Heath Lodge

Heath Lodge provides care and accommodation for up to eight adults with a learning disability, mental health needs and complex needs. At the time of the inspection there were six people living there.

Although the service had not initially been developed and designed in line with all of the principles and values that underpin 'Registering the right support' and other best practice guidance it did fulfil the criteria and 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. The provider advised they would review the principles in practice to see how they could update the service to further reflect best practice.

We have made a recommendation for the registered provider to review best practice guidance in updating their service and on reflecting the principles of 'Registering the Right Support.'

People living at Heath Lodge and their relatives told us that their experience of using the service was overall very positive. People consistently told us how they were treated with kindness from all of the staff who were also very supportive. People told us they had enjoyed activities and events that they had been supported with.

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.

Staff were well trained in various topics appropriate to their role. They were knowledgeable in how to safeguard people from the risk of harm and abuse and were well trained in safely managing people's medications. People received care and support by staff who had been appropriately recruited and had undergone the necessary recruitment checks.

We found there was an effective process in place to monitor the quality and safety of care people received. Quality assurance checks were routinely carried out and the provision of care was monitored, assessed and improved upon accordingly. We noted some improvements were needed in the record keeping of staff rotas for one to one support and in accurately signing records.

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

Rating at last inspection

The last rating for this service was 'requires improvement' (published 23 October 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re inspection programme. If we receive any concerning information we may inspect sooner.

Heath Lodge provides care and accommodation for up to eight adults with a learning disability and complex needs. At the time of the inspection there were seven people living there.

The inspection took place on 12, 13 and 18 September 2018 and was unannounced on day one. At the last inspection we identified significant breaches of the Health and Social Care Act Regulations regarding regulations 9,11,12,13,16,17 and 19 and the service was placed into special measures. During this inspection we found that improvements had been made and that the registered person was no longer in breach of regulations 9,11,12,13,16 and 19, although there was a continued breach of regulation 17 of the Health and Social Care Act Regulations. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. At this inspection the overall rating for the service is 'Requires Improvement'.

The process for regular evaluation of care plans was not sufficiently robust and quality assurance systems in place had not identified all of the concerns noted within this report. A new comprehensive quality assurance audit had been introduced however, this had not highlighted that some care plans had not been regularly evaluated and that significant information about safe transportation had not been updated.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy

At the time of this inspection there was no registered manager in post with day to day management provided by a manager from another of the registered provider’s services. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Following the last inspection, due to the seriousness of concerns identified, we used our enforcement powers and a decision was made to cancel the manager’s registration.

Registered persons are required by law to inform the Care Quality Commission (CQC) of certain events which occur within the service. During the last inspection we found that on several occasions they had failed to do so. This was an offence under Regulation 18 (1) (e) (f) of the Care Quality Commission (Registration) regulations 2009. Therefore, we used our enforcement powers to issue a Fixed Penalty Notice which resulted in the registered provider being fined £1,250. During this inspection we found that notifications had been submitted as required.

Improvements had been made regarding management and administration of medicines. The registered provider had liaised closely with a community pharmacist to raise standards and weekly audits were carried out.

Staff had received training and were knowledgeable about how to protect people from abuse and felt able to do so without fear of repercussion. They were also aware of whistleblowing procedures (reporting outside of the company). We saw that incidents had been reported to the local authority and notifications submitted appropriately.

There were procedures in place to record accidents and incidents and assess people’s associated risks. Although analysis of accidents/incidents was being undertaken, we found that action had not always been taken in a timely manner where themes were emerging. We discussed this with the management team and risk management measures were implemented.

A consistent staff group was in place and we found that there were sufficient staff on shift during the inspection to meet people’s needs and staff told us they felt this was the case. However, we found that a strategy noted to manage the risk of aggression would not have been feasible once staffing levels dropped in the afternoon.

Staff had access to ample supplies of personal protective equipment (PPE) to control and prevent the spread of infection and we found that this was used effectively.

We found that improvements had been made regarding compliance with the Mental Capacity Act 2005. People were deprived of their liberty only when legal authorisation was in place, although for one person we noted a lack of clarity about support requirements when accessing the community.

During the last inspection we identified significant concerns about the management of people’s finances which resulted in a detailed investigation being carried out by the registered provider in liaison with the local authority safeguarding team and the CQC. We found that procedures had improved and the registered person is currently in the process of agreeing final re-imbursement figures.

People told us that the food was good and we saw that menus and choice had improved.

Staff received the training, support and supervision they needed to carry out the roles they were asked to do.

Positive relationships had been developed between staff and the people living at Heath Lodge. We observed interactions to be kind, considerate and caring. We saw that the level of physical altercations between people had reduced considerably and that staff used de-escalation techniques effectively.

People’s rooms were personalised and could be locked in line with personal choice. Staff were encouraging people to maintain their independence and reach their potential.

People could express their views in a variety of ways. Regular meetings were held and there was a complaints procedure in place which people knew how to use. We saw that complaints had been recorded and responded to in line with this policy.

We saw that people were supported to various activities including bowling, wrestling, snooker, meals out, garden centre, shopping and the Friday Club. Staff were planning to introduce additional activities within the home such as film and games nights.

Following the last inspection, the registered provider has worked in liaison with the local authority safeguarding team and the CQC providing updates from investigations and submitting ongoing versions of an improvement plan, although we had not received the most recent updates. We were told that the last months had been a difficult period but that learning had been taken and quality audits had been revisited. The nominated individual and director of operations are to carry out more detailed reflective learning review.

Heath Lodge accommodates eight adults who have a learning disability and/or complex needs. At the time of the inspection the home was fully occupied. Five bedrooms were located in the main house with three annex buildings in the garden. The home is located in a residential area of Warrington, close to shops, other local facilities and is on the bus route to Warrington town centre.

