Worsley Lodge

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the three key questions to at least good. The provider subsequently submitted action plans to CQC on a regular basis. The provider had regular meetings with Salford quality assurance team to monitor progress and to review the action plan. We found there had been significant improvements in two key questions but further improvement was still needed in relation to the key question Well led. This was because the registered manager still needed to embed effective systems to sustain the improvements achieved in the service and to develop further oversight of records.

Worsley Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate a maximum of 48 people. When we inspected there were 39 people living at the home, some people were living with dementia. Accommodation was provided over two floors in single rooms, 33 rooms were en-suite. There was a lift. There were a variety of communal areas for people to access which included quieter areas for people who preferred this. There were extensive gardens with a variety of furniture which people could access directly through one of the lounges downstairs.

Since the last inspection the home manager had successfully applied to CQC to be the 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.

People living in Worsley Lodge and their relatives told us they felt safe in the home. At our last inspection we had found the service had failed to manage some of the assessed risks they had identified, a small kitchen door had been propped open which had exposed some people to the risk of scalding. At this inspection we found there had been an improvement. The door was not propped open unless a member of staff was present to maintain people's safety. At the last inspection fire escape signage had been removed from the first floor and not replaced in a timely way. Shortly after the last inspection this had been replaced to ensure people knew where their nearest fire exit was.

Medicines had not been managed safely. Some medicines had been out of date, stocks were not accurate, records were incomplete and we could not be confident people had received time sensitive medicines or topical treatments when required. Since the last inspection the home had worked with the quality assurance team pharmacist to improve their medicines procedures and records. At this inspection we found this had been significantly improved and were confident medicines were being managed safely.

At the last inspection we found staffing levels had been low, staff had been very rushed and found it difficult supervise vulnerable people. This was reviewed during the last inspection and increased. This increased level remained in place and a further increase had happened since then.

People continued to be protected from the risk of harm and abuse by staff who were knowledgeable about what might be a safeguarding concern and how to raise this. The home had raised safeguarding matters however, there had been some concern expressed by the local safeguarding team about how quickly the home had responded to their requests for information during a recent safeguarding investigation.

Risks associated with peoples care and support needs had been assessed and plans developed to minimise the potential for harm. Risk assessments had also been completed in relation to the premises and equipment. These had been reviewed and updated when required.

People were protected from the risk of infection. Staff were observed to use personal protective equipment such as gloves and aprons when providing personal care.

People's needs were assessed prior to them moving into the home, this ensured the service was confident they could meet the persons needs.

People received support from trained staff who had the appropriate knowledge and skills to support them. At the last inspection we found induction training for agency staff had not been effective and the home had been in breach of the regulations relating to staffing. At this inspection we found this had been addressed fully.

At the last inspection we found people had not received effective support to maintain their nutritional needs. Records had not been completed and care plans had not been updated to reflect changes. The home had been in breach of the regulations in relation to meeting people's nutritional needs. At this inspection we found this had improved significantly.

People received a variety of food and drink throughout the day. People we spoke with told us they thought the food was good or alright. No one told us they did not like the food.

People were supported to maintain their health and wellbeing. Records in care plans showed people had regular screening and were supported to access health professionals when required.

The home continued to support people in kind and caring ways. We observed staff throughout the inspection and saw they took their time to respond to people and reassure them. Staff were seen to be skilled at maintaining peoples' dignity and promoting choice and independence.

People continued to receive personalised care that was responsive to their needs. Care plans included details of the person's history, background, cultural identity and preferences. Reviews were held regularly and plans updated to reflect any changes to a persons needs or wishes. People and their relatives had been involved in reviews.

There was a complaints policy and we could see how the home had followed this in relation to complaints received.

People were supported at the end of their lives to have as dignified and pain free death as possible. People had been supported to have discussions about this aspect of their care and to consider their wishes.

Staff who worked at Worsley Lodge told us they felt the home was well managed. Some people identified specific improvements that had been made since the last inspection. One of the relatives we spoke with also praised the management team.

We looked at the governance systems in place to see whether auditing and monitoring systems had improved. At the last inspection we had found audits and walk around checks had not been consistently completed and some had failed to identify the issues we had found. This meant the home were in breach of the regulations in relation to governance. At this inspection we found there had been significant improvements in the frequency and scope of audits. However, some records were not readily available during the inspection and the local safeguarding team had found it difficult to obtain up to date information in a timely way to inform their investigation. Further improvement was needed in this area.

