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Princess Lodge Limited Requires improvement

Reports


Inspection carried out on 15 August 2019

During a routine inspection

About the service

Princess Lodge is a residential care home providing personal and nursing care to 31 people aged 65 and over at the time of the inspection. The service can support up to 32 people.

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

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

A dependency tool was in place to assess staffing levels in the home. However, people, relatives and staff raised concerns about staffing levels in the home and staffs’ ability to respond to their needs in a timely manner.

People felt safe and were supported by a group of safely recruited staff who were aware of the risks to them and how to manage those risks on a daily basis. Where safeguarding concerns arose, they were acted on and responded to appropriately. People were supported to receive their medicines as prescribed by trained staff who had their competencies assessed. Accidents and incidents were reported and acted on appropriately and analysed for any trends.

Staff felt supported and well trained. Staff received training that was appropriate to them in their role and supported them in provided care in the way people wanted. New staff benefitted from an induction that included shadowing more experienced members of staff. Staff supported people to access a variety of healthcare agencies in order to maintain good health.

People spoke positively about the choices of food that were provided. We observed people were offered a variety of drinks throughout the day to support their wellbeing.

Staff had a good understanding of obtaining people’s consent prior to supporting them and the manager had a good understanding of the principles of the Mental Capacity Act (MCA). 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 seen to be kind and caring in their interactions with the people they supported. People were treated with dignity and respect and supported to maintain their independence where possible.

People were supported to take part in activities, but not everyone in the home benefitted from these experiences and the manager was looking to ensure people who were nursed in bed benefitted from regular social interaction.

People’s opinions matter and they were given the opportunity to raise any issues or concerns they may have through meetings or surveys. People had no complaints but were confident that if they did raise an issue it would be dealt with appropriately.

Staff were highly complimentary of the manager who had introduced a number of changes to they way they worked. Staff felt supported and listened to. The manager had a plan for action to continually improve the service and staff were on board with the plans for improvement.

A variety of audits were in place to provide the manager with oversight of the service.

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

Rating at last inspection

The last rating for this service was good (published 25 January 2017).

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.

Inspection carried out on 1 December 2016

During a routine inspection

Princess Lodge Limited is registered to provide accommodation for 32 people who require nursing or personal care. People who live there have health issues related to old age and/or dementia. At the time of our inspection 31 people were using the service.

Our inspection was unannounced and took place on the 1 December 2016. At our last inspection in January 2016 the provider was meeting all the regulations but we identified that some areas in the key questions of effective, responsive and well-led required improvement. We found on this our most recent inspection the provider had made the necessary improvements.

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.

People were safely supported by staff in all aspects of daily living. Staff understood their role and responsibilities in relation to protecting people from abuse and avoidable harm. Records in relation to risks were reviewed and updated regularly. Staffing levels were adequate and people’s needs were met in a timely manner. Staff recruitment procedures that were operated by the provider were effective. Sufficient quantities of people’s medicines were available and these were stored, disposed of and administered effectively.

Staff accessed training in a variety of subject areas that were specific to the needs of people using the service. The provider ensured that all new staff were provided with an induction before fully commencing in their role. Staff had regular supervision and opportunities to discuss their performance and development needs. People’s human rights were respected by staff who worked within the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. People were supported to access a good variety of food and frequency of access to drinks. Staff supported people to maintain their physical and mental wellbeing.

Staff knew how best to interact and communicate with each person and this enabled them to readily offer people the appropriate reassurance or emotional support they needed. Staff took the time to verbally explain any questions people had about their stay, care and/or treatment. Staff communicated with people in a respectful manner and supported them in a dignified and discreet way. People were supported to maintain relationships with their families and able to have visitors at any time, without restriction.

People were involved in planning their care and received it how they would like it to be. People’s preferences, likes and wishes were well known by staff. The provider employed a dedicated activities coordinator who had tailored their interactions and interventions with people in a way that met their individual preferences. Family and friends who visited were made welcome. People were being supported to maintain their religious observances. The provider acknowledged, investigated and responded to complaints in a timely manner and in accordance with their own policy.

