Worstead Lodge

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Worstead Lodge is a residential care home providing accommodation for persons requiring nursing or personal care to up to 20 people. The service provides support to autistic people and people with a learning disability. At the time of our inspection the home supported 19 people. 8 people lived in an adapted detached house, while 11 people lived in smaller self-contained flats and bungalows on the premises, sharing with 2 or 3 others. The provider company had changed ownership in April 2023, however this did not require any changes to the provider’s registration with CQC.

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

Right Support:

People were generally happy living in Worstead Lodge and many had lived there for a very long time. However, recent changes brought about by the change of ownership of the provider company had destabilised the support people received and left them feeling vulnerable and ill-at-ease in their home.

People were at risk of not receiving safe care. People’s personal care and support records did not always reflect their needs, and some documents had been destroyed leaving newer and agency staff without the guidance they needed to support people safely. Medicines were not always administered safely. Maintenance checks were regularly undertaken and emergency plans were in place.

The home was larger than that indicated by best practice guidance, however this was mitigated in part by the inclusion of smaller, self-contained flats and bungalows within the care home’s grounds.

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.

Right Care:

Staff were not always effectively deployed to ensure people received person-centred care. The systems in place did not always protect people from financial abuse. Staff were kind and caring in their interactions with people and people were comfortable with the staff they knew well. Staff were recruited safely and had been appropriately trained.

Right Culture:

A closed culture had developed in the home due to a lack of management oversight, however the provider had taken appropriate action as soon as they had become aware of this. A new management team had been very recently appointed and a new position created to improve oversight of the support people received. New systems had been introduced however these had not yet been fully implemented so we could not be assured of their effectiveness at the time of our inspection. The new management team were committed to improving the service.

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 21 December 2021).

Why we inspected

We received concerns in relation to safeguarding, staffing, management of medicines, and the leadership and governance of the service. As a result, we undertook a focused inspection to review the key questions of safe 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 changed from good to 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 sections 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 Worstead Lodge on our website at www.cqc.org.uk.

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.

Worstead Lodge is a residential care home providing personal care and support to 19 people with a learning disability, autistic people, or people with mental healthcare support needs. The service can support up to 20 people. Accommodation was spread over five buildings; the main house and four self-contained bungalows.

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

People were encouraged to manage their medicines independently, with staff support available where required. People were responsible for maintaining the cleanliness and condition of their own bedrooms, bathrooms, as well as communal spaces, with staff oversight in relation to COVID-19 checks. People understood about COVID-19 risks, testing, vaccines, social distancing and the importance of hand hygiene. Staff were observed to wear personal protective equipment appropriately throughout the visit to maintain people’s safety.

People were involved with the day to day running of the service, and their individual lives; staff told us they worked alongside people to support personal achievement. The service was well-led, with strong, and consistent leadership. The registered manager, and overall provider team were passionate about giving people consistently good standards of personalised care.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

Based on our review of key questions Safe and Well-led, the service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. People received personalised care and support, tailored to their individual needs and wishes. People were able to make choices about who they wished to live with, what they wanted to do and where they wanted to spend their time.

Prior to the pandemic, people had active social lives within the local community, including having jobs and access to educational courses. Whilst the pandemic had curtailed some people’s abilities and confidence to safely access the local community, changes have been made within the care environment to reduce the risk of social isolation and loss of hobbies, whilst maintaining adherence to COVID-19 risk management guidelines. People consistently told us they felt safe, supported and well cared for living at Worstead Lodge, and this was reinforced by feedback received from people’s relatives.

Right support:

• Model of care and setting maximises people’s choice, control and independence.

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human rights.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives.

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

Rating at last inspection

The service was last inspected on 02 April 2019 and rated Requires Improvement; the report was published on 18 July 2019.

We carried out an unannounced, comprehensive inspection of this service on 02 April 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve regulation 17 (good governance).

Why we inspected

This was a planned inspection based on the previous rating.

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 COVID-19 and other infection outbreaks effectively.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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

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:

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

People were cared for by staff who understood safeguarding principles.

Medicines were generally managed safely however more support is required for people who self-administer.

