Archived: Throwleigh Lodge

Throwleigh Lodge is a care home providing support to up to 17 adults with learning disabilities, mental health support needs and complex healthcare needs which require support from trained nurses. At the time of our inspection 13 people were living at the service. The service provided bedrooms and communal areas over the ground floor and first floor of an adapted building.

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

Despite provider assurances that the service had made improvements we found that this was not reflective of people’s experiences. Concerns raised during the inspection have led to ongoing safeguarding investigations and urgent actions taken by the provider to keep people safe.

There was an absence of strong leadership to effectively coach and constructively challenge staff practices. This coupled with the heavy reliance on agency nurses and care staff meant that staff did not have the necessary skills and experience to deliver support in line with best practice.

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.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

• People were not supported to have maximum choice and control of their lives. Staff did not support them in the least restrictive way possible and in their best interests.

• Staff were not deployed in a way that enabled personalised and effective support.

• The continued breakdown in effective relationships and communication across all aspects of the service meant support did not always meet people’s needs.

• Despite some well-meaning and caring members of staff, the running of the service did not support a culture of compassionate support.

Right care:

• People experienced delays in receiving care which subsequently left them at risk of harm.

• Support was task focused with an emphasis on managing people as a collective rather than enabling them to lead individual and meaningful lives.

• People had limited access to activities that developed their skills and independence.

• People were not always treated with privacy and dignity and this impacted on their basic human rights.

Right culture:

•The service lacked a positive culture and people were not at the heart of the service they received.

• There was a lack of accountability for mistakes that had been made, with a focus on blame rather than reflection and improvement.

• Provider oversight was reactive, and improvements were dependent on external pressure and support.

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 Inadequate (published 23 February 2021). That was following a targeted inspection that focused on the Safe, Responsive and Well-led domains where we found multiple breaches of regulations. Following that inspection, we imposed a condition on the provider’s registration which required them to complete an action plan and submit monthly evidence of the improvements that had been made. At this inspection, we identified that the service had not improved in the way we had been informed it had, and the provider was still in breach of regulations.

This service has been in Special Measures since February 2021.

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.

Enforcement

We identified multiple breaches in relation to the safety of the care people receive, staff deployment, safeguarding, person-centred care and the management of the service at this inspection. We met with the provider immediately after the inspection and in response to our inspection feedback, they made the voluntary decision to close the service.

Since our inspection we have worked closely with the provider and local authority to ensure people received safe care as they were supported to move to new homes.

Follow up

At the time of publication of this report, Throwleigh Lodge has closed and therefore no longer providing a regulated activity. We have accepted the provider’s application to de-register both the registered manager and location and these are now being processed.

Throwleigh Lodge is a care home providing support to up to 17 adults with learning disabilities, mental health support needs and complex healthcare needs which require support from trained nurses. At the time of our inspection 15 people were living at the service. The service provided bedrooms and communal areas over the ground floor and first floor of an adapted building.

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

Risks to people’s safety and well-being were not always monitored and accident and incidents were not used to ensure improvements were made to people’s care. The service was not cleaned to a satisfactory standard and safe infection control processes were not consistently followed. In addition to providing care, staff were required to undertake tasks including cleaning and laundry. This meant they did not always have time to spend with people socially.

People’s care was not always person-centred and there was a lack of opportunity for people to be involved in planning their care. Communication plans lacked detail and did not provide guidance to staff on how to support people’s communication needs. Activities were repetitive with little opportunity for people to access community activities. Some people benefited from weekly visits from the local church and a local charity providing communication sessions.

There was a lack of management oversight of the service. Despite previous concerns being highlighted, action had not been taken to improve the service. Quality assurance processes had not identified concerns regarding people’s care and staff did not feel listened to or supported.

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 guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support: The model of care did not maximise people's choice, control and independence. The service was larger than most domestic style properties and adaptations to how people’s support was provided had not been made to minimise the impact of this.

Right care: The support people received was not always person-centred and did not maximise people’s choices and opportunities. People were not always supported safely

Right culture: There was a task focussed culture within the service. The views of people, their relatives and staff were not always sought and responded to.

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 (10 March 2020) and there were two breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 24 January 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they 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, Responsive 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 Inadequate. 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 Throwleigh Lodge 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 have identified breaches in relation to the safety of the care people receive, staff deployment, safeguarding, person-centred care and the management of the service at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for 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.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Throwleigh Lodge is a care home providing personal and nursing care to 15 people adults with learning disabilities at the time of the inspection. The service can support up to 17 people. The home provided bedrooms and communal areas over the ground floor and first floor of an adapted building.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

The service was a large home, bigger than most domestic style properties. This is larger than current best practice guidance. However. the size of the service having a negative impact on people was mitigated by the building design fitting into the residential area and the other large domestic homes of a similar size. There were deliberately no identifying signs outside to indicate it was a care home.

