The Care Quality Commission
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Archived: Kent Lodge Residential Home

Overall: Inadequate read more about inspection ratings

434 Woodbridge Road, Ipswich, Suffolk, IP4 4EN (01473) 716146

Provided and run by:
Mrs P Kent

All Inspections

9 & 14 September 2015

During a routine inspection

We carried out this unannounced, comprehensive inspection over two days, on the 9 and 14 September 2015 to check that the provider had made the improvements required following our previous unannounced inspections on the 30 April 2015, 9 March 2015 and the 13 and 17 February 2015.

Following our previous inspections in February, March and April 2015, we asked the provider to take action to make improvements as we found evidence of major concerns at all three inspections in relation to the quality and safety monitoring of the service. There was a continued failure by the provider to ensure that people were protected from the risks associated with improper operation of the premises. This meant that the safety and welfare of people using the service was at risk and the provider was failing to provide a safe service. There was a continued lack of training and supervision support provided for staff. The provider was not meeting the requirements of the law as they did not protect people against the risks of receiving care and treatment that was inappropriate or unsafe.

We formally notified the provider of our escalating and significant concerns following our comprehensive inspection on 13 and 17 February 2015 and ongoing emerging risk and concerns shared with us by stakeholders. We informed the provider that we were in the process of making a decision with regards to their continuing failure to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed a condition on their registration to stop them admitting any further people to their service. We asked the provider to inform us immediately of the urgent actions they would take with immediate effect to protect people and raise standards. We received a response to the urgent action letter on 6 March 2015. This contained a basic action plan but did not address all of the requirements of the urgent action letter. This was further evidence of our lack of confidence in the provider’s ability to understand the issues and independently ensure that the service provided safe and effective care.

We carried out a focused inspection on the 9 March 2015 following further concerns identified by the local safeguarding authority and to check if improvements had been made as described in the provider’s action plan. At this inspection we continued to have major concerns regarding the lack of action taken by the provider to safeguard people. There was a continued lack of leadership of the service as the service continued not to have a manager registered with the Care Quality Commission (CQC) as is required by law.

A further unannounced inspection on the 30 April 2015 found that some improvements had been made following the recruitment of a new manager. However, we continued to have major concerns regarding the lack of action taken by the provider to monitor the quality and safety of the service, provide training and supervision for staff and safeguard people in the safe management of their medicines as prescribed. Whilst action had been taken by the provider to rectify the lack of hot water to people’s bedrooms and install heating to bathrooms, further action was needed to maintain standards of hygiene and improvement of the laundry area.

Visits from environmental health inspectors and a fire officer highlighted a number of areas where action was required by the provider to improve the safety of the environment and protect people from the risk of harm. Although care plans had been produced and people at risk of malnutrition and pressure ulcers had these risks identified with action plans in place to guide staff in the steps they should take to mitigate and reduce risks to people’s health, welfare and safety. Action to support people at risk of inadequate nutrition and hydration was not consistent and this continued to place people at risk.

Following our inspection of Kent Lodge on the 30 April 2015 we asked the provider to send us an action plan which would describe the actions they planned to take to meet legal requirements. The provider sent us their action plan which described the action they would take. However, we found that action as described in the provider’s action plan to support staff with training, action in response to a recent fire inspection and the monitoring of people at risk of malnutrition and acquiring pressure ulcers had not been taken. This was further evidence of our lack of confidence in the provider’s ability to understand the issues and independently ensure that the service provided safe and effective care.

Kent Lodge provides accommodation and personal care support for up to 30 older people who require support including people living with dementia. On the two days of our inspection there were 14 people living at the service.

