Maple Lodge

About the service

Maple Lodge is a residential care home providing personal care to people who have a learning disability and/or autistic spectrum disorder. The service can support up to 5 people. Maple Lodge is a detached bungalow located in a residential cul-de-sac in Colchester and is 1 of a group of 5 similar properties in the same cul-de-sac and owned by the same provider. At the time of the inspection 5 people lived at the service.

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

Right Support: People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. The provider failed to ensure people had the right support. The care records guiding staff as to the support people required were not effective as staff had not received adequate training to support people safely and this included in the use of physical and chemical restraint. A refurbishment programme was in the process of starting prior to the inspection, but this had not been completed and some areas of the home, still required urgent attention and renewal to promote cleaning to an acceptable standard. Infection prevention and control measures were not robust, and some areas of the service was visibly unkempt, not well maintained and unhygienic.

Right Care: Staff cared about the people they supported but were frustrated by their inability to deliver person centred care because of the provider's failings. Requests for training to the provider from the registered manager were not followed up or listened to. Systems and processes were not always effective in ensuring people were protected from the risk of avoidable harm.

Right Culture: The provider failed to ensure the service was being provided in a way which was compliant with the CQC's Right Support, Right Care, Right Culture guidance, or other national best practice guidelines to meet people's needs in this type of specialist setting. People experienced or were at risk of harm because of a lack of protection, they experienced or were at risk of abusive incidents, including unnecessary restraint. The governance systems used by the provider were not effective and did not identify concerns related to quality and safety, restraint, medicine administration, infection control or risk.

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

Rating at last inspection

The last rating for this service was Good (published 20 September 2018)

Why we inspected

The inspection was prompted in part due to concerns received about the use of unauthorised restraint used at one of the provider’s ‘sister’ services. A decision was made for us to inspect and examine those risks.

We undertook a focused inspection to review the key questions of Safe, Effective and Well-Led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

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

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding, and governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will 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 to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

We found the following examples of good practice.

The service adhered to government guidance and arrangements were in place for the safe facilitation of visiting by two named family members. This was within an individualised risk assessment framework and enabled people’s right to meaningful family relationships be re-established following lockdown.

Whole home testing for people and staff, including weekly testing and rapid testing was undertaken. Consent was gained from people each time prior to testing. Best interest decisions were taken on an individual basis for people who did not understand. Tests were not undertaken when people declined despite best efforts to support or were likely to be distressed by the process.

Contingency plans were in place to ensure effective management of an outbreak. Following an isolated incident where a staff member tested positive contingency arrangements were triggered. People isolated within their rooms and rota’s were changed to ensure people received support on a one to one basis. This limited staff contact and staff movement within the service and ensured people received continued occupation and engagement. The staff member isolated on full pay. The exposure to Covid-19 was contained.

Everybody using the service has now received both vaccinations against Covid-19.

Staff had received training on the use of personal protective equipment (PPE) and infection control practices and processes were in place to minimise the spread of infection. There was an adequate supply of PPE.

Cleaning regimes had been increased including regular hard surface contact cleaning.

Staff promoted people’s wellbeing during lockdown by supporting them to go out for walks or car drives every day. Alternative activities at home were introduced which included a lot of art and crafts and baking.

This unannounced comprehensive inspection took place on the 19 and 23 July 2018.

At the last inspection in May 2017, the service was rated as requires improvement. We had concerns people were not always safe as staff did not have the necessary guidance about how to safeguard people from abuse and there were shortfalls in the storage and management of people's medicines. The requirements of the Mental Capacity Act 2005 were not being met when making decisions for people who lacked capacity. We also found some staff did not treat people with respect. A lack of oversight by the manager meant these shortfalls had not been picked up and resolved as required.

At this inspection we found the provider had addressed our concerns and we rated the service as good in all areas.

There was a new registered manager in post who had arrived at the service at the end of 2017. 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 new registered manager was a passionate leader who inspired staff to share in the improvements at the service, which were ongoing and based on research into best practice. The culture of the service had become more person-centred and there was a focus on respect and openness. There were systems in place to check on the quality of the care, though there was room for improvement in the oversight the provider had of the service. There was limited impact during our inspection from this however due to the strength and quality of the registered manager.

The registered manager had focused on reducing risk at the service, in particular reducing the number of medicine errors. Every area of medicine administration had improved, from staff skills to guidance and quality checks. This demonstrated a commitment by the new manager to ensure people at the service received safe support.

There were improved systems when concerns had been raised that people were at risk of abuse. Investigations were open and the registered manager communicated well with outside organisations as necessary. Staff knew who to contact if they were concerned about people’s safety.

Risk was well managed in a personalised manner through effective assessment and planning. Measures to reduce the spread of infection were practical and effective. There were enough safely recruited staff to meet people’s needs.

