Archived: Crest Lodge

The last inspection was on 27 April 2017 and we rated the service Requires Improvement in the key questions of Safe, Responsive, Well-led and overall. We asked the provider to complete an action plan to show what they would do and by when to improve these key questions to at least ‘Good’.

Crest Lodge is a 'care home'. People in care homes receive accommodation with nursing and personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to accommodate up to 47 people with mental health needs. The main building has three floors of accommodation and there is additionally a two bedroom bungalow in the grounds. Communal rooms are situated on the ground floor of the main building. The provider employs registered mental health nurses and general nurses who work at the service 24 hours a day. At the time of our inspection 43 people were living at the service. Everybody had a diagnosis associated with a long term mental health need, although people had a range of different needs including psychosis, brain injuries, anxiety, depression, Schizoaffective disorders, Huntington's disease and dementia. Some people needed support with aggression, self-harm or self-neglect. A small number of people were supported with rehabilitation with a view to moving to a more independent setting, although this was not the case for the majority of people who required on-going long term care and treatment. Some people also had a physical disability.

Crest Lodge was the only location for the provider who was an individual. The management of the service was overseen by the CHD Living Group who employed the staff and developed policies and procedures. The CHD Living Group is a provider of care homes and home care services in London and South East England.

The registered manager left the service at the beginning of 2018. The provider had employed another manager who had previously been the clinical lead at the service. They had been in post since February 2018. They had applied to be registered with the Care Quality Commission and this application was being processed at the time 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 and associated Regulations about how the service is run.

People were happy living at the service. They felt well cared for and supported. They liked the staff and said that they had good relationships with them. We saw evidence of this and saw that interactions between staff and people who lived at the service were kind, friendly and positive. People felt their needs were being met. They were involved in planning and reviewing their care. We saw that they had been consulted and their opinions had been recorded.

The staff were happy working at the service. They felt well supported and they liked the manager. They told us they had the training and information they needed to carry out their roles and responsibilities. They demonstrated a sound knowledge of essential policies and procedures and about the people who they were caring for. There were enough staff to keep people safe and meet their needs. There were effective systems for communication so that the staff had a consistent approach.

The provider had assessed whether people had the mental capacity to make decisions about their care and asked them to consent to this. Where people lacked the mental capacity the provider had acted within accordance of the Mental Capacity Act 2005 and had made decisions in their best interests alongside people's representatives.

People had enough to eat and drink from a varied menu of freshly prepared food. The staff supported people with their mental and physical healthcare needs. People were encouraged to take responsibility for staying healthy and were provided with support and guidance about this. The provider employed a mental health specialist who oversaw how people's needs were being met. They provided individual and group support, reviewed care plans and risks assessments and trained the staff so they understood people's needs.

People were safely cared for. They received their medicines as prescribed and in a safe way. There were procedures designed to protect people from abuse and the provider had responded appropriately when people had been placed at risk of harm. The environment was safely maintained and people had unrestricted access around the home and grounds.

People were able to make complaints or suggestions for improvements and the provider listened to them. There were effective systems for monitoring the quality of the service. Records were up to date, accurate and appropriately maintained. There was evidence the provider had made significant improvements to the service since 2016. There were plans for further improvements. The provider had a team of senior managers who offered support and regularly visited the service.

The provider sent us action plan following our inspection in June 2016. This told us how they would address the breaches in regulation. The improvements made since our last inspection had addressed the breaches in regulations and helped to improve the way the service ran. Our previous rating for this domain was Inadequate. The rating of Requires Improvement reflected that the improvements had been recognised. The provider will need to demonstrate longer term consistency in order to achieve a Good rating.

There was a registered manager in post and present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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.

There was not sufficient detailed information in people's care plans about the individualised support they needed with their mental health. Immediate action was taken to rectify this by the provider. However other aspects of the care people needed was detailed and provided staff with the appropriate guidance.

Records were not always well written or maintained in a secure way with consideration to maintaining people’s confidentiality. We have made a recommendation about this.

