Thistley Lodge

Thistley Lodge is registered to provide nursing and personal care for up to eight people who have a diagnosed mental health condition. At the time of our inspection visit there were five people living at the home. Care is provided across two floors and communal lounge and dining areas were located on the ground floor. People’s bedrooms were not ensuite so people used communal bathrooms located on each floor.

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

Since the last inspection visit, the registered manager had changed. The new manager had been in post since February 2019 and became CQC registered manager on 29 April 2019. The provider had begun to improve their internal audit systems. The provider’s internal quality assurance teams had completed audit visits against the providers action plan to improve the quality of care people received. However, some records of completed audits and the actions taken required closer scrutiny and monitoring. Fire risk assessments needed to be updated and time is needed for the quality assurance system to become embedded in normal practice to show its effectiveness and sustainability.

Staff said the registered manager and nurse were visible, approachable and supportive. Staff said changes over the last few months were for the better. Staff felt they worked better as a team which helped ensure people received the physical and emotional support they needed. The registered manager was working with other organisations and healthcare professionals to improve outcomes for people.

The provider used agency staff to support their own staff whilst recruitment continued. Staff said agency use was limited and the provider used the same agency staff for consistency which helped people feel more relaxed with those staff providing their care.

There were sufficient numbers of care staff on duty to keep people safe from risks of harm. The nurse used staff dependency tools to ensure staffing levels continued to meet people’s needs. The registered manager and deputy manager could support staff on the floor if emergencies happened.

Staff training had improved since our last visit. Some staff had completed training and further training sessions were planned to ensure staff’s skills and knowledge continued to be refreshed. Staff understood their roles and responsibilities, such as safeguarding people from poor practice. Staff told us they were confident to record poor care and if no action was taken, staff were more confident to refer onwards to safeguarding teams and to us.

People’s dietary needs, preferences and nutritional needs were assessed and known by staff and when needed, people were referred to other professionals to support their healthcare needs. Some people had their food and fluid intake monitored and further improvements were needed to ensure those records were of value to determine next steps.

People received their medicines safely from trained and competent staff. Nurse staff completed regular checks on stocks, administration and storage to ensure medicines were given safely and as prescribed.

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

Rating at last inspection and update

This service has been in Special Measures since 11 December 2018. People who use adult social care services have the right to expect high-quality, safe, effective and compassionate care. Where care falls below this standard and is judged to be inadequate it is essential that the service improves quickly for the benefit of people who use it. Special measures will give people who use the service the reassurance that the care they get should improve.

Following our last Inspection in December 2018 where the provider had numerous breaches of the Health and Social Care Act, the provider completed an action plan after the last inspection to show what they would do and by when to improve. We took enforcement action which included imposing conditions on their registration to restrict admissions to the service while the provider took measures to improve the quality of service.

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 and the provider was no longer in breach of regulations.

The last rating for this service was Inadequate (published 5 April 2019).

Why we inspected

This inspection was based on the rating at the last inspection. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions Safe, Effective, Caring, Responsive and Well Led.

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our 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

Thistley Lodge is registered to provide care for up to eight people. At the time of our inspection there were five people living at the home. The inspection was prompted by the notification of an incident following an investigation by the provider and safeguarding authorities. This incident is subject to a police investigation and as a result at this inspection we did not examine the circumstances of the incident. However, the information shared with CQC about the incident, indicated potential concerns about the management of risk and people’s safety.

Our inspection looked at whether people’s care was managed safely and that staff had the right level of competency and skill. When the investigation is concluded we will consider any further action we may take.

At our previous inspection in December 2017 we had rated the home as ‘Good’ overall, with ‘Requires Improvement’ in Well Led. This was because the provider’s audit system was not effective and there was a lack of audits and checks for us to review. In some cases, audits were not made available to us. In addition, there was no registered manager at the home. At this inspection we found there had been significant changes in how the home was run which had adversely affected the quality of care people received. We have rated the home ‘Inadequate’ in Safe, and Well Led, and ‘Requires Improvement’ in Effective, Caring and Responsive. This meant the service was rated ‘Inadequate’ overall.

There was a registered manager employed at the home at the time of our inspection visit who was registered with CQC to manage two care homes owned by the provider. However, the registered manager was also overseeing two additional homes for the provider, and so only spent up to two days per week at the home. 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.

Although people told us they enjoyed living at Thistley Lodge, senior staff were not always trained and supported in how to recognise and report safeguarding concerns. The provider did not always report and act on safeguarding concerns to ensure people were always cared for safely and risks to people were effectively managed.

Staff with the required skills and competencies were not always available to respond to people’s health needs and keep people and staff safe. Risks to people were not always properly assessed. Care plans did not provide sufficient information for staff to support people safely and minimise risks to their health and wellbeing.

Some care plans and risk assessments contained important health information and advice, which was not followed, to ensure staff provided consistent support that met people’s changing needs. People did not always receive support to maintain their health, where it was required.

Care plans were not effectively reviewed to ensure staff had the necessary and up to date information to support people as their needs changed. People’s care records did not always describe to staff how to support people with their communication needs.

People were not supported in line with the requirements of the Mental Capacity Act 2005 (MCA). Mental capacity assessments were not completed and best interest’s decisions were not recorded for scrutiny and oversight. Legal advocacy arrangements were not checked to ensure people’s rights were protected under the MCA.

Staff did not have all the skills they needed to support people safely and effectively. The provider had ineffective systems to monitor staff training had been completed.

Systems to assess the quality of the service provided were not always effective because improvements had not been identified, sustained and fully implemented. Some risks associated with the management of medicines and people’s care and treatment had not been identified because effective checks were not undertaken. Accidents, incidents and safeguarding concerns were not always learned from to prevent further incidents from happening.

