Monread Lodge

Monread Lodge is a residential care home providing accommodation and personal and nursing care to 54 people at the time of the inspection. The service can support up to 62 people.

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

There had been a high number of skin tears, both explained and unexplained. Additional training had been provided and these were reported appropriately but we found these numbers had yet to reduce. Pressure care was not always managed safely as mattresses were not always set correctly and repositioning was sometimes missed.

People living with dementia were not always supported swiftly or in a way that reduced the risk of distressed behaviours. Staff had received training and, in most cases observed, were kind and attentive, but this was not consistent.

People’s medicines were managed safely, staff had been trained and audits were in place. We found systems did not always ensure records were accurate, this was addressed on the day of our visit. We also found the morning round was still taking a long time to complete. A plan was put in place to address this.

Management systems did not ensure these issues were identified or managed. There were monitoring and quality processes in place, but these had not ensured consistent safe practice throughout the home.

People told us they were happy and felt safe, and staff were kind. Relatives gave mixed views about the care and support provided. Care plans were in place and staff knew people well. People were supported to eat well, dietary needs were catered for.

Individual risks were assessed. Infection control measures were followed. People told us there were normally enough staff to assist them as needed, relatives gave mixed views. Staff told us there was enough of them to meet people’s needs. Staff received training and regular supervision. They felt well equipped for their roles.

People, relatives, and staff were positive about the registered manager and how the service was run. There were regular meetings to share feedback and obtain views.

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 information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

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.

Rating at last inspection

The last rating for this service was good (published 22 February 2023). The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

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

Improvements had been made to the quality of the service provided since our last inspection. Risks to people’s health and care needs were assessed and documented. Oversight by the management team had been embedded within the day to day management and identified where improvements were required. However, some records required additional information to fully describe the support people required or explain fully decisions made on their behalf.

Staff supported people in a kind and compassionate way, considering their dignity and privacy. People were supported by enough staff who met their care needs in a timely way. People told us they were safe and suitable arrangements were in place to protect people from abuse and avoidable harm. Learning from incidents and accidents was in place and where incidents occurred people had their care plans reviewed to prevent future incidents where possible. People received their medicines as prescribed and infection prevention control procedures were robust.

The staff team was committed to providing good care. They had undertaken training so that they were skilled and knowledgeable to effectively meet people's needs with further developments planned to further support this approach. People were supported to access healthcare services when needed and staff worked in partnership with health professionals to meet people’s needs.

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.

People and their relatives told us the service was well-led. Quality assurance arrangements enabled the provider and registered manager to monitor the quality of the service provided and staff performance. There was a positive culture throughout the service. Staff told us they enjoyed working at the service and felt valued.

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

Rating at last inspection

At the last inspection we rated this service requires improvement. The report was published on 17 March 2022.

Why we inspected

This inspection was prompted by a review of the information we held about this service. This report only covers our findings in relation to the key questions of safe, effective and well led.

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.

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 requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Monread Lodge is a purpose-built residential care home with nursing. It is registered to provide accommodation with personal and nursing care support for up to 62 people, some living with dementia. It is also registered to provide treatment of disease, disorder or injury. At the time of our inspection there were 39 people using the service.

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

Improvements had been made to the quality of the service provided since our last inspection. There was an improved organisational oversight from the management team. Audits were undertaken to monitor the quality of the service provided and meetings held to review, discuss, learn and act following an accident, incident or near miss. However, some records held within the service were not always accurate and up to date. This meant that the improved governance system had not yet been fully embedded as improvements to records held were still needed.

Staff now knew the people they supported well and were knowledgeable about individual people’s known risks. Staff demonstrated how they used their improved knowledge when assisting people, in line with people’s wishes and choices. However, people’s records held within the service did not always match staff’s knowledge. Some records were not always accurate and up to date to guide staff, particularly new staff or agency staff.

