Archived: St Mary's Lodge Residential Care Home for the Elderly

At our last inspection in September 2016 we found three breaches of regulations in relation to safe care and treatment, meeting nutritional needs and good governance. Because of the level of risk to people’s safety, we gave the service a rating of ‘inadequate’ for the question, ‘Is the service safe?’ We imposed conditions on the provider’s registration that meant they were not permitted to admit people to the home until the condition had been lifted. The provider was also required to submit evidence to us showing they had made the necessary improvements, which we received.

The purpose of this inspection was to check the improvements the provider said they would make in meeting legal requirements. In addition, our processes indicate that we should carry out a further comprehensive inspection within six months after a service is rated ‘inadequate’ in any key question. We found that the provider had made all the necessary improvements to address the concerns we identified at our last inspection in relation to the three breaches of regulations and so had met the requirements of the conditions we imposed. As a result of improvements made by the provider we have initiated procedures to remove the aforementioned imposed conditions on the provider’s registration.

St Mary’s Lodge is a care home providing personal care for up to 40 people, some of whom may be living with dementia. When we carried out this inspection there were 26 people using the service. 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, we found the service was not safe because hazardous chemicals were not stored securely, windows were not appropriately restricted, showers ran at dangerously hot temperatures, some risk assessments were missing or incomplete and unsafe materials were kept in a part of the garden where people could access them unsupervised. At this inspection we found the provider had made improvements to the safety of the environment and to people’s individual risk assessments. They had put systems in place to ensure hazardous chemicals were locked away securely when not in use and that hot water used for washing or bathing was maintained at safe temperatures. Upper floor windows we checked were appropriately restricted and the environment, including the garden, was free from hazardous materials and debris. People had access to alarms if they needed urgent assistance.

People had individual risk assessments and management plans, which were updated regularly or according to their needs. However, some details were still missing from some people’s assessments and the provider had not fully considered risks posed by the use of a collapsible ramp for staff to move loaded food and drink trolleys up and down a step. The provider assured us that they would address these issues.

At our last inspection we found people did not always have the support they required to eat and drink. Staff did not always make appropriate referrals in a timely manner when people were at risk of malnutrition. At this inspection, we found the provider had made improvements meaning people had access to the equipment and staff support they needed to eat and drink. Staff monitored people’s weight and made timely referrals to healthcare providers if they observed any significant changes or if people required support with any other aspect of their health.

We saw evidence that the registered manager had discussed the previous inspection findings at a staff meeting and used the discussion to ensure all staff were aware of their responsibilities in relation to the provision of safe care and treatment, good record keeping and other areas of concern we identified. This had helped them to make improvements since our last inspection in terms of governance and quality improvement. We found the provider’s audits and checks were now more effective and also more proactive as they had put in place new tools to assess and monitor several aspects of service provision and identify areas for improvement.

We also found at our last inspection that the provider did not always ensure people’s privacy was respected, particularly around the storage of confidential personal information. At this inspection we found this information was securely stored. Staff supported people in ways that respected their privacy and promoted their dignity and independence.

The provider had made improvements to care plans since our last inspection, by removing inaccurate or out of date information and ensuring that care plans were reviewed as regularly as needed. Care plans were based on people’s needs, preferences and their own views about their care and what was important to them.

There were enough staff to care for people safely and the provider had recruitment procedures in place to help ensure only suitable staff were employed. However, their recruitment procedures did not include always obtaining a full work history from new employees. The provider obtained this information during our inspection.

There were systems in place to protect people from abuse and medicines were managed safely.

Staff received appropriate training and support to carry out their roles effectively. The provider sought advice on best practice from appropriate sources and applied the guidance to their work.

Staff obtained people’s consent, where possible, before carrying out care tasks. There were systems in place to ensure that where people did not have the capacity to consent the provider acted in line with legal requirements to make decisions on people’s behalf. This included any decisions to deprive people of their liberty where they were unable to consent to being admitted to the home. We observed staff giving people the information and time they needed to make choices about their care. Staff shared information via care plans about how to support people to make choices, particularly those with more complex communication needs. They involved relatives and others who were important to people when making more complex decisions, such as those around end of life care. The service facilitated peer discussions on this topic for people’s relatives.

People had access to a variety of activities at the home. The service had recently employed an activities coordinator, who was in the process of developing a programme of person-centred activities to suit individual needs and tastes.

The provider continually sought feedback from people, their relatives and staff and used this to improve the quality of the service. The provider also had appropriate procedures in place to deal with complaints.

