Archived: Forest Lodge

Forest Lodge is a residential care home that provides personal and nursing care to people aged 65 and over and people living with dementia. At the time of the inspection 45 people were using the service. Care and support were provided in one adapted building. The building had three units providing care to people: Beech, Ash and Cedar Unit. Forest Lodge is owned and operated by the provider Sussex Healthcare.

Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached. Forest Lodge is not part of this investigation.

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

Staff had received training and practice development in most areas; however, training had not been sought to cover all people’s more specific needs that are significant but secondary to their diagnosis of dementia. For example, learning disability. The providers quality monitoring systems had failed to identify this issue.

The culture of the service was positive, relatives, professionals and staff were complementary of the management and provider. Improvements had been made to systems and process that monitored the quality of the service being delivered and accuracy of records. Staff knowledge and practice in supporting people living with dementia had improved and the atmosphere in the service was friendly and calm. These improvements needed to be sustained and become fully embedded into practice.

The provider had updated their governance framework, and more support was in place from the provider’s quality team, which the registered manager told us was helpful. The changes to quality monitoring and the transfer from paper based to electronic recording were recent, evidence they will be sustained over time will be reviewed at the next inspection.

Risks to people's safety had been assessed, and people were supported to stay safe. Staff knew how to identify potential harm and report concerns. People received their medicines safely from registered nurses.

People were supported to have maximum choice and control of their lives and staff supported them in their best interests; the policies and systems in the service supported this practice.

We observed people being treated with dignity and respect, staff listened to people’s views and demonstrated in practice their understanding of how to support people in their own reality, whist being aware of how to positively change the course of the conversation if people became anxious.

Staff actively engaged people in activities, which we observed were enjoyed.

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 January 2020) and there were four breaches of regulations. At this inspection we found improvements had been made and the provider was no longer in breach of regulations 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, regulation 13 (Systems and processes were not established and operated effectively to prevent abuse of service users) and regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to quality monitoring, the effectiveness of audits. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

The last rating for this service was requires improvement (published January 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last six consecutive inspections.

Why we inspected

We inspected to follow up on breaches found at the previous inspection.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The inspection was prompted in part due to concerns received about safe eating and drinking support, the administration of medicines and record keeping in relation to bruising and weight. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe and Well-led sections of this full report.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remains Requires improvement. This is based on the findings at this inspection.

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

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.

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.

Forest Lodge is a residential care home that provides personal and nursing care to people aged 65 and over and people living with dementia. At the time of the inspection 49 people were using the service. Care and support was provided in one adapted building. The building had three units providing care to people: Beech, Ash and Cedar Unit.

Forest Lodge is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns previously raised, the provider is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

People and their relatives spoke highly of the service. Comments included, “I am as happy as I can be here, yes I feel safe as everything is made to make you feel safe here,” and “Perfectly safe here, I watch and listen and formulate, I have never seen anything to worry me or I would be doing something about it.” Risks associated with people’s care were not however, consistently safe. Where people displayed behaviours which challenged, robust guidelines and risk assessments were not always in place. The risks around restrictive practice were not regularly reviewed and documentation to monitor people’s behaviour were not accurately completed.

Quality assurance frameworks were in place; these were not consistently effective in driving improvement or identifying shortfalls. Forest Lodge has been in continuous breach of regulations since May 2018 and internal quality assurance frameworks have failed to drive and sustain improvements. Accurate documentation was not consistently maintained. Links and engagement with the local community required strengthening.

People were not always supported to have maximum choice and control of their lives. The application of the Mental Capacity 2005 was inconsistent and people’s capacity to consent to specific decisions had not always been assessed. The provision of activities required further development. Activities were not consistently meaningful or tailored to people's needs. The care planning process required further development to ensure people's social and emotional needs were understood and met. The risks associated with social isolation had not always been assessed or mitigated. We have made a recommendation for improvement. Further work was required to ensure information about people's care and treatment was always made available in the most accessible way.

Staff felt supported and had access to a range of training. People's nutritional needs were met, and people spoke highly of the food provided. Risks associated with catheter care, skin integrity and dehydration were managed well. People had ongoing access to healthcare professionals and staff recognised and responded well to signs that a person's health might be deteriorating. Advanced decision care plans were in place and the registered manager was working with staff, people and relatives to make these care plans more personalised.