There were now enough suitably trained and knowledgeable staff to help support people in a timely manner. This was an improvement from our last inspection. Improvements when inducting new staff to the service had been put in place. Staff had received further training since our last inspection including positive behaviour support training to help support people with complex behaviours. Potential new staff to the service had a series of checks carried out to try to make sure they were suitable to work with the people they supported. Again, the records to evidence this were not always accurate and up to date.

Staff had improved their infection prevention and control practices in line with government guidance since the last inspection. This helped reduce the risk of cross contamination within the service.

Staff demonstrated a much better understanding of how to report safeguarding concerns promptly. The registered manager and provider were now open and transparent with people’s family and friends when an incident, accident or near miss had occurred. People and their relatives told us communication was good and they felt listened to. Lessons were learnt and shared with staff when improvements were needed to help reduce the risk of incidents recurring.

Staff supported people to take their prescribed medicines safely. Staff worked with external health professionals. This helped make sure people received joined up care and support. People and their relatives were asked to feedback on the service provided by staff. Suggested improvements were acted upon wherever possible.

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 21 December 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 this inspection we did not inspect all the breaches of regulation. We found improvements had been made in the majority of the breaches of regulation that we inspected. However, there remained an ongoing breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service has been in Special Measures since 21 December 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was also prompted in part due to concerns received about poor moving and handling, staff not following professional advice and unsafe use of bedrails. We also received concerns about a lack of reporting incidents and incidents occurring between people, high use of agency staff and infective actions of management teams. These were similar concerns we found in the previous inspection. A decision was made for us to inspect and examine those risks to ensure the provider was making the necessary improvements as they detailed in the action plan, they sent to us. 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 inadequate 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 COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

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

Enforcement

We have identified a continued breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection. Improvement had been made at this inspection; however, it was too soon to demonstrate that improvements to the governance systems in place were robust and had been fully embedded.

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 monitor the service and will take further action if needed.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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 carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 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 care service.

Service and service type

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

The service had a manager registered with the Care Quality Commission. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced. We visited the service on 08 and 15 September 2021.

What we did before the inspection

We spoke with 14 relatives about their experience of the care provided. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection

We spoke with three people who used the service about their experience of the care provided. We spoke with 11 members of staff including, nurses, care staff, housekeeping, kitchen staff, the registered manager, deputy manager and two senior managers for the provider.

We reviewed a range of records. This included eight people’s care records, accident and incident records and multiple medication records. We looked at records relating to the management of the service including audits, meeting minutes and the service improvement plan. We provided feedback to the registered manager and senior management team on 24 September 2021.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We referred our findings to the local authority commissioning team.

The inspection took place on 21 and 22 November 2018 and was unannounced. At our last inspection on 25, 27, 29 September and 9 October 2017, the service was found not to be meeting the required standards in the areas we looked at. There were breaches against regulations of the Health and Social Care Act (Regulated Activities) 2014.

The breaches included regulation 9. Care and treatment of service users did not always meet their nutritional needs.

Regulation 12. The provider had not ensured people’s changing needs were reviewed and actions put in place to mitigate risks.

Regulation 13. The provider had not ensured all incidents had been reviewed and investigated to ensure people were safe.

Regulation 17. The provider had not ensured effective systems to monitor and improve the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions in safe, effective, caring, responsive and well-led to at least good. At this inspection we found that the provider had made the improvements required.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

The service was safe. Staff received training in safeguarding and understood how to report concerns. Recruitment practices ensured that suitable staff were employed. Accidents and incidents were monitored to identify any trends or patterns to ensure appropriate actions could be taken. Identified risks to people were reviewed regularly to ensure people’s changing needs and risks were managed. Medicines were managed safely by staff that received appropriate training. People were protected from the risk of infections by staff who followed correct infection control procedures.

The service was effective. People’s nutritional needs were managed appropriately. Staff received training to meet people’s needs effectively. Staff had inductions and supervisions and were supported to do their job. Staff worked in line with the principles of the mental capacity act. People’s care was reviewed regularly.

The service was caring. Staff knew people well and staff cared for them in a compassionate way. Staff respected people’s privacy and dignity and supported people to maintain relationships. Staff delivered care that was supportive, kind and caring. People were involved in deciding how their care was provided and staff promoted their choice.

