Archived: High Street Lodge Limited

High Street Lodge Ltd provides care and support to people living in three ‘supported living’ settings, so that they can live in their own home as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

Not everyone using High Street Lodge Ltd receives a regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

The service supports people with a mental health condition. The service can accommodate a maximum of 17 people. On the day of the inspection there were nine people using the service.

A registered manager was in post at the time of this 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.

High Street Lodge has been inspected three times since February 2016. In February 2016 we found significant shortfalls in the care people received and the way in which the service was managed. We identified breaches of seven Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to inadequate risk assessments, people not being involved in planning their care, inadequate provision of staff training, staff not understanding of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS), a lack of staff supervision and a lack of auditing processes to ensure good governance and overall management of the service. Enforcement action was taken against the provider and the registered manager.

In September 2016 we inspected the service to check whether the required improvements had been made. We found that although some improvements had been made the service continued to be in breach of the regulations. We found that some aspects of risk management were not safe and there was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the serious nature of the breach we took further enforcement action against the registered provider.

In April 2017 we carried out a focused inspection to check that the most significant breach of legal requirements in relation to Regulation 12, concerning risk assessments, which had resulted in enforcement action, had been addressed. During this inspection we found that the provider had addressed this issue and were no longer in breach of the regulations. The service was rated overall ‘Good’.

At this inspection we found significant concerns and shortfalls in the care and support people received and the overall management of the service. Improvements that had been made previously had not been sustained.

Although the service identified and assessed people’s risks associated with their health and care needs, not all risks were appropriately assessed. This meant that care staff were not given appropriate information and guidance on how to manage people’s risks and keep them safe and free from harm.

Medicines management and administration was not safe. People were not always receiving their medicines safely and as prescribed.

Senior care staff completed monthly medicines audits, however, these did not identify any of the issues that we highlighted as part of this inspection. The registered manager did not monitor and evaluate the overall quality of care and support people received so that issues could be identified, improvements made and further learning and development implemented.

The registered manager and senior care worker had not improved on their level of knowledge on how to meet the regulations, especially considering that the service had a history of non-compliance.

People did not receive care and support that was in line with current best practice and reflective of their needs and requirements. Where change in people’s health and care needs had occurred, care plans had not been reviewed or updated to reflect this.

Records written about people, especially in relation to incidents, were not person centred. People were not referred to with dignity and respect.

Although we observed sufficient numbers of staff available to meet people’s needs we could not always be assured that where people required support to go out and take part in activities, sufficient number of staff would be available to support them.

People were not supported to engage and participate in a variety of activities that they may have enjoyed. People were observed sitting at home either in the lounge or in their own bedrooms with very little in the form of stimulation available to them to support them with positive well-being.

The service had not involved people or their relatives to give feedback about the quality of care and support that they and their relative received. This meant that the service was unable to learn and improve where required.

Care staff told us and records confirmed that they were supported through regular training, supervision and annual appraisals. However, where care staff received medicines training, competency assessments were not completed to assess that staff were competent when administering medicines.

People and their relatives told us that they felt safe when receiving support from the care staff at High Street Lodge Ltd. Care staff demonstrated a good understanding of how to recognise abuse and the steps they would take to report this.

Safe recruitment processes in place ensured only those staff assessed as suitable to work with vulnerable adults were employed.

People told us that they had enough to eat and drink. Some people were able to purchase and cook their own food and staff supported them. In some houses, staff cooked for people. Care staff told us that people were given choice when deciding what to eat.

People were supported to have some 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. People, where possible, had consented to the care and support that they received.

The service had no recorded complaints since the last inspection. Policies in place gave clear direction on how people and their relatives could complain. People and their relatives knew who to speak with if they wanted to raise a concern.

We identified breaches of Regulations 9, 10, 12 and 17 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 the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be 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.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 their registration or to varying the terms of their 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.

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

The service offers supported living services to people with enduring mental health problems. At the time of our inspection the provider was supporting nine people across three locations.

At the last inspection of this service on 26 and 27 September 2016 we found that some aspects of risk management were not safe and there was a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the serious nature of the breach we took enforcement action against the registered provider.

At the time of this focused inspection, there was a registered manager 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.

We undertook this announced focused inspection to check that the most significant breach of legal requirements in relation to Regulation 12, concerning risk assessments, which had resulted in enforcement action, had been addressed. During this inspection we found that the provider had addressed this issue and people’s risks were well documented and being managed appropriately. Risk assessments were written, where possible, in collaboration with people. People were able to tell us why they had risk assessments and how risk assessments helped them identify triggers in them becoming unwell.

At our last inspection we also found that the provider was not always ensuring that appropriate staff recruitment checks were carried out. We issued a requirement notice for this breach of Regulation 19. At this inspection we checked to see if the provider had addressed this issue. We found that staff recruitment was now safe and the provider had met this breach of Regulation.

People told us that they felt safe and supported by the service. Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report it to if people were at risk of harm.

Medicines were administered safely and on time. Staff had completed training in medicines and administration.

There were auditing processes in place that checked the quality of the service. Where issues were identified these were documented and followed up.