People told us they felt safe living at Forest Lodge. Relatives also confirmed that they felt confident leaving their loved one in the hands of staff. Systems were in place to determine staffing levels and safe recruitment practices were operated. People told us that staff responded promptly to their care needs. People and staff spoke highly of the registered manager and the registered manager was compassionate about ensuring people received high quality care

The provider employed a team of dedicated housekeepers. Staff had access to personal protective equipment (PPE) and the service presented as clean and tidy. People and their relatives told us staff were kind and caring, listened to them and respected their choices. People were encouraged to be involved in their day to day care and be as independent as possible. Staff recognised the importance of meeting people’s emotional needs and made visitors feel welcome.

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

Rating at last inspection:

We last inspected Forest Lodge on 8 and 9 May 2019. The report was published in July 2019 and then re-published to include information about enforcement action on 23 October 2019. The service was rated Inadequate. The provider was found to be in breach of Regulation 12 – Safe Care and Treatment, Regulation 13 – Safeguarding Service Users from Improper Abuse or Treatment, Regulation 9 – Person Centred Care, Regulation 15 – Premises and Equipment. Regulation 11 – Need for Consent, Regulation 18 – Staffing and Regulation 17 – Good Governance. Enforcement action was taken. At this inspection, some improvements had been made but the provider remained in breach of four regulations.

This service has been in Special Measures since May 2019. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures

Why we inspected:

This was a planned inspection based on the previous rating. You can see what action we have asked the provider to take at the end of this full report.

Enforcement:

We have identified four breaches of regulation in relation to mental capacity, safe care and treatment, safeguarding and good governance.

We had previously imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

Following the last inspection in May 2019, we imposed conditions on the provider’s registration which required them to submit a monthly report regarding the management of activities, falls, moving and handling, medicine management, infection control and behaviours which challenge at Forest Lodge. We will continue to use this information to help us review and monitor the delivery of care at Forest Lodge.

Follow up:

We will request an action plan from the provider to understand what they will do to improve the standards of quality. We will also meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority and care commissioners to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Forest Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. This does not include Forest Lodge but the investigation is on-going and no conclusions have yet been reached.

People’s experience of using this service:

Risks to people were not always assessed, monitored and managed safely.

People were not always kept safe from risk of abuse.

Medicines were not always managed safely.

There were not always enough suitably qualified, competent, skilled and experienced staff deployed to meet people’s needs.

Adequate cleaning to combat odours caused by incontinence was not taking place.

Lessons were not always learnt and improvements made when things had gone wrong at the service.

People and those acting lawfully on their behalf had not always given consent before being provided with support.

Conditions on authorisations to deprive a person of their liberty were not always being met appropriately.

People’s needs and choices were not always assessed so staff did not always know or understand how to deliver support for them to achieve effective outcomes.

People did not always receive personalised care that was responsive to their individual needs, including support with meaningful activities within the service and the wider community.

Information about people’s care and treatment was not always made available in the most accessible way for people.

Quality assurance and governance systems were not operating effectively. Staff and management were not supported to understand or fulfil their responsibilities and ensure that quality performance and risks were understood and managed.

There were safe recruitment practices.

Staff had regular training, updates and supervisions.

People and their relatives told us staff were kind and caring, listened to them and respected their choices.

People were encouraged to be involved in their day to day care and be as independent as possible.

Complaints were managed and responded to appropriately.

We have recommended that the provider seeks advice and considers how to improve the design and adaptation of the home and outside spaces, to better meet the needs of people and promote the independence of people.

This inspection identified continued breaches of Regulations 9, 12, 15, 17, 18 and breaches of regulation 11 and 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Rating at last inspection: We last inspected Forest Lodge on 23 and 24 May 2018. The report was published in August 2018 and then re-published to include information about enforcement action on 24 January 2019. The service was rated Requires Improvement.

Why we inspected: This inspection took place on 8 and 9 May 2019 and was a scheduled and planned inspection based on the previous rating.

Enforcement: We imposed conditions on the provider’s registration, due to repeated and significant concerns about the quality and safety of care at several services they operate. The conditions are therefore imposed at each service operated by the provider, including Forest Lodge.

The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Follow up: The overall rating for this service is inadequate. This means the service has been placed in Special Measures. Services in special measures are kept under review and 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.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. Services in Special Measures will 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 or varying the terms of their registration.

Full information about the Care Quality Commission’s regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

Services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May 2017 and May 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Forest Lodge is a care home that provides nursing and residential care. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided and both were looked at during this inspection.

