Archived: Chadwick Lodge Residential Home

Updated 31 July 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 26 and 27 May 2015 and 2 June 2015 and was unannounced.

This inspection was undertaken by four inspectors.

Before our inspection we reviewed information that we hold about the service such as safeguarding information and notifications. Notifications are the events happening in the service that the provider is required to tell us about. We used this information to plan what areas we were going to focus on during our inspection.

We also used information gathered from liaising with other stakeholders such as the local authority and the Police. We had been working with these agencies due to the high level of safeguarding concerns being raised about the service.

During the inspection we spoke and interacted with all 11 people using the service during our visits. We spoke with four relatives, two visiting entertainers, a visiting professional, the registered manager, four members of care staff, two agency staff and two volunteers.

Not everyone who used the service was able to communicate verbally with us so we used observations, spoke with staff, reviewed care records and other information to help us assess how their care needs were being met.

As part of this inspection we reviewed seven people’s care records. This included their care plans and risk assessments. We looked at the support records for six members of staff. We reviewed other records such as complaints and compliments information, quality monitoring and accident records.

Updated 31 July 2015

This inspection was unannounced and took place on 26 and 27 May 2015 and 2 June 2015. Chadwick Lodge Residential Home can accommodate up to fifteen older people who require personal care and support and who may have care needs associated with dementia.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

The service had 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 Chadwick Lodge Residential Home the Registered Manager is also the owner/provider of the service run as a Limited Company.

This inspection found that although people and their relatives told us they were happy with the service, there were significant concerns about how the service was being run and managed. Improvements were needed in many areas where the provider was not meeting the requirements of Regulations.

Management and staff in the service had been unable to recognise poor practices and had not made referrals to the appropriate agencies, such as the local authority safeguarding teams, when this was needed. This had left people at risk and had not protected them from harm.

The local authority was investigating multiple concerns that had been raised in relation to the service. These related to issues such as staff and management behaviours, institutionalised practices and poor or neglectful care. Many of these had been substantiated.

Information from other agencies and our inspection found that people using the service had been left at risk in a number of ways.

There were no evident audit and monitoring processes in place to ensure that the service recognised and took action when improvements were needed.

Practices in the service were institutional and not person centred or person led. This meant that people were not always given meaningful choices in relation to their daily routines.

There were shortfalls in recruitment procedures that should protect people from receiving care from people not suitable to undertake a caring role. Staff were not fully trained to ensure that they understood and could meet people’s needs effectively. People’s levels of dependency were not assessed to establish if the staffing levels provided were suitable to meet their needs.

The environment had not been maintained to a high standard, health and safety risks were not adequately assessed and account had not been fully taken of how the environment should meet the needs of people living with dementia.

People’s rights were not being protected through management and staff having a good knowledge of the Mental Capacity Act 2005 and the Deprivation of Liberty safeguards.

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

People were supported to eat well and enjoyed the food provided. There were opportunities for people to engage with activities. People’s medicines were being managed adequately and only minor practice issues were highlighted to improve the systems in place.