The storage of people’s medicines needs to be improved.

Further improvements to the management and oversight of records are needed.

Staff supported people to keep safe by assessing risks and identifying measures to mitigate potential causes of harm.

The service was person - centred and assessed people’s needs and individual preferences.

Health care professionals were involved in people’s care.

People were supported to have maximum choice and independence.

Staff sought people’s consent and supported them in the least restrictive way possible.

People were supported to pursue their own hobbies and interests.

People were involved in making decisions about their care.

Staff were knowledgeable about individual people and knew how to communicate well with them.

People were relaxed in the company of staff.

There was a friendly, open and welcoming atmosphere and a positive culture in the service.

The service remains in breach of Regulation 17 HSCA RA Regulations 2014 ‘Good Governance’.

We made recommendations about staff training and support for people who self-administer medicines.

Rating at last inspection: Requires Improvement (January 2018)

Why we inspected: This was a scheduled, planned inspection based on the previous rating

Follow up: ongoing monitoring; seeking an improvement plan; meeting with the provider

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

Worstead 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. Worstead Lodge accommodates up to 20 people, some of whom may be have learning disabilities and/ or autism, in one adapted building. At the time of our inspection there were 19 people living in the home.

The home did not have a registered manager in post. They have not had a registered manager in place since July 2016. A manager from the provider’s other location was overseeing the day to day management of the home. No application had been submitted to us for them to become the registered manager for both services. 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 medicines continue not to be managed in a safe way. At our previous inspection on 26 and 27 May 2017 we found that the provider was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection in January 2018 we found that the provider had not made sufficient improvements in this area and remain in breach of this regulation. Medicines audits were not regularly carried out and staff were not routinely observed to ensure good practice in relation to managing people’s medicines safely. Records relating to the administration of people’s medicines were not always complete and therefore we could not be sure people received medicines as the prescriber intended.

We found further breaches of the regulations which related to the governance of the service. There were a lack of effective systems in place to monitor and assess the quality of service being delivered. Audits were not carried out on a frequent basis and the quality assurance measures in place did not identify areas for improvement. Staff recruitment records were not complete. Appropriate references had not been requested and there was no employment history for one member of staff.

In addition the provider did not notify of us of a significant event which they were required to by law.

Individual risks to people’s health and wellbeing had been identified and planned for. Risk assessments were detailed and gave staff sufficient information about how they could manage known risks. Risks within the environment had been identified and appropriate risk assessments were in place which documented how the risk was being managed and what steps staff could take to maximise people’s safety.

Staff understood their responsibilities in relation to safeguarding. They knew how they would report any concerns and to whom. There were consistently enough staff to support people and staffing levels were adjusted accordingly to meet people’s needs.

Accidents and incidents were recorded and these were reviewed regularly by the provider so any trends or patterns could be identified.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found that the service was working within the principles of the MCA but staff did not have a good understanding of how the MCA affected their work.

Staff received training relevant to their role and they were supported to pursue further training to develop their skills and knowledge. Staff were further supported through supervisions with a senior member of staff.

People were supported to maintain a healthy nutritional intake and were given a choice about what they would like to eat. Mealtimes were informal and were sociable. Risks relating to people’s nutritional needs were identified and guidance from healthcare professionals was clearly documented in people’s care records. Timely referrals were made to relevant professionals where there were concerns about a person’s health or wellbeing.

People were involved in the design of the service and were able to personalise their rooms to their taste. People were consulted about the design of the garden and how it could be used for meaningful activities.

Staff were caring and treated people in a compassionate way. People felt listened to and were involved in their care planning. People were supported to be as independent as possible and be involved in their local community. There were no restrictions about when people could have visitors.

People’s right to privacy was respected and they were treated in a respectful manner.

Records relating to people’s care and treatment were person centred and gave staff detailed information about how people liked to be supported and their preferred ways of communicating. Staff were responsive to people’s needs and spent most of their time in the communal areas where they were accessible if people needed them.

There was a complaints procedure in place and people felt comfortable in raising a complaint if they needed to.

The values of the service were to put people at the centre of their care and promote independence. Staff demonstrated these values and this helped to create a homely environment with a sense of community.