The care home provides personal care for up to 38 people, some of whom may be living with dementia. At the time of our visit, 33 people were using the service. The home is not fully wheelchair accessible but provides support for people who are independently mobile or who use walking aids. 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 this inspection we found a continuing breach of the regulation which related to safe care and treatment. The provider had not taken sufficient action to improve the safety of the service. Hot water from showers ran at above 44°C, which was above the temperature recommended by the Health and Safety Executive and meant people were at risk of serious injury from scalding. Dangerous chemicals, such as bleach, were not securely locked away and there was a risk of people coming to harm through coming into contact with them. There was a risk of people falling from height through windows, because some windows did not have appropriate restrictors. Some alarm pull cords were placed out of reach so people were not able to call for help in an emergency. There were no assessments or management plans for a number of risks we identified, including hazardous materials kept in the garden and staff carrying trays of hot food and drinks down a narrow communal passage with a step.

In addition, some risk assessments were still not adequate because they were out of date or did not include risks such as those associated with moving and handling and choking on food or drink. Staff told us they took action to reduce risks but these were not included in risk management plans, meaning there was a risk that some staff were not aware of what they needed to do to keep people safe.

We also found a continuing breach of the regulation in relation to good governance. The provider’s quality checks were still failing to identify serious risks to people’s safety and did not find any of the concerns described in this report. Some health and safety checks were not marked as complete, meaning the provider could not be sure that they had been carried out. The provider had not identified when their checks were not sufficiently thorough, such as their water temperature checks failing to find that showers were too hot, despite these issues arising at our two previous inspections. The registered manager was not always aware of their responsibilities around monitoring the quality of the service, meaning they only carried out some important actions when we told them to do so. However, their checks around medicines management and cleanliness were fit for purpose and helped to ensure people’s safety in these areas.

Staff were not always clear about what support people needed to eat, because this was not always in their care plans. We observed two people left without the support they needed for 15 minutes during a meal. Staff did not always take appropriate action when people were losing or gaining significant amounts of weight, where this posed a risk to their health. We found the service was in breach of the regulation in relation to meeting nutritional needs.

Although most people said they felt safe using the service, we found there was no clear procedure in place for people, visitors and staff to report suspected abuse. Staff knew they should report safeguarding concerns to the manager but there was no written information about what to do if staff wanted to escalate their concerns outside of the home.

Staff asked people for their consent before they carried out care tasks or, where people did not have the mental capacity to make decisions for themselves, staff followed the requirements of the Mental Capacity Act (2005). However, we found some misleading or contradictory information in care plans which suggested people did not have the capacity to make decisions when they might have been able to do so.

The provider was meeting their responsibilities under the Deprivation of Liberty Safeguards (DoLS). These safeguards are there to help make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom.

Some aspects of the home environment were not adapted to fully meet the needs of people who used wheelchairs or were living with dementia.

People felt that staff were caring, although they were not always able to spend time talking to people. Staff were aware of the need to protect people’s privacy when they were supporting them with personal care, but people’s personal and confidential information was not always kept securely, meaning that there was a risk that people’s privacy around their personal information could be compromised.

People had care plans with some detailed information about how staff should care for them, but this was often contradictory, incorrect or out of date and some information was missing. There was therefore a risk that people might not receive the care they needed.

There was equipment in place to help people move around the home and use washing facilities safely. The equipment was checked and serviced regularly to make sure it was safe to use. The home was clean and the provider took appropriate precautions to help protect people from the risks of infection through poor hygiene practices. Medicines were stored appropriately, staff recorded administration of medicines and there were regular checks of medicines stocks to help ensure people received their medicines as prescribed. There were enough staff to care for people safely and the provider carried out appropriate checks to help ensure staff they employed were suitable to work with people.

Staff received the support they needed to carry out their roles effectively, including regular supervision and training. People were able to access healthcare professionals when they needed to. Staff knew how to give people the emotional support they needed and had information about people’s preferences about their care and what was important to them. Staff gave people the information they needed to make decisions about their care.

People were able to take part in a range of activities and spend time in the garden if they wanted to. People’s religious needs were met. The provider responded appropriately to concerns and complaints made by people and their relatives. They acknowledged people’s concerns and took action to address them. The provider regularly sought feedback from people, their relatives and staff and used this to make improvements to the service.

During this inspection we found repeated breaches of regulations in relation safe care and treatment of people and governance. We also identified a new breach of the regulation in relation to meeting nutritional needs.

