White Lodge Care Home

White lodge Care Home is a residential care home providing personal care and accommodation to up to 25 people, including people living with dementia. At the time of the inspection they were supporting 20 people. Accommodation is arranged over two floors in single bedrooms. There are two communal lounges, a dining room and access to a garden and patio area.

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

Risks to people using the service had not always been assessed. Plans were not always in place to mitigate these risks. There was a lack of guidance and information for staff about some risks which meant people were at risk of receiving inappropriate or unsafe care and treatment.

We received mixed feedback about the staffing levels in the home. The provider did not have a robust or effective system in place to determine the number of staff required to meet people’s needs. Suitably trained and competent staff were not always available on-site to administer people’s medication. Not all the required checks had been completed as required to help ensure people were protected from the employment of unsuitable staff.

External medicines were not always administered as prescribed, the operations manager told us they would investigate this. The effectiveness of a person’s medication with a variable dose was not monitored to mitigate risks to the person from their condition. We have made a recommendation about the management of these medicines.

The system in place to identify, asses and mitigate risks to people from the quality and safety of the service was not always effective. We received mixed feedback from staff about the culture in the service. Staff views had not been formally sought and analysed over the past year.

People’s relatives told us their relatives were safely cared for in the home and they had regular communication about their relative from staff. Restrictions on visiting meant relatives had not been able to have in person contact regularly inside the home over the past year. People we spoke with who were able to tell us about their care told us they felt safe and well-cared for in the home.

Rating at last inspection

The last rating for this service was Good (published 03 March 2020).

Why we inspected

We received concerns in relation to the management of medicines, staffing levels, people’s needs in relations to falls and moving and handling, leadership and culture. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to safe care and treatment, staffing fit and proper person employed and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

White lodge Care Home is a residential care home providing personal care and accommodation to people aged 65 and over including people living with dementia. The service can support up to 25 people. 23 people were living in the home at the time of the inspection. Accommodation is arranged over two floors in single bedrooms. There are two communal lounges, a dining room and access to a garden and patio area.

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

People and relatives told us the service provided safe care and staff were kind and caring. A system was in place to safeguard people from abuse and action was taken to promote people’s safety when an incident occurred.

Staff had a good understanding of the risks to people. However, some records required review to ensure up to date guidance about people’s needs was available. A plan was in place to address this and underway at the time of our inspection. Environmental risks were assessed and monitored.

Staff had completed training and were supported to carry out their role. Staff told us they had enough time to meet people’s needs. Although we received some mixed feedback about staffing levels from people and relatives no one told us people’s needs were not met. Checks were carried out to help ensure only suitable staff were employed. This process was improved during our inspection.

People’s medicines were managed safely, and they were supported to access the healthcare support they needed. People and relatives spoke highly of the food provided and their individual dietary needs and preferences were met.

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.

Peoples care needs were assessed and care was planned to meet them. Staff treated people with dignity and respect. There was a range of activities available for people and the service aimed to support people with their individual requests and wishes.

A system was in place to monitor and improve the quality and safety of the service people received. There was a homely and welcoming atmosphere in the service and staff told us they were supported in their role by the management team.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 January 2019) and there was one breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

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.

White Lodge is a ‘care home without nursing’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

White Lodge accommodates up to 25 people living with dementia and physical frailty. There were 21 people at the home when we inspected.

At the last inspection in April 2018, the service was rated Inadequate and nine breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 were found. Following the inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions safe, effective, caring, responsive and well-led to at least ‘Good’. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements.

This inspection found that whilst improvements had been made and number of regulatory breaches had been met. There were areas still to improve and embed in to everyday practice. The service has been taken out of special measures.

There had been no registered manager in place since August 2018. A manager had been appointed and they had begun the process of being registered with CQC. They will be referred to as the manager in the report. 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.

There had been improvements to the management of medicines, although further improvements were needed. Actions had been taken to address medicine errors made by staff, and supervisions and daily audits had been implemented to improve the management of people’s medicines in the home. However, there were still concerns about some medicines management. For example, maintaining accurate records regarding the safe administration of medicines.

