Lime Lodge

About the service

Lime Lodge is registered to accommodate up to nine people in one adapted building. People living at the service had a learning disability and / or autism. At the time of our inspection, seven people were living at the service. Accommodation is provided over two floors and within the grounds of the service.

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

Right Support

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support the best practice.

Improvements were required in how people were involved in their care and treatment that maximised their choice, control, and independence. People’s independence was not always sufficiently promoted and there were limited opportunities to engage in meaningful activities based on people’s interest and hobbies.

Risk assessments and support plans review and monitoring needed improvement. Risks in relation to the environment and infection prevention control had not been fully assessed and mitigated.

Medicines management processes did not follow best practice guidance.

People who lacked capacity to make certain decisions for themselves or had fluctuating capacity did not have their mental capacity assessments regularly reviewed to ensure the decisions made by staff on their behalf were in line with the law and supported by effective staff training and supervision.

The examples of menus we saw did not consistently promote healthy, varied diet. We did not find evidence of staff supporting people to be involved in preparing and cooking their own meals in their preferred way. Access to the kitchen was restricted by a pad lock which did not promote people’s independence. People’s cultural preferences in regard to diet were respected.

People were referred to health care professionals to support their wellbeing, however the updates and guidance from the professionals was not always recorded and we could not be assured if all the staff were aware of the guidance.

The interior and decoration of the service was not fully adapted in line with good practice to meet people’s sensory needs. People’s care and support was not always provided in a clean and hygienic environment. People personalised their rooms and were included in decisions relating to their own room’s decoration.

Right Care

There was a risk people may not receive consistent safe care because their support plans and risk assessments had not always been developed or were not up to date.

Staff did not ensure all people had up-to-date care and support assessments, including medical, psychological, functional, communication, preferences and skills. People, those important to them and staff, did not review plans regularly together. There was a lack of clear pathways to future goals and aspirations, including skills teaching in people’s support plans.

People received kind and compassionate care. Staff protected and respected people's privacy and dignity.

Staff understood and responded to their individual needs.

Staff understood how to protect people from poor care and abuse.

Right Culture

The provider did not frequently check staff’s competency to ensure they understood and applied training and best practice. The provider's systems and processes used to monitor quality and safety were not fully effective. The provider's internal governance, systems and processes had not fully identified the shortfalls we found. There was no ongoing action plan to drive improvements. The provider had limited oversight and monitoring of the service.

Prior to our inspection, following a whistleblowing concern, we had contacted the provider and established that some staff did not complete mandatory training. This meant people were at risk of being supported by staff without the essential skills and qualifications. The provider addressed it immediately and at the time of our inspection all staff had received the mandatory training. People were supported by staff who had received basic mandatory training, however this did not include training in the wide range of strengths and impairments people with a learning disability and or autistic people may have, mental health needs, communication tools, positive behaviour support, trauma-informed care, human rights and all restrictive interventions.

Safe staff recruitment checks were completed before staff commenced their employment.

Staff were positive about the support and leadership of the provider. An external professional and relatives gave overall positive feedback about the service.

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 15 July 2021) and there were breaches of regulation. At this inspection we found the provider remained in breach of two regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about medicines, training, infection control and management of the service. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with the overall oversight of the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe, effective 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 that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lime Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safety, need for consent and good 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

People were supported to access community in a way that mitigated the risk of catching and spreading infection.

There were ample supplies of personal protective equipment (PPE) available and the staff were observed to wear them correctly.

Cleaning schedules were in place and regular cleaning took place. Infection prevention control (IPC) audit was completed weekly.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture. Improvements were required in how people were involved in their care and treatment that maximised their choice, control, and independence. People did not receive consistent person centred care and the promotion of independence was limited. Opportunities to engage in stimulating and meaningful activities, interest and hobbies including social inclusion was also limited.

Risk assessment, review and monitoring needed improvement. There was a risk people may not receive consistent safe care due to a lack of guidance for staff. People’s individual support plans and risk assessments had either not been developed or were not sufficiently detailed. Risks in relation to the environment had not been fully assessed and mitigated.

Staff deployment was not sufficiently planned and did not meet people’s individual care and support needs. Staff did not have sufficient time to maintain expected standards in cleanliness and hygiene of the service. Improvements were required to ensure people were protected from COVID-19.

The provider’s systems and processes used to monitor quality and safety were not fully effective. The provider’s internal governance, systems and processes had not fully identified the shortfalls we found. There was no ongoing action plan to drive improvements. The provider had limited oversight and monitoring of the service.

Staff’s ongoing training and development needed improved monitoring to ensure all staff were sufficiently trained. Safe staff recruitment checks were completed before staff commenced their employment. Medicines management processes did not fully follow best practice guidance.