We have taken action against the provider for the breaches of regulations described above. Full information about CQC’s regulatory response to any concerns found during inspections is added to the back of reports after any representations and appeals have been concluded.

We undertook this focused inspection on 22 March 2016. We checked the provider had followed their plan and made the improvements they said they would to meet 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 St Mary's Lodge Residential Care Home for the Elderly on our website at www.cqc.org.uk.

St Mary’s Lodge Residential Care Home for the Elderly provides accommodation for up to 40 older people some of whom were living with dementia. The care home is comprised of three converted properties and is run as one unit. During our inspection there were 35 people using the service.

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 this inspection we found the provider was now meeting the regulation relating to safeguarding people. The registered manager had reported possible incidents of abuse to the local authority safeguarding team for investigation. They had also updated people's care plans and risk assessments in relation to guidance from safeguarding meetings for staff to follow in keeping people safe. However, the registered manager had not notified CQC of allegations of abuse as required by law.

We found a continuing breach in relation to safe care and treatment. This was because the provider was still not adequately assessing some risks relating to the premises, equipment and to individuals specifically and putting suitable management plans in place to reduce the risks. These risks included scalding due to hot water temperatures, environmental assessments and risks to individuals relating to mental health needs, stoma care, pressure ulcers and bed rails.

We identified the provider had improved some aspects of how risks relating to health and safety of the premises and equipment were managed. Frequent checks of the fire system and call bells were carried out and an electrical installation check had also been carried out. The provider had also improved their recording of accidents and incidents to ensure an audit trail. In addition aspects of medicines management found lacking at the last inspection had also been improved, such as putting in place protocols to guide staff on administering 'as required' medicines and monitoring the temperature of the medicine storage area to check the temperature would not damage the medicines. The provider also had systems in place to monitor, respond to and reduce malodours in the home having replaced flooring and implementing a more robust cleaning schedule.

Although there was a range of systems in place to assess, monitor and improve the service these audits had not always been effective because they had not identified the issues we found during our inspection.

We found three breaches of regulations at this inspection. In relation to breaches regarding notifying CQC of allegations of abuse and good governance you can see what action we told the provider to take at the back of the full version of this report. We are taking further action against the provider in relation to safe care and treatment. We shall report on this when we complete our action.

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

We considered our inspection findings to answer five questions we always ask:

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

Is the service safe?

The service was safe. The provider had considered the risks associated with the design and layout of the home. People had access to the garden. Appropriate arrangements had been put in place to protect people from the risks of Legionella infections, a bacteria which accumulates in hot water systems and can be fatal to people. Medicines management was safe and staff recruitment procedures had been improved with all staff files being audited and appropriate references obtained where necessary.

Is the service caring?

The service was caring. The provider had made the necessary improvements to the service so that people were treated with dignity and respect. Consideration was given to people's personal appearance, and the manager had employed a laundry worker since our last inspection to ensure that people were not wearing creased clothes.

Is the service responsive?

The service was responsive. The provider had responded well to remedy the concerns we raised at our last inspection. Consideration was also given to people's social needs, and a programme of regular activities was in place. Staff spent time talking with people and providing a personalised service.

Is the service effective?

The service was effective. Systems had been put in place since our last inspection to monitor people's food and drink intake where necessary. People were regularly supported to drink fluids and were provided with a choice of food and drink. Where people took nutritional supplements these were recorded appropriately to ensure that they were being administered in the right way.

Is the service well-led?

The service was well-led. Since our last inspection the provider had put in place systems to routinely gather the views of people using the service with monthly reviews. Systems had also been put in place to effectively assess and monitor the quality of care and health and safety in the home.

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

We considered our inspection findings to answer five questions we always ask:

' Is the service safe?

' Is the service caring?

' Is the service responsive?

' Is the service effective?

' Is the service well led?

Is the service safe?

We observed the way staff interacted with the people who used the service and saw they treated people with respect and dignity. People we spoke with told us they felt safe living at St Mary's Lodge.

We found the service's safeguarding procedures were robust and staff understood how to safeguard the vulnerable people they supported. The home had proper policies and procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) and the team leader we spoke with understood when an application should be made, and how to submit one.

People told us they felt comfortable living at St Mary's Lodge, but we also found that people may be at risk because of the unsuitable design and layout of the home. Risk relating to how staff can know when people in their bedrooms need assistance had not been fully considered and assessed. People did not have safe access to the garden. We found one fire exit obstructed which meant that people could have been placed at risk in the event of a fire. The home did not have appropriate arrangements in place to protect people from the risks of Legionella infections. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the safety and suitability of the premises.