The provider had not been completely open and inclusive or properly sought the consent of people in their decision to use video surveillance at the home. The provider was keen to actively involve people to express their views about the service provided. The registered manager understood their responsibilities for reporting incidents and events to us and other external agencies that had occurred and had affected people who used the service. People knew the registered manager and staff approached the management team without hesitation. The registered manager and provider undertook regular checks and audits to monitor the safety and effectiveness of all aspects of the service.

Inspection carried out on 27 January 2016

During a routine inspection

This unannounced inspection took place on 27 January 2016.

At the last comprehensive inspection in August 2015 this provider was placed into special measures by the Care Quality Commission (CQC). We found that the provider was not meeting six of the regulations associated with the Health and Social Care Act 2008 which related to; safe care and treatment, notification of incidents, staffing and displaying their overall rating. In addition we issued two warning notices in respect of safeguarding people who use the service and good governance. We told the provider to take action to make improvements. The provider sent us an action plan outlining the actions they had taken to make the improvements. This inspection found that there was enough improvement to take the provider out of special measures.

The provider is registered to provide accommodation for 32 people who require nursing or personal care. People who live there have health issues related to old age and dementia. At the time of our inspection 22 people were using the service.

The registered manager had left their post in September 2015 but had not applied to cancel their registration and therefore remains on our register. A new manager for the service had recently started work and they told us they were planning to apply for registration with us. 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 found that overall medicines administration within the service was safe. The provider had systems in place to protect people from abuse and harm. Staff had a clear knowledge of how to protect people and understood their responsibilities for reporting any incidents, accidents or issues of concern. The provider had a suitable number of staff on duty with the skills, experience and training in order to meet people’s needs. Systems in place for recruitment ensured staff working at the service had the right skills, experience and qualities to support the people who used the service.

Staff had access to a range of training to provide them with the level of skills and knowledge to deliver care safely and efficiently. Staff were able to give an account of what a Deprivation of Liberties Safeguard (DoLS) meant for people subject to them; however they were not clear about which people were subject to an authorised DoLS. The mealtime experience was well structured and encouraged people to identify it as a social event. Staff were knowledgeable about how to support people to maintain good health and accessed professional healthcare support for them when necessary.

Staff interacted with people in a positive manner and used encouraging language whilst maintaining their privacy and dignity. People told us they were involved in their own care and felt listened to. Those people who wished to were supported to continue to maintain their religious observances by their family; the manager was planning some further work on accessing services within the local community for people. Staff provided support to people in a way that helped them to remain as independent as possible.

Staff were knowledgeable about people’s personal preferences and what was important to them.

The provider had not fully responded to complaints received in line with their own policy.

Activities on offer to people were available for people based on group and individual preferences and abilities. People were asked to provide feedback about service through questionnaires and meetings.

People and staff spoke confidently about the leadership skills of the deputy manager and were positive about the impact the new manager would have. Structures for supervision and meetings for staff were in place; which allowed staff to be more in

Inspection carried out on 3 & 4 August 2015

During a routine inspection

Princess Lodge Limited is registered to provide accommodation for 32 people who require nursing or personal care. People who live there have health issues related to old age. At the time of our inspection 26 people were using the service.

Our inspection was unannounced and took place on the 4 & 5 August 2015. At our last inspection in October 2014 the provider was not meeting the regulations which related to safeguarding people from being unnecessarily deprived of their liberty. Evidence that we gathered during this, our most recent inspection, showed that the improvements required had not been made.

The manager was registered with us as is required by law. 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.

Feedback was received from the local authority’s Contracts Team following a monitoring visit on 27 July 2015. They told us that the providers response to issues they had identified as a result of their last meeting was disappointing and that more had not been done to address the issues raised.

People and/or their relatives told us they felt the service provided to them was safe and protected them from harm. Staff we spoke with were clear about the how they would protect people from abuse and how to report any concerns they received or witnessed.

We found that when people’s health needs changed staff were not always proactive in accessing professional advice and/or support in a timely manner. Systems for completing care records were effective.

Medicines were not consistently administered as prescribed. We found that storage and the application of analgesic patches was in line with good practice.

The registered manager used a dependency tool to calculate the amount of staff necessary to support people and complete care safely; however, from our observations and feedback we received the care provided was often task led and not person centred due to the availability of staff, particularly during the busy morning period.

