Archived: Chorley Lodge

Chorley 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. The care home accommodates up to 66 people. At the time of the visit there were 54 people who lived at the home.

Following our last inspection the registered provider Orchard Care Homes.com (4), was placed into administration. The administrator appointed another company to oversee the day to day running of the home. A new provider was in the process of applying to be registered with the CQC. The registered manager had left the service following our last inspection and a new manager had been appointed and was applying to register with the CQC. 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.

At the last focused inspection on 07 March 2018, we found five breaches of the regulations. This was because there were shortfalls to the safe management of people’s medicines. In addition, risks associated with receiving care including, nutrition and hydration had not been adequately managed and staff had not been adequately supported with supervision and ongoing training. The governance and quality assurance systems were not effective in identifying shortfalls to generate improvements to the quality of the service. These were breaches of regulation 12, 14, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following our last inspection of March 2018, we took enforcement action to impose conditions on the providers’ registration. We met with the provider to discuss what actions they intended to take to improve the quality of the care and addressed the shortfalls. We asked them to take immediate action to address the shortfalls and regularly submit evidence of their actions to CQC. We took enforcement action by adding conditions to the providers’ registration. The provider was also asked by the local authority’s contracts monitoring team to complete an action plan under their quality performance and improvement planning process.

During this inspection, we reviewed actions the provider told us they had taken to gain compliance against the breaches in regulations identified at the previous inspection in March 2018. We also looked to see if improvements had been made in respect of the breaches. We saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service.

However, we found three breaches of the regulations of the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014. These were in relation to the management of risks to receiving care, good governance and failure to meet the conditions of their registration. We also made a recommendation in respect of mental capacity assessments. We also found that the work to improve the service was still in its early stages. Further improvements were required to ensure a consistent delivery of safe care and treatment that could be evidenced in the longer term. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals are concluded.

People who lived at the home told us that they felt safe in the home and that there was sufficient staff available to help them when they needed this. People and their visitors spoke highly of the care staff. They told us there had been improvements to the quality of care provided and that they were happy with the care and treatment.

Improvements had been made to the management of risks including risks associated with nutrition and hydration, medicines management and people experiencing frequent falls. Staff had closely monitored people to ensure they were having enough to eat and drink. However, we found shortfalls to the systems for reviewing risks levels and ensuring lessons learnt were shared in the service. Actions had been taken when people had experienced injuries however, accident and incident records had not always been overseen by the manager to check whether staff had taken appropriate action to support people. Some risk assessments we reviewed were generic and not specific to each person.

Management and governance systems in the home had improved however, this was at an early stage since the home had been placed in administration since May 2018. Further improvements were required to ensure that the new policies and procedures were fully established and embedded within the staff team and the governance systems in the home. The service had a new manager who had been in post for approximately three months. We noted an improvement in the systems designed to assess, monitor and improve the service. A significant number of audits and quality assurance processes were in place; they were supported by an action plan. However, the manager had not always followed up on delegated tasks to ensure they were completed to the standards required and within set time scales. We found a number of shortfalls which could have been picked up by robust audit systems. In addition, the provider had not effectively complied with the conditions set by CQC at the last inspection. The shortfalls we found indicated the quality assurance and auditing processes had not always been effective, as matters needing attention had not always been identified and/or addressed in a timely manner.

Records showed that staff had been recruited safely and the staff we spoke with understood how to protect people from abuse or the risk of abuse.

There had been improvements to staff training arrangements. Staff had received induction and appropriate training. People and their relatives felt that staff had adequate knowledge and skills to meet their needs effectively. Further improvements were required to ensure staff received regular supervision in line with the organisation's policy.

We observed people being supported in a sensitive and caring manner. People told us the staff who supported them were caring and respected their right to privacy and dignity. People told us staff encouraged them to be as independent as they could be.