Staff felt well supported and valued. They were enabled by the registered manager to develop specialist skills and gain a better understanding of the needs of the people they supported. The staff team worked together and communicated well to provide consistent support. People’s physical and mental wellbeing was promoted and they received support to access health and social care professionals when required.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. We found the registered manager and staff met their responsibility under the MCA. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff supported people to become better informed so they could take more control over the choices they made

The registered manager promoted a culture where people were treated with dignity and warmth. Staff communicated with people in a variety of way to ensure they understood their preferences and were involved in their care.

People lived full lives, engaging in a variety of activities which developed their independence and skills. Care plans had been adapted to be more person centred and provided staff with the necessary information to meet people’s needs and keep them safe. The registered manager encouraged people and families to raise concerns where necessary and used information from feedback and complaints to improve the service.

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

Further information is in the detailed findings below.

There was 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 manager is registered for this service and one other local care service and is also one of the organisation’s directors.

This inspection took place on the 9 May 2017 and was unannounced.

Prior to our inspection we received information of concern regarding incidents of alleged abuse against people who used the service. Despite a previous, recent reminder to the registered manager of the need to do so, we found they had on three occasions in the last four months failed to notify the Care Quality Commission (CQC) as they are required by law to do so of alleged safeguarding incidents of abuse towards people who used the service. This included incidents investigated by the police.

Staff had been provided with training in Safeguarding Adults from abuse. However, policies which guided staff in how to report poor practice and safeguard people from the risk of abuse had not been regularly reviewed. These policies contained out of date information and did not provide staff with up to date, relevant guidance in line with local safeguarding protocols and current regulatory requirements.

We found shortfalls in the proper and safe management of people’s medicines. Controlled drugs were not held safely and there was a lack of audit trail which meant it was not possible to carry out audits. There was a lack of robust and effective audits which would have identified the shortfalls that we found at this inspection to enable the provider to respond to medication errors. The provider's medicines management policy, which provided staff with procedural guidance for ensuring the safe administration of people's medicines, did not provide the level of detail required in line with current legislation including National Institute for Clinical Excellence (NICE) guidance for managing medicines in care homes.

People were cared for safely by staff who had been recruited and employed after appropriate checks had been completed. People’s needs were met by sufficient numbers of staff. Staff were provided with training relevant to their roles and responsibilities. People were not always treated with respect. Whilst most staff demonstrated caring attitudes to people who used the service, the culture and practices had been undermined by some.

The requirements of the Mental Capacity Act 2005 were not being met. Decisions were being made on behalf of people without the correct process having been followed to determine this was appropriate. Staff were making decisions on behalf of people without appropriate assessments to support decision making which put people at risk of not having their human rights upheld.

People's needs had been assessed and care and support plans outlined their preferences and how they should be supported. People were supported to access the community and follow their interests. There were systems in place to support people to maintain their health and wellbeing. People had balanced nutritious food provided. People’s weights were regularly monitored and recorded. However, we noted that some weights recorded showed significant losses and gains from week to week with no information recorded as to any actions taken in response. People were supported to access health care including learning disability and epilepsy specialists.

There were systems in place to manage complaints and review incidents, audit performance as well as monitoring the quality and safety of the service. However, these were not effective at identifying the shortfalls that we found at this inspection. This put people at potential risk of harm.

During this inspection we identified a number of 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 this report.

We saw that each person had their own unique communication plan which staff and other professionals used to support them in understanding people's wishes and aspirations.

We saw that care plans and risk assessments were regularly reviewed with people who used the service or relatives if they were unable to fully participate. We saw that staff were knowledgeable about people's needs and promoted their independence. During our discussions with staff we found that they had a good understanding and awareness of people's care needs and preferences.

We saw that the provider had an effective recruitment and selection process in place.

We saw that there was a complaints policy and procedure in place which was in an easy read format. The staff were able to explain the complaints procedure. People who used the service told us they were aware of how and who to complain to.

People who lived at Maple lodge had very complex needs and they had different ways of telling us about their experiences. On the day of the inspection, we observed that people were supported by staff who engaged with them in an encouraging and direct way. The staff were aware of the individual needs, communication styles and behaviour of people who used the service.

Maple Lodge had made improvements since our last inspection in June 2012. These included reviewed and updated care plans, risk assessments and behaviour management strategies. Consent to care and support arrangements had been implemented and person centred activities were now in place which gave people more choice and control in their lives.

The changes made to the administration of medication in the home meant that people were kept safe and protected from the risks associated with the management of medicines. Staff training and support had improved in order that the staff could perform their caring role satisfactorily.

A quality assurance system was now in place which included action plans, regular audits to check quality and safety, better recording and information sharing about people's needs. People at Maple Lodge could be assured that systems and processes were in place to keep them safe and to protect their rights.