Archived: Buckingham Lodge Care Home

Buckingham Lodge is a residential care home providing personal and nursing care to up to 73 people aged 65 and over. At the time of the inspection there were 58 people using the service. The service is provided in a purpose-built home over three floors, ground, middle and top floor providing residential care, dementia care and nursing.

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

The service had a poor regulatory history which could have affected people’s experiences over time and damaged the service’s reputation. The service had at this inspection made some notable progress and had a better organisational structure with a registered manager, deputy manager and unit lead on each floor. It had fully recruited to its nursing posts but still had some agency usage. Some staff were new and still settling into their role. Training across all staff was improving and people mainly received consistent standards of care.

The service had continued to strengthen its governance and oversight to help ensure risks were quickly identified and managed effectively. Daily walk around, safety debriefings and daily management meetings had been implemented to help focus staff on where the risks were and deploy staff where necessary. Record keeping could be improved to clearly show how incidents were effectively managed and reduced as far as possible, with clear lines of accountability across the whole staff team.

Staffing levels were reviewed in line with the numbers of people who used the service and their needs, but some felt staffing levels were not always appropriate and they had to wait for their care which was not provided in line with their preferences.

Staff understood how to safeguard people and how to raise concerns. The audit trail had improved but there were still a number of risks associated with people’s needs and behaviours which at times affected others. Care plans did not always detail enough information about how staff could reduce and help people manage their anxiety which could affect their behaviour.

Medicines were well managed, and we did not identify any concerns in this area. The service was meeting people’s health care needs and working hard to improve joint working with other health care professionals. A number of whom told us there had been issues with communication, record keeping and uptake of training.

Staff recruitment was sufficiently managed which meant staff employed were suitable but there were concerns about employment of temporary staff who did not necessarily have the right skills. The service tried to mitigate this risk by asking the agency for information and by completing an in-house induction.

People were supported to eat and drink and risks of not eating enough or drinking enough mitigated as far as possible. The dining room experience could be enhanced further if people were encouraged to socialise together and staff joined in.

Staff were caring and considerate of people’s needs. Although the service took into account people’s preferences this was not always fully recorded. Records generally had significantly improved but were still not sufficiently person centred but were regularly reviewed and updated.

People were asked their views and staff promoted choice and sought people’s consent. Records relating to capacity were sometimes contradictory.

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.

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 requires improvement (published 14 February 2019) and there were multiple breaches of regulation.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, sufficient improvement had been made and the provider was no longer in breach of regulations but still rated requires improvement throughout.

Why we inspected

This was a planned inspection based on the previous rating.

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.

At our latest inspection on 8 & 10 January 2019 we found improvements had been made but these were not firmly embedded. We found two repeated breach. Regulation 9 of The Health and Social Care Act 2014. person centred care, and regulation 11, consent. We also had concerns about the competencies and skill mix across the service but were confident that this was being effectively addressed so have not made a breach. We have made recommendations for several key areas of practice which if adopted will help to strengthen and improve the service further. We found improvements were still required in four of the five questions and judged the service was not yet good.

Buckingham 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 care home can accommodate up to 73 people in one adapted building which has three separate units across three floors, one specialising in dementia care. The others are for broadly speaking nursing and residential. At the time of our inspection there were 61 people using the service and two people in hospital.

At the time of our inspection there was a manager at the service but their post was an interim post and they were not registered with the Care Quality Commission. A registered manager is a person who has registered with the 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.’

In summary we found the service was improving and there were systems and processes in place to help identify the risks to people, the resources needed and an emphasis on lessons learnt following incidents. We found however that not all care plans and daily records clearly showed how people’s needs were being met. Care plans were not all up to date and did not clearly reflect peoples’ preferences and preferred routines. Risk assessments and care plans were not cross referenced and information was in different places, making it difficult to track through and gave a poor oversight of the person’s needs. We noted when people’s needs had changed this was not always picked up in reviews which tended to comment, ‘no change’. Daily notes were brief, mainly task oriented, functional and did not appear to reflect any specific objective. We also had concerns about the timeliness of information with care plans, assessments and risk assessments not being put in place quickly enough for new admissions.