Staff had regular monthly team meetings that allowed them to share idea and opinions. There were regular management meetings that discussed the progress of the service.

This report only covers our findings in relation to safe and well-led. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for High Street Lodge Limited on our website at www.cqc.org.uk.

At our last inspection we rated safe and well-led as ‘requires improvement’. At this inspection we found that the provider has addressed the issues identified and have re-rated safe and well-led as ‘good’. This now means that the service is rated ‘good’ overall.

At our last inspection on 19 and 24 February 2016, we found significant shortfalls in the care provided to people. We identified breaches of regulations 9, 10, 11, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to inadequate risk assessments, people not being involved in planning their care, inadequate provision of staff training, staff understanding of the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS), a lack of staff supervision and a lack of auditing processes to ensure good governance and overall management of the service provided. We were not satisfied that care and treatment was being provided safely.

We took action to impose a condition to restrict new admissions to High Street Lodge without the prior written agreement of the CQC. We also imposed conditions that the provider undertook audits of the training and supervision of all staff at High Street Lodge and people’s risk assessments and care plans and send the CQC monthly written reports of the results of these audits and any action taken or to be taken as a result of the audits.

The provider was also placed into special measures. Special measures are designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Its purpose is to ensure that inadequate care significantly improves and provides a clear timeframe within which the provider must improve the quality of care they provide. When a provider is placed into special measures, the CQC will re-inspect within six months.

This inspection was carried out within the six month time frame to check if improvements to the quality of care had been implemented.

The service offers supported living services to people with enduring mental health problems. At the time of our last inspection, the service was supporting 14 people across five locations where care was provided. At this inspection, the provider had closed two of the locations where care was provided and was supporting nine people across three locations.

There was a registered manager in place who was present during our 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.

All people living at the service had new style risk assessments completed. However, whilst these were better than the risk assessments at the last inspection, they failed to provide staff with adequate guidance on how to mitigate risks in a person centred way. Some of these risks were significant.

The service was not always ensuring that appropriate staff recruitment checks were carried out. We found that the service had not monitored one staff member’s eligibility to work in the UK. One criminal records check and some references had not been obtained.

At our last inspection, we found that the provider was not adequately assessing and mitigating known risks for people and there was a lack of management oversight regarding safe staff recruitment. At this inspection, we found that the provider had still not adequately addressed risk assessments and staff recruitment and failed to ensure that the service was meeting the regulatory requirements in this area.

The service carried out monthly health checks on things such as blood pressure and weight. For one person, the service had failed to identify a possible health concern and refer them to the correct healthcare professional. Generally however, people were referred to healthcare professionals in a timely manner.

Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report it to if people were at risk of harm. Staff had an understanding of the systems in place to protect people who could not make decisions and were aware of the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

People told us that they felt safe within the home and well supported by staff. We saw positive and friendly interactions between staff and people.

People were supported to have their medicines safely and on time. There were records of medicines audits and staff had completed training on medicine administration. The home had a clear policy on administration of medicine which was accessible to all staff.

There were systems in place to identify maintenance issues. Staff were aware of how to report and follow up maintenance.

Since the last inspection, the provider had brought in a training company. Numerous training sessions had been provided and there was a plan in place for when staff required refresher training. Staff training was updated regularly and monitored by the registered manager.

Staff had regular supervision and annual appraisals that helped identify training needs and improve the quality of care.

People were supported to have enough to eat and drink. People were encouraged and supported to cook and plan their meals. Where people were unable to cook, people had choice on what they wanted to shop for and eat and were supported by staff.

Care plans were person centred and reflected individual’s preferences. There were regular recorded key working sessions.

There was a complaints procedure as well as an accident and incident reporting.

We observed kind and caring interactions between staff and people. Staff knew people well and were able to tell us individual’s likes and dislikes.

The registered manager and deputy manager were accessible and spent time with people. We saw that there was an open culture within the service and this was reflected by what the staff told us. Staff felt safe and comfortable raising concerns with the manager and felt that they would be listened to.

There were regular health and safety audits and monthly medicines audits. These allowed the provider to ensure that issues were identified and addressed.

There was an open atmosphere within the home. The management now encouraged a culture of learning and staff development.

We identified continued breaches of regulations 12 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to identifying and appropriately mitigating risks for people that used the service and ensuring safe staff recruitment procedures were in place.

You can see what action we told the provider to take at the back of the full version of the report. However, some enforcement action regarding our findings at this inspection are on-going. We will publish what action we have taken at a later date.

As the provider has demonstrated significant improvements and the service is no longer rated as inadequate for any of the five questions, it is no longer in special measures.

At the last inspection, 21 August 2014, the provider was in breach of Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010. Risk assessments had not been undertaken for lone workers and provision of personal alarms had not been provided as specified in the organisations 'Lone Worker' policy. Staff were not supported and safe when carrying out their duties in accordance with regulation. At this inspection we found that the provider had partially met this breach. An emergency contact system had been put in place. However, risk assessments around lone working for staff had not been completed.

The service offers supported living services to people with enduring mental health problems. The service can accommodate a maximum of 17 people. On the day of the inspection there were 14 people using the service across five supported living locations.

