27 November 2014, 5 December 2014
During a routine inspection
This inspection took place on 27 November and 5 December 2014 and was unannounced on the 27 November.
There were no previous inspections as Samuelson Lodge was registered with the Care Quality Commission on 30 April 2013.
Samuelson Lodge is a care home that provides accommodation and support with personal care for up to three adults with mental health conditions. On the day of our visit there was only one person living at the service.
The service was run by the registered provider. A registered provider has legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
We found several shortfalls and breaches to multiple regulations relating to, care and welfare, records, medicine management, safeguarding, privacy and dignity, supporting staff and maintenance of premises.
Staff were not always on duty to meet the needs of the person living at the service and to keep them safe. For example when we arrived at the service there were no staff on duty and we found there were not enough staff to meet the person’s needs.
One person had damaged their room and there were no plans to repair the damage. Furniture including a broken mirrored cupboard and a broken bed were a potential risk to people living at the service.
Safeguarding procedures were not always followed as we were told of incidents that were not reported to the CQC. People were not always protected from abuse. For example, we were informed of incidents that should have been reported as safeguarding, on the day of inspection.
Medicines were not stored or handled appropriately. Medicines were stored in a filing cupboard that could easily be opened. Medicine administration record charts (MARS) were not completed properly and MARS prescriptions were incorrect as they had the name of the medicine but no had dose shown.
The service was ineffective. The manager described the processes that would be followed if capacity to consent were absent including best interests decisions made after discussions with an advocate. However, steps that would need to be taken to lawfully deprive a person of their liberty were not always taken.
There were inadequate measures in place to ensure that people were supported to choose and eat a balanced diet.
The service was not managed well. People were not protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them.