Forest Lodge is registered to provide nursing and accommodation for up to 73 people. People cared for were older people who needed nursing care, some people had complex health needs and/or some people were living with dementia. At the time of our inspection there were 56 people living at the home. Accommodation is provided across three units Ash, Cedar and Beech. Eight people shared bedrooms and the rest were of single occupancy. People shared communal areas such as a large lounge and dining room.

A registered manager was in post who was not present during 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.

On one occasion the service did not demonstrate the correct action was taken after an incident involving a person had occurred. This included any routine health checks to ensure harm had not been caused. We found inconsistencies with how risks were being managed, by the service, on behalf of people.

Staff were not always adequately trained to assist them in carrying out their role and responsibilities safely and effectively. We found there was an offensive odour related to urine incontinence in some communal areas. We recommended the provider reviews how many staff were deployed at night time as their was a lack of information available about how decisions were made about how many staff were needed to meet people's needs.

Group activities were offered to people. However, personalised activities and stimulation were not always provided. We observed caring approaches used by staff when supporting people. However, some aspects of the service were not consistently caring.

Systems were not always effective in measuring and monitoring the quality of the service provided. There were ineffective systems in place to drive continuous improvement.

People's consent to care and treatment was gained in line with the requirements of the Mental Capacity Act 2005. People were supported to have choice and control of their lives and for staff to support them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff received supervisions and appraisals and they found the registered manager’s approach supportive.

People were provided choices on a daily basis regarding what food they ate and clothes they wore. Complaints were managed effectively. The provider sought feedback from people and their relatives regarding the care received.

The registered manager had sought information about the new Key Lines of Enquiry (KLOE) which the Commission introduced from 1 November 2017. They were keen to improve the quality and safety of care provided to people living at the home.

At this inspection we found the service was in breach of five of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Forest Lodge is a large house which had been extended. People’s bedrooms were provided over two floors, with a passenger lift in-between. There were sitting rooms and a dining room on the ground floor. Forest Lodge was situated in its own grounds, which were shared with other services, also owned by the provider. This group of services were situated in a rural area near Uckfield in East Sussex. The provider for the service was SHC Rapkyns Group Limited, who own a range of services across south east England.

Forest Lodge 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.

The last inspection took place on 3 and 9 November 2015. At that inspection we found the service required improvement. This was because the service was not always safe, responsive or well led, due to people’s assessments and care plans not always reflecting all of their needs. This was a breach of Regulation 12 of the HSCA 2014 Regulations and we required that the provider take action to address this. The provider and registered manager had met the requirements of this regulation. People now had relevant assessments and care plans, which outlined how their risk was to be reduced and care and treatment needs met.

At this inspection, the provider’s systems for audit required improvement because their audits had not identified there was a lack of consistency across the home in people’s care plans and documentation. The provider’s other systems for audit were effective, including receiving and acting on feedback from relevant persons.

People’s medicines were managed in a safe way and there were full records about supporting people with their medicines. All medicines were securely stored. People received the support they needed to enable them to eat and drink what they wanted. They could choose where they ate their meals. Staff were available to support people who needed assistance with eating and drinking.

People said there were enough staff on duty to support them. Staff were available to respond quickly to people when they needed assistance. Staff were recruited in an effective way, to ensure they were safe to care for people.

Staff knew how to ensure people were protected against risk of abuse. All staff were aware of their responsibilities where people lacked capacity. People had clear individual assessments in relation to their capacity. The registered manager had ensured relevant referrals were made to the local authority under the Deprivation of Liberty Safeguards (DoLS).

All people had relevant care plans, including where people had complex healthcare, nursing and treatment needs. People also had clear care plans about living with dementia, these were followed by staff. Where people needed support from external professionals, such as the tissue viability nurse (TVN) or speech and language therapist (SALT), the home ensured referrals took place promptly and professionals’ directions were followed.

People and their relatives said staff were caring. Throughout the inspection, we saw many examples of a caring attitude from staff to people. Staff supported people’s independence and helped them to make choices. People’s privacy and dignity was respected in their daily lives.

The home employed several activities staff. A range of activities were provided to people to suit their diverse needs. People were fully supported in participating in activities as they wished.

Staff were trained in their roles, including supporting people who were living with dementia. Staff were appropriately supervised to ensure they could provide effective care and treatment to people.

Both people and staff said they could raise issues with managers when they needed to. They felt confident action would be taken if they did this. People and staff commented on the support they received from the registered manager and other senior managers for the provider. People said the home was well managed and supportive of their needs.