There had been some improvements to the support people received with their nutrition and hydration. Actions had been taken to monitor people’s intake and to seek support where required. Improvements were still required to ensure the practices for monitoring and recording were consistent throughout the staff team. Referrals were made to community healthcare professionals where required to ensure that people received appropriate support.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way. The service had taken appropriate action in line with the Mental Capacity Act 2005. However, further improvements were required to ensure capacity assessments were decision specific and best interest decisions were recorded. We made a recommendation about decision making and seeking consent.

People told us they received care that reflected their individual needs and preferences. Staff told us they knew people well and gave examples of people who required extra monitoring and their preferred routines. However, evidence we found showed people and their relatives were not always involved in the writing and reviewing of their care plans. This would ensure a person-centred approach to care planning.

We received mixed feedback regarding the caring approach of the staff from two relatives. However, the majority of the feedback we received in relation to the caring nature of staff was positive.

People were supported to take part in activities and events. They told us they were happy with the activities that were available at the home. We found the service had a policy on how people could raise complaints about care and treatment and improvements were required to demonstrate how complaints had been received and concluded.

Staff communicated effectively with people. They supported people sensitively and spoke to them at their level when providing care. People’s communication needs were identified, and appropriate support was provided.

The manager had sought feedback from people and their relatives about the support they received and shared with them improvement plans in the home.

People living at the service and staff told us they had noticed improvements in the management of the service and were happy with the leadership. They told us the new manager was approachable and supportive.

The manager had engaged with other health and social care stakeholders such as the local authority, Clinical Commissioning Groups and local health care professionals to improve the quality of care provided to people.

There was a business contingency plan to demonstrate how the provider had planned for unplanned eventualities which may have an impact on the delivery of regulated activities. The equipment and premises had been maintained and further renovations were in progress.

The provider had sent notifications to CQC for notifiable incidents, such as allegations and incidents of abuse and significant events that affected the smooth delivery of services.

After the comprehensive inspection, we asked the provider to complete a report on what they would do to meet legal requirements in relation to the breach. Following the inspection in October 2017, we received concerns from the local authority’s safeguarding team about an incident in the home. In addition we received a notification of a serious incident which raised concerns regarding the assessment and management of risk in relation to people’s nutrition and hydration as well as falls. As a result, we undertook a focused inspection to look into those concerns and to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in October 2017 had been made.

The inspection team inspected the service against two of the five questions we ask about services: is the service safe and well led. This report only covers our findings in relation to those topics. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Chorley Lodge on our website at www.cqc.org.uk.

Chorley 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. The care home accommodates 66 people across three separate floors, each of which has separate adapted facilities. Two of the units specialise in providing care to people living with dementia. At the time of the visit there were 63 people who received support with personal care. There is no nursing care at this service.

The service had a registered manager in place. 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.

During this inspection we identified a continuing breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risks associated with receiving care and risks associated with the unsafe management of medicines were not adequately managed. In addition we identified breaches of Regulation 14 and Regulation 17 and 18. This was because we found significant concerns to the systems for assessing, managing and monitoring risks associated with dehydration and malnutrition. People’s care records had not been completed or reviewed to reflect their needs and there was a lack of oversight and good governance to ensure the home operated safely and to identify and act on concerns. We also found shortfalls in staff training and development. 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.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, 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.

Systems for assessing and monitoring people’s nutritional and hydration needs were not operated and implemented effectively; this meant staff could not adequately identify people who required support or monitor that they were having enough to drink or eat. People had been exposed to risks of dehydration. People who were at risk of unintentional weight loss were not adequately supported and monitored for deterioration. People who had been assessed as needing weekly weighing or additional support to increase food or fluid intake were not always supported. There was a lack of clear guidance on how to monitor people’s hydration needs. People were not always referred to specialist professionals when risks had increased. In some instances professional guidance had been provided on how to monitor the risks of malnutrition and dehydration however, this was not put into action. There were significant gaps in records for monitoring people’s fluid and dietary intake.

There were systems in place to record significant events and incidents which occurred within the home. Risks of falls had been monitored and people had received medical attention where required. However, falls risk assessments were not always reviewed or updated to identify ways of reducing the risks especially where people had suffered multiple falls.

