The Lodge - Dementia Care with Nursing

The Lodge – Dementia Care with Nursing is a residential care home providing personal and nursing care to up to 96 people. The service provides support to older people, people who may be living with dementia, and people who may have mental health needs. At the time of our inspection there were 85 people using the service.

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

People were supported to take their medicines however improvements were required to make sure this was managed safely. We have made a recommendation about making specific guidance available for staff regarding some care interventions. The home was clean and comfortable and there were enough staff to meet people’s needs. People were protected from the risk of abuse and the risk of mistakes being repeated due to effective systems. Relatives told us staff were caring, 1 relative said, “Staff are very kind and caring, I am happy with the staff.”

People’s needs were assessed according to guidance and staff were well trained in their roles. People were supported to eat and drink via a local meals delivery service. Staff worked well with other health care agencies and supported people to live healthy lives. There was good awareness of the needs of people with dementia and mental health issues.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Improvements were required to make sure there were effective governance systems to monitor outcomes and make improvements. The registered manager was supported by a deputy manager and team leaders. People were supported by staff that enjoyed their jobs and staff told us they received good support from managers.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 3 September 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At our last inspection we recommended that the provider consider guidance regarding the safe management in medicines. At this inspection we found improvements were still required and were now in breach of the regulation.

Why we inspected

We received concerns in relation to the safe management of people’s health needs, including medicines. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has remained requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led section of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for The Lodge – Dementia Care with Nursing on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safe management of medicines and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

People and staff were tested regularly for COVID-19, in line with government guidance. All staff employed at the home had been vaccinated, to help keep people safe from the risk of infection. Any staff who tested positive for COVID-19 self isolated at home as per government guidance. Staff told us they felt safe coming to work due to the training and support made available by the management team.

Infection control policies and audits helped ensure that the home adopted best practice which complied with current guidance.

The service was clean and well maintained, with some communal areas having recently undergone refurbishment and some still in progress.

Cleaning schedules and audits were in place. The service had recently recruited additional domestic staff to help maintain cleanliness and minimise the spread of infection.

Staff were trained and competent in infection prevention and control best practices and how to don and doff PPE. An 'app' was made available to staff on their work phone where they could access a wealth information about infection control procedures and the most up to date guidance.

The management team undertook daily walk rounds of the service to ensure the cleanliness of the building and that staff were adhering to good infection control practices.

The service had adequate supplies of appropriate PPE and hand gel and PPE stations were made available throughout the building for staff and visitors.

The service supported people to maintain contact with those who were important to them, to aid their emotional and psychological well-being. The service had recently further developed its gardens and grounds so people had access to pleasant outdoor space.

Each unit had its own designated visiting area to facilitate face to face visits. The service also supported alternatives to in-person visitation, such as virtual visits.

The service had close links with external health professionals to enable people to receive the care and intervention they needed. Virtual consultations took place as and when necessary.

The Lodge - Dementia Care with Nursing is a care home providing personal and nursing care. It is registered to provide 24-hour care and support to up to 80 people who are living with dementia and require support with nursing or personal care. At the time of the inspection 77 people were receiving support. The home is divided into four communities, each with a separate lounge, dining room and kitchen. Shared bathroom and shower facilities are available in each community. Two of the communities provided care and support for people who may display behaviour which challenges the service.

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

People could not be assured governance systems were sufficiently implemented and embedded to drive improvements at the home. Care records did not always record the latest information about people and care reviews were not consistently documented.

Medicines were provided to people in a person centred way and there were policies and processes to guide staff regarding medicines management. We have made a recommendation about the safe management of medicines.

Some areas of the home required cleaning and staff did not always wear personal protective equipment in accordance with current guidance. Some staff wore jewellery which was not in line with best practice and guidance.

The manager had reviewed staffing to check the current arrangements met people’s needs. Changes were being made to help ensure sufficient numbers of staff were available to support people. Staff had received training in key areas such as moving and handling and infection prevention control to maintain their skills and competence. People were supported by staff who had undergone sufficient recruitment checks to help ensure they could support them.

