Archived: Samuelson Lodge

Updated 13 May 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 27 November 2014 and 5 December 2014 and was unannounced and was carried out by one inspector and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before our inspection we reviewed the information we held about the service which included the Provider Information Return (PIR). The PIR is a form we asked the provider to complete prior to our visit which gives us some key information about the service, including what the service does well, what they could do better and improvements they plan to make. We also contacted the local authority and the local Healthwatch to obtain their views about Samuelson Lodge.

During our inspection we observed how the provider interacted with people who used the service. We looked at how people who used the service were supported during the day of our inspection.

We looked at one care record, one staff file and other records relating to the management of the service, such as policies and procedures and gas and insurance certificates.

During and after the inspection we spoke to the community mental health team to get their view of the service as they had weekly contact with one person using the service.

Updated 13 May 2015

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.