People’s ability to make important decisions were considered in line with the requirements of the Mental Capacity Act 2005. However, we found that the provider had not made the necessary improvements to meet the regulations in relation to protecting people using the service by failing to make applications, when restrictions were identified, for consideration of a Deprivations of Liberty Safeguards (DoLS) authorisation.

People were not always supported appropriately to take food and drinks in sufficient quantities to prevent malnutrition and dehydration. We observed that the lunchtime experience was overall relaxed and the food was nutritionally balanced.

Staff interacted with people mostly in a positive manner and maintained people’s privacy and dignity when providing support.

People and their relatives were involved in the planning of care. Some staff told us they were too busy to look at care plans and risk assessments, although they had been encouraged to do so by management. Staff we spoke had a good but basic understanding of people’s needs.

Information and updates about the service was made available to people and their relatives, in meetings and with the use of notice boards. The complaints procedure was displayed and people and their relatives knew how to and who to raise a complaint with.

People, relatives and staff gave us variable feedback about leadership skills of the registered manager. Structures for regular supervision and appraisal to provide staff with feedback about their performance and to discuss their training needs were lacking.

Quality assurance audits were undertaken regularly by the registered manager. These systems were not always robust enough to identify some of the issues we found during our inspection.

The registered manager had failed to meet the requirements of their registration with the Commission as we found a number of incidents that had occurred within the service had not been reported as required.

The history of this service is that the provider has not been meeting the requirements of the law fully over the last two years; within this time the Commission has undertaken this and five other unannounced inspections. On this our most recent inspection, we found the requirements of the regulations were not being adequately met.

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 inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

Inspection carried out on 6 October 2014

During a routine inspection

Our inspection took place on 6 October 2014 and was unannounced so no-one knew we would be inspecting that day.

Princess Lodge Limited is registered to provide accommodation and nursing care to a maximum of 36 people. On the day of our inspection only 20 people lived at the home. People living there had a range of conditions some of which are related to old age. Only 20 people lived there because the local authority had suspended new placements due to concerns we identified during our last inspections and those identified by external health agencies.

At the time of our inspection there was no 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 our last inspection on 30 June 2014 and CQC pharmacist inspection on 8 July 2014 the provider was not meeting six of the regulations we inspected. These included the safeguarding of people, recruitment of staff and medicine safety. During this inspection we found that some improvements had been made regarding for example, the safeguarding of people and the recruitment of staff. This meant that people were safer than they were at our previous inspection. However, further improvements were needed to ensure that people were not placed at risk due to unsafe medicine practice.

People told us that they felt safe living at the home. We found that systems were in place to prevent people being harmed or suffering abuse.

People were supported to have drinks throughout the day so that they were less at risk of dehydration. Some people told us that they would like to be better informed about the meals on offer and what alternatives were available.

We observed that interactions between staff and the people who lived at the home were mostly positive. Staff were friendly, polite and helpful to people. People and their relatives described the staff as kind and caring.

Deprivation of Liberty Safeguarding (DoLS) is a legal framework that may need to be applied to people in care settings who lack capacity and may need to be deprived of their liberty in their own best interests to protect them from harm and/or injury. Not all staff were aware what Deprivation of Liberty Safeguarding process (DoLS) meant. We identified that care planning concerning DoLS was lacking. This meant that people could be at risk of not receiving care in line with their best interests. We identified a breach in the law concerning a person’s DoLS management needs. You can see the action we told the provider to take at the back of the full version of the report.

Staff were equipped with the skills and knowledge to provide safe and appropriate care to people. Staff told us that were adequately supported in their job roles.

We found that a complaints system was available for people to use. Relatives told us that if they raised issues that they were addressed satisfactorily.

We found that overall quality monitoring processes required improvement to ensure that the service was run in the best interests of the people who lived there. Better checking of records and more frequent management observations would ensure that improvements were made to prevent shortfalls in practices and risks to the people who live there.

Inspection carried out on 30 June and 8 July 2014

During a routine inspection

The names Mr Frank Brown and Mrs Jayne Elizabeth Whitehouse appear in this report. However, those people were not in post and were not managing the regulatory activities at this location at the time of our inspection. Their names appear because they were still identified as registered managers on our database at the time of our inspection.