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

Following the previous inspection the provider had been sent an action plan to complete. On this inspection it was noted that only minimum changes had been made to improve the service.

Accidents and Incidents had not been monitored or analysed to identify potential trends and patterns to prevent future occurrences.

Fire safety concerns were raised in relation to equipment not being easily accessible. This included sliding sheets and mobility aids for people who were unable to use the stairs in the event of an emergency. Infection control concerns were identified and only minor improvements had been made in response to the previous recommendation to improve the adaptation and design of the home to meet people’s needs. This meant that there was an impact on people receiving person-centred activities that met their needs.

Medicine audits had not identified concerns found on the day Quality assurance audits had not identified the above mentioned shortfalls, or addressed any issues in the home to make improvements. The provider had not fully implemented the previous action plan in the absence of a registered manager.

The new manager had only been in post for two weeks prior to the inspection. We received robust assurances and confirmation of new processes that were implemented immediately after the inspection. We will check whether these have been continued and sustained at our next inspection.

People told us that they felt safe at Throwleigh Lodge. Relatives told us of how staff supported their loved ones to improve their health. Records showed staff had followed health professional guidance to ensure people’s health improved. Risks were assessed, monitored and reviewed to ensure any change in risks or new risks identified were well managed.

People were supported to have a balanced diet and access to drinks regularly to remain hydrated. Staff followed guidance from the Speech and Language Therapist (SALT) Team to ensure people with complex needs that required additional support with their diet received their food in a safe way.

People were supported by trained staff that had been recruited safely and had completed a thorough induction process. Staff were kind and caring towards the people living at Throwleigh Lodge and were aware of equality and diversity and were seen to support people appropriately.

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.

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.

The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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 02 February 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made or sustained and the provider was still in breach of regulations. The service remains requires improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to three regulations at this inspection. We have identified breaches in relation to Regulation 12 (safe care and treatment), accidents and incidents were not always analysed to look for trends, Regulation 15 (premises and equipment), the environment was not set up in a way to ensure the appropriate storage of equipment and Regulation 17 (good governance), quality assurance was not always robust.

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 for 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.

Throwleigh Lodge is a care home providing nursing care for people living with complex learning difficulties and physical disabilities. At the time of the inspection there were 13 people living at the home and up to 17 people could be accommodated.

This service was set up and registered prior to Building the Right Support and Registering the Right Support (2015) which sets out the values and standards for the size of a service for people living with a learning difficulty or autism. Although the size of this service was larger than our Registering the Right Support standards, people were being cared for in smaller group settings over two floors to enable more personalised care to be given. However, we found that more could be done to involve people, and their families and representatives, in the design of services.

People in residential care homes receive accommodation and 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.

On the day of the inspection the registered manager was not present due to ill health. 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 the inspection we had difficulty gathering all the information we required and the staffing records were difficult to locate. Some care and dietary records were confused and handwritten notes were not always clear. The registered manager assisted us with further information on their return to work but record keeping and organisation was an area that required improvement.

people and their relatives were not formally involved in the development of the service. Policies were a few years out of date and needed review. There was low reporting by the service to the CQC and some statutory notices had only been sent after a care professional had highlighted a concern.

The numbers of accidents and incidents were recorded but there was no evidence of any learning outcomes from these.

We discovered that some infection control measures and equipment were not at the required standard. Some aspects of the premises needed attention to ensure that a homely and uncluttered environment was provided for people.

Risks to people were being identified and staff showed awareness of the actions to take. Staff also had knowledge of safeguarding processes and an openness to report. Medicines practice and storage was safe. Staffing levels were good enough to achieve safe care. However, there had been a high turnover of staff and a reliance on bank or retired nurses.

People’s needs had been assessed. Good knowledge of people’s complex needs was demonstrated by the nurses. The care staff were competent and they received monthly supervision from the new registered manager. There was good daily communication between staff.

There was evidence of working with the multi-disciplinary community team for people with learning difficulties, and referrals were made to meet specific health needs. People’s special dietary needs were understood and met. Environmental checks were undertaken.

People’s consent was sought in line with the legal requirements of the Mental Capacity Act. Where people's liberty was restricted to keep them safe, the provider had followed the requirements of the Act, and the Deprivation of Liberty Safeguards (DoLS), to ensure the person's rights were protected.

The staff displayed a caring attitude towards people and showed patience and understanding. Care plans were person centred and demonstrated a good understanding of each person’s life. There was a personalised activity plan in place for each person.

People’s wishes at the end of their life were recorded, albeit separately from the person’s care plan. Good care was given to people at the end of their life and those who were bereaved were remembered.

The service had a complaints procedure in place. An easy to read picture policy was also available.

In the absence of the registered manager staff had a good knowledge of the service and the people they cared for. Staff also told us they were supported and involved through regular meetings. Quality assurance and health and safety monitoring was in place and improvements had been identified. The new registered manager told us they had a vision to improve the service, the environment, and the way records and policies were organised.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also made one recommendation. The provider started to take action following the inspection.