During this inspection we identified significant breaches of the Health and Social Care Act Regulations with regard to regulations 9, 11, 12, 13, 16, 17, and 19. These related to concerns regarding consent; safe care and treatment; safeguarding people from abuse; person centred care, complaints and governance. The provider had also failed to submit relevant statutory notifications to the Commission. A notification is information about important events which the provider is required to tell us about by law. Failure to submit notifications is an offence under the Care Quality Commission (Registration) regulations.

We identified several instances where the registered manager had not notified the CQC as required with regard to safeguarding concerns and incidents reported to or investigated by the police. This meant that the registered manager had not complied with the legal obligations attached to their role.

Heath Lodge adhered to the provider’s own internal quality assurance system. This included audits of areas such as care files, medication, finance and infection control. Although we could see that regular audits were being carried out, we had concerns about the effectiveness of them as they had failed to identify the issues and breaches of regulation noted during this inspection

We saw that the service had not always operated within the principles of the Mental Capacity Act 2005 particularly with regard to assessment of mental capacity and best interest decision making. Significant purchases had been made from service users’ monies and we found several references to restrictive practice. The provider was unable to demonstrate that these decisions had been made in peoples’ best interests. Records relating to management of service user finances were not sufficiently robust.

Although people told us that they felt safe at Heath Lodge, we found that safeguarding policies and procedures were not established and operated effectively to protect people from harm and abuse. Whistle-blowing concerns were received during the inspection. These included an allegation of aggressive and threatening behaviour by a member of staff towards a service user which had not been dealt with to ensure that the people living at Heath Lodge were protected from abuse and harm. We were also informed by the whistle-blower that the registered manager had instructed them not to inform the inspector of this incident. We reported the whistle-blowing concerns to the local authority safeguarding team.

People’s medicines were not managed or administered in a safe way. People did not always receive their medicines as prescribed, medical advice was not always sought when stocks were allowed to run out and we found that staff were instructed to sign Medicine Administration Records (MAR) retrospectively.

We asked people if they felt the staff were caring in attitude. Responses varied as some people said they were, however, one person felt they were spoken to with disrespect. We looked at daily living notes and found that the language used was at times disrespectful and inappropriate. During the inspection we observed staff speaking with people in a considerate way.

Recruitment procedures had not always been followed robustly to ensure that suitable people were employed.

People had access to external health professionals to support their health needs. However we found that referrals were not always made when required.

Responses varied as to whether care plans had regularly been discussed with the people living at Heath Lodge or that they had contributed to them. We found that care plans/risk assessments were not always sufficiently detailed or reflective of people’s current needs. In addition monthly key-worker reviews were not always accurate or evidence that care plans had been reviewed.

People told us that they were happy with the food provided at Heath Lodge. We saw that people were regularly purchasing their own snacks and food items. We raised this matter with the nominated individual who informed us that they would be reviewing this to ensure that people’s preferences were fully considered when weekly shopping orders were placed.

Staff were aware of people’s dietary needs. A food safety and hygiene inspection was carried out by Warrington Borough Council in May 2017 and Heath Lodge was awarded a 5 star rating.

People were able to personalise their rooms and were able to choose how they spent their day. Details of advocacy services were available and we saw evidence that people had been supported to access this type of service.

The provider had a policy in place which included guidance for staff about infection prevention and control. Staff had access to personal protective equipment (gloves and aprons). Communal areas of the home were generally clean, tidy and had a homely atmosphere however some areas including paintwork and en-suite facilities required cleaning.

People living at Heath Lodge and staff told us there were enough staff to meet their needs, however that more staff were needed at weekends. Activities were provided but some people felt that there needed to be improvement in this area and said that one person could no longer attend the Friday Club due to lack of staff to support them.

We were told that a dependency tool was not used to determine staffing levels but that these were adjusted depending on service needs. We saw that staffing had been increased on the first day of inspection to support people for lunch at the local pub.

Values noted within Registering the Right Support and other best practice guidance include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. We found that the service did promote independence and inclusion however that choice was not always respected.

Records were kept securely and were accessible to staff. We saw that service contracts and safety checks were completed as required for example, electric, gas safety, Legionella compliance and fire safety. People had a personal emergency evacuation plan (PEEP) detailing the support they would need in the event of any major incidents/emergencies.

At the time of the inspection there was no one receiving end of life care. We saw from care plans that some consideration had been given to this and where appropriate a do not attempt resuscitation (DNAR) instruction had been put in place.

The home had a registered manager in post who was present on the first two days of the inspection. 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 saw that there was a process for staff induction training, supervision and appraisal. Staff told us that they felt they had received the training they needed to carry out their job and that they felt the supervision and appraisal processes in place were worthwhile.

Immediately following the second day of inspection the provider put in place alternative arrangements for day to day management of Heath Lodge pending the outcome of an internal investigation. In addition alternative staffing arrangements were implemented in response to whistle-blowing allegations received by the inspector during and subsequently to the inspection visits. The nominated individual submitted an action plan and has provided on-going updates.

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. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 i

A record of the supervision sessions which staff received was seen on the staff files and all training was monitored and refreshed regularly. The staff said they found the management 'very supportive'.

The staff told us that they encourage people to be as independent as possible and one person living at the home told us how everyone helps with choosing the meals and he helps with shopping and meal preparation.

Another person who lived at the home showed me their new bedroom furniture and said he kept his room clean himself.

A record of staff interviews were present in the staff files and people who lived at the home were involved in the process. One person told us that he was on the interview panel for new staff and had interviewed the manager.

We spoke with people who lived at Heath Lodge and they said "the staff are really great" " they are always around if you need them"