You can read the reports from our comprehensive inspection carried out 13 and 17 February 2015 and our focused inspections 9 March 2015 and 30 April 2015, by selecting the ‘all reports’ link for ‘Kent Lodge Care Home’ o our website www.cqc.org.uk

At this comprehensive inspection 9 and 14 September 2015 we found improvements with regards to the implementation and review of care plans, medicines management and supervision for staff. However, we continued to have major concerns regarding the lack of action taken by the provider to plan for continuous improvement of the service, provide appropriate training for staff and safeguard people from the risk of abuse. The provider continued not to provide staff with training relevant to their role, effective monitoring of people at risk of pressure ulcers, dehydration and failed to take action to deliver care in such a way as to meet people’s individual needs and to safeguard them from harm. People’s safety had continued to be compromised in a number of areas. This included the continued lack of checks to ensure that staff employed were of good character and safe to work with people who used the service. The provider had continued to frail to identify areas of the service that were unsafe and protect people from the risks associated with improper operation of the premises. This meant that the safety and welfare of people using the service was at risk and the provider failing to provide a safe service.

The provider has failed to register a manager with the Care Quality Commission (CQC) for four years. The current manager had been in post since March 2015. 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 a lack of provider oversight and we found concerns about the ongoing financial stability of the service. We were not assured that the provider had taken all reasonable steps to meet the financial demands of providing a safe and effective service as described in their statement of purpose to the required standards.

The provider did not operate a safe and robust system when recruiting staff. Checks on the suitability of staff including Disclosure and Barring (DBS) checks had not been carried out on all staff.

Although we found some improvement at this inspection with staff provided with opportunities to receive regular supervision and attend team meetings, we found that the provider did not have a systematic approach to determine their training and development needs. Staff continued not to be provided with the training required, relevant to their roles which would provide them with the skills and knowledge to keep people safe. This failure to consider, plan and provide for the range of skills required put people at risk of their health, welfare and safety needs being met and keep them safe at all times.

At our previous inspection 30 April 2015 we found shortfalls in the support of people at risk to enable them to receive adequate nutrition and hydration. We found at this inspection people’s weight was monitored and referrals were made to the GP or dietician as necessary. However, we found that people who had been assessed as at risk of dehydration and acquiring pressure ulcers were not consistently monitored to ensure that their health, welfare and safety needs were met and this placed people at risk.

Where visits from environmental inspectors and a fire officer highlighted a number of areas where action was required by the provider to improve the safety of the environment and protect people from the risk of harm, there was a continued lack of action to mitigate these risks. Fire doors continued to be wedged open. Food and hygiene safe practices continued to be ignored by staff with these designated responsibilities to safeguard people from the risk of harm.

People continued to be at risk as there was a continued failure to ensure that people were protected from the risks associated with improper operation of the premises.

During this inspection we identified a number of breaches of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

30 April 2015

During an inspection looking at part of the service

We carried out this focused inspection on 30 April 2015. This focused inspection was carried out to check that the provider had made the improvements required following our comprehensive inspection on 13 and 17 February 2015 and our unannounced focused inspection on the 9 March 2015.

Following our previous comprehensive inspection in February 2015 and our focused inspection in March 2015, we asked the provider to take action to make improvements as we found evidence of major concerns at both inspections in relation to the quality and safety monitoring of the service. There was a continued failure to ensure that service users were protected from the risks associated with improper operation of the premises. This meant that the safety and welfare of people using the service was at risk and the provider was failing to provide a safe service. There was a continued lack of training and supervision support provided for staff. The provider was not meeting the requirements of the law as they did not protect people against the risks of receiving care or treatment that was inappropriate or unsafe.

We formally notified the provider of our escalating and significant concerns following our comprehensive inspection on 13 and 17 February 2015 and ongoing emerging risk and concerns shared with us by stakeholders. We informed the provider that we were in the process of making a decision with regards to their continuing failure to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the lack of management within the home. We placed a condition on their registration to stop them admitting any further people to their service. We asked the provider to inform us immediately of the urgent actions they would take with immediate effect to protect people and raise standards. We received a response to the urgent action letter on 6 March 2015. This contained a basic action plan but did not address all of the requirements of the urgent action letter. This was further evidence of our lack of confidence in the provider’s ability to understand the issues and independently ensure that the service provided safe and effective care.