The service had reviewed all the care plans on the residential unit and these were more comprehensive and reflected people’s needs. We have recommended that this care plan format should be adopted across the service to ensure they addressed people’s needs in a holistic way. We also recommend staff sign care notes to help ensure there is a clear audit trail and staff accountability.

Activities of daily living for people could be improved as some people had insufficient opportunity to engage in activities meaningful to them and care observed was functional rather than holistic. This was being addressed by the current manager who told us it took time to change an ‘established culture.’

The service was not always working in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found that staff understanding of MCA and DoLS was adequate and appropriate DoLS referrals had been made for people. Care records around care and capacity needed review to ensure they were not contradictory.

People were not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible; the policies and systems in the service do not support this practice. We found records around capacity and how staff were to support and promote people’s choice and best interest were not always in place or accurately reflecting the support people needed, why and who had been consulted.

Staffing levels were better and in line with people’s assessed needs. Although staffing was sufficient we found team work was poor and staff were not sufficiently deployed across the shift. We found staff had in the past received poor induction and poor training which had not enabled them to feel confident in their role or lead effectively. This was being addressed by the current manager who told us many staff were being performance managed with clear objectives which were reviewed as part of their supervision and appraisal of their performance. Mandatory training was being brought up to date and it was recognised that e-learning was not always the most appropriate way to train staff. The manager had identified a list of essential training and had planned it in over the next year to help support staff development.

Several things had been implemented to try and identify more accurately people’s experience of care and how the service was responding to their feedback. ‘You said, we did’ had recently been introduced and showed how the home was listening to people. Audits carried out across the home included daily walk rounds and more focused audits on specific elements of the care such as night audits and dining audits. These were happening but not firmly embedded. We have made a recommendation about community engagement and reviewing why people are spending so much time in their rooms.

People received the care they needed and the care was safe. There had been a number of medication errors and medicines had not always been available as people needed. The service had reported the errors and had put robust systems in place around this to ensure all incidents were managed robustly and lessons learnt. Some health care professionals expressed concerns that improvements were not firmly embedded across the service. We found there had been a lot of rapid change which had included new staff, the departure of two registered managers in the spate of a year and a temporary manager in post. There had also been two clinical leads leave and a new one start. This meant that although the service had made changes these had not always been clearly communicated or embedded as each manager had different priorities. We had concerns that support for the service had been provided but this had not been provided in a timely way or for long enough to help changes to become firmly embedded. We however recognised the providers commitment to getting it right and making the right resources available.

The service was working to an agreed and established action plan which was rated according to risk. This ensured the immediate priorities to stabilise the service would be addressed with longer term goals to improve outcomes for people. We found that some of these changes such as increased staffing were starting to have a positive effect but there were still areas of concern particularly the skill mix of the team. Health care could be improved upon by upskilling the nurses and by continuing to develop more positive relationships with other health care professionals and family who had lacked confidence in the service.

People were supported with their physical care needs and staff were kind and engaging but people would benefit from more support and engagement to pursue their own interests, fill their day and be less socially isolated.

The cook knew people well and was pivotal in ensuring people ate what they wanted and had access to home -made, wholesome food. Meal times would be enhanced if there was more interaction and staff being available to sit with people to encourage them to eat and drink in line with their assessed needs. We have made a recommendation about this.

The environment was clean and an outbreak of infection on the ground floor quickly contained. Some areas of the home had odours in isolated areas. The environment was fit for purpose but lacked personalisation and signage. This had been identified by the service and they were in the process of changing the use of some rooms to make them more appropriate to use and more accessible.

Staff recruitment processes were adequate and staff induction was improving to help ensure staff had the necessary competencies for their role.

