Archived: Connemara Lodge

Connemara 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 service accommodates up to eight people who live with mental health needs in one adapted building. Nursing care is not provided at this service. At the time of this inspection, five people were living at Connemara Lodge.

Our previous inspection on 29 March and 4 April 2018 found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to, failure to have an holistic approach to ensure people’s physical, mental and emotional needs were met. Despite the providers intentions for Connemara Lodge to be a rehabilitation service, there were no rehabilitation plans in place to demonstrate what skills people needed to develop in order to move to a more independent living. Risks to people’s health and safety were not assessed, mitigated and reviewed appropriately. People's medicines were not managed effectively. Staff were not always effectively deployed to meet people’s needs. Staff had not received adequate training to give them the knowledge they needed to keep people, and others safe. Staff did not recognise or understand the wider aspects of safeguarding people from risks. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. Systems to assess, monitor and improve the quality of care were not effective and failed to identify the issues stated above.

Immediately following the inspection, we formally notified the provider of our escalating and significant concerns and our decision under Section 31 of the Health and Social Care Act 2014, to impose conditions on their registration as a service provider in respect of the regulated activity with immediate effect to restrict further admissions to the service. Conditions to drive improvement were also imposed. We requested the provider tell us by the 13 April 2018 what actions they would take to mitigate the risks we identified at this inspection. The service was given an overall rating of inadequate and placed into special measures. Services in special measures are kept under review and inspected again within six months.

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.

This inspection was carried out to see if the provider had made the improvements, required within this timeframe. At this inspection we found, whilst some improvements had been made, specifically in relation to people’s care planning, improvements were still needed to ensure people were supported to stay safe and have their needs met.

There was a registered manager in post who was also the provider and registered manager for their other service, Meadow View. 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.

The registered manager, was absent during the inspection. They had previously informed CQC they were stepping down from day to day management of the service and this role had been delegated to an acting manager. However, we found the acting manager had not been fully prepared, or trained to manage the service. They did not have a clear understanding of the fundamental standards of care and associated Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 or how these applied to the service to ensure people received high-quality care and support. Neither did they have access to the resources needed to achieve compliance.

The acting manager and staff understood what constituted abuse and the reporting process, however lacked understanding of when to raise a safeguarding alert. Concerns and complaints were listened and responded to, however where complaints had raised safeguarding matters there had been a failure to recognise the safeguarding element and make the necessary referrals. Whilst it is recognised there has been improvements made to manage risk, where incidents had occurred, not all incidents were recorded and investigated. Neither had risk management plans been reviewed following incidents to reduce the risk of such incidents happening again. Additionally, there were no systems in place to analyse safety incidents and safeguarding concerns to review what went wrong, look for trends and themes and learn from such incidents.

The staffing arrangements were not sufficient to meet people’s needs. The acting manager and office administrator were recorded on the rota as part of the staffing numbers, however in reality this left one person to support up to five people, with challenging mental health needs, between the hours of 9-5. Staff had minimal capacity to support meaningful activities. It was evident from recent complaints that there was a need for additional one to one support for a person when accessing the community.

Staff recruitment practices had not been carried out robustly to ensure people were protected from staff unsuitable to work with vulnerable people. Convictions, and gaps in employment on staffs Disclosure and Barring Service (DBS) checks had not been explored or assessed to vouch for the character and fitness for the role.

Medicines management had improved since the last inspection; however, improvements were still needed to ensure accurate records were kept. Where changes to PRN medicines had been made by health professionals, changes had not always been amended on people’s medication administration charts, which meant people may not receive their medicines as prescribed.

Staff confirmed, and records showed they had completed training designed to give them the skills and knowledge to carry out their roles. This had included breakaway training; to protect staff and people using the service at time of challenging behaviour. However, none of the staff had completed the care certificate when starting work at the service. The Care Certificate was developed jointly by the Skills for Care, Health Education England and Skills for Health. It applies across health and social care and sets a minimum standard that should be covered as part of induction training of new care workers. This was a particular issue with a member of staff with no previous experience of working in care and no recognised National Vocational Qualification (NVQ).