Our inspection of October 2013 and our pharmacy inspection of January 2014 highlighted some serious non-compliance. As a result we issued two warning notices to the provider and also set compliance actions for improvements to be made. After we issued the second warning notice we determined some improvement but identified that further improvement was needed in relation to care and welfare. During this, our most recent inspection, we again found non-compliance relating to the same areas we had previously.

Our inspection was carried out over two days. An inspector conducted the first inspection day and our pharmacy inspector inspected the medicine management systems on a second day. No-one knew we would be going to the home on either day as our inspection days were unannounced.

During our inspection days 25 people lived at the home. During our inspection days we spoke with eight people who lived there, three relatives, seven members of staff and the manager. Several people who lived there were unable to tell us about their care and support experiences so we spent time observing how staff interacted with people and looked at the daily routines.

The summary is based on our observations during the inspection, discussions with people who used the service, the staff supporting them, and by looking at records. If you wish to see the evidence supporting our summary please read the full report.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Systems to protect vulnerable people from the risk of abuse were not followed so had not ensured people�s wellbeing and safety.

Staff we spoke with had a basic knowledge of Deprivation of Liberty Safeguard (DoLS) processes. DoLS is a legal framework that may need to be applied to people in care settings who lack capacity and may need to be deprived of their liberty in their own best interests to protect them from harm and/or injury. However, we found that an application or advice that should have been sought for one person was not.

Recent recruitment practice did not comply with the law. It was not safe or effective and placed the vulnerable people who lived there at risk of harm from potentially unsuitable staff being in contact with them.

People were not protected against the risks associated with medicines because staff were not following arrangements in place to manage medicines safely.

Is the service effective?

People we spoke with gave us mixed views about the standard of care and support they received. One person said, �They look after me well, I do not know about the other people�. Another person said, �It could be a lot better here. I do not think it is that good�.

We found that staffing numbers were in need of a review as they did not demonstrate that they could effectively meet people's needs and preferences. A number of people and staff we spoke with highlighted that additional staff were needed. People told us that at times, they had to wait for support and assistance.

The provider had taken note of previous concerns raised by us, the Care Quality Commission, the local authority and Clinical Commissioning Group (CCG) at the end of 2013 and had made some improvements. However, insufficient action had been taken to ensure that those improvements were sustained. This inspection identified similar issues to those we had identified in 2013. This did not give assurance that the service provided was effective.

Is the service caring?

Overall, we found that care and support was provided with kindness and compassion. People told us that they could make some choices about how they wanted to be supported. All people we spoke with were complimentary the staff and described them as, �Kind� and �Caring�. One person told us, �Staff are kind and friendly�. A relative told us, �The staff themselves are caring�.

We spent some time observing interactions between staff and the people who used the service. We saw that most staff showed patience when supporting people. However, we observed durations when there was no engagement or interaction from staff. People were asleep in their chairs, or looked unhappy. We saw that their faces had a blank expression and some people were restless.

Is the service responsive?

We found that basic systems were in place to give people and their relatives the opportunity to raise any issues. However, the issues about the lack of staff and activity provision had not been adequately addressed. This showed that the provider had systems in place listen to the views of the people who lived there but did not always take action to address them adequately.

We found that for one person nursing staff had not assessed a person�s sore arm when the care alerted them to this. This meant that the person was at risk of continuing unnecessary discomfort.

Is the service well led?

At the time of our inspection, although a manager was in post, they had not formally registered with us as is required by law. The registered provider gave us assurance that they would ensure that the manager applied for registration as a matter of priority.

We found that the manager was responsible for this and another home. Evidence presented to us by documents and verbally from staff indicated that there was not adequate manager input. Inadequate manager input and the findings from our inspection did not give confidence that the home was well led.

We identified from observations and care plans that some staff did not follow instructions. During our inspection we identified some issues that should have been reported to social services as people were not being safeguarded as they should have been. This had a negative impact on people's health and wellbeing and did not demonstrate a well led service.

Staffing was not always organised to ensure people�s needs were met and support was not always available for activities. A number of people told us that they had to wait for staff assistance.