Staff had a sufficient understanding of safeguarding p

There was a registered manager in post at the time of our most recent inspection.

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 service is a purpose built home which can accommodate up to 73 people who may or may not have a nursing need and whom may have a diagnosis of dementia. The home has three floors, ground, middle and top and people on the ground floor receive a residential service where people on the other two floors fall within the category of nursing although some people on these floors did not require nursing care. The residential floor was overseen by a unit manager whilst the first and second floor were overseen by a registered nurse. The home was situated at the edge of Watton a small town in Norfolk. At the time of our inspection there were 61 people using the service.

During this inspection the service demonstrated to us that improvements have been made but progress was slow and had been compromised by poor levels of staffing. There were repeated breaches of regulation from the last inspection. We observed variable care practices depending largely of the levels of staffing and the skill mix on shift. The provider had recognised that the action plan implemented from the following inspection had not been fully acted upon. They had put in a team of internal auditors, (quality team) to support the management team and staff to make and sustain improvements within the service. Some improvements were still in their infancy and the provider had not been able to demonstrate how they would sustain these improvements. They did provide us with an updated action plan and further plans to show how the improvements would be maintained. The registered manager was off sick and there was an interim manager in post who was experienced and familiar with the service.

We found the biggest concern was staffing levels which had not been consistently maintained, partly due to high staff sickness rates and unfilled staffing vacancies. Agency staff and bank staff were heavily relied on to meet the needs of people using the service. There was however an improving picture in terms of staff recruitment with all substantive nursing posts filled apart from one night post. Analysis of staff sickness and exploration of why staff retention was poor was underway and was viewed in context of the geographical area and local recruitment issues. The service had employed a person specifically to drive up recruitment. The impact of low staffing had meant people experienced variable patterns of care and social stimulation. It also meant not all staff were familiar with everyone’s needs or responding adequately to them.

We found risks to people’s safety associated with their care and welfare were mostly well managed. Staff regularly checked people to help promote their safety. Basic care was being provided and there were no immediate imminent risks we were aware of. We did not identify anyone with pressure areas but did identify people whose nutritional needs were not being met.

Staff had a reasonable understanding of what constituted abuse and knew how to raise concerns and were confident they would be addressed by senior management. All staff knew about external agencies they could report and refer to. We saw records of safeguarding concerns which had been reported as required but records did not provide a clear audit as to the stage of investigation or lessons learnt.

Medication practices were good and regular audits and staff training were designed to ensure staff administering medication were competent to do so. We raised concern about the length of time it took to administer some medication and the possible implications this had of the right spacing between individual medication doses.

The service was spotlessly clean and only a few odours were identified in a few isolated areas but this was soon addressed. The staff team were short but coped extremely well.

Monthly analysis of accidents, incidents and falls were carried out. They identified any trends and helped ensure that necessary action was taken to mitigate the risk of any future occurrences. However we were not always able to see examples of actions taken and whether lessons were learnt.

There were processes in place to support new staff and ensure they had the necessary skills and competencies for their role. Training was ongoing and staff received supervision although not regular. However there were no observations of practice or mentoring for staff who were not performing to expected level. Nurses did not have regular support to enhance their clinical skills and most were new to post so were still within their probationary period.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Whilst MCA assessments had been carried out, decisions made in people’s best interests were not always documented and some initial assessments of capacity were contradictory. We could not see how relatives were always consulted and involved in the decision making processes.

People were not always supported to eat and drink in sufficient quantities. Records demonstrated that there was clear monitoring of people’s needs in regards to hydration and food intake. However people who were unable to initiate for themselves when they were hungry and thirsty did not always get support in a timely way.

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People’s health care needs were mostly met but we found gaps in staff knowledge so could not be assured staff were always adequately responsive.

