The White Lodge

The White Lodge is a care home providing personal and nursing care to 67 people aged 65 and over at the time of the inspection.

The White Lodge accommodates up to 80 people across three separate floors, known as communities, each of which has separate adapted facilities. One community specialises in providing care to people living with dementia.

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

People and their relatives told us they were safe. Staff knew and understood their responsibilities for safeguarding people against potential risk or harm. They were able to tell us how they would report concerns relating to people, or concerns about the service.

People’s medicines were administered, stored and managed safely. There were appropriate systems in place to check and monitor medicines closely, regular audits took place. The pharmacy had undertaken their own audit and the home GP undertook regular reviews of people’s prescribed medicines.

Staff were recruited safely. People were supported by staff who had access to training to fully equip them with the skills and knowledge to meet their needs. Staff were well supported through one to one supervision, appraisal, induction and a leadership ‘open door’ policy.

People and their relatives told us the staff were caring and they were well looked after. We observed and heard many kind and compassionate interactions between staff and the people they were supporting. Staff were gentle and patient and treated people with dignity and respect.

Staff sought people’s consent prior to undertaking any support or assistance. Staff had knowledge of the Mental Capacity Act (2005) and associated Deprivation of Liberty Safeguards (DoLS). People were offered choices of what to do, where to go, what they would like and were encouraged to do things for themselves where able.

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.

Care plans were person centred and included people’s likes dislikes and tasks they were able to undertake independently. Care plans were reviewed regularly. People had access to community and specialist health and social services such as the home GP, speech and language therapists and occupational therapists.

People had access to plenty of pass-times, interests and activities. These included a social café, outside events such as the Summer fete, games and clubs. There were extensive accessible outside grounds with wildlife, where people could sit or walk around the perimeter.

The White Lodge had a registered manager who had made significant improvements to the running of the service and the quality of people’s lives. An effective leadership team meant people, their relatives and staff were fully supported and were happy with the standards of care.

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 22 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook a focused inspection to check they had followed their action plan and to confirm they now met legal requirements (published 07 June 2019). At this inspection we found improvements had been made and the provider was no longer in breach of the regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: At our last comprehensive inspection in August 2018, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with two warning notices. This was because the registered person failed to provide care and treatment in a safe way and the registered person failed to assess, monitor and improve the quality and safety of the services provided.

We issued a fixed penalty notice for a breach of the Care Quality Commission (Registration) Regulations 2009, Regulation 18 Notification of other incidents.

We also wrote to the provider to ask them what immediate action they would take to make the necessary improvements to meet the legal requirements. The provider sent us an action plan stating what action they were taking and by what date the action would be completed.

During this inspection we found that the provider had made the required improvements.

Most people and relatives we spoke with said the service was improving. People told us they felt safe and said the staff were caring.

Rating at last inspection: Requires improvement (report published September 2018 and updated in January 2019 with details of our enforcement action). At this inspection the overall rating has remained the same. They were no longer in breach of the Regulations, but continued and sustained improvement was required.

Why we inspected: We undertook this focussed inspection to check that the provider had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to the question Is the service safe? and Is the service well-led? You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The White Lodge on our website at www.cqc.org.uk

Follow up: We will monitor all intelligence received about the service to inform when the next inspection should take place.

The White Lodge is registered to provide accommodation for persons who require nursing or personal care for up to 80 older people, some of who may be living with dementia. At the time of our visit 63 people were using the service. The home is situated over three floors. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. 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.

There was no registered manager in post at the time of our inspection. The last registered manager left the service in December 2017. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons. Registered persons have the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected the service in June 2017. The service was rated Good in each domain and Good overall.

At this inspection we have found the service was not always safe, responsive or well-led. Therefore, the service has been rated as Requires Improvement in these three domains. The service remained Good in effective and caring domains. As a result, The White Lodge has been rated overall as Requires Improvement.