There was a registered manager in place who was present during our 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.

Staff did not have access to risk assessments at the locations where people were supported. One person who presented significant risks did not have a risk assessment . Risk assessments held at the providers head office were a tick box format and did not state how risks were mitigated or managed. Care plans noted some risks. However, these did not always match the risk assessments and failed to give staff adequate guidance on how to mitigate risks and work effectively with people. This put people, staff and others at risk of harm.

The provider did not always follow safe recruitment practices for staff. We identified three staff who were working with vulnerable adults without criminal records checks. The registered manager was not aware if staff working with people were appropriate for the role and did not safeguard people adequately.

Medicines management was inadequate. The provider did not complete medicines audits and had not identified any of the issues we had identified. Staff did not have any guidance on ‘as ‘needed’ medicines (PRN) and when to offer them to people. Staff were unable to tell us in what circumstances ‘as needed’ medicines should be given.

There were some omissions in signing the Medicine Administration Record (MAR). We found that some medicines had been removed from blister packs but had not been administered. This had not been documented and there was no evidence of safe disposal of these medicines.

Staff had not received training in the Mental Capacity Act (MCA 2005) or the Deprivation of Liberty Safeguards (DoLS). The majority of staff were unable to tell us that the MCA and DoLS were and how it could impact on the people that they worked with.

Staff did not receive regular effective supervision. Staff had received an annual appraisal, but training needs and other issues were not followed up.

People told us that they had enough to eat and drink. Some people were able to purchase and cook their own food and staff supported them. In some houses, staff cooked for people. People were consulted but staff told us that they cooked what they thought people should have. People did not always have choice.

The provider did not keep appropriate records of training, identify staff training needs or monitor when staff needed their training updated. Staff told us that all the training that was received was ‘in-house’ and given by the registered manager and the deputy manager. The registered manager did not ensure that training met current best practice.

We observed some interactions between staff and people using the service that were not respectful. We discussed this with the provider during the inspection. The provider told us that they would investigate.

People were not effectively involved in planning their care. Care plans had not been signed by people or staff. Care plans were not person centred and did not state people’s individual preferences.

No audits were carried out for any aspect of the service. This included medicines, care plans, risk assessments, staff files and health and safety. The provider did not have a system to identify issues and correct any problems.

Overall, we found significant shortfalls in the care provided to people. We identified breaches of regulations 9, 10, 11, 12, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. We will publish what action we have taken at a later date.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special Measures'. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, the service will be 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.

Below is a summary of what we found. The summary is based on our observations during the inspections, speaking with people using the service, the staff supporting them and from looking at records. We visited the head office to meet with the registered manager and reviewed centralised records such as staff files and visited two of the five houses where people were accommodated to speak with people using the service and their carers.

If you want to see evidence supporting our summary please read our full report.

Is the service safe?

Risk assessments were completed for each person using the service to identify potential risks such as self-neglect and poor hygiene. Staff had received appropriate training to protect and safeguard vulnerable people using the service. Staff had received training to safely manage and administer medicines. There were appropriate arrangements in place to respond to an emergency and staff knew how to respond if a person using the service became unwell.

Is the service effective?

People's health and care needs were assessed with their involvement where possible. Care plans were developed which reflected the level and type of support each person required to be safe and receive appropriate care to meet their needs and preferences. We saw relatives had been involved to ensure people's best interests were considered.

Is the service caring?

We observed people using the service had their privacy and dignity respected and staff sought people's agreement before providing support. We spoke with people using the service who told us they were given support when they needed it but were allowed to be fairly independent. One person said, 'I can do pretty much my own thing but I let them (staff) where I am going and when I expect to be back.' We observed people were encouraged and helped to make decisions about their own day to day routine. People had been involved in the development of their support plans and supported by their relatives to identify their preferences and what was important to them. Staff demonstrated a good understanding of each person's needs and how to effectively communicate with them.

Is the service responsive?

There was a system in place to respond to and handle complaints. We observed peoples wishes were responded to appropriately and guidance given to ensure peoples safety without limiting their independence. There was evidence to show the service worked effectively with other health care professionals such as dentists and doctors to ensure people received care they had needed.

Is the service well led?

Accidents and incidents were reported and recorded but these were not analysed to identify trends to improve the quality and safety of the service. People using the service had been supported to participate in meetings to obtain their opinion of the service and there was evidence to show the registered manager had responded to people's feedback to improve the service. Although there was a Lone Worker policy to ensure staff safety parts of the policy had not been complied with. We saw there were policies and procedures in place but these were not made available for staff. This meant staff did not have the necessary information and guidance to support them in their role.

People told us they felt staff understood the needs of their needs. One person's comments were typical when they said, 'staff do help me when I need it, and they are fantastic.' People confirmed that regular checks were carried out by the agency to make sure that people received the quality of care they expected. They said that the service made sure that their needs were met.

People we spoke with told us that they had visited the placement prior to admission and that they felt this was the "right place". They added that they were involved in community activities for example adult education. People made positive comments about the staff team and said that staff were respectful. People also told us that that there was a "family atmosphere" when they visited and that they were aware of the formal complaints procedures.