The service was responsive. People received person-centred care. People`s needs were assessed to ensure they received the support they required. People were involved with their care plan reviews. People were given the opportunity to think about what was important to them regarding end of life care. People had a voice and the opportunity to discuss and raise concerns.

The service was well-led. The registered manager was very clear about their vision regarding the purpose of the home. Staff understood their roles and responsibilities and worked well as a team. There was an open culture and staff felt they could approach the management team at any time. There were effective systems to monitor the quality of the service, identified issues were actioned and lessons learned. People, relatives and staff were positive about how the home was run.

Further information is in the detailed findings below.

This inspection took place on 25, 27, 29 September and 09 October 2017 and was unannounced.

When we last inspected the service on 11, 12, 15 and 24 May 2017 the provider was not meeting the required standards in all of the areas we looked at. We found breaches of the regulations in relation to providing safe care and treatment, staffing levels across the home, and ensuring governance systems were effectively operated to monitor the quality of the service provided.

At this inspection we found that some improvements had been made, however there were areas that continued to require improvement, particularly in relation to the safety and wellbeing of people using the service and the service being well led. Following this inspection we referred our concerns to the local authority commissioning and safeguarding teams, and told the provider they must improve the quality of care people receive.

A registered manager was not 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 at the time of inspection was supported by three interim managers, the regional manager and a senior manager.

People felt safe living at Monread Lodge. Staff were knowledgeable in relation to keeping people safe from harm and reporting incidents to management, however some incidents were not consistently reported and investigated. Staff awareness of people's current needs had improved however we found this was at times conflicting due to incomplete care records. People were supported by sufficient numbers of staff. People's medicines were managed safely and medicines were administered to people as the prescriber intended.

People told us they enjoyed the food provided, however, those people with specific dietary needs did not always have their needs met. Staff sought people’s consent prior to supporting them, however records did not always accurately record people’s consent to care and treatment. Staff told us they felt supported by the management team, and were receiving training and supervision in key areas. People were supported by a range of health professionals when their needs changed.

The consistency of involving people in their care was variable; however staff supported people in a kind and compassionate way. Staff were observed to have developed positive and caring relationships with people who lived at the home. When personal care was provided, this was carried out in a respectful way that promoted people's dignity but did not always take account of their needs and wishes.

People did not consistently receive support that met their changing needs and took account of their preferences and personal circumstances. People were able to pursue their individual interests; however there were not always sufficient opportunities for people to take part in meaningful activities. People and their relatives knew how to raise concerns and were kept informed regarding changes within the running of the service.

Improvements had been made to monitor and improve the quality of care people received by reviewing the systems used. However, these were not always consistent in identifying areas for improvement or maintaining these. We saw action plans were developed to support and drive improvement across the home, however at the time of inspection it was too early to measure their effectiveness and this will be further reviewed. People’s care records, although being reviewed continued to require additional work to ensure these were accurate.

The home had a registered manager in post. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The inspection took place on 11, 12, 15 and 25 May 2017. This inspection was in response to concerns we received regarding low staffing levels in the home. The inspectors arrived early in the morning of 11 May 2017 to inspect the service unannounced. On 12 and 15 May 2017 we contacted people’s relatives by telephone, and on 25 May 2017 we met with the provider to seek assurances due to the nature of the concerns identified at this inspection.

At our previous inspection on 18 October 2016 we found a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people were not supported by sufficient numbers of suitably trained and skilled staff.

At this inspection we found improvements had not been made in areas relating to safe care and treatment, staffing levels, and governance systems to ensure the service provided was safe and of good quality. At this inspection we found a continued breach of Regulation 18, and new breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to safe care and treatment, because people were not supported by sufficient numbers of staff deployed, and ineffective governance systems were in place to identify and improve the quality of care people received.

Following this inspection we referred our concerns to the local authority commissioning and safeguarding teams, and told the provider they must improve the quality of care people receive.

