Imperial Lodge

Updated 22 March 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 2 inspectors.

Service and service type

Imperial Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Imperial Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who used the service about their experience of the care provided. We spoke with 6 members of staff including the registered manager, a manager, deputy manager, and support workers.

We reviewed a range of records. This included 4 people’s care records and multiple medication records. We looked at 5 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures, records of complaints, quality audits, meeting minutes and improvement plans were reviewed. After the inspection, we continued to seek clarification from the provider to validate evidence found. We looked at staff rotas and quality assurance records.

Updated 22 March 2024

About the service

Imperial Lodge is a care home which is run by a small private organisation. The provider owns and manages one other care home. One of the owners is also the registered manager for Imperial Lodge. The service provides support to up to 10 people with mental health needs and/or people who have experienced substance misuse. The service aims to help people with recovery and to support people to move on to places where they need less care and support. At the time of our inspection 8 people were using the service.

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

The provider had not always carried out appropriate checks to recruit staff safely, for example, obtaining references from previous employers.

The provider could not demonstrate that new staff received an induction or that staff received regular supervision to be able to support people effectively.

The provider had not ensured there were enough suitably competent and qualified staff to meet the needs of the service. The provider relied on temporary (agency) staff for most shifts. However, there was no evidence agency staff received an induction into the service or training appropriate to the needs of people who used it.

The staff completed online training but had not received specific training in techniques to work with people who had difficulty managing their emotions and anxiety. We did not see any evidence the staff’s competencies were assessed to help ensure they had the skills to undertake their roles.

The provider did not always learn lessons when things went wrong. Although a serious incident had taken place recently, we saw no evidence of meetings or reflective sessions with staff in relation to the incident or any previous incidents.

People’s medicines were managed safely to help ensure people received their medicines as prescribed and in line with national guidance. However, the staff’s competencies to manage medicines were not carried out regularly.

Although the staff undertook some daily safety checks, some checks and audits had not been regular, with most having stopped between June and August 2022.

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.

People’s needs were recorded in their care plans and met. Staff knew people’s needs and how to meet these in line with their care plans.

People told us they felt safe when receiving care and relatives agreed with this. The provider had processes in place for the recording and investigation of complaints and incidents and accidents. Risk assessments contained guidelines and plans for staff on how to minimise risks for people using the service.

The registered manager and senior staff were responsive to and worked in partnership with other agencies to meet people’s needs.

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 that the service can respond to COVID-19 and other infection outbreaks effectively.

Rating at last inspection

The last rating for this service was good (published 28 March 2018).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk to people’s safety. This inspection examined those risks. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only.

We found no evidence during this inspection that people were at risk of harm from this concern.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Imperial Lodge on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to staffing, recruitment and governance at this inspection.

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.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.