Archived: Hilsea Lodge

We inspected Hilsea Lodge on 19 June 2018. The inspection was unannounced.

Hilsea Lodge provides accommodation for up to 35 older people living with dementia. Single room accommodation is arranged on one level in four separate units, each unit having its own dining and lounge area. There was an enclosed garden. At the time of inspection 17 people were living in the home.

There was a registered manager in place. 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, in November 2017 we identified widespread and systemic failings and rated the service ‘Inadequate’ overall. We identified eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were breaches of Regulation 12 because the management of medicines was not safe and risks to people were not managed effectively; Regulation 13 because people were not safeguarded against abuse; Regulation 11 because the principles of the Mental Capacity Act 2005 had not been followed; Regulation 17 because there was a lack of effective governance processes; Regulation 18 because staff had not received regular supervision, appraisal or training to effectively undertake their role; Regulation 15 because the premises had not been properly maintained; Regulation 9 because people were not provided with person centred care and Regulation 10 because people’s privacy and dignity was not always protected. We also found a breach of Regulation 18 of the Care Quality Commissions (Registration) Regulations 2009 because the registered persons had not always notified CQC of significant events that happened in the home.

Following the inspection, we placed the service in special measures in order to monitor it closely. The provider was required to send us an action plan telling us what they would do to meet the requirements of the law. They sent this to us and we saw at this inspection improvements had been made although more time was needed to determine if these improvements could be sustained. As a result of the improvement seen, this service has now been removed from special measures.

Measures were put in place to mitigate risks to people, however risks to people were not always assessed or monitored effectively. We made a recommendation that the provider seeks advice on how to assess people’s level of risk in relation to skin integrity and falls appropriately. Measures were put in place on the day of inspection to improve the monitoring of people’s food and fluid intake and the risks associated with constipation.

People were not always provided with information they could understand and we made a recommendation that the provider adheres to the Accessible Information Standard to ensure information was available in a format that people understood.

The management of medicines had improved and was safe.

Environmental risks to people were managed effectively. The home was clean and hygienic and staff followed best practice guidance to control the risk and spread of infection.

There were sufficient numbers of staff deployed to meet people's needs and to keep them safe. The provider had effective recruitment procedures in place and carried out checks when they employed staff to help ensure people were safe. Training for staff had improved, however staff needed time to embed the knowledge that they had learnt. Staff were well supported through induction and supervision systems.

Systems had been put in place to protect people from harm and abuse, accidents and incidents had been investigated, analysed and monitored and lessons learned from these had been shared with staff. Staff knew how to report concerns about people’s safety and well-being and felt these would be acted on by the registered manager.

Care plans contained sufficient information to guide staff on how to support people, however some areas of the care plans could be more person centred. People were cared for by people that knew them well and responded to their needs.

Adaptations had been made to some areas of the home to make it supportive of people living with dementia and further work was planned to continue this.

The service complied with the requirements of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLs), and people were encouraged to make choices about their day to day life.

Staff treated people with dignity and respect, people’s privacy was protected and people were supported to be as independent as possible. People were cared for with kindness and compassion. We observed positive interactions between people and staff throughout the inspection, with one isolated exception.

There were a wide variety of stimulating activities planned within the home. People looked engaged, relaxed and happy and were supported by staff that knew them well.

People’s dietary needs were met and they received appropriate support to eat and drink. People were supported to access other healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care.

People were aware of how to raise a complaint and we saw that complaints had been investigated and resolved. Feedback was encouraged from people, staff and other health professionals and this was used to improve the service.

Quality assurance systems and processes had improved, however, we identified that quality assurance systems needed further development and time to become fully embedded in practice.

The registered manager and the senior team were visible and approachable and staff told us that the support that was provided to them had improved. Staff were organised and felt engaged in the way the service was run. They demonstrated commitment to the service and the people living within it.

The service had an open and transparent culture. People were consulted about the way the service was run. Visitors were welcomed and the registered manager notified CQC of all significant events.

The inspection was unannounced and took place on 15 and 21 November 2017. There was a registered manager in place. 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, on 30 June and 4 July 2016, we identified a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Areas in the home were of disrepair which could affect people’s safety. There were also areas of malodour. The provider had taken the required action in relation to the concerns raised during that inspection. However, we found other concerns which led to a continuing breach of this Regulation. There were also breaches of Regulation 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The quality assurance system had not been robust and staff had not received appropriate training or supervision. At this inspection we found continued breaches of Regulation 17 and Regulation 18, together with other concerns.

