The Care Quality Commission
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  • Care home

Archived: Spring Lodge Residential Care Home

Overall: Inadequate read more about inspection ratings

7 Madeira Avenue, Madeira Avenue, Worthing, West Sussex, BN11 2AT (01903) 522022

Provided and run by:
Holly Spring Limited

Important: The provider of this service changed. See old profile

All Inspections

18 and 20 November 2014

During a routine inspection

At an inspection on 11 October 2013 we asked the provider to take action to make improvements to care and welfare, staff recruitment and staff training. Following that inspection we also issued a warning notice telling the provider they had to improve quality assurance processes. We carried out a follow up inspection on 17 January 2014 to check compliance with the warning notice and found improvements had been made.

The inspection took place over two days on 18 and 20 November 2014 and was unannounced.

We found that the provider and the registered manager had not taken action to improve care and welfare, staff recruitment and staff training, and were not meeting legal standards. In addition we found the provider and the registered manager had breached nine further regulations, relating to assessing and monitoring quality, safeguarding vulnerable adults, cleanliness and infection control, medicines management, meeting people’s nutritional needs, respecting and involving people in their care, consent to care, staffing levels and notifying the Care Quality Commission of events.

Spring Lodge Residential Care Home provides accommodation and personal care for up to ten older people. The home is situated in a residential area of Worthing close to the sea front. Some people living in the home were living with dementia or a learning disability which meant their ability to understand and communicate their needs and wishes was limited. There were nine people living in the home at the time of our inspection.

A registered manager was in post. 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.

Following our inspection, the registered manager submitted applications to cancel both the registered manager and provider registrations with CQC. These applications are currently under consideration. She also told the local authority of her intention to close the home on 5 December 2014. Social services worked closely with relatives to ensure that everyone using the service was safely transferred to another home.

The registered manager was responsible for care and decision making in the home. The culture of the home was not centred on the needs of people using the service, and care practices were poor. Staff were not supported effectively and there was a lack of governance to improve the quality of care.

People’s care was not delivered safely. Risk assessments in respect of moving and handling were not accurate or up to date and we witnessed moving and handling practice which was unsafe. An urgent referral to social services safeguarding team was made for one person using the service because we were concerned for their care and welfare. People were not protected from abuse. The registered manager had not followed safeguarding guidance when signs of abuse were witnessed.

People’s dignity was not respected. The registered manager had taken actions to control potential behaviours which may challenge without taking professional advice and without putting behaviour management plans in place. Actions included rationing sweets, chocolate, toilet paper, wipes and incontinence pads. People were ‘told off’ if they didn’t ‘behave’ and were spoken about in a way which was derogatory. Some people using the service were unhappy and fearful. There was a set routine in the home about what time people could get up, what they did during the day, what time they ate, what time they got ready for bed and what time they went to bed. People were not free to make their own choices. There were no planned activities, these were on an ad hoc basis when staff had time.

Care planning around the administration of medicines was unsafe and records were difficult to read and were incomplete. There was a risk that people would not receive the right medicines at the right time and staff were not given enough information to administer medicines safely.

The home was dirty. The provider had not employed a cleaner and staff did not have time to complete cleaning tasks in addition to caring for people. The infection control policy did not refer specifically to the home and made no reference to ‘The Health and Social Care Act 2008 Code of Practice on the prevention and control of infections’. This code of practice was not followed in the home, and unsafe procedures were followed in respect of cleaning, laundry, food storage and the disposal of contaminated waste. People using the service were at enhanced risk of infection because of these poor practices.

There was not enough staff on duty at night to keep people safe. Only one member of staff was on duty during the night shift in the home and they were expected to carry out cleaning and laundry duties whilst looking after nine people. This level of staff did not meet people’s needs and was unsafe. Staffing levels were not based on people’s assessed needs.

Recruitment procedures were unsafe as proper checks were not carried out. Two members of staff were working without a full criminal records check. Appropriate references and employment histories were not obtained. During our inspection an attempt was made by the registered manager to fake a reference. The registered manager could not be sure that the staff recruited were suitable for the role.

People using the service were at risk of malnutrition and dehydration. Risk assessments were inaccurate and out of date and suitable actions, in terms of monitoring and seeking professional advice, had not been sought to address the identified risks. One person was identified at risk of choking but the advice of a speech and language therapist had not been sought. This put the person at risk of harm.

