Archived: Alston Lodge Residential Home Limited

Alston Lodge Residential Home Limited is a care home that was providing personal care and accommodation to 13 people aged 55 and over at the time of the inspection. The service can support up to 16 people some who may be living with dementia, physical or mental health needs.

People’s experience of using this service

People and their relatives told us that they received safe care and treatment. They spoke positively about the care and support provided. The registered manager had reported safeguarding concerns to the local authority. However, the reporting procedures were not robust to ensure all safeguarding concerns were reported to allow independent investigations. Our findings showed improvements were required in a number of areas to ensure the care delivered was consistently safe, reliable and person-centred.

The registered manager had assessed people’s needs and, in some cases, provided staff guidance on how these needs were to be met. However, this was not consistent as we found three people had no care plans and people who had experienced falls and people who received medicines covertly did not have care plans for this. This meant staff did not have adequate guidance on meeting people’s needs effectively. Care records were generic and not person-centred. We made recommendation about care planning.

People did not always receive their medicines in a safe and effective manner. Practices for the management of covert medicines and ‘as required’ medicines were not robust. In addition, medicines storage practices and medicine records had not been managed in line with best practice and national guidance.

Staff showed a good understanding of their roles and responsibilities for keeping people safe from harm. Staff showed a motivation to deliver care in a person-centred way. However, individual risks to people and the environment had not been adequately monitored to minimise the risk of avoidable harm re-occurring. People were not adequately observed for injuries that may appear after a fall and the provider did not show how they had learned from incidents, events or near misses in the home. The registered manager and the provider had maintained the premises and any faults were timely rectified.

Staff supported people to have maximum choice and control of their lives however staff’s understanding of mental capacity principles needed improvements. Consent records were signed by family members without mental capacity assessments to show why people could not consent on their own. Some authorisations for restrictions on people’s liberties had been considered or applied for where required. However, we found up to four people who required applications for authorisation did not have this in place. The registered manager took action after our inspection.

Staff had received a range of training and support to enable them to carry out their role safely. This included the care certificate. However, staff training arrangements at the home needed to be reviewed to ensure staff were provided training by a recognised and competent training provider and to ensure training arrangements were consistent with best practice. We made a recommendation about staff training.

Governance arrangements were in place to monitor and improve the care delivered. However, we found the audits and quality checks had not been adequately implemented to support the registered manager and the provider in identifying shortfalls.

The provider had made improvements to the staffing levels since our last inspection. They had also made improvements to ensure people were supported with meaningful day time activities.

People received support to maintain good nutrition and hydration and their healthcare needs were understood and met.

People were not adequately supported with to discuss their end of life preferences. We made a recommendation about end of life care planning.

People and family members knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly. Previous complaints had been dealt with appropriately.

The leadership of the service promoted a positive culture within the staff team. People, family members and staff all described the registered manager as supportive and approachable. The registered manager showed they were committed to improving the service and displayed knowledge and understanding around the importance of working closely with other agencies and healthcare professionals where needed.

Rating at last inspection

At the last inspection the service was rated requires improvement (published 11 April 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

At the last inspection the provider was in breach of regulations because they had not provided adequate numbers of staff and people were not supported with meaningful day time activities.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider is no longer in breach of these two regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the management of risks to people’s health and well- being including the management of falls, safe management of medicines. We also found breaches in relation to seeking authorisations for care that involved restrictive practice. We have also made recommendations in relation to person centred care records and the environment at this inspection.

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

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. In addition, 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 with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

Alston 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.

Alston Lodge is registered to provide accommodation for up to 17 people who require 24-hour care. At the time of our inspection, 15 people were living at the home. The premises are an adapted house near Longridge. Accommodation is provided over two floors, with a stair-lift for access between floors.

At the last inspection in March 2017, we found the provider was not meeting legal requirements in relation to Good governance. At that inspection, we rated the service ‘Requires Improvement’.

During this inspection, we checked and found the provider had made improvements in respect of good governance.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found staffing levels were in breach of legal requirements of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, because the provider had not ensured a sufficient number of staff were deployed at all times.

We found the provider had not ensured activity provision at the home met people’s needs and reflected their preferences. This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found the detail in people’s written plans of care was not always sufficient. Staff were able to confidently describe the steps they took to ensure people’s needs were met, but important detail was not always recorded. We have made a recommendation about this.