Risks to people were not always managed effectively. Clear plans and records were not in place for people at risk of pressure injuries, falls and behaviour that challenges. Accidents, incidents and falls were not analysed to prevent further accidents from happening.

People’s care plans were not always up to date and did not always reflect people’s current needs. Staff relied heavily on the information they were given at handover. This meant we could not be assured people were receiving care in line with their needs and preferences.

Some risks associated with the management of medicines and people’s care and treatment had not been identified because effective checks were not undertaken.

The quality assurance system in place was ineffective. Audits to assess the quality of service provision were not completed regularly and were ineffective in identifying improvements needed. Action plans were not developed to ensure improvements were made. Feedback from people was sought to improve the service but was not always responded to. Records showed concerns raised by staff were also not addressed

Allegations of abuse were not always reported to the relevant authorities or investigated by management.

Risks posed by the environment were not managed appropriately and some fire safety checks had not been completed. There was a lack of fire evacuation training which meant staff would not know what actions to take in the event of an emergency.

A shortage of domestic staff meant that the set daily cleaning schedules could not always be completed. Records of weekly and monthly cleaning were not complete and we could not be assured these cleaning tasks were always undertaken. There were areas of malodour in the home and some areas were not clean.

There were not enough staff to ensure people’s safety or provide personalised care. The provider was unable to provide the rationale for the current staffing levels and the service often relied on agency staff. Supervisions and appraisals were not taking place regularly which meant staff were not always appropriately supported in their role.

Not all staff had completed training in line with the provider’s policy and staff did not receive an appropriate induction into their role. Staff were not always knowledgeable about pressure area care, mental capacity or medicine storage requirements. The provider had no effective systems to monitor when refresher or further training was expected.

People were not supported to have maximum choice and control of their lives because the policies and systems in the service did not support this practice. Whilst staff sought verbal consent from people, before providing support, they did not always follow legislation designed to protect people’s rights when making decisions on their behalf. Care plans did not have mental capacity assessments in place.

Staff had not always notified CQC of significant events that occurred in the home. Neither had they followed legislation that required them to act in an open and transparent way when people came to harm.

People were supported to access other healthcare services when needed. They enjoyed the meals provided, however people did not have their food and fluid intake adequately monitored and a lack of nutritional care plans and assessments put people at risk of malnutrition and dehydration.

People were complimentary about the staff. Most interactions we observed between staff and people were positive although, on occasions, staff did not treat people with consideration and their dignity and privacy were not always protected. Staff encouraged people to remain as independent as possible.

Some beneficial activities were provided to people, however we noted more were needed to ensure the wellbeing of people.

Due to the concerns we found we made referrals to the local authority and the fire service. We told the provider to take immediate action. Following the inspection we received an action plan from the provider detailing how they would address the immediate risks to people.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. 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.

We found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

There was a registered manager in place, but they were off site managing another of the providers’ homes at the time of inspection. In their absence, the home was being managed by a unit manager who had been in post since April 2016, and had applied to become the new 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.

There was a lack of audit systems in place to assess, monitor and improve the quality and safety of the service provided. Staff had not all received regular supervision or annual appraisals. Staff meetings were ad hoc and not inclusive, with some staff not being invited to attend.

Medications at the home were ordered, stored and recorded safely. However, staff administering medication had not all completed their annual medication update training.

The general decoration appeared tired and dated, with some areas of disrepair inside the building and in the garden area which could affect people’s safety. However, the environment was clean and tidy.

Staff had a good understanding of how to keep people safe from abuse and avoidable harm. Staffing levels were sufficient to support people safely. Safe recruitment processes were in place to ensure that only suitable workers were employed to work within the home.

Not all staff had received the appropriate training and supervision to maintain their skills and knowledge. Staff were aware of the importance of gaining consent from people when providing care and support. There was a good understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and applications were completed well.

People were supported to eat and drink in order to maintain their health and wellbeing. Where people had specific dietary requirements the kitchen staff met their needs. There were varied food choices available. People were able to access support from external healthcare professionals, including the GP, community nursing teams and chiropodists.

People living at the home and their relatives described caring and supportive interactions with staff. People felt able to contribute to decisions about their care and that their views were listened to. Staff were encouraging and respected people’s privacy and dignity. Care plans were personalised and contained enough information to enable staff to support people well. However, information was not always consistent.

The home had a warm, homely atmosphere where people and staff appeared happy and supported by the unit manager.

We found three 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 end of the full version of this report.