Worstead Lodge provides residential care for up to 20 younger people who are living with a learning disability. At the time of this inspection there were 19 people living within the home. The accommodation includes two self-contained bungalows, two self-contained converted stables and the main house where people had access to a number of communal areas.

There was 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.

The service did not have procedures in place that fully reduced the risks associated with the management of medicines. Good practice was not being followed in all areas. Although the individual risks to the people who used the service had been identified and reduced, those associated with the environment had not been fully identified, assessed and managed.

The home had a system in place to monitor the quality of the service being delivered and this was effective in most areas. However, the system had failed to identify the issues associated with the safe management of medicines.

The people who lived at Worstead Lodge benefited from being supported by staff that were trained and competent in their roles. Staff had received an induction and the service had processes in place to ensure this was effective. Staff felt valued and supported in their roles. Safety checks had been completed to ensure that only suitable people were employed.

An open and inclusive culture was promoted and staff treated people with respect and kindness. Staff encouraged people to be independent and empowered them to make decisions for themselves whenever possible. The service worked in partnership with those that lived at the home in order to ensure it ran smoothly. People described the home as welcoming with a special atmosphere.

Processes were in place to help protect people from the risk of abuse and staff understood these. They gave us examples of abuse and the symptoms that may indicate potential abuse. Staff understood their responsibility to report any concerns they may have and knew the procedure for this both inside and outside of the organisation.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Staff understood the need to gain people’s consent before assisting them and they demonstrated that they fully encouraged people to make their own decisions where possible. However, staff knowledge of the MCA and MCA DoLS was variable and training had not been provided.

People had been involved in the decisions around what support they required and the support plans we viewed confirmed this. People, and their relatives, told us their needs were met. The support plans, and our observations during the inspection, demonstrated this. Support plans were individual to the person and gave staff clear information on the support people required and wished for. They showed that people’s independence was promoted and encouraged.

The service supported people to follow their interests and hobbies. This was done on an individual basis and the service went to great lengths to ensure people engaged in the activities they enjoyed, providing support where required. People told us of all the activities they engaged in which were many and varied.

People received interventions from, or had access to, a variety of healthcare professionals in order to maintain their physical and emotional wellbeing. Their nutritional needs were met and people were encouraged to participate in preparing meals for themselves and others who lived in the home. Participation in the running of the home was promoted in a manner that supported cooperation.

All the people we spoke with talked highly of the management team at Worstead Lodge and the service it provided. The relatives of the people who used the service described how the service had led to their family members leading happy, independent and fulfilled lives. They praised the providers in their approach to supported living and the positive impact the service had had on the lives of their family members.

This is a summary of our findings. If you would like to see further evidence supporting this summary please read the full report.

Is the service safe?

We saw that there were detailed risk assessments in place that covered many aspects of people's daily life and each of these had been completed specifically for the individual they referred to. The risk assessments we looked at were up to date and had been regularly reviewed.

All the areas of the main house that we saw were safe and accessible for the people living in or visiting the home and no hazards to people's health or safety were noted. One person also showed us around one of the new bungalows that they lived in. We saw that all areas were clean and well maintained with no health or safety hazards noted.

The manager told us that a member of staff ensured that general maintenance matters were dealt with promptly.

A recent visit from the Fire Safety Officer confirmed that the fire precautions in place in the main house were 'generally of a good standard', with one minor area for consideration. The fire officer's report in respect of the flats, situated in the grounds of Worstead Lodge, stated that the fire precautions in place were satisfactory, with no areas for consideration noted.

Is the service effective?

The information we looked at, together with discussions and observations, confirmed to us that people were supported to follow lifestyles of their choosing and be as independent as possible.

We observed that the ethos of Worstead Lodge was very much about empowering people by supporting them to do things for themselves, rather than having things done for them.

During our previous inspection on 30 August 2013, we had been concerned that there were some shortfalls in areas such as care records, record keeping and some other administrative areas. The provider sent us a plan of the action they intended to take to rectify the non-compliance issues. During our inspection on 10 April 2014, we found that appropriate action had been taken and that people's care records and support plans had been reviewed and updated accordingly.

