with the policy.

• We saw evidence of staff training but not of how it was being monitored so staff remained up to date with their training and the provider knew when training was due.

• The provider did not always follow the principles of the Mental Capacity Act 2005 (MCA). Information around people’s mental capacity to give consent was not clear and was sometimes contradictory. Deprivation of Liberty Safeguard (DoLS) applications were not always applied for and followed up in a timely manner.

• People’s pre-admission assessments and changes in their needs were not always reflected in their care plans. Therefore, people may not have been cared for in a way that met all their needs.

• Care plans we viewed did not always identify people’s wishes or provide clear guidance to staff for the delivery of care in a person-centred manner. Key working sessions were used to involve people in planning their care. However, we saw that key working sessions were not being held regularly with all people using the service and therefore not everyone had the opportunity to develop their care plan.

• Activities were not always meaningful and people we spoke with did not always want to take part as the activities on offer were not ones they were interested in.

• The provider had a system to deal with complaints. There had not been any since the last inspection.

• The provider did not have effective systems in place to monitor, manage and improve the quality of the service delivery and to improve the care and support provided to people.

• We saw there were procedures for reporting and investigating allegations of abuse and whistle blowing. Staff we spoke with knew how to respond to safeguarding concerns.

• People's needs had been assessed prior to moving to the service and care plans included people's background and some personal history.

• The service liaised with other professionals and we saw evidence that people were supported to access healthcare services appropriately.

• We found six breaches of regulations in relation to person-centred care, consent to care, safe care and treatment, premises and equipment, good governance and fit and proper persons employed.

Rating at last inspection:

• Previously, at the November 2017 inspection we found five breaches and rated the service requires improvement. At the inspection in May 2018 we found eight breaches. Five of those were also breaches identified in the November 2017 inspection. The service was rated Inadequate and placed into special measures.

• The last comprehensive inspection was 3 and 4 January 2019. We found two previous breaches had been fully met, three remained, and there were three additional breaches of regulations. We rated the service inadequate overall. The report was published on 6 March 2019.

Why we inspected:

• This was a planned inspection based on the previous rating.

Enforcement

• We are taking action against the provider for failing to meet regulations. Full information about CQC's regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

• The overall rating for this service is 'inadequate' and the service is therefore in 'special measures'. This is the third time the service has been rated inadequate.

• 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.

Follow up:

• We will monitor all information received about the service to understand any risks that may arise and to ensure the next planned inspection is scheduled accordingly. If any concerning information is received, we may inspect sooner.

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

Telford Lodge is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection, 36 people were using the service. They were mainly older people and people living with the experience of dementia. This is the only location for Telford Lodge Care Limited which is registered as a charity.

The service did not have a registered manager. 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 last registered manager left the service in February 2018. At the time of the inspection, the provider was advertising for a new registered manager and the nominated individual was fulfilling the manager role.

The provider sent us an action plan indicating how they would meet the breaches of regulations and make improvements. However, the management of the home have not been able to meet their action plan according to the timescale they said they would make improvements in the service. As a result, people using the service continue to experience a sub-standard quality of care and support and were placed at risk of unsafe care and treatment.

During this inspection we found that staff were not being deployed to effectively meet the needs of the people using the service.

Incident forms did not have information about how these were investigated or what the outcome was. Care plans were also not being updated to reflect incidents. Risk management plans were not robust enough and lacked detailed and effective guidance to mitigate risks. They were also reactionary rather than preventative. This meant the provider was not assessing, monitoring and mitigating risks to people to help minimise their exposure to the risk of harm.

The environment was not always well maintained, and checks were not consistent. The home was not dementia friendly with distinctive features to help people with dementia care needs orientate themselves. Signs for CCTV cameras did not make it clear they were recording both visually and with sound so people and visitors were aware of these.

The provider did not ensure medicines were always managed safely, and audits did not always identify discrepancies to help ensure people always received their medicines in a safe way. For example, there was a lack of guidance for staff in care plans relating to high risk medicines.

Safe recruitment practices for new staff to ensure they were suitable to care for people using the service were not always followed. The provider’s audit had not identified this so they could make the necessary improvements.

Supervisions were not held in line with the provider’s policy. We saw evidence of staff training but not of how it was being monitored so staff remained up to date with their training and the provider knew when training was due.

Where people lacked the mental capacity to consent to specific decisions, the provider did not always follow the principles of the Mental Capacity Act 2005 (MCA). Nor did care workers have a good understanding of the MCA.

There was a lack of evidence that records to monitor peoples’ nutrition such as fluid intake and weight charts were not being monitored which meant the provider could not effectively monitor people's weight and nutritional status to identify any risks relating to nutrition so appropriate action could be taken in a timely manner to manage the risks and to meet people's needs.

The provider did not demonstrate they had a robust system to deal with complaints. There were no formal investigation records where there had been complaints and there was a lack of recorded outcomes and learning points.

The provider did not have effective systems in place to monitor, manage and improve service delivery and to improve the care and support provided to people.