On the day of our inspection there were only 33 people using the service. During our inspection of Hilsea Lodge we were unable to speak with people using the service because they were unable to communicate verbally with us in a meaningful way. We spoke to three relatives of people who used the service, five members of staff and three assistant managers. The manager who was applying to become the registered manager was not present on the day of the inspection.

Two inspectors carried out this inspection. The focus of the inspection was to check the service was compliant with the Warning Notice that had been served regarding consent to care and treatment and to follow up on previous non-compliance with care and welfare and assessing and monitoring the quality of service provision. The provider sent us an action plan and told us they would be compliant by 15 June 2014.

We also wanted to answer five key questions; is the service safe, effective, caring, responsive and well led? Below is a summary of what we found. The summary describes what people using the service, their relatives and staff told us, what we observed and the records we looked at.

Is the service safe?

Relatives told us they felt their relatives were safe living at the home. One person told us 'They are well looked after.'

People were protected against risks associated with their medicines and people's medicines were safely and appropriately managed by the home.

The home had a policy and procedure in place in relation to the Mental Capacity Act. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. At the time of our inspection applications were being submitted to review whether the arrangements for people's care and treatment in the home amount to a deprivation of their liberty.

There were effective recruitment and selection processes in place and appropriate checks were undertaken before staff began work. Relatives we spoke to felt staff were skilled an experienced to care for their relative. One relative told us, 'Well run, good service, staff are good.'

Is the service effective?

Relatives told us they were happy with the care and support their relatives received. People's needs were assessed and updated regularly. Care plans were personalised and reflected people's individual needs and preferences. It was clear from what we saw and from speaking with staff they understood people's care, support and communication needs and they knew them well.

People's relatives told us they were involved in developing the care plan with their relatives. One relative told us, 'My relative is involved in any decisions but as a family we feel involved.'

Is the service caring?

Relatives told us staff were kind and caring. One relative told us, 'Yes staff are kind and caring. No complaints about staff.' Another relative said, 'My relative gets on well with the carers, they always communicate and say hello as they walk by.'

We observed on many occasions, care staff and assistant managers speak to people and relatives in a kind and caring manner. We saw a number of relatives come to the home to visit their families and staff and managers supporting people when required.

Is the service responsive?

The service had improved their quality assurance processes and we saw a new resident's survey had been put in place and sent out to people who used the service so that people and their relatives were able to give their views on the service. We saw actions had been highlighted with timescales for completion where issues had been raised in the surveys

The manager had changed their medicines audit process following our last inspection. The medicines audits were completed by assistant managers on a monthly basis to ensure any discrepancies were highlighted and actioned.

Those people who needed a 'mental capacity assessment' or best interest decision' had these made by the right people. Most staff had been trained on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Is the service well led?

There was a manager in post who was not the registered manager. The manager is applying to become the registered manager. The manager was not present on the day of the inspection but had left clear guidance for the assistant managers to manage the service in their absence.

We observed these management arrangements provided leadership and there was an open culture. Staff told us they felt supported and could raise any concerns with the registered manager.

The provider was required to submit a plan detailing the action they were taking to ensure compliance with both of these standards and the date at which they would be compliant. We received this on 16 December 2013. The provider told us they would be compliant with these standards by 31 December 2013.

At this inspection we found that the provider had taken the sufficient action to ensure that people's views and experiences were mostly taken into account in the way the service was provided and delivered in relation to their care.

One person who used the service gave us positive comments. They said, 'I get up when I want to. We are quite free here to do what we want'.

We found that there was a lack of understanding with regards to the use of best interest decisions for people who were not able to make informed decisions about their care and treatment.

We found that people's needs were assessed but care and treatment was not always planned and delivered that ensured people's safety and welfare.

At our previous inspection we found that the provider did not have effective systems in place to monitor and assess the quality of the service they provided. We saw at this inspection that the the provider had a system to seek the views of people using the service. However, some of the analysis of the surveys was not correct which was reflected in the report and subsequent action plan.

There was a lack of an effective audit system to assess and manage risks to the health, safety and welfare of people using the service.

Throughout our observations during our visit, there was very limited engagement between staff and people using the service in conversation or activity.

People who used the service told us that they had no concerns about how their personal care needs were met. They told us that staff were helpful and that the home was nice.

People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

We spoke with three members of staff. They told us that there were sufficient staff on duty at any one time to support people who lived at the home. We also spoke with one relative of a person living at the home. They told us they did not have any concerns about the numbers of staff on duty.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.