People’s records sufficiently documented their needs and most staff knew them and responded adequately. However at times the skills mix on shift was poor and staff sometimes worked with other staff who did not people they were supporting well .This put pressure on the whole team and meant the care was not always individualised. We found some days only peoples basic care needs were being met and people could not always choose when to take a shower or bath where they required assistance. We also found records were not always completed fully so we could not see the care being provided. People received some emotional stimulation but when staff were busy this was compromised. The range and scope of activities provided had improved but was still limited and needed to be developed further. There were no volunteers at the service which limited people’s opportunity to take part in different activities

Very few complaints had been received about the service. There was literature advising people and their relatives about the complaints process and some relatives expressed concerns with us on the day of the inspection. We found there was poor engagement from the organisation in terms of asking people for their feedback and encouraging them to raise concerns as appropriate. Surveys aimed at establishing people’s level of satisfaction had not been completed since the previous inspection and relative/resident meetings were poorly attended and we could not see how feedback was acted upon.

The service had not been consistently managed despite best efforts of the manager and deputy manager without strong clinical oversight and regular nurses in post the service had struggled to meet people’s needs. The turn- over of staff and sickness rates had impacted on the care and created a variable pattern of care across the unit and across the days of the week.

At this inspection we found the heavy involvement of the management team and internal members of the organisation supporting staff to implement improvements and continue to strengthen the improvements already made. We saw a great deal of auditing going on which highlighted weaknesses and action to address these areas. Staffing levels had been increased and reviewed in line with people’s dependencies and where additional hours were required the service had asked the Local Authority to reassess and review funding.

However our concern were around how the service would embed and sustain improvements and why actions had not been timely following our last inspection. We were also concerned that what was driving improvement did not seem to take into account the views of experiences of people using the service. A lot of audits were around inputs rather than observations of practice both of staffs skills and competencies and people well- being.

We found a number of breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report

Buckingham Lodge provides accommodation and nursing and personal care for up to 73 older people. There were 64 people living in the home on the day of our inspection.

This inspection took place on 8 and 10 February 2017 and was unannounced.

Buckingham Lodge Care Home requires a registered manager to be in post as part of the registration requirements from the Care Quality Commission. There was no registered manager in post at the time of the inspection and there had not been since May 2016. On the day of the inspection there was a home manager who had been in post since October 2016. They have been referred to as the ‘home manager’ throughout this report. The home manager was in the process of completing a CQC registered manager’s application. A registered manager is a person who has registered with the 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.

At the last inspection the home was rated good overall. At this inspection the home has been rated requires improvement in four of the key questions and overall and only rated good in ‘caring’. This means that there were more concerns at the home now than at the previous inspection.

The provider was not consistently taking appropriate action to manage risks. Risks were not always identified and there was no clear guidance in place for staff to follow to manage all risks effectively.

The service was not always acting in accordance with the Mental Capacity Act 2005 including the Deprivation of Liberty Safeguards. People’s rights were therefore not always being promoted.

Staff did not always work within these principals when supporting people who lacked the mental capacity to make decisions.

There were systems in place for managing medicines in the home. A medicine procedure was available for staff and staff had completed training in relation to safe medicine administration. Improvements were needed to the management of ‘when required’ medicines. Healthcare professionals such as chiropodists, opticians, GPs and dentists were involved in people's care when necessary.

Care plans were not all up to date; the information within them was not always current and was contradictory in some incidences. We could not be confident that people always received the care and support they needed.

People and their relatives felt the service was well managed and acknowledged the improvements that had been made to date. Staff felt the management team were approachable and gave them the opportunity to give their views at team meetings.

There was a quality assurance audit in place however the system was not always effective because issues identified at the inspection had not been recognised during the monitoring and auditing process.

Staff had an understanding of abuse and safeguarding procedures. They were aware of how to report abuse as well as an awareness of how to report safeguarding concerns outside of the service. Staff undertook safeguarding training providing them with knowledge to protect people from the risk of harm.