Records we reviewed showed people or, where appropriate, others acting on their behalf had been involved in care planning and review, but not in all cases. We have made a recommendation about this.

We found confidential personal information was not always stored securely when not in use. We have made a recommendation about this.

Senior staff carried out audits and encouraged people to share their views on their experiences of the service. This helped to ensure the quality of the service was assessed and monitored regularly. However, these systems had not identified the shortfalls we identified during this inspection. We have made a recommendation about this.

We found the service had safe practices with regard to managing medicines. Staff who administered medicines had all been trained to do so safely.

Staff had assessed risks to individual people and risks posed by the environment. Plans to lessen risks had been developed. These had been kept under review and updated accordingly.

People told us they felt safe living at the home. The provider had systems to protect people against the risks of abuse or unsafe treatment. Staff we spoke with were aware of procedures to follow in order to help people to keep safe.

The service followed a robust recruitment process which helped to ensure only people of good character were employed to work at the home.

Staff had received training around the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. However, we found the service had not assessed people’s capacity in line with the MCA. By the third day of our inspection the provider had implemented new documentation to record assessments of people’s capacity.

People’s needs were met by a well-established and trained staff team. Staff received a good level of support from the management team.

People we spoke with told us staff were kind and caring. Staff respected people’s privacy and dignity. People were treated as individuals and enabled to maintain as much independence and control as possible.

The service sought guidance and advice from external professionals when necessary, in order to ensure people’s ongoing health needs were met.

The provider had a complaints policy. People knew how to make a complaint or raise concerns and felt they would be listened to. People told us they felt any concerns would be dealt with appropriately.

The service addressed people’s wishes and preferences for care at the end of their life. Staff had received training in order to provide people with a good standard of care in their final weeks and days.

People we spoke with and staff told us they felt the home was well-led. They told us the registered manager was approachable and willing to make time to listen to people.

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

At the time of inspection there was a manager who was registered with the Care Quality Commission. 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.

We last inspected Alston Lodge Residential Home Limited on the 07 December 2015. We identified several breaches of regulation. We found person centred approaches were not in place when people had behaviours which may challenge, risks to people who lives at the home were not always identified and action taken to minimise these risks. We also found people were not safeguarded from potential abuse as incidents were not always reported to the local safeguarding authorities and quality assurance systems had not identified the need to ensure referrals to safeguarding authorities were made promptly when required.

At the last inspection on the 07 December 2015 we asked the registered provider to take action to make improvements. We were provided with an action plan which detailed how the registered provider intended to ensure improvements were made.

We undertook this comprehensive inspection to check they had followed their plan and to confirm they now met legal requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Alston Lodge Residential Home Limited on our website at www.cqc.org.uk.

During this inspection carried out on the 17 November 2016 we found some improvements had been made. Staff told us they had received training in person centred care to enable them to support people with individual needs. We viewed care documentation which recorded the support people required and people told us they were involved in the planning of their care. We saw evidence referrals were made to the Lancashire safeguarding authorities if these were required and these were documented to ensure accurate records were kept.

We found improvements were required to ensure medicines were managed safely. We have made a recommendation regarding this. We also identified concerns with some of the safety checks carried out at the home. The gas safety certificate had not been completed annually and there was no Legionella risk assessment in place to minimise the risk of legionella developing in the water system at the home. We discussed this with the registered provider who took action. Prior to the inspection concluding the registered provider wrote to us. They informed us they were in the process of ensuring a legionella assessment was carried out. They also provided documentation to evidence the gas equipment had been checked for safety. It was a concern to us these issues had not been actioned prior to the inspection. We considered improvements were required to ensure an effective quality monitoring system was in place which assessed, monitored and mitigated risks. This was a continued breach of Regulation 17 (Good Governance.)

Recruitment checks were carried out prior to a staff member starting work at the home. We found sufficient staff were available to meet peoples’ needs and training and development activities were available to ensure staff skills remained up to date. Staff told us they received supervision from the registered manager. We saw documentation which confirmed this. We noted this did not allow for the recording of any further actions. We have made a recommendation regarding this.