We saw there were procedures for reporting and investigating allegations of abuse and whistle blowing. Staff we spoke with knew how to respond to safeguarding concerns.

Relatives were positive about the level of care provided.

People's needs had been assessed prior to moving to the service and care plans included people's background and some personal history.

The service liaised with other professionals and we saw evidence that people were supported to access healthcare services appropriately.

We found eight breaches of regulations in relation to person-centred care, dignity and respect, consent to care, safe care and treatment, premises and equipment, receiving and acting on complaints, good governance and fit and proper persons employed.

We are taking action against the provider for failing to meet regulations. Full information about CQC's regulatory responses to any concerns found during inspections is added to reports after any representations and appeals have been concluded

The overall rating for this service is 'inadequate' and the service is therefore in 'special measures'. This is the second time the service has been rated inadequate.

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.

Telford Lodge is a ‘care home’ for up to 45 people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection, 34 people were using the service.

The service had a registered manager. 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.

During the inspection we received mixed information about staffing levels, and from our observations we concluded that staffing levels were not always adequate to minimise risks to people using the service.

The provider had a number of risk plans in place for people using the service but not everybody had a Personal Emergency Evacuation Plan (PEEP) to provide guidance for reaching a place of safety in an emergency. Additionally, incidents and accidents were recorded but analysis to mitigate the risk of reoccurrence of incidents were not up to date. Therefore it was not clear how improvements were made to the service.

Medicines were not always managed safely and we found a discrepancy in one person’s medicine records. Medicines audits were carried out but these were not always effective as they did not identify the discrepancies.

The provider did not ensure all premises and equipment were suitable for the purpose for which they were being used and properly maintained and there was no overall plan for improving the environment, for example upgrading the communal bathrooms.

Information recorded in people’s care plans was inconsistent and based more on a medical model than a person centred model. Care plans did not always contain information about people’s preferences. They were reviewed but not always monthly as per the provider’s procedures.

There was a lack of effective assessment, monitoring and identified actions to improve the quality of the service to meet the needs of the people using it which meant the service could not ensure a consistent quality of care.

The provider had procedures in place to protect people from abuse. Care workers we spoke with knew how to respond to safeguarding concerns. People had some risk assessments and management plans in place to minimise risks.

Care workers had completed training in infection control and used protective equipment as required.

Care workers had an induction, probation meeting and up to date relevant training to develop the necessary skills to support people using the service. However one to one supervision was not up to date and appraisals had not yet taken place in 2017. Safe recruitment procedures were followed to ensure care workers were suitable to work with people using the service.

People were supported to have maximum choice and control of their lives and care workers were responsive to individual needs and preferences. There were a number of activities available to people.

People's dietary and health needs had been assessed and recorded but monitoring records about peoples’ intake were not consistently updated to make sure they were eating and drinking adequate amounts.

There was a complaints procedure in place and people and relatives told us the registered manager was approachable. Feedback from surveys was positive.

We found five of breaches of regulations. These were in relation to staffing, safe care and treatment, premises and equipment, person centred care and good governance. You can see what action we told the provider to take at the back of the full version of the report.

We undertook this focused inspection on 11 March 2017 to check that the provider had followed their plan and to confirm they now met the legal requirement. This report only covers our findings in relation to the requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Telford Lodge on our website at www.cqc.org.uk.

Telford Lodge provides long term accommodation for up to 44 older people, some of whom are living with dementia. At the time of our inspection there were 26 people living at the service.

The registered manager had been in post since September 2016. 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 focused inspection on 11 March 2017, we found that the provider had not followed all of their action plan, dated 29 March 2016, and therefore the legal requirement had not been fully met.

Some people’s care files contained mental capacity assessments and consent forms but this was not consistent across the files.

The provider had not audited care files to ensure consent from people using the service was sought, and where appropriate, mental capacity assessments had been completed. However, the registered manager took action on the day of the inspection and completed an audit of people’s care files and told us these would be undertaken on a monthly basis.

Not all staff we spoke with understood the principles of the Mental Capacity Act (MCA) 2005 but the registered manager confirmed MCA training had been arranged for April 2017. Additionally, the registered manager and team leaders met on the day of the inspection, in a meeting that had already been scheduled, to discuss the practical aspects of MCA and Deprivation of Liberty Safeguards (DoLS) as they applied to the service.

The registered manager made DoLS applications appropriately and followed these up as required.

The inspection took place on 16 and 17 February 2016 and the first day was unannounced.

The last inspection of the service was the 12 and 14 May 2015 when we found breaches of Regulations relating to supporting staff and good governance. At this inspection we looked at whether these breaches had been met and we found improvements had been made.

There was a 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.

There was not always the evidence that people had been asked to consent to their care and treatment. In some cases decisions had been made by others without evidence that the person had consented or had knowledge of decisions being made about their lives. However, there had been work carried out to ensure people were not being unlawfully deprived of their liberty.

People’s individual care and support needs had been assessed and documented. The provider took action to identify, manage and regularly review possible risks to people using the service.

There were systems in place to keep people safe and support staff followed these.

