Archived: Norfolk Lodge

Norfolk Lodge is a residential care home providing personal care and accommodation for five people with learning disabilities at the time of the inspection. The service can support up to eight people.

The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. These values were not always seen consistently in practice at the service. For example, some people could live independent lives and were supported to do so. However, other people were not receiving the assistance with communication they needed to be as independent as possible.

Norfolk Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. This does not include Norfolk Lodge; the investigation is on-going, and no conclusions have yet been reached .

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

Risks were not consistently being managed safely, such as around people’s health needs, and staff did not fully understand who to report to under safeguarding. People did not always receive their prescribed medicines when they needed them. Lessons were not learned when things went wrong.

People were at risk of not receiving the right amount to drink as fluid charts were not completed correctly. There were some gaps in staff training and competency checks had not happened when they were needed. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People’s privacy and dignity was not always upheld; we found personal medical details discussed in a staff communication book. People did not always have their care plans in the format they needed them. Staff treated people with kindness and people told us they liked their staff.

People’ care plans were not personalised, and some had important information missing. Activities were not person centred and they were not tracked to see what people did or if they enjoyed it. People knew how to make a complaint and the service was helping people make decisions around how they wanted to be supported at the end of their lives.

The service was not well led as audits had not been effective in putting right issues we found at the last inspection. We had not been told about all serious incidents and the previous inspection rating was not being displayed in the service. There was a new manager at the service who was registering with CQC and was working to change the culture in the service.

People told us that they liked living at Norfolk Lodge and that they liked their staff.

We saw some examples of kind and considerate support from staff who had a caring approach.

People knew how to complain and were confident they would be listened to.

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 Inadequate (published 17 April 2019) and there were multiple breaches of regulation.

This service has been in Special Measures since April2019

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to person centred care, dignity, mental capacity, safe care and treatment, safeguarding, governance, displaying ratings and notifying CQC of incidents at this inspection.

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

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.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

• Norfolk Lodge is a residential care home that provides care and support for up to eight people with a learning disability and other complex needs, including autism and mental health. At the time of our inspection there were five people living at the home.

• Norfolk Lodge is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have yet been reached.

• At the previous inspection in August 2018 we found seven breaches of regulation in relation to person centred care, dignity, consent, safe care and treatment, safeguarding, governance and staffing. At this inspection we found one breach had been met in relation to dignity and six regulations continued to be breached. We also found a new breach of the registration regulations relating to informing us of significant incidents.

• The service has been developed and designed in line with the values that underpin the 'Registering the Right Support' and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. These values were not always seen consistently in practice at the service. For example, some people could live independent lives and were supported to do so. However, other people were not receiving the assistance with communication they needed to be as independent as possible.

People’s experience of using this service:

• Some aspects of the service remained unsafe.

• Some people were at risk from harm as some risk assessments were not effective in reducing the likelihood of harm and staff had not taken steps to keep people safe after an injury.

• Not all incidents had been reported to the local safeguarding authority as per the provider’s policy or agreement with the local authority and CQC.

• Staff had not consistently been deployed in a safe way. There were times when staff that were trained to use essential equipment were not working, leaving people at risk of unsafe care and treatment.

• Learning from incidents had not been consistently implemented. One person had experienced episodes of choking and these were not reported by staff.

• Staff told us they needed more training to meet people’s needs around behaviours that could be challenging to others.

• Some health needs were not being met effectively.

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

• People did not always receive personalised care. One person required adaptations, and care documents in large print and these were not being provided.

• There was no registered manager in day to day charge of the service. Although the registered manager was still registered with CQC they were no longer managing the service, had left the employment of the provider, and the provider was recruiting a new registered manager.

• Quality audits had not been effective in highlighting and putting right all the shortfalls we found at this inspection.

• People were supported in a kind and caring way by staff who knew them well.

• People told us that they liked their staff and could get help when they needed it.

• People received sensitive support when they were upset.

• People had enough to eat and drink and knew how to make a complaint.

• The new management team were working towards making positive changes to the service and had worked with other stakeholders to improve the support people received.

More information is in the detailed findings below.

Rating at last inspection:

At our last inspection in August 2018, the service was rated "requires improvement" overall with an Inadequate rating in the safe domain. Our last report was published on 7th February 2019. This is the second time this service has been rated as Inadequate in the safe domain.

Why we inspected:

All services with one key questions rated "Inadequate” are re-inspected within six months of our prior inspection. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Enforcement:

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Follow up:

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

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. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Services operated by the provider had been subject to a period of increased monitoring and support by commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is on-going and no conclusions have been made. We used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May 2017 and July 2018, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Norfolk Lodge is a “care home”. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Norfolk Lodge is registered to provide care and support for up to eight people with learning difficulties, older people and younger adults. At the time of the inspection there were six people living permanently at the home and one person staying there for respite care. The home is a converted house in the centre of Horsham. The house has an accessible garden and the local shops, park and theatre are nearby.

At the last inspection on 19 September 2016 we rated the home as Good overall. At this inspection on 28 and 29 August 2018 we rated the service as Inadequate in Safe and identified breaches of seven regulations and other areas of practice that needed to improve. Breaches included, failures to keep people safe from abuse, failures to identify and manage risks effectively, failure to maintain sufficient numbers of suitable staff, failures in providing appropriate care to meet people’s needs, failure to protect people’s dignity and to obtain consent, and failures in management systems to identify shortfalls. The overall rating for the home is now requires improvement.