During the inspection we saw people were supported promptly and with patience and kindness. Care records reviewed contained sufficient information to enable staff to deliver care and support which met peoples’ needs and wishes.

People told us they were happy with the meals at Alston Lodge Residential Home Limited. Comments we received included, “The food’s lovely. I get a second helping if I want one.” We saw documentation which evidenced people’s weight was monitored. Staff told us if they had any concerns regarding a persons’ weight management they would seek further medical advice.

We saw individual risk assessments were in place and written plans were developed to manage associated risks. Staff were knowledgeable of peoples’ assessed needs. We noted one risk assessment had not been reviewed since August 2016. We have made a recommendation regarding this. People who received care and support and their relatives told us they were happy with the care provision from Alston Lodge Residential Home Limited.

We viewed documentation which showed people were supported to access other health professionals if this was required and this was confirmed by speaking with staff and their relatives.

People told us they were supported to take part on activities at Alston Lodge Residential Home Limited. One person commented, “Singers come in sometimes, that’s always a good time.”

There was a complaints policy available to people who received care and support. People told us they were confident any complaints would be addressed.

You can see the action we told the provider to take on the full version of the report.

Although risks assessments had been undertaken, the actions to minimise the identified risks had not been undertaken. People were protected from abuse by systems in place; however, staff required further training in all the service’s safeguarding policies and procedures. The provider had robust recruitment procedures in place, with a sufficient number of staff and skill mix, however, not all the records relating to safe recruitment were in place. People's medicines were managed by staff who had the competency and skills to administer medication safely. There were sufficient numbers of trained staff deployed to ensure that people had their needs promptly. This was regularly reviewed and adapted to reflect people’s changing needs.

The managers understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. People’s liberty was not unnecessarily restricted and people were fully supported to make choices about their day to day lives. When people had specific physical or mental health needs and conditions, the staff had contacted healthcare professionals and made sure that appropriate support and treatment was made available. Staff understood how to support people who had or did not have capacity to make decisions for themselves. Staff were trained and effectively supported through supervision. People were given choices about food and received a balanced diet. Drinks were available, and support was given when required.

Caring relationships were developed; however, some institutionalised practice meant that some people were not always treated with kindness and respect. We have made a recommendation about this. When practices such as these are identified, staff should have the ability to raise them as a concern and measures put in place find more appropriate person centred approaches. Staff interacted well with people living at the home. People were able to express their views by being involved in discussions, with staff and family members.

Person centred approaches must be adopted when supporting people with behaviour management concerns and needs. People had access to activities that reflected their interests. Further discussion with people at the home regarding the development of the activities programme should take place. We have made a recommendation about this. Resident and relatives knew how to make a complaint and told us they would be comfortable to do so.

There were quality assurance systems in place which monitored people’s well-being and safety, however, in some instances, these were ineffective, and therefore, people were put at risk. Although systems were in place for recording and managing complaints; safeguarding concerns and incidents and accidents were not always referred onto the most appropriate social care agency as required. .

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to Safe Care and Treatment, Person Centred Care, Safeguarding people who use the service and Good Governance.

You can see what action we have taken at the end of this report.

'I've got no complaints at all.'

'The food is always good and they are on hand for anything you need.'

'I find them all very obliging.'

'I am happy with the way I'm looked after. They are very, very nice here.'

We observed residents who appeared to be enjoying listening to music and having a chat with staff. All appeared settled and contented and seemed to enjoy the company of staff.

We looked at standards in relation to the care and welfare of people who used the service and arrangements for gaining their consent for care and treatment. We also assessed processes for ensuring that the home was maintained in a clean and hygienic manner. Areas relating to the selection and recruitment of staff and monitoring standards and quality within the home were also inspected. We did not identify any concerns and found the service to be compliant in all areas inspected.

'They are very kind and friendly.'

'They are lovely company, very friendly.'

'The food is grand ' they put some fair meals on here.'

'I am well looked after.'

We also spoke with a visiting relative, who expressed satisfaction with all aspects of the service and commented, 'They are the best. We are very happy with the way they look after (name removed).'

During the inspection we looked at standards including how the provider involved people in the running of the service and promoted their care and welfare. We also looked at staff training and processes for monitoring quality. We found that the service was compliant with the majority of areas we looked at, although we identified a minor concern in relation to quality assurance.