The Care Quality Commission (CQC) has rated Wisteria Lodge in Uckfield, East Sussex, inadequate overall for the second time, following an inspection in July.
Wisteria Lodge is a residential nursing home registered to provide personal and nursing care to 20 people with learning disabilities, physical disabilities and a range of neurological conditions such as autism. The service is comprised of two separate buildings: Wisteria Lodge, and Stable Lodge. At the time of the inspection, there were 19 people living at the service.
Wisteria Lodge is owned by SHC Clemsfold Group Limited, also known as Sussex Health Care. Services operated by Sussex Health Care have been subject to a period of increased monitoring and support by CQC and local authority commissioners. Due to safeguarding concerns raised about the provider, Sussex Health Care as an overall provider is also currently subject to an investigation by Sussex police, the investigation is on-going, and no conclusions have yet been reached.
Wisteria Lodge was rated inadequate and put into special measures at the previous inspection, which meant it has been subject to additional monitoring by CQC and support from local agencies to drive improvements to the safety and quality of care. Despite these interventions, the provider hasn’t been able to implement or sustain effective improvements and inspectors were still concerned that people were not being cared for safely.
After the last inspection, the provider completed an action plan outlining the improvements it planned to make, and by when. However, after the inspection in July, the service was still in breach of regulations, and it was rated inadequate overall and inadequate in respect of safety and leadership for the second time.
CQC would have taken further action at Wisteria Lodge, however, Sussex Health Care took the decision to close six of its services*, including Wisteria Lodge, on 30 September 2021. All people who were using the service have now been moved to alternative homes.
Debbie Ivanova, CQC’s deputy chief inspector for people with a learning disability and autistic people said:
“We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Yet, at Wisteria Lodge, we found that the model of care and the setting of the home did not maximise people’s choice, control and independence.
“The service was in a rural area and located in private grounds and opportunities for people to access the community were limited. Activities were in groups, rather than being personalised for the individual, which meant that some people became bored or distressed. We also found that people were not being cared for in a safe way and staff did not always recognise when people were in pain or distress.
“In short, there were widespread and significant shortfalls in the leadership of this service. It is incredibly disappointing that the provider was unable to make the required improvements, despite the intervention and support it was given and, in the circumstances, it has made the right decision to close the service.”
Inspectors found the following issues at the service:
- There was a lack of effective governance and systems, and audits did not highlight all concerns or remedy shortfalls that were identified
- The service did not have a positive culture and people were not supported to be as independent as they could be. Care was not person-centred and did not promote people's dignity, privacy and human rights
- People were not being protected from abuse or neglect
- People who were in distress were not supported to use communication aids to indicate why they were distressed, and their support did not change, despite their distress being recorded regularly
- There was unsafe monitoring and management of risks around behaviours that may challenge others, deteriorating health needs, choking risks, access to assessed levels of physiotherapy, risks around constipation care and skin integrity. For example, some people were not receiving the correct level of support with physiotherapy, which was putting them at risk of reduced physical movement. Some people, who were at risk of choking when food or saliva entered their airways, were not being supported to eat safely. Some people wore incontinence pads and relied on staff to change these at regular intervals. However, there were times when people had gone long periods, sometimes double the recommended time, before having their pads changed. Not only would this have been extremely uncomfortable for people, it also put them at risk of developing skin conditions
- There was a lack of learning when things went wrong. Incidents had not been managed well so that staff and people could learn from them and prevent them reoccurring. In the two months preceding the inspection, there had been 21 incident reports relating to marks bruises and injuries. Follow up of these incidents had not been robust.
Full details of the inspection are given in the report published on our website.
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