Staff had received training in the management of people’s medicines. However, we found shortfalls in the safe storage of medicines and the management of information on medicines allergies. We found the temperatures for medicine storage areas had not been consistently monitored and recorded. Keys to the controlled drugs cabinets were not kept securely to reduce the risks of medicines misuse.

Staff had received training in the safeguarding of people and they were aware of how to report unsafe practices.

People who lived in the home, and staff, were provided with opportunities to comment on the service provided. Satisfaction surveys had been distributed by the provider to seek people’s views. During the inspection, we received mixed feedback regarding the staffing levels at the home and how this impacted on people living in the home.

People who used the service told us they felt safe and comfortable at Chorley Lodge. However, our observations showed that there were missed opportunities for staff to engage with people in a meaningful way. Staff had only engaged with people when there was a task to be completed.

We received mixed views about the governance of the service. Three staff told us they enjoyed working in the home and supporting people to meet their needs. However, we also received negative feedback about the way the service was led from relatives of people who lived in the home and from community based health professionals who dealt with the service on a regular basis. We also found there was a lack of robust oversight on staff from the registered manager; the senior leadership in the home had not adequately monitored whether the registered manager was complying with regulations. Systems for monitoring the quality of the service were in place. However, findings from audits and quality assurance tools were not always used to improve the safety of the care provided and the outcomes for people living at Chorley Lodge.

Recruitment processes were sufficiently robust to protect people from the risk of unsuitable staff.

People were cared for in a safe and clean environment. Systems were in place to deal with any emergency that could affect the provision of care.

At the last inspection on 21 and 22 October 2015, the service was rated ‘Good’. During this inspection we found the service to be in breach of one regulation. This was in relation to the care planning and the management of risks to receiving care and treatment. You can see what action we told the registered provider to take at the back of the full version of the report.

Risk assessments had been developed to minimise the potential risk of harm to people who lived at the home. These had been kept under review and were relevant to the care and support people required. Improvements were required to the records related to risk management. We found shortfalls in relations to care records. Care plans had been reviewed however the information was not always person centred, detailed or accurate. Care plans for people who were living at the home temporarily also known as respite care, were not adequately completed. Care records did not always demonstrate how people had been involved in the review of their records.

People had received their medicines as prescribed and staff had been trained in the safe management of medicines. However, we found areas that required improvement in the medicines administration records and audit systems. The registered manager took immediate action to make the required improvement during the inspection. Medicines were stored securely to ensure they were safe. There were risk assessments which identified risks to people and management plans had been put in place to ensure people’s health and well-being were maintained.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s consent to various aspects of their care was considered and where required DoLS authorisations had been sought from the local authority. However, improvements were required to the quality of the documentation relating to mental capacity assessments. The registered manager had identified this and had started to make the required improvements to the documentation. People who received support, or where appropriate their relatives, were involved in decisions and consented to their care. People’s independence was promoted.

The registered manager had systems in place to record safeguarding concerns, accidents and incidents and take appropriate action when required. Recruitment checks were carried out to ensure suitable people were employed to work at the home. There had been previous concerns regarding staff shortages. Our observations and discussions with staff and people who lived at the home confirmed sufficient staff were on duty.

We observed regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration. Comments from people who lived at the home were all positive about the quality of meals provided. One person said, “The food here is the best.” We found people had access to healthcare professionals and their healthcare needs were met.

People who lived at the home told us they were encouraged to participate in activities of their choice and a range of activities that had been organised. We observed the activities coordinator engaging people and offering a range of activities. People who used the service and their relatives knew how to raise a concern or to make a complaint. The complaints procedure was available and people said they were encouraged to raise concerns.

The registered manager used a variety of methods to assess and monitor the quality of care at Chorley Lodge. These included, regular internal audits of the service, surveys and staff and resident meetings to seek the views of people about the quality of care being provided. Improvements were required to ensure quality assurance processes were robust in identifying and dealing with shortfalls in a timely manner.