There were sufficient staff deployed in the service to provide appropriate care to people. Risk assessments for people were up to date although we raised concerns over one person’s risk assessment that the provider is reviewing. There was information to guide staff in how to reduce the risks to people. Incidents and accidents were recorded and followed up and detailed actions put in place to reduce the risk of incidents occurring. Staff that worked at the service had appropriate recruitment checks before they started work.

The safety of the premises and equipment was well maintained to safe standard. People's medicines were being managed in a safe way and staff had been competency assessed in medicine management.

Personal evacuation plans were in place for people who lived at the service and staff had received fire safety training. There was a service contingency place in the event the building had to be evacuated. Staff had knowledge of safeguarding adult's procedures and there was a safeguarding adult's policy in place. People said that they felt safe.

People's rights were protected under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had been completed specific to the decision that needed to be made around people's capacity. DoLS applications had been submitted to the local authority where appropriate.

People were receiving care from staff that were competent, skilled and experienced. Staff competencies were assessed as they had regular supervisions. Training was provided to staff specific to the needs of the people that lived at the service.

People were provided choices that met their reasonable preferences including at meal times and what care they wanted. People at risk of dehydration or malnutrition had systems in place to support them. People had access to health care professionals to support them with their health needs. People told us that they felt well looked after.

Staff were caring and considerate to people. People told us that staff were kind towards them and treated them with dignity and respect.

There were sufficient activities on offer specific to the needs of people. People said that they had the opportunity to take part in activities if they wished and to go when they wanted.

There were effective systems in place to assess and monitor the quality of the service. Audits had been undertaken and used to improve the quality of care for people. People and relatives were given opportunities to provide feedback to improve the quality of care. There was a complaints procedure in place and complaints were investigated. People said they knew how to make a complaint.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The provider had informed the CQC of significant events.

At the last inspection in June 2016 this provider was placed into special measures by CQC. This inspection found that there was sufficient improvement to take the provider out of special measures.

There was a registered manager in place however they were on leave on the day 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 were assisted during the inspection by the clinical lead, the operations director and a member of staff from the quality assurance team.

The last inspection of this service was on the 15 April 2015 where we found breaches around inadequate cleaning and infection control, lack of detailed and personalised care plans, staff training and supervisions, mental capacity assessments for people and the lack of robust quality assurances. We found on this inspection that whilst some improvements had been made there were still concerns.

The environment had not always been well maintained at Crest Lodge however the Cottage environment was clean and tidy.

People’s safety could not be assured because risk assessment guidance for people was not always followed by staff. There was a risk that staff did not have most up to date and appropriate guidance around the risks to people. Staff were not always following infection control guidance.

People were not always having the health monitored whilst on medicines that required particular checks. Medicines were safely stored and people received their medicines when they needed them. Not all Medicines Administration Records (MARs) for people were signed appropriately. All medicines were disposed of safely by staff.

Staff did not always have a good knowledge of safeguarding adults procedures. Although there were clear policies in place staff were did not always record incidents of abuse appropriately.

People’s rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these need to be authorised by the local authority as being required to protect them from harm. Assessments had not always been completed specific to the decision that needed to be made around people’s capacity. DoLS applications had been submitted to the local authority but were not always supported by the appropriate mental capacity assessments.

People were not always receiving care from staff who had received appropriate training around the specific needs of people. Other aspects of service mandatory training and clinical training were up to date. One to one supervisions with staff were up to date.

The environment did not always meet the needs of the people, particularly those who had a mental health diagnosis.

There were mixed opinions from people about the food at the service and people did not always have a choice around meals. However people at risk of dehydration and malnutrition had their needs met. People were supported to remain healthy.

People were not always supported to be independent and were not always involved in the planning of their care. At times people were not treated with dignity and respect and staff were not always caring. We also saw some caring interactions with people and staff and it was clear that staff knew people well

People did not always have access to meaningful and person centred activities.

Staff did not always have the appropriate information about people before they moved into the service and care plans did not always provide guidance around the most appropriate care for people.

There was a complaints procedure but complaints were not always recorded appropriately and there wasn’t always evidence of how complaints were responded to.

There were not effective systems in place to assess and monitor the quality of the service. Audits and surveys had been undertaken with people but had not always been used to improve the quality of care for people. Records were not always kept securely and people’s care was not always discussed discreetly.