If people needed medical advice this was arranged for them and changes made to their care to support their well-being. Staff knew the help people needed to remain safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 Good (published 05 December 2018).

We also carried out a targeted inspection on 26 May 2021. This was to ensure infection prevention and control practice was safe and the service was compliant with IPC measures. We found processes were operated to ensure the risk and spread of infection was minimised.

Why we inspected

We received concerns in relation to the management of staffing, quality of care and leadership. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

The manager responded quickly to our concerns and took action to minimise the risk by directing key personnel to complete audits and act on the findings.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Lodge - Dementia Care with Nursing on our website at www.cqc.org.uk.

Enforcement

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.

Follow up

We will request an action plan from 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.

We found the following examples of good practice.

¿ The provider had ensured staff could access comprehensive and informative training in various aspects of infection control. Staff confirmed they felt confident in the training and this helped them deliver care based on best practice.

¿ The environment and equipment had been arranged to minimise the risk of infection and was clean and clutter free.

¿ Information was gathered from visitors to help minimise the risk and spread of infection.

¿ Risk assessments were carried out to minimise the risk and spread of infection.

¿ Processes to minimise the risk of infection were carried out by staff. For example, temperature checks, safe waste disposal and increased cleaning of the home took place.

¿ COVID-19 policies and risk assessments were available and followed by staff.

¿ Checks and audits were carried out on the cleanliness of the home and action taken if this was needed.

¿ Adequate handwashing facilities, hand sanitiser and personal protective equipment was available to support best practice. The provider ordered more foot operated bins to complement the equipment provision at the home.

¿ Staff supported people to use electronic tablets and telephones to maintain contact with loved ones. People could see their visitors in designated areas within the home

¿ People were supported to access health professional advice and maintain their well-being.

¿ Staff and people were tested regularly for COVID-19.

¿ People and staff were taking part in the vaccination programme. People at the home were supported to decide if they wanted to participate. Processes were in place to ensure if people were unable to make this decision for themselves, best interest discussions were held with relatives and documented.

When we last inspected the service in March 2017 we found the provider was not meeting legal requirements in relation to Person-centred care – Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because of a lack of organised activities and engagement from staff. During this inspection we found improvements had been made and the service was meeting legal requirements.

A dedicated activities coordinator had been employed who had implemented a wide range of organised activities for people who lived at the home. These included group activities, visits from local community groups, pet therapy and various outings. The activities coordinator had worked to provide activities that individuals would find meaningful to them. With regard to engagement, we found staff engaged well with people during our observations and were responsive to people’s needs.

The Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home is registered to provide 24-hour care and support to up to 80 people who are living with dementia and require support with nursing or personal care. The home is divided into four communities, each with a separate lounge, dining room and kitchen. Shared bathroom and shower facilities are available in each community. Two of the communities provide care and support for people who may display behaviour which challenges the service.

The service had a 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.

The provider had systems to safeguard people against abuse or improper treatment. Staff had received training to spot abusive or inappropriate practices and knew how to report them. The service followed a robust recruitment process to ensure only suitable candidates were employed.

Staff assessed risks to the health and well-being of people who used the service and plans were put in place to lessen these risks. Environmental risk, for example around fire safety, had been assessed and appropriate plans put in place to lessen risks. The service promoted positive risk taking in order to help people maintain as much independence as possible.

The provider had systems which recorded any adverse incidents or events. We saw analysis of accidents and incidents was undertaken in order to make positive changes to reduce the risk of recurrence.

Staff had received training to reduce the risks related to the spread of infection. We observed staff follow good practice guidance whilst undertaking their duties. The home was clean and tidy during our inspection.

The service ensured a sufficient number of staff were deployed at all times. Staff retention had improved and more staff were available to cover shifts at short notice, if required. The registered manager reviewed staffing levels against people’s needs to ensure there were always enough staff.

The service followed best practice guidance in relation to the management of medicines. Regular checks were undertaken to ensure people received their medicines as prescribed. Staff responsible for assisting people with their medicines had received training to ensure they had the competency and skills required.