People were not supported by sufficient numbers of staff. Staff did not respond promptly when people required assistance. Staff were knowledgeable in relation to keeping people safe from harm and reporting incidents to management, however patterns were not always robustly investigated and responded to quickly. Staff were not consistently aware of people's current needs and how to keep people safe from the risk of harm. People's medicines were not consistently managed safely and we found an incident where one person had not received their medicines as intended by the prescriber.

Relatives and staff told us the registered manager was not responsive to concerns raised with them and was not visible around the home. People’s relatives told us they did not raise issues or concerns with the registered manager for fear of repercussions and previous lack of action from them. Governance systems were available to the registered manager to use to monitor the quality of care provided, however they were not effectively used. Continual concerns regarding staffing levels raised at the previous inspection and subsequently by staff, people and relatives had not been addressed. People’s records were not reflective of their current change of needs.

Monread Lodge is registered to provide accommodation for up to 62 people. The home provides support with personal care and nursing care for older people, some of whom live with dementia. At the time of the inspection there were 60 people living there.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

People received care that met their needs. However, people, relatives and staff all told us that staffing was an issue. On the day of our inspection we noted people had their needs met in a timely fashion in the main part of the house, however, in the smaller unit there was a delay in people receiving support. People were supported by staff who had undergone a robust recruitment process and were sufficiently trained and supervised. .

People’s medicines were managed safely and individual risks were assessed and monitored. People were supported in accordance with MCA and DoLS, were given choice and involved in the planning of their care. People had a choice of healthy food and received support to eat as needed.

There was regular access to health and social care professionals and communication in the service was effective. People were treated with dignity and respect. They told us staff were kind. Confidentiality was promoted.

People had their own care plans which gave staff clear guidance. Activities on offer supported hobbies and interests.

People, their relatives and staff were positive about the management of the service. Staff enjoyed working at the service and people liked living there. There were systems in place to identify and address any issues and the registered manager was enthusiastic about looking for ways to improve the service. Complaints were investigated and responded to and people's feedback was listened to.

People were provided with food and drink prepared according to their individual needs. People also experienced kind and stimulating interaction with staff members. The risk of people developing pressure ulcers was assessed and care plans were in place that were followed by staff in order to manage this risk. One person who was being nursed in bed told us, 'They change my position every now and again when I feel uncomfortable.' Another person said, "There is nothing I am unhappy about, they are always accommodating."

The number of staff on duty at all times was in accordance with the provider's guidance on staffing requirements. There were sufficient staff on duty during lunchtime to ensure people's nutritional needs were met. Call bells were answered on time showing that there were enough staff to respond to people if they summoned help.

We looked at people's food and fluid monitoring charts and found they were accurate and fit for purpose. One person said, "The nurses write down everything I drink."

We saw that people's care and treatment was planned according to their specific needs. We also saw that care in the dementia unit promoted people's cognitive abilities and orientation.

People had plenty to eat and drink and their dietary choices and needs were respected. Nutritional risk assessments were effective.

Medicines were appropriately stored and administered. Staff at the home were utilising a new, simplified and effective medication system.

There were arrangements in place to ensure that there were sufficient skilled and experienced staff employed throughout the day and night.

People's records were stored securely and accessible to staff that needed them. People's records were generally completed diligently and were fit for purpose.

People's care and treatment was delivered in accordance with a care plan that arose from an assessment of need. One person said, 'I get everything I need here, never want for anything.' Another person said, "I am lucky to be here."

The care of people living on the dementia unit reflected research and guidance and the environment and treatment enhanced people's cognitive abilities and orientation.

People's rights in relation to their capacity to make decisions about resuscitation were not protected because the assessment and documentation used to make 'best interests' decisions was not robust or in line with good practice.

People were otherwise safe because staff at the home could identify abuse and could respond if abuse was suspected or alleged.

Staff were supported by an ongoing training schedule and an effective supervision process. However, there was insufficient qualified nursing staff to meet people's needs.

People were able to provide feedback to the provider about the service and there was an effective system to regularly assess and monitor the quality of service.