Worsley Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate a maximum of 46 people. When we inspected there were 38 people living at the home; 22 on the first floor and 16 on the ground floor, some people were living with dementia.

At the previous inspection, prompted in part by a visit from Salford Council Infection Control Team, the service was found to be in breach of three areas of the Health and Social Care Act 2008 (HSCA). Medicines were not being managed safely, infection control was not being effectively provided and governance relating to monitoring and audits were not identifying issues needed to be addressed. We asked the provider to complete an action plan to show what they would do to improve these, they had produced action plans in relation to each of these areas and we looked at how far these had been achieved at this inspection.

At this inspection, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to; safe care and treatment (two parts), meeting nutritional needs, staffing and good governance . Of the five breaches we found at this inspection, two were continuous breaches, identified at the previous inspection, in relation to; safe management of medicines and good governance.

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, 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 out 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.

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.

The medicine inspector found medicines were still not being managed safely. Some medications were out of date, opened bottles, inhalers and creams did not have the date of opening on them, stocks of medicines were not accurate, records were not clear, especially in relation to 'as required' medications because the advice about when to administer this was either missing or ambiguous. There were some gaps in the signing for topical creams, one person did not have a topical cream chart at all.

We found the provider had not properly managed risk in relation to access to a small kitchen area with a boiling water geyser. Serious harm could have occurred to people who were unsupervised and unable to recognise the risks posed.

Fire exit direction signs had been removed from the first floor during decorating and not replaced.

Monitoring and audits had not been completed as regularly as outlined by the provider. The audits undertaken had been ineffective in identifying the concerns we found during this inspection.

We found there had been significant improvement in relation to infection control, there were more hours in the rota for housekeeping and effective systems had been developed to maintain a good standard of hygiene throughout the home. The majority of staff had received infection control training and there were plans in place for those who still needed to achieve this.

Worsley Lodge is registered to provide accommodation and personal care for up to 48 older people, some of whom may be living with dementia. The home is a purpose built, two storey service situated in Worsley on the outskirts of Manchester. It is situated in pleasant grounds and has access to all local facilities. On the day of the inspection there were 43 people using the service.

The service did not have 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. The previous registered manager had moved to manage another service in the organisation earlier in the year. Since then, the service had been managed by the current acting manager and also another manager who resigned after working at Worsley Lodge for a short time. The acting manager confirmed they intended to submit their application for registration.

We found poor standards of hygiene throughout the home. We found communal areas, people’s bedrooms, bathrooms, sluice areas, equipment and furniture had not been thoroughly cleaned.

We saw there were shortfalls in the administration and recording of some people’s medicines. Guidance for staff around the use of ‘as needed’ medicines was found to be inconsistent.

We found the quality monitoring system had not been effective in highlighting shortfalls in the service and action had not been consistently taken in order to address these. Delays in the renewal of areas of the premises were evident, however the operations director who attended the inspection made arrangements during the day for improvement work to the sluice areas to be completed as a priority.

The above areas breached regulations in cleanliness and infection prevention and control, safe administration of medicines and monitoring the quality and safety of the service. You can see what action we have asked the registered provider to take at the back of the full version of the report.

People told us they felt safe living in the service. We saw staff interacting with people and they did so in a kind, caring and sensitive manner. Staff showed good knowledge of safeguarding procedures and were clear about the actions they would take to protect people.

We saw there were enough skilled and experienced staff on duty to meet people’s needs. We found staff had been recruited using a robust system that made sure they were suitable to work with vulnerable people. They had received a structured induction and essential training at the beginning of their employment. This had been followed by regular refresher training to update their knowledge and skills.

We found staff ensured they gained consent from people prior to completing care tasks. In the main, staff worked within mental capacity legislation when people were assessed as not having capacity to make their own decisions. However, we found one person’s deprivation of liberty safeguard (DoLS) authorisation had expired and an application of renewal had not yet been made. We also found the decision about a person’s resuscitation status required review following the outcome of a more recent assessment of their capacity. These issues were addressed shortly after the inspection.

People liked the meals provided to them and there was sufficient quantity and choice available. We saw people’s weight, their nutritional intake and their ability to eat and drink safely was monitored and referrals to dieticians and speech and language therapists took place when required for treatment and advice. During the day, we observed people were served drinks and snacks between meals.

People’s privacy and dignity were respected and staff provided people with explanations and information so they could make choices about aspects of their lives. There were positive comments from relatives about the staff team.