The staff team worked with external health and social professionals. Staff were positive about the support and leadership of the registered manager. An external professional and relatives gave positive feedback about the service.

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 Good (published 4 November 2017).

Why we inspected

We received concerns in relation to the environment, hygiene and cleanliness and opportunities for people to engage in activities. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

The provider took immediate action to mitigate some of the risks identified during this inspection; This included reviewing people’s risk assessments.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lime Lodge on our website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified three breaches in relation to assessing and mitigating risks, staff deployment, and governance of the service. Please see the action we have told the provider to take at the end of this report.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People received safe care and processes were in place to reduce the risk of people experiencing avoidable harm. Window restrictors were not in place in two bedrooms on the first floor, which posed a risk to people’s safety. This was rectified immediately. Sufficient numbers of staff were in place to meet people’s needs, although the induction processes for agency staff members needed reviewing and formalising. Safe medicine management processes were in place and people received their prescribed medicines safely.

The principles of the Mental Capacity Act 2005 (MCA) were adhered to when decisions were made for people who lacked the ability to make specific decisions themselves. People were supported to lead a healthy lifestyle with encouragement to maintain a balanced diet and where needed, to lose weight. Staff were well trained, received regular supervision of their work and felt supported by the registered managers to develop their roles. People’s day to day health needs were met.

Staff were kind, caring and showed genuine empathy and compassion when supporting people. People were treated with dignity and respect and their right to privacy was respected. There was a positive and friendly atmosphere within the home with people encouraged to do as much for themselves as possible.

People were able to lead their lives how they wanted and were supported to take part in the activities that were important to them. People’s support records were detailed and provided staff with the information needed to support people effectively. People were provided with an ‘easy read’ complaints process that supported people living with a learning disability. Effective systems were in place to manage any complaints the provider may receive.

The service continued to be well-led. The registered managers were well liked and they carried out their roles in a dedicated and caring manner. People, staff and the management all interacted well which resulted in a positive environment. Staff enjoyed working at the home. Effective auditing processes were in place.

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

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

This was an unannounced inspection. We spoke with two people who used the service. We also spoke with the manager and three members of staff. We looked at written records, which included copies of people's care records, staff personnel files and quality assurance documentation.

Is the service safe?

We saw that care plans and risk assessments were informative and up to date. Staff we spoke with were familiar with their contents, which enabled them to deliver appropriate and safe care.

We found the home to be warm and clean. The accommodation was suitable to meet the needs of people living there. People were protected by safe and effective recruitment processes.

People were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening.

Is the service effective?

People we spoke with were satisfied with the care and support they received. This was consistent with positive feedback reported in the provider's own annual quality assurance survey. People were given information and support to help them understand the care and support available to them and were encouraged to increase their independence.

Is the service caring?

We spoke with two people who used the service. Due to their communication needs we were not able to have extended conversations with them. We were not able to speak with some of the other people. One person said to us, "The staff are nice. I like the staff." We asked another person if they were happy living at the home. They nodded and replied, "Yes."

There was a calm atmosphere throughout the home and a good rapport between staff and the people who lived there. We witnessed the care and attention people received from staff. All interactions we saw were respectful, kind and friendly and staff were attentive to people's needs. People were treated with dignity and respect.

Is the service responsive?

People were consulted about and involved in their own care planning and the provider acted in accordance with their wishes. Where people did not have the capacity to give consent, we found the provider acted in accordance with legal requirements.

Care plans and risk assessments were regularly reviewed.

Is the service well led?

Staff said that they felt well supported by the manager and they were able do their jobs safely. The manager had a range of quality monitoring systems in place to ensure that care was being delivered appropriately by staff, that the service was continuously improving and that people were satisfied with the service they were receiving.

Our observations showed that people were comfortable, well kempt and were being supported in a homely environment. People's bedrooms had been decorated according to their personal taste and we found that people were involved in all aspects of the running of home wherever possible. The provider may find it useful to note that some areas of the home were starting to look dated and some people's bathrooms were grubby.

We found that staff treated people with dignity and respect and demonstrated a genuine rapport with the people who used the service. Staff we spoke with had a good understanding of the needs of people who used the service and were positive about their role.

We found that people's independence and community involvement had been promoted by the service and that people's individual wishes had been respected.

We looked at the records of three people who used the service and found care had been planned and delivered appropriately with regard to people's health, safety and welfare.

The service had arrangements in place to respond to allegations of abuse; however we found evidence that the service had not always protected people from the risk of abuse. This was because the service had not recognised and appropriately responded to incidents where a person using the service was harmed.

Staff had been appropriately screened to ensure they were appropriate to work with vulnerable people and had received a thorough induction.

There was a robust system in place to monitor the quality of service people received.