We looked around the building and found it had been maintained, was clean and hygienic and a safe place to live. We found equipment had been serviced and maintained as required.

People were provided with a choice of meals. We saw regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration. Nutritional risks were monitored and managed appropriately.

The service had a complaints procedure which was available to people who used the service and their relatives. The people we spoke with told us they were happy with the service and had no complaints.

People’s care and support had been planned with them or, where appropriate, others acting on their behalf. They had been consulted and listened to about how their care would be delivered.

The service followed good practice guidance in relation to obtaining consent from people. Where people lacked capacity to consent, the service followed best interest processes, as outlined by the Mental Capacity Act 2005 code of practice. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Care plans were detailed and had identified care and support people required. We found they were informative about care people had received.

The service ensured staff had the skills, knowledge and a good level of support in order to meet people’s needs effectively. Staff received a thorough induction when they began working at the home, alongside additional training and regular supervision form senior staff.

The provider had systems in place to assess, monitor and improve the quality of the service provided to people. We saw where shortfalls were identified, action was taken to make improvements for people who used the service.

We found that improvements had been made at this inspection and the actions from the previous inspection had now been completed. However we found one breach to Regulation 9 of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was due to the long term absence of a dedicated activities coordinator and planned activities taking place on a regular basis, which we felt was vital for the service and for the well-being of the people living at The Lodge. This had resulted in a lack staff engagement generally which we saw evidence of through observations, discussions with people, relatives and staff and via the homes own internal monitoring processes.

One other issue was the high use of agency staff deployed, particularly at night. We could see that attempts had been made to attract and retain staff at the home and that staff were supported. There was a large service restructure on-going at the time of the inspection which had created a certain level of anxiety within the staff team, which was evident from speaking with staff. We did not judge this to be a breach of regulation as we felt that the issue regarding the use of agency staff had been recognised and suitable efforts made to recruit and retain staff and the restructure had imposed some limits to staff recruitment activity. We discussed at length with the registered manager how the home had attempted to resolve the issue and what plans were in place going forward. We felt that many of the issues were out of the control of the home and that they were being proactive in finding ways to redress the balance of having the correct number of suitable staff in place to meet the complex needs of the people at the home.

The Lodge is located within Buckshaw Retirement Village, Chorley and accommodates up to 80 people who have a dementia related illness and who require help with nursing or personal care. There were 67 people living at the home at the time of our inspection.

The home was undergoing a service and staffing restructure at the time of our inspection. We discussed some of the detail of the restructure with senior staff. At the time of writing this report much of the detail of the restructure was still not finalised so we are unable to give much detail. The restructure has been mentioned as many of the staff we spoke with raised this with us, with some staff giving the restructure as a reason for some staff leaving. We therefore wanted to recognise this even though little detail can be referred to given the sensitive nature of any restructure. In addition to this the home had recently been given notice on a long standing block contract arrangement with the local Clinical Commissioning Group (CCG). This was being factored into the restructure and how the service would operate going forward. The Director of Operations told us that they were looking on this positively as it meant they were able to shape the service towards a more community model long term which was the original intention for The Lodge.

Since our last inspection there has been a large extension and refurbishment to the home. Previously the home was registered for 64 people. There are four distinct units or communities within The Lodge. Raleigh is a residential unit and there are three other units for people with varying degrees of dementia. Two of the units are for people who can display behaviour that challenges. These are Mountbatten and Churchill. Mountbatten is an all-male community. Wilberforce is the remaining community. There are a range of facilities within the home, including a bar, shops and a cinema. Each community has a dining room and lounge areas. There are bathing facilities throughout the home. There are ample parking spaces available and public transport links ware within easy reach.

People whom we spoke with, and their relatives, told us that they felt they or their loved ones were safe living at The Lodge. Staff we spoke with knew how to keep people safe and how to recognise safeguarding concerns as well as how to report such concerns.

We reviewed recruitment practices and found that all staff had the required pre-employment checks including DBS and references. All files had the required information under schedule three of the Health and Social Care Act 2014.