During the inspection we spoke with six people using the service, three members of staff and the registered manager. Prior to the visit we spoke to one relative and after the visit to a social worker. We considered all the evidence we had gathered under the outcomes we inspected. We have used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found:

Is the service safe?

There were systems in place to ensure people's safety. The staff had received training on protecting vulnerable adults from abuse and there were clear policies and procedures setting out how staff should respond if they suspected or witnessed abuse occurring in the home.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. At the time of the inspection mental capacity assessments were being carried out for all people living in the home to determine their capacity to make decisions about their care. One person had a deprivation of liberty safeguard approved by the local authority. Deprivation of liberty safeguards are part of the Mental Capacity Act 2005 and are designed to ensure that a person's loss of liberty is lawful and they are protected.

Is the service effective?

People received effective care. People received care from staff who had completed relevant training for their role. People's healthcare needs were assessed as part of the care planning process and records were maintained of all contact with healthcare professionals.

Is the service caring?

We observed the staff to be caring and sensitive in their approach to people living in the home. People told us they had a good relationship with the staff. Staff spoken with demonstrated a good understanding of people's needs and were aware of their personal preferences and wishes.

Is the service responsive?

Staff were responsive to people's needs. Each person had a detailed care plan which was reviewed at regular intervals. People were allocated a keyworker and a care plan coordinator. This meant staff could work on an individual basis with people and were familiar with their needs.

Is the service well led?

The service was well led. The home had a registered manager and there was a clear hierarchy of staff. Systems were in place to monitor the quality of care and the operation of the service. Monthly quality checks were also carried out by a representative of the company.

Below is a summary of what we found.

The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. Safeguarding procedures were in place, staff received training in this area and understood their responsibilities in keeping people safe.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints and investigations. This reduced the risks to people and helped the service to continually improve.

The home had reviewed their policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. New paperwork was being introduced and updated training was in progress. This provided legal protection for individuals who lacked capacity and who may be deprived of their liberty, to protect them from harm.

Staffing arrangements took into account the different needs of the individuals living at the home. This helped to ensure people had their needs met.

Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

The individual or their representative such as a relative was involved in the assessment and support planning processes. Support plans reflected people's individual wishes and preferences. Specialist equipment, such as for mobility and pressure relief, was in place when needed.

The home had been designed to meet the needs of people with dementia. The layout, decoration, signage and fittings were appropriate for use.

Relatives confirmed they were able to visit at any time and that staff made them welcome.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'They work hard. They are a jolly lot.' And 'They have been very kind.'

Relatives told us they were satisfied with the quality of care provided.

People using the service and their relatives were able to attend meetings and told us they felt able to raise any issues or make suggestions. Surveys were also used to gain feedback from relatives. Where shortfalls or concerns were raised these were addressed.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. The records for one person stated their desire to dress smartly and we saw that staff had helped him dress in a shirt, jacket and tie. This person told us; 'I like to be smart. It's who I am.' Staff showed a good understanding of the importance of respecting people's differences and preferences.

Is the service responsive?

People could take part in a range of activities. We saw a high level of engagement in planned activities during our visits to the home.

Complaints were taken very seriously and if shortfalls were identified, these were responded to. There were good systems in place which helped the service to improve and learn from untoward incidents.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a robust quality assurance system. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities and were supported to work to a high standard. This helped to ensure that people received a good quality service.

Some people with dementia were unable to tell us their views. We spent time observing how staff supported these people. Staff were gentle, kind, spoke to people respectfully and took time to explain what they were doing. We also saw that staff followed guidance from care plans when they were helping people.

Medicines were securely kept, handled appropriately and safely administered.

Regular checks and audits, helped to ensure staff were following agreed procedures.

The majority of people we spoke with felt there were enough staff to meet their needs. Senior staff worked alongside care staff, providing support and guidance. We were told that staff were very approachable and worked hard.

We saw that the quality was monitored and risks were identified and managed. Audits resulted in actions being taken to make improvements. Meetings took place for staff, people living at the home and their relatives. These provided good opportunities for people to share their views.

There was an effective complaints system in place. Complaints were taken seriously, monitored and promoted service improvements.