Inspection carried out on 6 February 2014

During an inspection to make sure that the improvements required had been made

On the day of our inspection 23 people lived at the home. The registered managers as detailed on this report no longer worked in the home and the new manager appointed is in the process of registering to become the registered manager. We spoke with four people who lived there and three of their relatives. We spoke with three visiting healthcare professionals, four members of staff, the manager and the general manager. Several people who lived there were unable to verbally tell us their experiences so we spent time observing how staff interacted with people.

At our last inspection in October 2013, we found that improvements were needed in a number of areas which included a warning notice. At this inspection we saw that overall improvements had been made in most of the areas.

We saw that people's care needs were assessed and so that their health and wellbeing was promoted and met. One relative said, "Staff look after people very well." One person told us, "I'm very happy with the care and staff." However, we saw that further improvements were still required to ensure that people�s needs were consistently met.

Safeguarding procedures were in place so that staff would recognise and report any allegations of abuse so that people were protected from the risk of harm.

The provider had robust recruitment systems in place so that only staff that were suitable to work with vulnerable people were employed.

We saw that there were enough staff employed to meet people's needs and ensure their safety.

We found that the provider had systems in place to support staff to enable them to provide care and support that met people's needs and kept them safe.

We found that people were asked for their views about the home and people were listened to. The provider had an effective system in place to ensure the quality of service provision was monitored so that any necessary improvements could be made.

Inspection carried out on 9 January 2014

During an inspection in response to concerns

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences.

We found the service had poor systems in place to ensure the safe management of medicines. We found poor medicine administration and disposal records meant that we were unable to see if people were having their medicines administered as prescribed. We found the lack of information about how medicines should be administered meant that the administration of medicines might not have been safe or effective.

Inspection carried out on 16 December 2013

During an inspection to make sure that the improvements required had been made

We inspected Princess Lodge Limited to check if improvements had been made following our last inspection in October 2013, when we served the provider a warning notice for regulation 10 and told them that they were required to become compliant with the regulation by 13 December 2013. This was because we found that effective systems were not in place to assess and monitor the quality of service that people received or ensure that the provider identified monitored and managed risks. We judged at the time that this had a major impact on people who lived at the home.The registered managers as detailed on this report no longer worked in the home.

At the time of this inspection there were 27 people who lived at the home, we spoke with three people and four of their relatives. We looked at two people's care records and medication administration records. We also spoke with the general manager, the deputy manager and four members of staff.

Our conversation with people and their relatives demonstrated that they were generally pleased with the staff, this was mostly because they felt staff were doing as much as they could reasonably do. One person told us, "Staff do their best". A relative told us, “Staff do try”. However, it was evident that there were still areas for improvement. One person told us, “You have to wait for everything”. A relative told us, “Who the manager is a bit of a mystery, if something crops up we are not sure who to go to”. We found that although the provider had implemented some quality monitoring systems, the improvements required to meet the warning notice had not been fully addressed.

Inspection carried out on 24 October 2013

During a routine inspection

On the day of our inspection 22 people lived at the home. The registered managers as detailed on this report no longer worked in the home and the position had been vacant for three weeks, however, we spoke with the deputy manager and the provider. We spoke with eight people who lived there, six of their relatives, and four members of staff. Several people who lived in the home were unable to tell us their experiences of living there so we spent time observing how staff interacted with people.

People were asked for their consent before any care was given so that staff acted in accordance with their wishes. One person told us, �They ask me nicely what I want all the time�.

We saw good interactions between people who lived there and staff. One relative told us, "On the whole the care is good�. We saw that people's needs were assessed by a range of health professionals and their healthcare needs had been monitored so that their health and wellbeing was promoted and met.

We looked at how the provider was protecting vulnerable people. Systems in place to protect people from the risk of unsafe care were not robust and they had not ensured people�s wellbeing and safety.

We saw that the provider did not have effective recruitment and selection procedures in place to ensure that only staff suitable to work with vulnerable people were employed.

There were not enough staff on duty to ensure people received care in a timely manner. This meant that the provider could not fully meet people�s needs and keep them safe.

We found that people were not asked for their views about the home and people were not listened to. Systems were not in place to seek the views of people using the service or audit all aspects of the quality of care so that any necessary improvements could be made.

Reports under our old system of regulation (including those from before CQC was created)