Green Lodge

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

People felt safe and were supported by staff who were recruited safely. Staff knew of the risks associated with people’s care. Medicines were managed safely. The provider followed safe infection prevention and control procedures.

People were cared for by kind, caring staff who created a warm and welcoming environment.

The provider had in place clear quality assurance and auditing processes. Staff felt supported 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

The last rating for this service was requires improvement (published 19 June 2019).

Why we inspected

We carried out an announced comprehensive inspection of this service on 20 June 2019. We identified that further and sustained improvement was needed in relation to medicine records, risk assessment records and quality assurance processes.

We undertook this focused inspection to check whether improvements had been made and sustained in these areas. This report only covers our findings in relation to the key questions Safe, Caring and Well-led.

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 the service can respond to coronavirus and other infection outbreaks effectively .

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 has changed from requires improvement to good. 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 Green Lodge on our website at www.cqc.org.uk.

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.

Green Lodge is a purpose build care home built across two floors and divided into three areas. On the lower floor Ash unit accommodates up to 25 people with residential care needs. The upper floor is split into two units, the Cedar and the Oak. The Oak unit offers accommodation for up to 15 people with early onset dementia. The Cedar unit is a dedicated dementia care unit designed for older people living with a dementia and can accommodate up to 17 people. At the time of our inspection there were 22 on Ash, 5 on Cedar and 12 on Oak.

People’s experience of using this service and what we found. At this inspection we found the management of medicines had improved. Improvements were needed to fire drills and risk assessments. Accidents and incidents were monitored and analysed each month. There were enough staff on duty.

People were supported to have choice and control of their lives and staff did support them in the least restrictive way possible; the policies and systems in the service did support this practice. People were happy with the food provided and were offered plenty of choice. People on the Cedar unit were not provided with the choice to enjoy their meal at a dining table. Staff had received training to carry out their role and received regular supervision. Work was needed with signage to support people living with dementia to orientate themselves.

We raised some concerns with the registered manager about the behaviour of staff on the day. People were not always spoken to in a dignified way and staff practices did not maintain a person’s privacy. People were encouraged to be independent.

Care plans had person-centred information recorded. The provider had introduced an electronic care planning system and all staff had access to this via a mobile device. Complaints were acted on with an outcome documented. People had end of life care plans in place.

People and staff said the service was well led. Audits were taking place to monitor the quality of the service. We have made a recommendation regarding the concerns we found during the inspection.

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

Rating at last inspection: At the last inspection the service was rated requires improvement (published 25 August 2018. The service remains requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Previous breaches: At the last inspection in August 2018 we found the systems in place for the management of medicines did not always keep people safe. We asked the provider to complete an action plan to show what they would do to improve and by when. 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 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 return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Green Lodge is a ‘care home’. 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 service is registered for 57 people and at the time of inspection there were 35 people living at the service. The service provided care to older people and people living with a dementia.

A registered manager was in post at the time of the inspection visit. They were registered with the Care Quality Commission (CQC) in December 2017. 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.

The last inspection of the service was carried out in June 2017 and found that the service was not meeting all the requirements of Health and Social Care Act 2008 and associated Regulations. We found concerns relating to risks to people arising from their health and support needs and risks to the premises and equipment. Staffing levels were low and medicines were not administered safely. We also found systems and processes were not in place to ensure effective operations of the service, there were limited checks to ensure the safety of people living at the service and the dining experience did not meet people’s needs or promoted their wellbeing. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good.

At this inspection we found that the provider had made improvements. However, work was still needed to make the administration of medicines safe. We found some medicines were out of stock for up to ten days and staff were not completing the electronic medicine administration records correctly. This is the second time the service has been rated requires improvement.

Audits were taking place with a full action plan along with an analysis and lessons learnt. However, the medicine audit did not highlight any concerns.

Risks associated with people's support needs were now fully considered and correctly documented in care plans.

Staffing levels had increased, and recruitment was still ongoing.

We have made a recommendation about staffing levels.

Accidents and incidents were recorded, analysed monthly with an action plan to support any lessons learnt.

The registered manager understood their responsibilities in relation to the DoLS. 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 training was up to date. Supervisions and a yearly appraisal were taking place or booked in.

Feedback on the quality of the service had been sought and was positive.

People enjoyed the food provided and the dining experience had improved. Specific cultural diets were provided if needed.

People could access healthcare services as needed.

People who lived at the service were safeguarded from abuse. People told us that they felt safe at the service and that they trusted staff. Staff had received training in the safeguarding of vulnerable adults and said they would not hesitate to report concerns.

A number of recruitment checks were carried out before staff were employed to ensure they were suitable to work with vulnerable adults.

People received support from staff who were kind, caring and compassionate. People felt they were treated with dignity, respect and valued as individuals. People's right to independence and choice was promoted.

Staff demonstrated a person-centred approach to care and they knew people well. Care plans had information of people’s wishes, preferences and life histories.

We saw evidence of activities taking place and people we spoke with enjoyed them.

