We carried out a review of the data available to us about Paisley Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Paisley Lodge, you can give feedback on this service.
We found the following examples of good practice.
Systems were in place to make sure visitors to the service followed government guidelines for wearing Personal Protective Equipment (PPE). Screening questions and temperature checks were requirements for all visitors.
A ground floor lounge had been converted to allow safe visiting for relatives and friends of people. The room had a purpose-built screen to reduce the risk of spreading infection. Visitors could access this room without walking through the main building.
The provider had appropriate arrangements to test people and staff for COVID- 19 and was following government guidance on testing.
People admitted to the service were supported following government guidelines on managing new admissions during the COVID-19 pandemic.
The provider's infection prevention and control policy was up to date and in line with current guidance.
Risk assessments were carried out to assess the impact of COVID- 19 on people and staff.
The provider ensured staff received appropriate training and support to help prevent the spread of infection. All staff had received training on infection control and the use of PPE. We observed staff followed current guidance and practice during our visit. The management team ensured regular checks to make sure staff complied with current guidance and practice.
There were systems in place to ensure any new guidance regarding infection prevention control and PPE was shared with all the staff.
Paisley Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as 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. This service provides nursing and personal care for up to 45 people. At the time of this inspection there were 34 people using the service.
People’s experience of using this service and what we found
People were happy with the care and support they received and told us they felt safe. Staff told us they felt people were safe as they knew them well.
People felt there were a lot of activities to support people’s wellbeing and interaction.
Medicines were managed safely. Staff were aware of risks to people and knew how to keep them safe. The registered manager was monitoring accident and incidents and taking action to prevent re-occurrences.
Staff were recruited safely, were well trained and had the required skills to meet people’s needs. Staff told us they felt well supported and received supervisions and appraisals.
The home was clean and well maintained. There was an ongoing refurbishment plan which included improvements to many areas of the home including people’s bedrooms.
People and relatives spoke of the kind and caring approach of staff. We saw staff treated people with respect and maintained their privacy and dignity. People had access to healthcare services. People were happy with the choices and quality of food and said they received plenty to eat and drink.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
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 26 October 2017). There was also an inspection on (17 and 18 October 2018) however, the report following that inspection was withdrawn as there was an issue with some of the information that we gathered.
Why we inspected: This is a planned re-inspection because of the issue highlighted above.
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.
At this inspection we found that people were being appropriately and safely assisted to move because staff were trained to do so, and staff competency was refreshed with supervisions. Therefore the regulation was met. However, we found that clinical waste was not always secured safely, and doors that were required to be locked were not always secured. There were malodours observed in the corridors on both floors.
People’s consent was not always recorded accurately and best interest’s decisions were not recorded as being made in partnership with others.
People did not receive regular and stimulating activities, and activities provision had been limited by a vacancy for an activities co-ordinator that had not been filled. Although there was a quality monitoring system in place this was not always effective in identifying concerns or resulting in the required improvements. This was a breach in regulation. You can see what action we told the provider to take at the back of the full version of the report.
Paisley lodge is a care home located in the Armley area of Leeds. The home has 45 beds, providing care for older people and people living with dementia. The building was split into two floors, with dining rooms and communal areas on both floors. The building was wheelchair accessible, with security provided by keypad entry. There were 36 people living at the service at the time of the inspection.
The service had a registered manager who had been in post for two weeks. 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.
Medicine records were accurate and detailed, and pain charts were used to monitor the effectiveness of painkillers.
Staff were recruited safely, and there were enough staff to deliver care safely.
People were supported with their nutrition and hydration by competent and well trained staff. Food was highly regarded and people’s food and fluid intake was assessed using nationally recognised monitoring tools.
People were cared for by compassionate and caring staff who created a warm, welcoming and friendly atmosphere. People spoke highly of staff who were looking after them.
Staff understood the importance of people’s privacy and dignity, and told us how they ensured this was maintained.
People’s care plans were detailed and person-centred. They were created in partnership with people and their loved ones. People’s relatives told us the service contacted them frequently with any changes or updates to their relatives’ wellbeing.
Complaints were recorded and responded to in a considerate, professional and timely way.
Staff told us the enjoyed working at the service and were supported with regular supervision. We also saw that staff meetings were held.
Paisley Lodge is situated in Armley, Leeds. Care is provided on two floors for up to 45 older adults living with Dementia. At the time of the inspection, the service had a registered manager. 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.
We saw positive practice whilst medicines were administered. However, not all relevant staff had received medication training.
Relatives and staff expressed mixed view about staffing levels. Staff rotas showed nearly all shifts were fully staffed over a four week period, although the registered provider was unable to show us how they calculated staffing levels.
Risks to individuals were recorded and provided staff with sufficient information in order to lower levels of risk. These were reviewed regularly. We identified one person needed an epilepsy risk assessment.
Infection control was mostly well managed, although the kitchen area needed further attention. Regular building maintenance was carried out and the necessary fire safety checks were completed.
People told us they felt safe and relatives agreed with this. Recruitment procedures were mostly safe, although one candidate failed to report a conviction which was not formally assessed. People had good access to healthcare as appropriate referrals were made to a range of services.
Staff were satisfied with the induction they received. Most staff received regular supervision and nearly all staff had a recent appraisal.
Mental capacity assessments were decision specific and covered a wide range of areas. Staff had received training in the Mental Capacity Act 2005 (MCA) and demonstrated their knowledge. Deprivation of Liberty Safeguards (DoLS) were generally well managed, although one application had been submitted for a person who had capacity.
People had a positive mealtime experience. People enjoyed the food and drink provided and we found they received adequate nutrition and hydration. The provision of activities had recently increased which meant they were being provided seven days a week. Records showed people engaged with activities when they wanted to.
Staff were very attentive to people’s needs. We saw positive interaction between staff and people and we found staff knew people very well. Privacy and dignity was protected based on our observations and what people told us.
Care plans were detailed, although we found some examples where information recorded did not match actual practice. Reviews were carried out on a monthly basis and every six months, people and relatives were invited to attend a full review.
Complaints were well managed and people knew how to complain as this information was made available to them. There was a positive culture amongst the staff team who worked well together. Staff told us they were warming towards the registered manager. The area manager had an active presence in the home. We noted audits were carried out, although action plans needed to be formalised. We saw a comprehensive service action plan was in place.
We found a breach of the regulations 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 this report.