Staff had not received sufficient training to carry out their roles. Moving and handling practical training had not been carried out and we saw unsafe moving and handling techniques in the home during our inspection. This unsafe practice put people at risk of harm.

Staff had received training in respect of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards however they did not know or understand the principles of the Act. Mental capacity assessments had not been carried out for anyone using the service where their capacity was in doubt and there were no best interest decisions recorded. There was a risk the home was providing care for people without valid consent. The provider had not made any applications under Deprivation of Liberty Safeguards to restrict their freedom of movement, yet people were not free to leave unsupervised. There was a risk that people were illegally deprived of their liberty.

People’s health needs were not responded to promptly and care plans were not an accurate reflection of people’s current needs and preferences. People were at risk of harm and inappropriate care because their needs were not attended to.

24 January 2014

During an inspection looking at part of the service

At our last inspection on 11 October 2013, we found that the provider was non-compliant with regard to regularly assessing and monitoring the quality of the services provided and managing risks relating to the health, welfare and safety of service users. We judged that this had a moderate impact on people who used the service. We asked the provider to become compliant by 20 December 2013.

During this inspection we spoke with the provider and reviewed documentation.

We saw evidence that the provider had systems in place to ensure that people who used the service and their representatives were asked for their views about their care and that they were acted on. We also saw that systems were in place to monitor the quality and safety of the service provided. There was evidence that learning from incidents had taken place.

There was no registered manager in post at the time of this inspection.

11 October 2013

During an inspection looking at part of the service

At our last inspection on 2 August 2013 we found that the provider was non-compliant in relation to requirements relating to workers, supporting workers and assessing and monitoring the quality of service provision. We asked the provider to send us an action plan which identified how they would achieve compliance in these areas. This was returned on 3 September 2013.

In October 2013 we received some information of concern relating to the care and welfare of the people who lived at the home. During this inspection we followed up progress on the provider’s action plan. We also investigated the concerns that had been raised. We spoke with one person who lived at the home and their relative, the manager and two care workers. We looked at the care records of four people. We also looked at the records for fifteen staff members.

We found that appropriate checks with the Disclosure and Barring Service (DBS) had now been undertaken for all staff members. However, gaps in employment history had not been identified. We saw that whilst most now staff had up to date training in key areas only three out of the fifteen members of staff had received supervision since our last inspection.The provider was unable to show us any evidence of how they assessed and monitored key aspects of the quality of service provision.

We saw that people’s needs had been assessed and that care plans were in place. However, some people’s care was not always delivered in line with their care plan.

2 August 2013

During a routine inspection

We spoke with three people who lived at the home and one relative. They were all happy with the care provided. One person said, "It's friendly. It's not too big. It's very nice." Another said about their relative who lived there, "X is so happy here. We, the whole family feel so lucky."

We looked at the care records of three people. We saw that their needs had been assessed and that care was delivered in line with their individual care plan.

We spoke with four members of staff. They all said they felt well supported and had been sufficiently trained to undertake their roles. However, not all of them had up to date training and supervision. They all felt there were enough staff on duty to meet people's needs, but not always enough time for management tasks to be completed.

We looked at the recruitment records for five members of staff. We found that four out of the five members of staff had been employed before a Criminal Record Bureau check had been received. This meant that appropriate checks had not been undertaken before staff began work to ensure that they were of suitable character.

We saw that people who lived at the home and their relatives were asked for their views on service provision through regular satisfaction surveys. However, there was no evidence that systems were in place to regularly assess and monitor other aspects of service provision.

19 February 2013

During a routine inspection

There were seven people living at the home at the time of the inspection. Throughout the inspection we saw that staff were communicating with people at a suitable pace, were relaxed and unhurried during their interactions.

We spoke to the new manager, care staff and the cook. Our observations provided evidence that people's individual wishes and needs were considered and met.

People living at the service told us that they 'felt safe' and that the staff were 'extremely kind.'

We found that staff had received training in safeguarding and were aware of how to report any concerns.

The provider did not have systems in place to assess and monitor the quality of the service provided.

14 October 2011

During an inspection in response to concerns

We talked to two people who live at The Victoria Park View. They told us they receive the care and support they need. Everyone we spoke with confirmed their satisfaction with the service provided.

We also spoke to two members of staff who were on duty. They told us about the level care they provide to people at The Victoria Park View. They also told us about the support and training they have received to enable them to provide good quality care.

We spoke to the deputy manager about the systems that were in place to assess and review the needs of each person.