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

Throwleigh Lodge provides care, support and accommodation for a maximum of 17 adults with learning disabilities, some of whom have additional physical disabilities and complex needs. There were 17 people living at the service at the time of our inspection.

There was no registered manager in post at the time of our inspection. The service manager had applied for registration with the CQC and their application was under consideration. 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 and associated Regulations about how the service is run.

There were enough staff on duty to meet people’s needs safely and promptly. Staffing rotas were planned to ensure that staff with appropriate knowledge and skills were available in all areas of the service. People were protected by the provider’s recruitment procedures. Staff understood safeguarding procedures and were aware of their responsibilities should they suspect abuse was taking place.

Risks to people had been assessed and actions to minimise the likelihood of harm were recorded.

The service aimed to learn and improve from any incidents and accidents that occurred. There were plans in place to ensure that people’s care would not be interrupted in the event of an emergency.

Medicines were managed safely but we identified two areas in which the provider should improve their practice. Some medicines were stored in a warm environment in which the temperature was not recorded, which meant the provider could not be certain that all medicines were being stored appropriately. When staff gave people PRN (‘as required’) medicines, they had not always recorded the reason for doing so. We raised these issues with the service manager during the inspection, who agreed to implement measures to address them.

People were supported by staff that had the skills and experience needed to provide effective care. Staff had induction training when they started work and ongoing refresher training in core areas. They had access to regular supervision, which provided opportunities to discuss their performance and training needs.

Staff knew the needs of the people they supported and provided care in a consistent way. Staff shared information effectively, which meant that any changes in people’s needs were responded to appropriately. People were supported to stay healthy and to obtain medical treatment if they needed it. Staff monitored people’s healthcare needs and took appropriate action if they became unwell.

The acting manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People’s best interests had been considered when decisions that affected them were made and applications for DoLS authorisations had been submitted where restrictions were imposed upon people to keep them safe.

People were supported to have a balanced diet and could have alternatives to the menu if they wished. People’s nutritional needs had been assessed when they moved into the service and were kept under review. Risk assessments had been carried out to identify any risks to people in eating and drinking.

Staff were kind and sensitive to people’s needs. People had positive relationships with the staff who supported them. Relatives said that staff provided compassionate care and were kind and caring. The atmosphere in the service was calm and relaxed and staff spoke to people in a respectful yet friendly manner. Staff understood the importance of maintaining confidentiality and of respecting people’s privacy and dignity.

The service manager provided good leadership for the service. People and their relatives had opportunities to give their views about the care they received and told us that the service manager responded appropriately to any concerns they raised. People who had complained in the past told us the provider had responded well to their complaint. Staff told us they had opportunities to express their views and raise any concerns they had.

The provider had implemented an effective quality assurance system to ensure that key areas of the service were monitored effectively. Records relating to people’s care were accurate, up to date and stored appropriately. The service had established effective links with relevant health and social care agencies and worked in partnership with other professionals to ensure that people received the care they needed.

We spoke to six people who used the service and four members of staff. We observed the interactions between staff and the people who used the service. We did this for the people who we were unable to verbally communicate with.

All the people we spoke with said they were happy living there. One person said 'Staff work really hard here, and they really help people. My medical condition has improved with their help.'

People told us that staff asked their permission before doing things for them. One person said 'They have to have my permission to go into my room. They never do anything I don't want them to.'

We saw that assessments of people's needs had been carried out. Where people's needs changed the plans had been reviewed. We saw that risks had been identified to protect the welfare and safety of people.

We looked around the house and saw that it was clean and tidy. People who used the service told us they were happy with the standards of cleanliness.

Staff told us that they felt supported to do their job. Staff received regular training and supervision to ensure they met the needs of people who lived there.

The complaints procedure was available to people who used the service in an easy read format. All the people we spoke with said they had never felt the need to complain, but if they did they thought the manager would listen to what they said.

During our visit we spoke with two people who use the service and four members of staff who were on duty (including the registered manager). We also spoke to two visiting activity workers and a pharmacist.

We saw written comments from relatives. Examples included 'Everything we see and know about the home is excellent.' And 'I and my family greatly appreciate the welcome we receive when we visit and the friendliness of all the staff.' All the written comments we saw from relatives were positive.

We spent time observing people who we were unable to verbally communicate with to see how staff interacted and supported them. We saw staff treating people with respect and involving them in activities throughout the time we spent at the service.

Two people told us that 'The staff here are lovely.' They also told us that 'The food is good and I get a choice of what I want to eat.'

Two visiting activity workers told us that 'Staff are always there to help and support people when we visit.' A pharmacist told us 'I am more than happy with this service' and that they were 'Impressed with the work the manager and staff did'.

We looked around the location and saw bedrooms, communal areas, bathrooms and toilets were clean and free from unpleasant odours.