Incidents and accidents were recorded however there was not always evidence of any learning from that had occurred to reduce the risk of falls and incidents in the service.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had not informed the CQC of all significant events.

There were enough staff to support people with acitivites. However other aspects of people’s cares needs were being met in relation to staff levels. Appropriate checks were undertaken on staff before they started work.

People and staff said they knew the manager and that they felt supported.

The overall rating for this service was rated as ‘Inadequate’. We found on this inspection that sufficient improvements had not been made and the service therefore will be placed into ‘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 time frame. 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

During the inspection we found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

If you wish to see the detailed evidence supporting our summary please read our full report.

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

Is the service safe?

People were protected from the risk of inappropriate or unsafe care. This was because the provider had effective systems in place to assess, plan, deliver and review the care that was provided. Staff knew people and their needs well and delivered appropriate care.

There were procedures to identify, assess and manage risks to the health, safety and welfare of people and care workers in relation to activities had been used effectively.

One person said, "They care for me well and I like the staff." Another person said, "They help me with what I need." people told us they enjoyed the food and that they could choose how they spent their time.

Not everyone we spoke with had a positive view about the care or the staff. Two people expressed negative views. The staff were aware of these people's needs due to their mental health conditions and this had been recorded. We observed that despite these people expressing negative views the staff took time to listen and reassure them.

Staff understood how to manage emergency situations and they had the training and equipment to do so safely.

Staff were supported, supervised and trained to carry out their roles to the expected standards.

Is the service effective?

People’s care needs had been assessed effectively. The staff were aware of people's assessed needs and this meant that appropriate care and support was delivered.

The staff were aware of people's health needs including changes to those needs and appropriate medical or specialist health advice and treatment had been provided.

Is the service caring?

People were supported by kind staff who knew them well. We observed kind and caring interactions between staff and people who used the service. The staff offered people choices and respected people's wishes. They provided time for people to express themselves and spent time sitting and chatting to people.

There were systems in place to ensure people and relatives could provide feedback to the provider about the quality of the service provided. There was also a system through which staff were enabled to share their experiences and views about the service.

Is the service responsive?

The service was responsive to people's needs because there were enough staff with the appropriate skills, experience and qualifications to meet people's needs at all times. Arrangements were in place to provide staff when there was a shortfall due to sick leave or holidays.

Is the service well-led?

The registered manager and the provider's had an effective system for assessing and monitoring the quality and safety of the service. This meant they had identified shortfalls and taken appropriate action to ensure people received a safe, effective, caring, responsive and well led service.

We found people's dignity was respected. The building smelt fresh and measures had been implemented to ensure this was maintained.

People had been supported and encouraged to express their preferences with regard to their general living environment and their rooms. People had been given more choice and control.

We found people had been asked to sign their consent to the care and treatment they received. Where people lacked the capacity to make a decision this had been assessed, documented and best interest decisions had been documented.

The results of initial assessments had been documented to enable staff to assess if they could meet people's needs. A clinical risk management tool had been introduced to ensure risks to people were accurately documented and managed.

Staff had been required to ensure they updated their knowledge in relation to adults at risk.

The provider had ensured all staff completed a declaration of their fitness to work, in accordance with legal requirements.

The staffing levels at the home had been assessed and increased. People told us "There are definitely more staff".

We found that people's dignity was not always upheld, people were not always supported to make their rooms their own and there was a smell of urine in some parts of the building.

People appeared to have been involved in their care planning, although people had not signed their care plans and where they lacked capacity to agree to their treatment this had not been documented. Care planning had not involved either thorough initial assessments or the use of risk assessment tools.

We spoke with one person who used the service who told us that they did not always feel safe when other people argued which happened frequently. Another relative told us that they found that the home 'felt chaotic'. We found that staff were aware of safeguarding procedures but were unclear regarding whistle blowing.

We found that there appeared to be enough staff and the people we spoke with felt that there were sufficient. The staffing levels required and the skill mix needed for the client group had not been assessed to determine if they were appropriate. Care staff had not received training in mental illness.

The provider had implemented processes to audit the quality of the service that they were providing.