There was a lack of management oversight by the provider and registered manager to check delegated duties had been carried out effectively. Checks were not regularly reviewed or records completed that showed what, if any, improvements had been made.

The provider’s governance and oversight lacked close scrutiny. The registered manager accepted their lack of support and regular attendance at the home had impacted on the focus and improvements that were required. Several shortfalls in how people were protected from abuse were identified by the provider, yet the culture at the home continued to put people at risk, which meant the service people received fell below the provider’s expected standards. The provider’s representative, Associate Director for Nursing, Safety and Clinical Services agreed that the levels of care and support people received was not what the organisation wanted.

Care records were kept securely in the registered manager’s office. However, at the time of our visit we received information that suggested people’s personal details may have been shared inappropriately. The provider is investigating this incident and had agreed to tell us the outcome of their investigation and findings.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special Measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

Thistley Lodge is a mental health nursing home, which provides care for up to eight people over two floors. At the time of our inspection there were five people living at Thistley Lodge. During our inspection visit, a person was spending the night at Thistley Lodge because they were planning to move there permanently from January 2018. This person wanted to make sure they enjoyed living there, before making a commitment. This increased the occupancy to six people during our visit.

People in care homes receive accommodation and nursing and/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.

A requirement of the service’s registration is that they have 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was no registered manager in post. The registered manager had left the service in September 2017. Since then a manager has been in post, and in December 2017, they had applied to become the registered manager at the home.

At the last inspection in November 2016 the service was rated ‘Good’ overall. At this inspection we found the service remained ‘Good’ overall.

People and relatives were pleased and satisfied with the quality of care provided. People were encouraged to make their own decisions about how they lived their lives, such as receiving their care and support in line with their expressed wishes and goals.

People were supported to remain as independent as possible so they could live their lives as they wanted. People made choices about what they wanted to do for themselves, such as what to do, where to go and what to wear. People were encouraged to maintain important relationships with family and people built friendships with people at the provider’s other home close by.

Care plans contained supportive information for staff to help them to provide the individual care people required. For people assessed as being at risk, care records included information so staff knew how to minimise risks to those in their care. Staff knew how to support people to minimise identified risks and staff knew what action to take if people did not follow their risk management plans.

Staff knew how to keep people safe from the risk of abuse. Staff and the clinical lead nurse understood what actions they needed to take if they had any concerns for people's wellbeing or safety. The provider safeguarded some people’s finances to reduce potential for financial loss

Staff understood people’s individual needs and abilities which meant they provided care in a way that helped keep people safe. Staff received essential and regular training to meet people’s needs, and effectively used their skills, knowledge and experience to support people.

People’s care and support was provided by a caring and consistent staff team. People told us they felt safe living at Thistley Lodge because they got on well with each other and the staff team. People said it felt like a big family. Relatives were complimentary about the staff team and that they did what they could to help people promote their family members independence.

Staff worked within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity, staff’s knowledge ensured people received consistent support so the right decisions and outcomes were made. Care records included the support people needed if they lacked capacity. Staff told us and we saw, they sought people’s consent before they provided care and support.

People were supported and encouraged to hobbies and leisure interests to keep them active and to have fulfilling lives. People and staff worked together to achieve goals that people had set which helped promote their social skills and lifestyle choices.

Most people prepared their own meals and did their own food shopping. Staff supported people to ensure they maintained a balance diet.

People received support from other healthcare professionals and some people made their own health appointments. Some people took responsibility for their own medicines management while staff supported others. Regular checks and monitoring ensured medicines were given safely and as prescribed.

The manager was not available during our inspection visit. We looked at examples of audits and checks they completed that assured them and the provider, people received a safe, responsive and effective service. Some identified actions were not always recorded as completed, which made it difficult to know if improvements had been made. People’s feedback was sought so they had an opportunity to feed into how the service was provided.

The provider had not submitted a Provider Information return (PIR) because of internal communication issues which have now been addressed to prevent this from happening in the future. The provider displayed a copy of the report, but had not displayed a rating poster. Immediately following our inspection visit this was rectified.

Further information is in the detailed findings below.

We found people and advocates were involved with providing their consent regarding the planning of care of people using the service. On the day of our inspection we noted staff asked people for their consent before supporting them.

People we spoke with told us that the care that was discussed with them matched the care that was being provided to people using the service. They also told us they were regularly kept up to date about the changes made to their care.

We saw that the support plans were person centred and reflected people's individual needs. We noted staff were compassionate and caring when supporting people. We found that staff had involved appropriate health professionals to review people's support needs and to help support that person.

We noted the home was clean and there was a cleaning schedule which staff followed. We saw checks were made to review the cleanliness of the home.

We saw the provider ensured that the appropriate checks were undertaken before a new member of staff was employed. The manager showed us the induction plan which new staff had to complete during their employment at Thistley Lodge.

We found the service was well led and had systems in place to monitor the quality of service being provided.

People we spoke with told us that the care that was discussed with them matched the care that was being provided to them. We saw there were regular reviews on people's care and progress towards their support plan. We saw staff listened to the people's input about their care needs and their wishes. We saw people's independence was promoted within their support plans and on the day of our inspection.

We saw that the care plans were person centred and reflected the people's individual needs. We saw the member of staff supported the person as detailed within their care plan. We saw care plans were easy to read and had pictures to help people understand their care plan.

People we spoke with told us that staff were friendly and supported their needs well. We saw staff knew what people's care needs were and how they needed to be supported.

We spoke with two staff members about what they thought abuse was and they showed they had a good awareness of the importance of keeping people safe. They understood their responsibilities for reporting any concerns regarding potential abuse.

We found records were accurate and stored securely when not being used.