We carried out a focused inspection on the 9 March 2015 following further concerns identified by the local safeguarding authority and to check if improvements had been made as described in the provider’s action plan. This inspection was unannounced. At this inspection we continued to have major concerns regarding the lack of action taken by the provider to safeguard people. There was a continued lack of leadership of the service as the service continued not to have a manager registered with the Care Quality Commission (CQC) as is required by law.

The provider continued not to provide staff with guidance in the actions they should take to deliver care in such a ways as to meet people’s individual needs and to safeguard them from harm. People’s safety had continued to be compromised in a number of areas. This included the continued lack for recording and analyses of accidents and incidents as well as a continued lack of guidance for staff in responding to emergency situations. The provider had failed to identify areas of the service that were unsafe and failed to take action to protect people from the risks of harm.

This report only covers our findings in relation to the previous breaches. You can read the reports from our comprehensive inspection carried out 13 and 17 February 2015 and our last focused inspection 9 March 2015, by selecting the ‘all reports’ link for ‘Kent Lodge Care Home’ on our website at www.cqc.org.uk

We carried out this focused inspection on 30 April 2015. This inspection was unannounced.

Kent Lodge provides accommodation and personal care support for up to 30 older people who require support including people living with dementia. On the day of our inspection there were 19 people living at the service.

At this focused inspection we found that improvements had been made with evidence that the service was working its way towards improvement. However, we continued to have major concerns regarding the lack of action taken by the provider to safeguard people in the management of their medicines as prescribed.

The service had employed a new manager since March 2015 who had been employed for just five weeks by the day of our visit and was not registered with the Care Quality Commission (CQC). This service has not had a registered manager for in excess of three years. 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.

All staff and people who used the service were complementary regarding the new manager. The manager’s action plan demonstrated steps taken towards planning for improvement of the service.

However, we found the provider continued to fail to take action to manage people’s medicines safely. There was a continued lack of systems in place which would enable effective monitoring of medicine stocks and audits of administration records. This meant that the provider that not taken steps to identify medicines administration errors and protect people from the risks of not receiving their medicines as prescribed.

Although we found some improvement at this focused inspection, we found the provider did not have a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service and keep them safe at all times.

Whilst action had been taken by the provider to rectify the lack of hot water to people’s bedrooms and install heating to bathrooms, further action was needed to maintain standards of hygiene and improvement of the laundry area.

Recent visits from environmental health inspectors and a fire officer highlighted a number of areas where action was required by the provider to improve the safety of the environment and protect people from the risk of harm.

Care plans had been produced and people at risk of malnutrition and pressure ulcers had these risks identified with action plans in place to guide staff in the steps they should take to mitigate and reduce risks to people’s health, welfare and safety. However, action to support people at risk of inadequate nutrition and hydration was not consistent and this placed people at risk.

9 March 2015

During an inspection looking at part of the service

We carried out this inspection on 9 March 2015. This inspection was in response to concerns raised by the Local authority Safeguarding team and to see if the Provider had made the improvements required following an unannounced comprehensive inspection at this service on 13 and 17 February 2015. At the inspection in February we had found several continued breaches of legal requirements.

Following the inspection in February, we asked the provider to take action to make improvements as we found evidence of major concerns in relation to the monitoring of the quality and safety of the service. There was a failure to ensure that service users were protected from the risks associated with improper operation of the premises. This meant that the safety and welfare of people using the service was at risk and the provider was failing to provide a safe, service. There was a continued lack of training and supervision support provided for staff. The provider was not meeting the requirements of the law as they did not protect people against the risks of receiving care or treatment that was inappropriate or unsafe.

We formally notified the provider of our escalating and significant concerns following our comprehensive inspection on 13 and 17 February 2015 and ongoing emerging risk and concerns shared with us by stakeholders. We informed the provider that we were in the process of making a decision with regards to their continuing failure to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the lack of management within the home. We placed a condition on their registration to stop them admitting any further people to their service. We asked the provider to inform us immediately of the urgent actions they would take with immediate effect to protect people and raise standards.

We received a response to the urgent action letter on 6 March 2015. This contained a basic action plan but did not address all of the requirements of the urgent action letter. This was further evidence of our lack of confidence in the provider’s ability to understand the issues and independently ensure that the service provided safe and effective care.