We saw that the care records were being regularly audited and people's individual needs and assessments of risk were also being reviewed and updated on a regular basis.

All the information we saw was clear, detailed and individual. It was also easily accessible by staff, providing clear guidance with regard to how each person required support, in accordance with their needs and wishes.

We saw that staffing levels were increased at key times during the day, such as evenings and weekends, when more people were at home. We were satisfied that the staffing levels were appropriate, as many people were very independent and required only minimal support, such as verbal prompting or encouragement. We also saw that people had regular one-to-one time with their keyworkers on their days at home.

Is the service caring?

When we spoke about the staff, one person told us, 'I need the staff to help me with things like cooking and they do that. They help me stop getting anxious; I worry and get upset quite a lot and they help me feel better'

We saw from one person's care records that they needed staff to help with cutting their food into manageable sized pieces. We noted that the person had agreed to this being done for them in the kitchen, which also maintained their dignity.

All the people we spoke with told us that the care and support they received was good and confirmed that they had regular discussions about their care with the staff. One person told us, 'I talk to my keyworker a lot' Another person said, 'My keyworker checks that I'm alright and we talk about things I need or things I want to do'

Is the service responsive?

One person had some difficulties with eating and swallowing and maintaining a healthy weight. We saw that there had been thorough assessments carried out by appropriate professionals such as the dietician and the speech and language team. We also noted from the care records, that staff followed the support guidance for this person in a 'Nutrition and Dietetic Care Plan' that had been provided by the dietician.

On the day of our inspection, we observed that an impromptu staff meeting had been called to enable staff to discuss the best way of meeting some specific support needs for one particular person.

We noted that quality assurance questionnaires had been sent out to people's relatives in February 2014. We saw that, in one instance, the provider had provided a written response to a person's relatives in order to reassure them in respect of a few issues they had raised.

Is the service well led?

Since our previous inspection on 30 August 2013, a permanent manager became registered with the Care Quality Commission and was predominantly based at Worstead Lodge. This meant that there was a clearer leadership and management structure within the home.

In addition, a new member of staff had been employed to provide some part time administrative support.

Eight members of staff told us that they were happy and felt confident in the work they did and knew each of the people they supported very well. All eight staff also told us that they were supported well by their manager or other seniors.

The manager told us that the staff team had gone through an unsettled period but that they had come through this very well. The manager also said, 'They're all good workers; hard working and very caring. The new staff are also very good.'

During our visit we saw that the manager had an 'open door policy' and actively encouraged comments, suggestions and feedback from the people living in the home, their friends and family and relevant professionals.

One person said they were really happy with their room and liked it a lot. They said: 'It's nice to have my own room ' it's my own space.'

This person told us that the food in Worstead Lodge was always nice and said: 'We've got a menu book ' I'll show you.' This person pointed out that the front page had a list of the food people didn't like, then showed us how the following pages listed the main meals that people had been served.

The person we spoke with told us that there was always plenty to eat and drink in the home and that they could always have something different if they didn't want the main option.

We observed people making drinks for themselves and others as they chose, during the course of this inspection.

One person we spoke with said, of the staff: 'They're all alright.' A second person said: 'Yes, they're good. I like them.'

One person also told us: 'I can talk to any of the staff if I have a problem. They always listen.'

Staff told us that managers were supportive and approachable; however the provider's arrangements for supervision and appraisal were not adequate.

We looked at the support plans for three individuals living in the home and found that they actively promoted people's independence. One person described how staff had discussed written information with them and made sure they understood it. Communication between staff about people's needs was effective and promoted continuity of care and support.

People were offered choices in their daily lives and were encouraged and enabled to be active in their local community by participating in activities and groups. Some people received one to one support to manage their money. People's health needs were managed proactively by staff encouraging individuals to maintain a healthy lifestyle, such as by choosing their meals wisely.

We found there were effective systems in place to reduce the risk and spread of infection and to monitor the quality of the service. Surveys of people living in the home, their parents, families and visiting professionals were completed in November 2011. We saw that improvements had been made in response to people's feedback