The home had a medicines management policy in place which included procedures for the administration, disposal, refusal and storage of medicines. People who were able to told us they received their medicines on time and had no concerns with this aspect of their care and support. Relatives we spoke with were happy with how their loved ones medicines were managed. We saw that controlled drugs were managed in line with the best practice guidelines and medicines were counted and checked as required.

Staff we spoke with told us they received a variety of training via different methods of learning such as classroom based, via e-learning and by completing work booklets. We saw evidence within staff files of training certificates and reviewed the homes training matrix.

Handover sessions between staff starting and ending their shifts took place twice a day for each community. We observed one of these sessions and found the information discussed to be detailed. Staff we spoke with told us they found handovers sessions useful.

The home was working within the principles of the Mental Capacity Act 2005. They had carried out appropriate assessment of people’s capacity to determine if they could make specific decisions. Assessments were based on specifics and where necessary specific best interest decisions were made and recorded.

People who lived at the home and relatives and visitor we spoke with were very complimentary about the approach of the staff team and the care they received. However we observed a lack of engagement from staff at various times throughout the two day inspection.

People we spoke with told us they knew how to raise issues or make complaints. They also told us they felt confident that any issues raised would be listened to and addressed.

A wide range of audits were in place that contributed to improving the quality of the service. Other quality monitoring systems were in place including visits from the organisations own internal quality department.

The registered manager told us that she was supported by her line manager and the senior management team. However we could find no formally recorded supervisions or appraisals of her performance from when she was first employed at the home. We have made a recommendation about this.

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

We asked if medicines were handled safely. We found that medicines were safely stored and administered by qualified nurses. However, written information about people's individual medicines needs were not always up-to-date. Similarly, clear records were not always made about the effectiveness of medication administered to help relive anxiety or agitation. This is important to help ensure that people receive consistent and effective treatment.

We spoke with 14 members of staff across both days of our inspection. This included nursing and care staff and also included some bank and agency staff. Five members of staff we spoke with had worked at The Lodge for six months or less. Staff we spoke with were positive about their role and the majority told us that they were supported to do their job.

Staff received a structured training and development programme, and this was supported by written documentary evidence held by the service. However, we noted a specific concern documented by a tissue viability nurse that some nurses at the home had not completed training in compression bandaging. Appropriate training is needed to help ensure the most effective use of this bandaging. The manager was unable to confirm which nurses were competent in this technique.

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People we spoke with, who were able to answer our questions, told us they felt safe living at The Lodge and felt able to raise any concerns. One person who lived at the home said, "Yes, it's a well-planned building, the staff are easy to communicate with". One relative we spoke with said, "Yes. There has been the odd occasion when I have brought things to the attention of staff and it has been resolved".

Medicines were not safely administered. We found people did not always get their medicines at the right time. For example, medicines that should have been given before meals were often given afterwards. One person who was prescribed medicines for Parkinson's disease missed the previous days evening dose and no reason for this was recorded. Their next dose was given late on the morning of our visit so there was a risk their symptoms would not be properly managed. On the day of our visit medicines that should have been administered in the morning were still being given at 12:30pm. Managers had recognised that the morning medicines round was taking too long but had yet to resolve how this could be improved. This meant there was risk to people's health and wellbeing.

Is the service effective?

We looked in detail at four people's care plans who lived at the home. People's preferences were recorded clearly throughout and we saw evidence that people were able to make informed choices during our inspection. Examples included giving people a choice of drinks and food and staff explaining to people when assisting them and asking permission to do so. Such observations were indicative of respectful care and ensured that even people with very significant cognitive decline were engaged in decision making at some level.

Is the service caring?

We spoke with four visiting families/friends regarding their relatives/friends care. All were happy that they were treated with dignity and respect. One person told us, "It's lovely here, it's a good environment and they understand him".

Is the service responsive?

A complaints log was kept at the home which we viewed on the day of our inspection. The log showed that complaints received were acknowledged and investigated / responded to as appropriate.

Is the service well-led?