We found the home was in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

As part of this inspection we spoke with nine people who used the service, three visitors and a visiting health care professional. We also spoke with the head of care, the Chief Operating Officer who represented the provider, and 10 members of staff. We also reviewed records relating to the management of the service which included six care plans, daily records, staff records and quality assurance monitoring records.

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 that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Risk assessments for care needs were completed and provided appropriate guidance for the identified risk to be reduced. They stated they were involved in reviewing their care plan and were supported to make decisions regarding their immediate care needs and wishes.

People received the care and support they required to improve their health and well-being. Care records were written in detail and provided clear guidance to staff members, Reviews of care plans were completed so that staff had guidance about supported each person safely.

Applications had been appropriately made in regard to Deprivation of Liberty Safeguards for people whose liberty was restricted. Staff members and the manager showed they had appropriate knowledge regarding recent guidance.

There had been an increase in staff members in all areas of the service since our inspection in March 2014. People using the service said there were now enough staff available to meet their needs. Information from staff members, the manager and records shows that there were enough staff available with the skills and training to care for people appropriately.

Is the service effective?

People told us that staff members helped them with everything they needed assistance with. They told us that they were satisfied with the care they received. Care records provided clear and detailed information about people's care needs and preferences.

Health needs were responded to and people had access to health care professionals if they needed this. Information and guidance given by health care professionals was included in people's care records so that staff members knew how to promote their health.

Is the service caring?

People said that staff members were polite and kind; they respected people's privacy and dignity, and involved them in their care. Staff members knew people's care needs and their personal preferences when we spoke with them.

People said that staff members were polite, kind and respectful, although one person felt they did not all stay long enough to chat with them. One visitor told us that the care staff, 'Were brilliant'. We observed interactions between people and staff members and we found that the members of staff were patient and understanding of people's individual needs. However, we found that there were missed opportunities for staff to spend time with people.

Is the service responsive?

We saw that people's individual physical and mental support, care and treatment needs were assessed and planned for. Their individual choices and preferences regarding their support and care were respected.

Is the service well led?

There had been an annual survey to gather the views of people using the service last year and a further survey was due to be sent out. Responses from the last survey were mixed and actions to individual issues could not be identified, although senior staff from the provider's head office were visiting the home to support and monitor improvements. There were other systems in place to monitor and assess the quality of the service provided; the service had analysed this information for any trends or themes resulting from complaints, accidents or incidents.

We spoke with people using the service and their relatives who told us that staff consulted them and respected and acted on the decisions they had made about the care and support they had agreed to.

People living in the home told us that activities were provided, but not every day and that they were sometimes bored.

We found that the plans of care were being redesigned and reviewed to ensure that they were complete and contained up to date information.

People using the service told us that they had received the nursing care and support they needed and that staff were kind and respectful.

People told us that their personal laundry sometimes took a long time to be laundered and returned to them.

We found that recruitment security checks had been carried out on each member of staff and that they had suitable skills, qualifications and experience to care for people.

People using the service told us that they had to wait for between fifteen to twenty minutes sometimes for a member of staff to answer the call bell.

Improvements were needed to care planning records. We found that they were being redesigned and reviewed to ensure they were complete and up to date.

Our observations showed us that staff members were responsive to the needs of people and that they were given the support and attention they needed.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted and protected.

Medication was administered, recorded and stored accurately and safely.

People living in the home and their relatives told us that adequate staffing levels were not always provided and they often had to wait for assistance from staff.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations, decision making and activities.

We found that plans of care contained the information staff members needed to ensure that the health and safety of people was promoted.

Relatives told us that people received the care and support they needed and that staff were very kind.

The environment was well maintained and the cleanliness of the home was adequate in most areas. However, some carpets were stained.

Staffing levels were inadequate which meant that people had to often wait to receive the care and support they needed.

People told us their complaints were listened to and resolved. We found that there was a complaints system in place that met the needs of people living in and visiting the home.