The registered provider failed to suitably assess risks to the health and safety of people who received care and treatment. Additionally, the service did not always do all that was reasonably practical to reduce such risks. This was a breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered provider failed to deploy sufficient numbers of staff to make sure that people’s care and treatment needs are met. This is a breach of Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The registered provider failed to operate an effective and accessible system for identifying, receiving, recording, handling and responding to complaints. This was a breach of Regulation 16 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Ineffective quality assurance systems meant that the provider could not always continuously learn, improve and innovate. Ineffective audits put people at risk of potential harm, as areas for improvement had not been addressed to mitigate risk. The provider did not always actively encourage feedback about the quality of care and overall involvement with people who use the service. This is a breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The provider had not always notified CQC of other incidents within a reasonable time frame. This meant we could not check that appropriate action had been taken to ensure people were safe. The provider is in breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

The registered provider did not always ensure that people’s mental capacity assessments were in line with the Mental Capacity Act Code of Practice. We made a recommendation that the provider seeks guidance to ensure they are meeting these standards.

Staff were trained and understood their responsibilities in regard to the safeguarding of vulnerable adults and were able to identify signs of abuse to keep people safe.

Staff received training relevant to their roles and were supported with regular supervision and annual appraisals. Staff spoke positively of the training that they were offered and undertook.

The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.

People received their medicines safely and on time from staff who were trained to manage medicines safely.

People were supported to maintain a healthy balanced diet. People told us the food was good and plentiful.

People using the service and their relatives commented the service was kept clean. The building was well maintained and provided a spacious environment.

Staff had developed caring relationships with people and treated people with kindness, and compassion. People were treated with dignity and respect. They were supported to maintain their independence wherever possible.

Staff spoke positively about the teamwork on units and expressed that they want the service to improve.

We identified three 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. Full information about CQC’s regulatory response to breaches in regulation 12 Safe care and treatment and regulation 17 Good governance, will be added to the report after any representations and appeals have been concluded.

We undertook a full comprehensive inspection on the 31 May and 01 June 2017. The first day of the inspection was unannounced. At our last inspection at The White Lodge in June 2016 we found the provider did not meet some of the legal requirements in the areas we looked at. After the previous inspection the provider wrote to us with an action plan of improvements that would be made to meet the legal requirements in relation to the law. We found on this inspection the provider had taken all the steps to make the necessary improvements.

A registered manager was employed by the service and was present throughout our inspection. 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 told us that staff worked really hard to keep them safe. Relatives felt reassured that their loved ones were safe because staff kept them well informed should any problems arise. Safeguarding training had been completed and staff were aware of how to raise any concerns about people’s wellbeing to ensure they were safe.

Risks were assessed and reviewed regularly and control measures were put in place to minimise the risks to people.

There were safe medicine administration systems in place and people received their medicines when required. Medicines were stored securely and disposed of safely.

People told us they enjoyed the food and had plenty of choice. They were supported to eat and drink sufficient amounts and maintain a balanced diet. People could choose where they wished to eat their meal and received appropriate support when required.

People said that the staff were kind and caring and that nothing was too much trouble for them. Relatives were complimentary when telling us about the care and support their loved ones received. During our visit we saw that people were relaxed and comfortable in the presence of staff. Staff were observed speaking in a kind and friendly manner with people, taking time to allow them to express their needs.

Care plans were in place which detailed how each person would like to receive their care and support. People were occupied and encouraged to socialise through a programme of engagement and activities.

The service acted in line with current legislation and guidance where people lacked the mental capacity to make certain decisions about their support needs. We saw that people were supported with making decisions around their care. Staff sought people’s consent before providing them with care and support.

There were sufficient numbers of suitably trained staff to keep people safe and meet their individual care and support needs. People were supported by staff who were skilled in meeting people’s needs and received on-going training and support to enable them to deliver effective care.

Quality assurance systems were in place to monitor the quality of service being delivered and the running of the home. Staff said they felt supported by the manager and could raise concerns. They felt appropriate action would be taken by the manager where required.

The inspection took place on the 28 and 29 June 2016. The first day of the inspection was unannounced. At our last inspection at The White Lodge in February 2015 we found the provider did not meet some of the legal requirements in the areas we looked at. The provider wrote to us with a plan of what actions they would take to make the necessary improvements. We found during this inspection that the provider had not undertaken all the necessary improvements required to fully meet people’s needs.