People’s needs had been assessed before they moved into the service and they had been involved in formulating and updating their care plan. The care files we checked were individualised and reflected people’s needs and preferences in good detail. Care plans and risk assessments had mostly been reviewed and updated on a regular basis.

People’s healthcare needs were met. People told us that they had access to their GP, dentist chiropodist and optician should they need it. The service kept clear records about all healthcare visits and appointments.

We saw people were encouraged to participate in a wide range of activities at Worsley Lodge and in the community and to maintain their independence where possible. Relatives told us they could visit at any time and we saw staff supported people who used the service to maintain relationships with their family.

People told us they had no complaints but would feel comfortable speaking to staff if they had any concerns. We saw the complaints policy was readily available to people who used or visited the service. There were systems in place to enable people to share their opinion of the service provided and the general facilities at the home.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found.

Is the service safe?

Both the people who lived in the home and their relatives were pleased with the care provided and felt that their views were respected and listened to. The staff worked in a safe and hygienic way and used appropriate protective clothing. There were enough staff to meet the needs of the people living in the home and a member of the management team was available on call in case of emergencies. One person said: 'I can't find any fault.' Another person said: 'I have never seen anything I did not like.'

Staff personnel records contained all of the information required by the Health and Social Care Act. This meant the provider demonstrated that staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

The deputy manager and the staff we spoke with understood the importance of safeguarding vulnerable adults, could identify potential abuse and knew how to report any concerns.

Is the service effective?

People told us that they were happy with the care that had been delivered and their care records were up to date. One relative said: 'Overall we are very happy with the home.' Another relative said: 'If there is ever any problem one of the staff will ring up.'

Care records confirmed people's preferences and needs had been recorded and care and support had been provided in accordance with people's wishes. One relative said: 'Nothing is too much trouble.'

We heard that information was shared effectively between staff. Several ways of sharing information included weekly management team meetings, handovers, daily records, and monthly reviews.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and encouragement when supporting people. One relative said: 'It was the only home I saw. I was happy with it immediately.' One person who lived in the home said: 'I'm happy with the staff. They are all lovely.'

Is the service responsive?

People's needs had been assessed before they were admitted to the home. Their needs for support and treatment were carefully described so that care workers knew exactly what tasks to undertake. Changes in people's care needs were reported to the senior carer and they briefed care staff.

A meeting with relatives had identified a concern about people entering someone else's bedroom without permission. The provider had fitted door locks in response to this.

Is the service well-led?

Staff had a good understanding of the culture of the home and quality assurance processes were in place. People told us they had received customer satisfaction surveys and a meeting for people who lived in the home was held every month to seek suggestions for any improvements required. Staff told us they were clear about their roles and responsibilities and were well supported. One said: 'I think she is a good manager.'

On the day of our inspection we were able to speak with the home manager and the area manager who was visiting on the same day, and they were able to show us where improvements had been made in relation to these areas.

The last inspection also highlighted concerns in meeting people's nutrition and hydration requirements. This was due to people not being assisted to eat their meals, food and fluid charts were incomplete and different choices of food were not offered to people. Again, we saw improvements in this area and found people's nutrition and hydration requirements were being met.

We spoke with staff to assess whether they felt they received adequate support to help them undertake their job role. One member of staff said to us 'Yes, I get enough support and I'm happy doing what I do. I did an induction when I started and shadowed another member of staff for four days'. However we did find some shortfalls in staff supervision and appraisal.

We found there were appropriate systems in place to effectively monitor the quality of service provision.

We found that detailed assessments of care needs had been undertaken, which were personalised, following a physical and social assessment. Appropriate risk assessments were in place, which included mobility, manual handling, nutrition, dependency and falls risks.

Medicines were effectively managed at Worsley Lodge. We found a new electronic medicines management system had been implemented four months ago. Pharmacy Plus PCS was an electronic ordering, recording and dispensing system, which was operated by a hand held device.

During the inspection we sampled five care files. We found that only one file contained a mental capacity assessment. We spoke with the deputy manager on duty at the time, who confirmed that communication assessments were undertaken when first arriving at the home, but that a more comprehensive mental capacity assessment was not routinely completed.

We found there was appropriate guidance in place for staff in relation to safeguarding vulnerable adults. Contact details of the local authority were available.

During the inspection concerns were observed about how people were supported during meal times and the decision was taken to review an additional outcome on meeting nutritional needs.