There were enough staff to meet people’s care needs.

The provider carried out pre-employment checks to make sure new staff were suitable to work in the service.

People received their medicines in a safe way.

People’s health care needs were assessed and monitored and they were supported to stay healthy.

The provider listened to and acted on people’s complaints. People felt able to raise concerns and felt these would be listened to.

There were audits and checks in place to monitor the quality of the service offered to people.

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

During this inspection we saw that the home had introduced daily checks of the Medicine Administration Records (MAR) and stock counts of medicines which were supplied in their original containers. We saw no omissions in recording administration or receipts of medicines into the home. When we audited samples of stocks from 13 MAR we identified three discrepancies which showed that the medicines were not given as prescribed.

There were improvements in obtaining medicines ready for the beginning of the monthly medicines cycle, but when there was not enough medicine to last for the whole month, staff were not taking action to obtain further supplies in a timely manner.

We saw that the acting manager had carried out audits on the medicines management system, but had not recorded what they did to address the areas of concern.

These shortfalls are a continued breach of Regulation 13 (management of medicines) under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

During this inspection we saw there had been some improvements made in medicine management. We saw medicines given to people at lunch time. They were given individually and with patience and encouragement and the Medicines Administration Record (MAR) charts were signed after they were given.

We talked to two people who took their medicines themselves. Both showed us where they kept them safely and explained how they took them and how they signed their own MAR chart afterwards. We saw that risk assessments were in place and that regular reviews were carried out to check compliance.

However, we observed that two people did not have their medicines administered for two days at the beginning of the current medicines cycle. We checked to ensure there was no significant impact of this on the people concerned. Several people were prescribed (PRN) or as required medicines to help their mood often up to three times a day. We saw no detailed individual protocols to aid staff in knowing the circumstances these medicines should be given or when they should be reviewed if they were needed regularly.

In addition, we found there were discrepancies of five of the 18 samples of the medicines that we looked at. Staff were not carrying out regular audits so we did not know whether these discrepancies were recording errors or whether the medicines had not been given, but signed as given. A new manager was due to start working in the home shortly after the inspection to take forward regular audits and competence assessments of staff.

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

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

Is the service safe?

Risk assessments had been completed for each person using the service to identify potential risks such as falls or pressure sores. Staff we spoke with knew how to respond if a person using the service became unwell and we saw evidence they had received training to provide safe care. Accidents and incidents were reported, recorded and responded to appropriately. There were systems in place to respond to emergencies.

Staff were trained, assessed and observed to safely administer medicines. Controlled drugs were not managed and recorded in accordance with regulatory requirements to ensure people were protected against the risks associated with the unsafe management of medicines.

Is the service effective?

People's health and care needs had been assessed with their involvement where possible. People's permission was sought before care was provided and we observed peoples wishes were responded to appropriately. People we spoke with told us they felt safe and supported to be independent and their wishes were respected.

Individualised care plans had been developed and these reflected the level and type of support each person required to be safe and receive care to meet their needs and preferences. People's mental capacity to make informed choices had been assessed and we saw relatives had been involved where possible to ensure their best interests were considered. Staff were properly trained, supervised and appraised. Staff told us they were supported to acquire further skills and qualifications.

Is the service caring?

We observed staff interactions with people using the service were kind and supportive. Staff showed a good understanding of each person's needs and the level of support they required. One person using the service said, ''I love it here; I'm only here for a short stay but would like to stay permanently. They let me go out and buy some steak for my lunch and cooked it for me just how I liked it.'

People had been involved in the planning of their care and supported by their relatives to identify their preferences and what was important to them. Another person we spoke with said, ''I've been here quite a long time and am happy here. If I don't feel well enough I don't have to come down to the dining room and can stay in my room. They make my drinks just as I like them. We are going to play musical bingo this afternoon which is fun.'

Is the service responsive?

There was a system in place to respond to and handle complaints. People were invited to be involved and make decisions about the service. We observed peoples wishes about aspects of their care and daily activities were respected and responded to appropriately.

Is the service well led?

There was no registered manager in post at the time of the inspection and the position has been vacant for over a year. The provider had completed audits of various aspects of the service to ensure the quality of service was maintained and improvements could be identified. There were satisfaction surveys undertaken to obtain feedback about the service and suggestions had been responded to appropriately. People using the service had also been supported by their families to participate in meetings to obtain their opinion of the service.

People we spoke with told us that they were able to make choices in all aspects of their daily lives. We saw that people were treated with consideration and respect. One relative we spoke with said that they were happy with the care and support that their family member received. One person said 'I have been here three years and I am very happy'.

People said that they received good care and support from staff. Arrangements were in place for people to report any concerns that they had. People said they felt safe at the home. A relative we spoke with said 'if I have any concerns I would speak up, I have no reason to think that my family member is not safe

Sufficient staff were on duty to meet the needs of people and the service. Comments we received included 'I never feel lonely, staff are always there for me' and 'I like my care worker'.

Effective systems to assess and monitor the quality of the service were in place, people told us that improvements had been made as a result of their feedback.