Archived: Epsom Lodge

Updated 13 November 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector on the first day of our inspection and two inspectors on the second day.

Service and service type

Epsom Lodge is a ‘care home’. 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.

The service did not have a manager registered with the Care Quality Commission. A manager was in post who had submitted an application to register. A registered manager means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

Both days of this inspection were unannounced.

What we did before the inspection

We reviewed all the information we held about the service, including data about safeguarding and statutory notifications. Statutory notifications are information about important events which the provider is required to send us by law. We sought feedback from the local authority in relation to information they held about the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

As part of our inspection we spoke with four people who lived at the service. We observed the care and support provided to people. We also spoke with four staff members, the manager and the two providers. We reviewed a range of documents about people's care and how the home was managed. We looked at care records for five people, medication administration records, risk assessments, safeguarding records and policies and procedures.

After the inspection

Following both days of the inspection we requested urgent assurances from the provider in relation to infection prevention and control procedures and fire safety procedures. In addition, we informed the fire safety officer of our concerns. We requested a range of information to be forwarded including copies of audits, staffing rotas and policies. We spoke with three relatives regarding their experience of the service provided at Epsom Lodge.

Updated 13 November 2021

About the service

Epsom Lodge is a care home providing accommodation and personal care for up to 13 older people, some of whom may also be living with dementia. There were 12 people living at Epsom Lodge on the first day of our inspection and 11 people on the second day. Accommodation is arranged over three floors of an adapted building with shared bathroom facilities on each floor.

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

There was a lack of management oversight of the service. The provider had failed to implement effective quality assurance and audit systems to ensure people received safe, effective and responsive care. The concerns found during our inspection had not been identified by the provider. People who had moved into Epsom Lodge in the past six months did not have care plans in place and their health care needs were not recorded.

The provider had not ensured robust procedures were in place to keep people safe from the COVID-19 virus. On the first day of our inspection we found staff were unaware of the guidance they should follow. Although improvements were found during our second day of inspection, continued areas of concerns were identified.

Risks to people’s safety were not always identified and acted upon. There was a lack of detailed risk assessments and guidance for staff to follow in relation to people’s individual risks and support needs. Accidents and incidents were not always reviewed to minimise risks and were not always shared with the local authority and CQC as required. We have made a recommendation in relation to the prompt reporting of safeguarding concerns.

Medicines were not always managed safely and staff competence in this area was not consistently assessed. There were not sufficient staff deployed to ensure people’s needs could be met in a responsive manner.

People and relatives told us they felt safe living at Epsom Lodge and that staff were kind and caring in their approach.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 29 May 2019) and a continued breach of regulation in relation to the governance of the service was identified. We completed a further targeted inspection on 14 January 2021 (published 17 February 2021) in relation to infection prevention and control procedures and identified a further breach of regulation. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

The provider completed an action plan following both of these inspections to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The first day of our inspection was prompted in part due to information received from the provider and local authority regarding an outbreak of COVID-19 at the service. Concerns were shared regarding the difficulties in sourcing staff and in relation to people’s safety.

During the first day of our inspection we found there were concerns in relation to how risks to people’s safety and medicines were managed so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risks to people’s safety and well-being, safe medicines processes, infection prevention and control procedures and staff deployment. We identified a lack of management oversight and robust quality assurance systems.

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 will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.