A quality assurance framework was in place. However, this was not consistently effective and shortfalls in the provision of care were not always identified.

There had been an improvement in the assessment and mitigation of risks associated with falls. Most of the risk assessment and management plans to minimise risks to people from falls were completed in sufficient detail and risk management plans were followed by staff.

Staff were knowledgeable about the risks associated with people’s care. The information available to new and unfamiliar staff, such as handover notes and care plans was consistent to guide staff on how to support people safely. However, work was still needed for care records to be more person centred.

There was robust recruitment procedures in place and staff had been safely recruited. Sufficient staff were available to meet people’s needs. The provider told us there had been changes to the number of permanent staff on duty and the more effective shift management and allocation of staff. However, people and their relatives told us they did not think there were always enough staff available.

The provider told us about the recent staffing changes they had made and were confident these would achieve improvements for people. This included recruitment to an operations manager post. Further time was required to embed these changes into practice and ensure sufficient staff were available to meet people’s needs and keep them safe at all times.

People told us they felt safe living at the home. Staff understood their responsibilities to protect people from abuse and referrals had been made to the local authority when incidents or allegations occurred.

Staff protected people from the risk of infection and followed procedures to prevent and control the spread of infections.

Equipment used to support people’s needs such as hoists and bed rails was checked and maintained to ensure it was safe for people. The premises were safely managed by maintenance staff including protective equipment such as fire safety equipment and the arrangements for the safe evacuation of people in an emergency.

An inclusive and open culture was being established and the provider welcomed feedback from staff, relatives and health and social care professionals to improve service delivery. A programme of audits and checks was needed to monitor the quality of the service and ensure improvements were made where required.

During our inspection we found one continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report.

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

The home sits within its own grounds and provides accommodation and support for up to 25 older people. Nursing care is not provided. Accommodation is sited over two floors. On the day of the inspection there were 23 people using the service.

The service requires 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 the time of the inspection there was no registered manager, although the manager had made an application to CQC to be registered. They will be referred to as “the manager” throughout this report. The previous registered manager had also been at the service on the first day of the inspection and where applicable they will be referred to as “the previous manager”.

At the last inspection in January 2017 the service was rated Requires Improvement and there were three breaches of the Health and Social Care Act 2008. Regulation 11, Need for consent; Regulation 12, Safe care and treatment; and Regulation 12, Good governance. At this inspection we found continued breaches in Safe and Well Led, together with other concerns.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Responsive, Effective and Well led to at least a rating of Good. We had to contact the previous manager to request an action plan, as one had not been sent.

At this inspection, although people and relatives gave mainly positive feedback about the service, we continued to have concerns about the safety and well-being of people. Emerging risks were seen in areas where there had been no previous concerns and breaches and continued breaches of Regulation were found.

Risks including those associated with medicines, people’s care, the spread of infection and fire drills had not been properly assessed or minimised in order to keep people safe.

People were at risk because staff did not administer or manage medicines safely. For example, there were no assessments of risk associated with blood thinning medicines. This was a repeated breach, and we saw deterioration since our last inspection in January 2017.

Accidents and incidents were not competently managed. We found the approach to reviewing and investigating causes to be insufficient. There was little evidence of learning from these occurrences.

The provider did not always make referrals for appropriate care and treatment at the right time. In some examples, we found that recommendations for care and treatment by other professionals were not always carried out as directed.

People's care needs were not regularly reviewed. We found care plans did not sufficiently inform staff of people's current care, treatment and support needs, which left people exposed to the risk of receiving inappropriate care or treatment.

Staff had not received training for them to be able to undertake their role and meet people’s needs.

There was minimal evidence to show the service was monitored to ensure its’ safety and there was no evidence that lessons had been learned and improvements made when things went wrong.

People's healthcare had not been effectively monitored and concerns escalated in a timely way. Care plans did not always reflect people’s needs which left people exposed to the risk of receiving inappropriate care or treatment.

The principles of the Mental Capacity Act 2005 and the associated Deprivation of Liberty Safeguards had not been properly understood or applied in the service.