We carried out this inspection on the 9 March 2015 following further concerns identified by the local safeguarding authority and to check if improvements had been made as described in the provider’s action plan. This inspection was unannounced.

This report only covers our findings in relation to the previous breaches. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for ‘Kent Lodge Care Home’ on our website at www.cqc.org.uk

Kent Lodge provides accommodation and personal care support for up to 30 older people who require support including people living with dementia. On the day of our inspection there were 21 people living at the service.

At this inspection we continued to have major concerns regarding the lack of action taken by the provider to safeguard people. There was a continued lack of leadership of the service as the service had continued to not have a manager registered with the Care Quality Commission (CQC) as is required by law. 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. On 6 March 2015 we were informed by Suffolk County Council that the manager was no longer working at the service and that the provider would be taking over full management control at the service until a new manager could be recruited.

The provider continued to not provide staff with guidance in the actions they should take to deliver care in such a way as to meet people’s individual needs and to safeguard them from harm. People’s safety continued to be compromised in a number of areas. This included the continued lack of recording and analyses of accidents and incidents as well as a continued lack of guidance for staff in responding to emergency situations. The provider had failed to identify areas of the service that were unsafe and failed to take action to protect people from the risks of harm.

We were not assured that people’s choices and rights were being respected. Staff had still not received training in the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). The provider did not demonstrate any understanding of their roles and responsibilities in safeguarding people and taking steps to follow the principles of the MCA. They were not fully meeting the requirements of the Deprivation of Liberty Safeguards.

There was insufficient planning to support people’s wishes and preferences regarding how they wanted to be cared for at the end of their life. There was also insufficient planning to promote and support people’s individual leisure interests and hobbies. We were therefore not assured that the planning and delivery of care supported people’s individual needs, wishes and preferences.

The service was not run in the best interests of people using it because their views and experiences were not sought. Improvements were needed in the ways that the service obtained people’s views and used these to improve the service.

Staff did not demonstrate that they had the required knowledge to be able to safeguard people and report any safeguarding concerns to the relevant safeguarding authority.

We found there continued to be a number of continued breaches. You can see what action we told the provider to take at the back of the full version of the report.

13 and 17 February 2015

During a routine inspection

This inspection took place on the 13 and 17 February 2015 and was unannounced.

At the last inspection on 15 May 2014 we asked the provider to take action to make improvements as we found that the provider had failed to assess and manage risks in relation to people’s health, welfare and safety. The provider had not taken action to regularly monitor the quality and safety of the service. There was a lack of training and supervision support provided for staff. We asked the provider to produce an action plan which would describe the action they would take to make improvements. The provider failed to send us any action plan.

We carried out this inspection to check if improvements had been made. We continued to have major concerns regarding the lack of action taken by the provider to safeguard people. Leadership of the service was found to be weak and inconsistent. Support and resources needed to run the service were not always available.

Kent Lodge provides accommodation and personal care support for up to 30 older people who require support including people living with dementia. On the day of our inspection there were 23 people living at the service.

Prior to our inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. They did not return a PIR and we took this into account when we made the judgements in this report.

This service does not have a manager registered with the Care Quality Commission (CQC) as is required by law. The current manager had been in post 12 months and had recently submitted their application to register with CQC. 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.

People’s safety was compromised in a number of areas. This included the management of people’s medicines and the recording and analyses of accidents and incidents.

Staffing levels were insufficient to meet the needs of people who used the service. The provider did not have a system in place to ensure continuous assessment of staffing levels and make changes when people’s needs changed.

The provider did not operate a safe and effective recruitment system. People were put at risk because the provider did not take steps to carry out Disclosure and Barring (DBS), criminal records checks prior to staff starting their employment.

We were not assured that people’s choices and rights were being respected. Staff had not received training in the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS). The provider did not demonstrate any understanding of their roles and responsibilities in safeguarding people and taking steps to follow the principles of the MCA 2005. They were not fully meeting the requirements of the Deprivation of Liberty Safeguards.