People could make a choice about what they wanted to eat and were supported to prepare and cook their own meals. People were supported to live healthier lives, and had access to healthcare services to meet their health needs. People were supported to express their views and be involved in making decisions about their care, support and treatment. The service was operating in line with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People were supported to have 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.

Significant improvements had been made to people’s care plans to ensure they were reflective of their needs and to ensure these were managed in a positive way. These reflected their care, treatment and support was being delivered in line with expert professional advice. Staff consistently referred to the service as a rehabilitation service, but this was not reflected in level of support provided. There was a lack of meaningful activity, occupation and engagement for people. We found no information in people’s care plans to support them to develop the skills they need to move to independent living.

People using care services are expected to be supported at the end of their life to have a comfortable, dignified and pain-free death. We found there had been no consideration for people’s wishes about their end of life care. We have made a recommendation about involving people in decisions about their end of life care.

Whilst it is recognised improvements have been made to the environment to make it safe and in particular people’s bedrooms, further improvements were needed to ensure it is fit for purpose. The premises needed a complete overall inside and out and improvements were needed to ensure people’s privacy was respected. Action had been taken to improve the cleanliness and hygiene in the service, to prevent the spread of infection, however further improvement was needed, as we continued to find areas of the service unclean. Not all staff were observed wearing protective aprons when entering the kitchen, or wearing gloves when preparing food. The premises had a designated, locked Control of Substances Hazardous to Health (COSHH) cupboard, however we found bleach and anti-bacterial spray bottles in un-locked cupboard under the kitchen sink on both days, that were a potential risk to people, if consumed.

The acting manager and office administrator had worked hard to make improvements to the service. Staff were complimentary about the acting manager. They felt they provided leadership, and supported them in their role. The provider and acting manager had worked well with other authorities to improve the service, but were failing to identify where improvements were needed, unless these were identified by other agencies. Although, the provider had a range of audits in place, it was difficult to see how these fed into the overall monitoring of the quality of the service an

There was a registered manager in post. The registered manager was also the provider. 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 culture within the service did not promote a holistic approach to people's care to ensure their physical, mental and emotional needs were being met. Robust and sustainable audit and monitoring systems were not in place to ensure the quality of care was consistently assessed, monitored and improved. Quality assurance systems had failed to identify the issues we found during our inspection.

The provider had failed to take the necessary actions to ensure that the risks to the health and safety of people were assessed, mitigated and reviewed appropriately.

We observed there were adequate numbers of staff on both days of our inspection however they were not always effectively deployed. Training was not sufficient to provide staff with the knowledge they need to support people in order to keep them and others safe.

People’s care had not been co-ordinated or managed to ensure their specific needs were being met. Risks to people injuring themselves or others were not appropriately managed. People were not adequately protected against environmental risks. People's medicines were not managed effectively to protect them from the risks of not receiving prescribed medicines.

Whilst care staff demonstrated they knew people well and were kind in their interactions with people living at the service, the provider had not ensured the service was being run in a manner that promoted a caring and person centred culture.

Care records were not recovery focused and did not demonstrate how people received personalised care that was responsive to their needs. Plans of care used negative language and sought to impose how people should behave and what they should do.

Despite the intentions of the provider for Connemara Lodge to be a rehabilitation service, there were no rehabilitation plans in place to demonstrate what skills people needed to develop in order to move to a more independent living..

The registered manager and staff demonstrated a lack of understanding regarding the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible.

Systems in place to reduce people being at risk of potential abuse were not robust. Staff were aware of their responsibilities with regard to safeguarding people from abuse. However, they did not recognise or understand the wider aspects of safeguarding people from risk as identified in this report.

We identified multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following this inspection we took immediate enforcement action to restrict admissions and force improvement. The commission is further considering its enforcement powers.

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, it 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.