Whilst we saw that staff asked for people's permission before carrying out care, people's care records did not always reflect how decisions had been reached in their best interests. We also found some staff were unclear about the requirements relating to consent.

We received mostly positive feedback from people, relatives and visitors who were able to speak with us. We observed that generally people were treated with dignity, respect and kindness during all interactions with staff. However, we noted that some staff did not always respond to the needs of people in a timely way.

The service was not well-led. Issues raised at our last inspection remained unaddressed in some cases and new problems emerged in other areas. Auditing had been ineffective in identifying shortfalls. There was little evidence of people's involvement in their care or decisions about it.

People had routine appointments with GPs, health and social care specialists, opticians, dentists,

chiropodists and podiatrists. People enjoyed their meals and were supported to eat if necessary.

Most people, relatives and staff felt the new manager was approachable and responsive.

We found seven breaches and continued 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. If we have not taken immediate action to propose to cancel the provider's registration of the service, they 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 and a rating of inadequate remains for any key question or overall, we will take action in line with our enforcement procedures. This could be 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.

You can see what action we told the provider to take at the back of the full version of the report. We are currently considering what action to take. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

White Lodge Care Home is situated in Emsworth near Portsmouth. The home sits within its own grounds and provides accommodation and support for up to 25 older people. Nursing care is not permitted. Accommodation is sited over two floors.

The home had a registered manager in place and our records showed she had been formally registered with the Care Quality Commission (CQC) since August 2014. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they were safe living at the home and staff had a good understanding of safeguarding issues and how to recognise and report them. There was regular maintenance of the premises and fire risk and other safety checks were undertaken. A gas safety certificate was not available on the day of the inspection but a new certificate was forwarded to us later. People had emergency evacuation plans in place. Accidents and incidents were monitored and any individual issues or concerns addressed.

Most staff had been subject to a suitable recruitment procedure and checks, to ensure staff had the right skills. Not all staff on induction at the home had received two references or a final Disclosure and Barring Service (DBS) check. We have made a recommendation about this. People told us there were enough staff at the home to meet their needs. We found some issues with the recording and management of medicines at the home. The home was clean and tidy. We found some issues with infection control around the use of commodes at the home and the storage of cleaning equipment.

Staff told us they had access to a range of training and updating. Individual records confirmed completed staff training, although there was no overall record to monitor this. Staff told us, and records confirmed they received annual appraisals. Records showed some supervisions had taken place, but the registered manager told us some staff still required supervision sessions.

People’s health and wellbeing was monitored and there was regular access to general practitioners, dentists, district nurses and other specialist health staff. We witnessed staff responding immediately and appropriately to health concerns.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. The registered manager confirmed appropriate applications had been made where people may need to be assessed for a DoLS application. People were asked their consent on a day to day basis. We noted records, where relatives had Lasting Power of Attorney and where best interests decisions needed to be made, were not always detailed.

People were happy with the quality and range of meals and drinks provided at the home. Special diets, individual dietary requirements and likes and dislikes were catered for.

People told us they were happy with the care provided. We observed staff treated people patiently and with due care and consideration. Staff demonstrated a good understanding of people’s individual needs, preferences and personalities. People said they were always treated with respect and dignity.

Care plans contained good person centred detail related appropriately to the individual needs of the people living at the home. Care plans often lacked detail to assist staff in supporting people. Reviews of care were not always comprehensive or carried out in a timely manner. A range of activities were offered for people to participate in. We witnessed a session by entertainers taking place at the home. People told us they had not made any recent formal complaints and would speak to the registered manager if they had any concerns. The registered manager had dealt appropriately with any complaints received.

Some checks were undertaken on people’s care and the environment of the home. However, these checks were often tick box in style and did not note any deficits or action required. The checks had failed to identify issues found at this inspection. Staff felt well supported by management, who they said were approachable and responsive. The provider had sought people’s views through the use of questionnaires which, whilst overwhelmingly positive were, limited in detail. Documents, including food and fluid charts, care records and medicine records were not always well maintained or up to date.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the Safe care and treatment, Need for consent and Good governance. You can see what action we told the provider to take at the back of the full version of the report.