People had not always been supported to access, when needed, the support of health care professionals. Staff had not recognised the onset of pressure ulcers and had not supported people to access care and treatment from health care professionals in a timely manner.

The service was not run in the best interests of people using it because their views and experiences were not sought enough. Improvements were needed in the ways that the service obtained people’s views and used these to improve the service.

Staff did not demonstrate that they had the required knowledge to be able to safeguard people and report any safeguarding concerns to the relevant safeguarding authority.

People told us their privacy and dignity was respected and made positive comments about care staff. There was insufficient planning to support people’s wishes and preferences regarding how they wanted to be cared for at the end of their life. There was also insufficient planning to promote and support people’s individual leisure interests and hobbies. We were therefore not assured that the planning and delivery of care supported people’s individual needs, wishes and preferences.

We found there to be a number of continued breaches. You can see what action we told the provider to take at the back of the full version of the report.

16 October 2013

During an inspection looking at part of the service

During our previous inspection of 20 August 2013 we found shortfalls in the way the service supported people who had increased nutritional needs. We completed a follow up inspection on 16 October 2013 to see if improvements had been made.

We found that the provider had made reasonable changes to support people with increased nutritional health needs more effectively. All staff had recently received training on the management of nutritional health.

We reviewed the care records of two people who used the service and also spoke with these people. We found these records were up to date and used correctly and the two people we spoke with confirmed that staff were supporting them to eat and drink sufficient amounts.

The three staff members we spoke with were able to tell us how they would support people with increased nutritional needs.

20 August 2013

During an inspection looking at part of the service

During our inspection of 19 April 2013 we found shortfalls in the care records of people who used the service and the recruitment records kept by the service. We completed a follow up inspection 20 August 2013 to determine whether improvements had been made. We found that the provider had taken action to update people's care records and the recruitment records of the staff employed by the service.

During this follow up inspection we found areas of concern regarding the provider's monitoring and support of people's nutritional needs.

19 April 2013

During a routine inspection

During our visit to the service we spoke with five people who used the service and asked them to tell us how they felt they were being cared for. They told us, 'Very nice.' and, 'Very good." We asked people how they felt the staff treated them. One person said, "Very good." A relative of a person who used the service told us they were, "Very happy with the care. There is a very relaxed atmosphere here." They told us that staff were friendly and kept them up to date with their relative's care needs.

Our observations indicated that staff asked the people who used the service if they wished to participate in activities and receive support to meet their personal needs. We observed that staff gave people choices.

The service had good infection control procedures in place and there had been one complaint in the past 12 months. The service responded appropriately to people's concerns.

We found shortfalls in the provider's record keeping.

18 April 2012

During a routine inspection

We spoke with eight people who used the service. They told us that they were treated with respect and that their views and choices were listened to and acted upon. People also said that they felt that their needs were met. One person said "You will find no problems here." They were provided with enough to eat and drink and that they could choose what they wanted. One person said that they had enjoyed their lunch and they said "The cook here is very good."

People were complimentary about the approach of the staff who supported them and they said that their requests for assistance were responded to promptly. One person said "They (the staff) are all very kind".

People told us that the environment was always clean and tidy and they were comfortable in the communal areas and their bedrooms.

We asked three people if they were provided with their medication at the times that they needed it and they told us that they were.

23 November 2011

During a routine inspection

We spoke with ten people who used the service who told us that the staff always treated them with respect and listened and acted upon what they said. They said that the staff were attentive to their needs and assisted them when they asked for help. One person said that they 'sometimes' had to wait when they had called for assistance using the call bell. All people spoken with were complimentary about the approach of the staff and one person pointed to the staff photographs that were posted in the entrance hall of the home and said 'there is our lovely staff'.

People told us that they were consulted about the care that they were provided with. They told us that they were provided with enough to eat and drink and that the quality of the food was good.

People told us that they could participate in activities if they chose to. Two people told us that they liked to help lay the tables for meals which they said kept them busy. Another person told us that they gave out the daily newspapers when they were delivered to the home.