We saw that several auditing systems were in place including a 'monthly early warning audit tool'. We also saw that the home had completed a first review under the 'National Care Forum (NCF) Quality First review framework'. This is a tool that demonstrates an organisations commitment to continuous improvement.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People's needs had been assessed and a plan of care had been generated from the information obtained. The plans of care were well written and person centred, outlining individual needs and how these were to be best met. This provided staff with clear guidance about the best way of supporting people. At the previous inspection it was noted that a 'quick read' version for each person living at The Lodge would be beneficial for new and agency staff. This had not been done at the time of our inspection but initial meetings had taken place to look at how this would be done and by what timescale.

We looked at staff rotas for the Mountbatten community for the four week period of our inspection as rotas were set in advance every four weeks. Whilst there was agency use across the home rotas indicated that the reliance on agency staff was becoming less. We were told by the duty manager that there were a lot of people using up their annual leave allowance at the time of our inspection, therefore the use of agency staff was higher than usual. As indicated at our previous inspection in February 2014 two staff were suspended who worked on Mountbatten, therefore those shifts also had to be covered until the disciplinary process was completed.

Is the service effective?

We spoke with eleven members of staff some of whom worked on the day shift and some of whom worked on the night shift. There was a very mixed response with regard to the support that staff felt they received.

Staff files seen contained a wide range of recent training certificates, such as moving and handling, challenging behaviour, infection control, the Mental Capacity Act, Deprivation of Liberty Safeguards and dementia awareness. However, it appeared that many staff had not received recent training in dementia awareness, which is a key area in this type of care environment. Knowledge questionnaires and work books covered areas, such as pressure care, continence management, moving and handling, dementia awareness, health and safety and the Mental capacity Act. Restraint training was raised as an issue by some staff, one person told us, "There is more restraint training needed on this unit. Some staff don't use the correct techniques. Restraint training has been provided for some staff in relation to specific residents.'

Is the service caring?

We spent time observing people living within the Mountbatten community and staff interactions throughout key periods of the day and evening across both visits. We saw good practice in terms of diversion techniques particularly during the lunchtime period, and it was obvious that the staff we observed knew each person living at the home well.

Is the service responsive?

A good explanation of specific illnesses were included in care files. This helped staff to understand people's diagnosis and therefore provide the care and support needed by each individual. People's likes, dislikes and preferred daily routines were recorded well.

Is the service well-led?

We spoke to eleven members of staff during our two site visits to The Lodge. There were mixed comments with regards to the management support they received and how they felt the home was managed. We saw evidence that issues raised at our previous inspection were beginning to be addressed. Staff did receive regular supervision sessions at which they could raise issues, however some staff members felt that even though they could raise issues their ideas were not always taken into consideration when changes were implemented.

During our visit to this location we concentrated our observations and discussions around Mountbatten Unit. We spoke with three people who lived there, although this was with only a small degree of success in terms of gaining responses to the questions asked. We also chatted with two visitors, who provided us with positive comments about the care and support their relatives were afforded, whilst living on Mountbatten Unit.

Comments received from those using the service and relatives included:

'I'm well."

'I'm very well thank you."

'Rooms are kept beautifully clean, the bedding is always clean."

'I'm generally happy and I know (Name removed) seems to be very happy."

At the time of this inspection we looked at how people's needs were being met and how people were protected from harm. We also assessed the recruitment practices, the arrangements for staff allocation and how employees were supported. Methods used for monitoring the quality of service provided were also established. We found that some areas needed to be improved and we discussed these with the manager of The Lodge at the time of our visit and through a subsequent telephone conversation.

Comments from people living at the home included:

"It is super here. Everything is tip top."

"The staff are marvellous."

"I cannot complain. Everything is laid on. We want for nothing. There is always help at hand if we need it."

During our visit we saw staff talking to people with respect and always in a polite manner. It was evident that individuals were being supported in an appropriate manner. One relative told us, "I couldn't wish for anything better for my husband. He is cared for so well here. The staff are genuinely kind and considerate people."

In this report the names of registered managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still Registered Managers on our register at the time of our visit.