Systems for recording incidents and raising safeguarding alerts were not operating consistently. Some records included details of incidents that had resulted in physical and psychological ill-treatment of people living at the home. These incidents had not always been identified and reported as potential safeguarding incidents.

Risks had not always been assessed, reviewed and managed to ensure that people were protected from harm and abuse. Systems for identifying trends and patterns had not been effective in identifying and managing risks. Staff did not all have the training and skills they needed to care for people safely and there were not always enough staff on duty to support people when incidents occurred.

Assessments and care plans were not sufficiently personalised and detailed to guide staff in how to provide appropriate care that met people’s needs. Care plans had not been developed in line with current best practice for supporting people with behaviour that could be challenging.

People were not always given the support they needed to protect their dignity.

Management systems and processes had failed to identify the shortfalls in practice that we found. The quality and safety of the service was not effectively monitored, risks were not being assessed, and managed and records were not complete and accurate. This meant that systems were not effective in supporting management oversight at the home.

Staff had received training in the Mental Capacity Act and understood the principles. However, practice was inconsistent with regard to obtaining consent from people and for identifying the least restrictive options for supporting people to be safe.

The registered manager was aware of their responsibilities under the Accessible Information Standard, however there was inconsistent practice with regard to ensuring that people’s individual communication needs were met.

Staff had not all received the training they needed to be effective in their roles. The registered manager took action to ensure that staff were booked onto relevant training as soon as possible.

People told us that they liked living at the home and described positive relationships with staff members. Staff knew people well and people appeared to be comfortable and happy with staff. They told us the staff were kind and caring, one person described a staff member as “My angel.”

People were supported to have enough to eat and drink and told us that they enjoyed the food on offer. People were able to access the health care services that they needed and staff supported them to attend appointments. Staff described positive working relationships with a range of health care professionals who were involved in people’s care and support.

People were receiving their medicines safely. Infection control arrangements ensured that people were protected from infections. People were able to access the local community facilities regularly and were supported to be as independent as possible. Staff supported people to maintain relationships that were important to them. People and their relatives were confident that any concerns or complaints they had would be listened to and resolved.

There was a clear management structure and staff were clear about their roles and responsibilities. People, their relatives and staff spoke highly of the registered manager. The model and scale of the home are in keeping with the principles of Registering the Right Support. The home is small and provides a homely environment. People have access to local amenities and were supported to participate in the community. People were able to use local health and social care services and staff supported people to be independent.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Norfolk Lodge is a residential care home, which provides care and support for up to eight people with a learning disability and other complex needs, including autism and mental health. At the time of our inspection there were six people living at the home.

Norfolk Lodge is a town house with communal areas over two floors (ground and first floor). The second floor of the house accommodated the manager’s office and the laundry room but there were no bedrooms on this floor. There was a kitchen and shared dining area which was open and accessible to people. There was a back garden and we were told that people helped with the gardening. There were two lounges (one on each floor) that were used both for down time (watching television/movies) and for activities. There was a small sitting area between two parts of the building with games and puzzles.

The service is required to have a registered manager. 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. A manager was appointed in April 2016; they had submitted an application to CQC to register as the manager of the service.

Although staff understood how to support people and we were confident they received consistent support, some people's individual care records did not accurately reflect their needs or were incomplete. This meant that it was not always possible to be clear if a person was supported in the right way. We have made a recommendation that the provider ensures agreed support is documented to ensure a consistent approach.

The complaints procedure was clearly displayed within the service; however was not in a suitable format for all of the people who used the service to understand and make use of. The manager recognised this needed further revision to meet the needs of people in this service.

People told us they felt safe with the home’s staff. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of potential harm.

People’s risks were identified, assessed and managed appropriately. There were also risk assessments in place to help keep people safe in the event of an unforeseen emergency such as fire or flood.

Thorough recruitment processes were in place for newly appointed staff to check they were suitable to work with people. There were sufficient numbers of staff to meet people’s needs safely. People told us there were enough staff on duty and records and staff confirmed this.

People were supported to take their medicines as directed by their GP. Records showed that medicines were obtained, stored, administered and disposed of safely.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no-one living at the home was currently subject to DoLS, the manager understood when an application should be made and how to submit one. The provider was meeting the requirements of DoLS. There were no restrictions imposed on people and they were able to make individual decisions for themselves. The manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.

Staff received training to help them meet people’s needs. Staff received an induction and regular supervision including monitoring of their performance. Staff were supported to develop their skills through additional training such as National Vocational Qualification (NVQ) or care diplomas. All staff completed an induction before working unsupervised. People were well supported and said staff were knowledgeable about their care needs.

People told us the food at the home was good and they were offered a choice at mealtimes. Staff monitored people's health to ensure they had access to other health professionals when

needed.

People’s privacy and dignity were respected. Staff had a caring attitude towards people. We saw staff smiling and laughing with people and offering support. There was a good rapport between people and staff.

People were involved as much as possible in planning their care. People had monthly meetings with their keyworkers to discuss all aspects of their care. The manager and staff were flexible and responsive to people's individual preferences and ensured people were supported in accordance with their needs and abilities. People were encouraged to maintain their independence and to participate in activities that interested them.

The manager told us they operated an open door policy and welcomed feedback on any aspect of the service. The manager monitored the delivery of care.

There was a stable staff team who said that communication in the home was good and they always felt able to make suggestions. They confirmed management were open and approachable.

A system of audits was in place to measure and monitor the quality of the service provided and this helped to ensure care was delivered consistently. Suggestions on improvements to the service were welcomed and people’s feedback was encouraged.