There were enough suitably competent staff on duty to meet the needs of the people who lived at St Mary's Lodge. However, staff recruitment procedures were not robust as suitable work references were not always obtained. We have asked the provider to tell us what they are going to do to meet the requirements of the law with regards to requirements relating to workers.

People's personal records, and other records relevant to the management of the service were generally accurate and fit for purpose.

Is the service caring?

The feedback we received from people who used the service was positive about the standards of care and support they received at St Mary's Lodge. Comments included, 'It's alright here' and, 'The staff are nice'.

We saw people who used the service were supported by kind, patient and compassionate staff. However, the home did not always provide due care and attention to people's personal appearance, as many people's clothes were creased and un-ironed. We have asked the provider to tell us what they are going to do to meet the requirement of the law with regards to respecting people.

Is the service responsive?

The provider had taken appropriate steps in response to issues identified by the Care Quality Commission (CQC) and London Fire and Emergency Planning Authority (LFEPA) following recent inspections of the home by both these regulatory bodies.

Is the service effective?

People were supported to be able to eat sufficient amounts to meet their needs. The feedback we received from people about the quality and choice of the meals they were offered at St Mary's Lodge was positive. One person told us, 'The food is ok here. No complaints' and another person said, 'I always like the meals'. However, the home did not have effective systems in place to monitor people's food and drink intake where necessary, including prescribed nutritional supplements. We have asked the provider to tell us what they are going to do to meet the requirments of the law in relation to meeting people's nutritional needs.

People were cared for by suitably trained staff, although many staff had not had dementia training for around three years. Some staff were not being supervised at regular intervals.

Is the service well-led?

The provider did not have effective systems in place to routinely gather the views of the people who used the service. Systems were not in place to effectively assess and monitor the quality of the care and health and safety at St Mary's Lodge. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the service is routinely assessed and monitored.

Most people using the service had dementia and were unable to tell us about their care and treatment. One person told us, "They're (staff) fine." Another person told us, "They're no bother." Another person said, "Very nice people." One visitor told us, 'There's always lots of staff.' Another visitor told us, 'I quite often see staff dancing with people.' Another visitor said, "There's not a lot of stimulation for people."

We found that there had been improvements around upholding people's privacy and dignity since our previous inspection. We saw some good examples of care. Although we saw some good examples of care these were outweighed by the inconsistency and poor content of care plans and the lack of activities and stimulation for people using the service.

We found that the manager and senior staff did not understand elements of the pan London guidance on safeguarding which raised concerns that the capability of the service as a whole to recognise, report and respond appropriately to safeguarding incidents. We found that there had been improvements in the administration of medicines since our last visit.

We found that there were sufficient numbers of appropriately trained and experienced staff on duty. We found that structures and responsibilities around record keeping and security were inadequate and required significant improvement.

You can see our judgements on the front page of this report.

The people who lived at the home had dementia and varying abilities to express their views verbally. One person was able to talk with us, they told us, 'its ok here' and the staff are 'polite and helpful'. Others were not able to communicate with us in a meaningful way and so we were reliant on general observations and our SOFI tool to gather information about the care provided.

St Marys Lodge had recently benefitted from redecoration and re-carpeting throughout most of the building. It was clean and free from offensive odour.

We checked the administration of medication and found a number of minor concerns which as whole could impact on the safety of people who use the service. We therefore made a compliance action, which required the provider to take some immediate action to ensure people's safety.

We saw that the staff that were on duty at the time of our inspection had knowledge of individuals needs and were able to respond appropriately. However, we also saw some evidence of poorer practice, particularly with regard to privacy and dignity. We have made a further compliance action in this regard.

We observed staff interacting with the people and in addition to providing direct support they were also engaged with people providing activities and conversation.

The staff we spoke with were aware of the guidelines for supporting people and also policies and procedures including safeguarding and complaints.

There were sufficient staff on duty and a comprehensive programme of induction and training which staff confirmed they had undertaken. The provider had put processes in place for keeping people safe and had appropriate procedures for safeguarding, whistleblowing and complaints

Most of the building had recently been decorated and the kitchen had undergone a major refurbishment, however, the carpet in communal areas was worn and stained and many of the bedroom doors had faulty or inadequate closure mechanisms.