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.’

People using the service, their relatives and staff did not always feel there were enough staff available to meet the needs of people using the service. Staff told us they felt “rushed” and that people only received the correct care and support because staff were “Going above and beyond their duties”.

People’s medicines were managed and administered safely. However during our inspection we found that three resident’s medicines had not been received from the pharmacy when expected. Medicines were securely stored in line with current regulations and guidance.

There was a general activity programme in place. However, there were not enough meaningful activities for people to access in groups or as individuals to avoid social isolation.

We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. Where people were still awaiting a best interest assessment to authorise their deprivation of liberty, we found that best interest decisions had not always been recorded, for example where people were refusing personal care.

Whilst most people spoke positively about the care and support they received there were some differences between how people felt about support they received during the day and night. Staff were genuinely concerned about people’s well-being. Staff knew the people they were caring for including their preferences and personal histories. People were supported to follow their preferred routines.

The provider had quality monitoring systems in place. Whilst the registered manager had an action plan in place to address any areas that required improving areas of improvement from the last inspection still remained outstanding.

People were protected from the risk of harm and abuse by trained staff who knew how to recognise abuse and what actions to take to keep people safe.

Staff told us they had received the relevant training to support them in their role. The staff we spoke with were positive about the training and felt it supported them to be able to carry out their duties effectively. Comments from care staff included “I feel I get enough and the training here is good” and “I have access to the right training”.

Arrangements were in place for keeping the home clean and hygienic and to ensure people were protected from the risk of infections. During our visit we observed that bedrooms, bathrooms and communal areas were clean and tidy and free from odours. Regular maintenance of the home was undertaken to ensure the safety and suitability of the premises. A call bell alarm system was in place to ensure people who use the service could call for help when required.

The registered manager investigated complaints and concerns. People and their relatives were able to share their views on the service and knew how to make a complaint. People and their relatives told us they could raise any concerns they had with the registered manager or any staff member. They were confident their concerns would be listened to and appropriate action taken. Accidents and incidents were investigated and discussed with staff to minimise the risks or reoccurrence.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report.

On the day of our visit there were 77 people living at the home. We spoke with twelve people who used the service, six of their relatives/friends and twelve staff. We observed care and treatment and looked at ten care records. We also carried out a short observational framework for inspection (SOFI). A SOFI is used to capture the experiences of people who used the service who may not be able to express this for themselves.

The inspection team who carried out this inspection consisted of two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Is the service safe?

The service was not always safe.

We found people who used the service were being put at risk because care was not being provided in line with their care plans. People who used the service were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

People were not always cared for safely because they were not protected against the risks associated with medicines. The arrangements in place in relation to the management, storage and recording of medicines were not always followed.

Following our inspection we asked the provider to refer two people to the Local Authority Safeguarding Team.

Is the service effective?

The service was not always effective. Staff did not always know how to support people living with dementia. We found that people were not always supported in a way that maintained their health and welfare. Care files did not show that risks had been explained to people in order for them to make an informed choice.

Is the service caring?

People were not always supported in a caring way. Some people were positive about the care they received, but this was not supported by some of our observations and other people's comments. People were not always treated with dignity and respect. People who were in their rooms received little meaningful interaction.

Is the service responsive?

The home was not always responsive to people's needs. We saw evidence that people's changing needs were not always communicated and advice from health care professionals not always sought.

People did not have sufficient time engaged in meaningful activities. People felt bored. People living with dementia received little stimulation.

Is the service well-led?

The service was not well led. People were put at risk because systems for monitoring quality were not effective. We found that 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 used the service.

We found that people were provided with a good variety of food and that choice was available. People told us they enjoyed the meals.

The home was clean and hygienic and staff received the appropriate training in infection control.

Staff we spoke with said they worked well as a team and were well supported by their colleagues and senior staff. The home had recently appointed a new training manager who was implementing a plan to update the training and supervision that was provided.

We observed staff meeting needs and interacting with people living in the home with a caring and positive approach.