The service had a complaints policy that was applied when issues arose. People and their relatives knew how to raise any issues they had.

The provider and registered manager understood their legal responsibilities, were open and honest about any issues that affected the service and had a wish to further improve the service, so people continued to receive good quality care.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

Green Lodge is a purpose built care home providing accommodation across two floors. The home itself is positioned in a residential area and offers designated parking to visitors and people who use the service. The ground floor Ash unit accommodates up to 25 people with residential care needs. The upper floor is split into two units, Cedar and Oak. The Cedar unit offers accommodation for up to 15 people with residential care needs. The Oak unit is a dedicated dementia care unit designed for older people living with a dementia and can accommodate up to 17 people.

Each unit has its own kitchenette area, where people who use the service, their visitors and relatives can make tea and coffee. Each bedroom offers en-suite facilities and each unit also has additional bathing and showering facilities.

The service 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. At the time of inspection the registered manager was on annual leave.

Risks to people arising from their health and support needs were not always assessed, and plans were not always in place to minimise them. Risks to people arising from the premises were assessed, and plans were in place to minimise them. A number of checks were carried out around the service to ensure that the premises and equipment were safe to use. However the file that would be grabbed in case of an emergency such as a fire contained personal emergency evacuation plans for six people who no longer lived at the service. This meant that in the event of a fire, emergency services would be looking for people that were no longer there.

We found there was not enough staff to meet people's needs. On the ground floor there was one senior care worker and two care workers, nine people needed two to one care and nurse call alarms rang continuously throughout the day.

Medicines records for applying topical creams were inconsistent, controlled drugs had not been checked since April 2017 and the temperature of the fridge where medicines were stored showed temperatures of between nine and 12 degrees Celsius on 16 occasions from the 1st to the 27th of June 2017. Fridge temperatures should be between 2 and 8 degrees Celsius.

We found the care plans were not person centred, and did not reflect people’s current needs. One person was receiving end of life care and had a syringe driver in place but this was not documented in the care plan. One person had a do not attempt cardiopulmonary resuscitation (DNACPR) in place, however in their care plan a note stated the DNACPR had been returned to the GP to have the address changed. This had happened on 9 June 2017 and no staff member had chased this up for 18 days. The purpose of a DNACPR decision is to provide immediate guidance to those present, mostly healthcare professionals on the action to take should the person suffer cardiac arrest or die suddenly. It had been this person’s choice not to be resuscitated but due to the DNACPR not being available their wishes would not have been respected.

Audits were taking place, however were not robust enough to highlight the issues we found during our visit. Many audits did not have action plan in place.

Staff did not receive supervision in line with the home’s supervision policy. The manager completed senior care workers supervisions and the senior care workers completed care workers supervisions. However senior care staff said they struggled with the time to do this.

Staff understood safeguarding issues and felt confident in raising any concerns they had, in order to keep people safe.

Staff had received Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) training and demonstrated a basic understanding of the requirements of the Act. The registered manager understood their responsibilities in relation to DoLS.

We found the premises was cluttered and dirty in some areas. The office upstairs was very untidy, people’s files were not stored confidentially as the office was not locked. An old fridge and chairs had been left outside the premises and looked unsightly.

We observed and joined people for lunch and found this to be a task driven service rather than an enjoyable experience for people. Mealtimes were meant to be protected however people were interrupted to have medicines administered. Where people were provided a food supplement this was handed to them whilst they were eating their meal. People should be encouraged to eat as much as possible and the food supplement offered as a top up. Providing them at mealtimes would fill the person up and prevent them eating.

We saw some evidence that staff worked with external professionals to support and maintain people’s health. However, one staff member found a problem with one person’s urine output and documented it in a care plan review, stating must push fluids. This information was never passed onto anyone else not even other staff and there was no record of extra fluid intake.

The interactions between people and staff was kind and respectful. We saw staff were aware of how to respect people’s privacy and dignity. People and their relatives spoke highly of the care they received. However, all the people we spoke with said they felt the staffing levels were too low and had to wait up to 30 minutes to get help.

Procedures were in place to support people to access advocacy services should the need arise. One person was using an advocate at the time of inspection.

We were told people had access to activities, which they enjoyed. However other than an impromptu sing a long upstairs no activities took place during insepction. People downstairs stayed in their own rooms and we were told they had always done this and it was their choice. Some of these decisions were made several years ago and were still accepted without being reviewed. There was no evidence that staff had attempted to encourage people to come out of their rooms and prevent social isolation.

The provider had a clear complaints policy that was applied when any concerns were raised. People and their relatives knew how to raise any issues they had. We were aware of one complaint before inspection and the regional manager had addressed this, however, this complaint was not documented in the services complaints file. Only one complaint was documented and this was filed under compliments. This complaint had also been addressed by the regional manager but we saw no evidence of learning from it to prevent the same happening in the future. Complaints raised to staff were passed on during their meetings, however they weren’t recorded or followed up.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.