Archived: Atherton Lodge

Atherton Lodge is a privately owned two-storey detached property that has been converted and extended into a care home. It is registered with Care Quality Commission (CQC) to provide accommodation for up to 40 older people who require personal and nursing care. Some people at the service were living with dementia. At the time of the inspection there were 17 people living at the service who required accommodation and personal care only.

There was no 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. There was a manager in post who had been interviewed by CQC for registration at the service.

At the last comprehensive inspection on the 12 and 13 December 2016 we identified breaches of Regulations 11, 12, 15 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found that a number of improvements were required at the service. People were not protected from the risk of unsafe care and treatment and the systems and processes which the registered provider had in place to assess, monitor and improve the quality and safety of care were not effective. Consent to care and treatment was not always sought in line with relevant legislation and the environment was not suitable to meet the needs of people living with dementia. We asked the registered provider to take action to address these areas.

This inspection found continued breaches of Regulations 11, 12, 15 and 17 as well as additional breaches of regulation 10 and 14 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded

Medication was not administered safely. Risk assessments and care plans were not followed for the safe administration of one person’s medicines. Staff failed to protect one person from a known risk of harm putting this person’s health and safety in danger. Instructions provided by a GP for the administration of medication were not followed. Records relating to medicines were not always kept up to date in a timely manner.

We found that parts of the service and equipment in use were not clean. There were ongoing risks identified with regards to infection control. Eight call bell cords were found to be tied up in toilets and communal bathrooms near to people’s bedrooms. This meant people were placed at unnecessary risk as the ability to call for help in an emergency had been restricted. Rooms containing hazardous equipment and substances were not secure. The management of health, safety and infection control was poor.

People were not consistently supported to have maximum choice and control of their lives. People were not always supported in the least restrictive way possible. Bedroom doors were locked at the service and this restricted people from gaining access to their bedrooms and possessions as and when they wished. Policies and systems relating to the Mental Capacity Act and Deprivation of Liberty safeguards in the service were not robustly followed.

The registered provider’s statement of purpose identified that the home is able to support people living with dementia. However, we found that the environment was not dementia friendly and limited adaptions had been made to aid and support people who were living with dementia.

People’s privacy was not ensured as records were not held securely at the service. People’s rights to choice, privacy and dignity were not always respected.

People were not always protected from the risk of malnutrition and dehydration. Where advice and guidance had been sought from health professionals this had not always been followed. Charts which were in place to record and monitor people’s food and fluid intake were not always completed effectively. Information relating to people’s fluid intake was not always completed in detail to accurately reflect what they had consumed. Food and fluid charts were not consistently totalled to accurately assess whether people had received adequate food and fluids to protect them from the risk of dehydration and inadequate nutrition.

The quality assurance systems in place were not effective. We found continued issues as part of our inspection relating to the analysis of accidents and incidents and the accurate completion of supplementary charts and care records at the service. Information analysed regarding accidents and incidents was not robust, There were no actions recorded to identify that the registered provider had considered how to minimise or respond to any risks, patterns or changes required to people’s care needs. Quality assurance systems used by the registered provider had not identified issues we raised as part of this inspection.

The CQC was not notified as required about incidents and events which had occurred at the service.

Care plans varied in detail and did not always accurately reflect the support people required to keep them safe. People’s needs were not always assessed and planned for to ensure they were met. One person had a behaviour chart in place which had been completed by staff. However no assessment or care planning documentation had been completed for this area of need. Records did not protect the person from the risk of known verbal and physical abuse from others. However, we noted that care plans to support people living with dementia had improved and offered guidance to staff on how best to support the person’s lived experience.

The registered provider had a complaints policy and procedure. Records did not always evidence verbal complaints received and correspondence issued by the service. We spoke with the manager and registered provider regarding the content, tone and language used in correspondence as this was not always appropriate.

The registered provider had clear policies and procedures in place for reporting any concerns they had about the safety and well-being of people they supported. The majority of people we spoke with said they were happy with the service that they received and that they felt safe. Observations showed that staff took time with people and were kind in their approach and manner. Throughout our visit observations showed that people were actively engaged in hobbies and interests.

Staff had been employed following appropriate recruitment checks that ensured they were suitable to work in health and social care. Staffing levels were continuously reviewed to ensure people were safely supported.

Staff had attended training sessions in areas such as moving and handling, safeguarding adults, equality and diversity and dementia to update their knowledge and skills. Staff confirmed that they felt supported by the manager and had the opportunity through their supervision to talk about areas of development. Records confirmed that supervisions and team meetings had been held at the service.

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.

Atherton Lodge is a privately owned two-storey detached property that has been converted and extended into a care home. It is registered with Care Quality Commission (CQC) to provide accommodation for up to 40 older people who require personal and nursing care. Some people at the service were living with dementia. Following the last inspection, the registered provider took the decision to cease providing nursing care. In conjunction with staff from the local authority and the Clinical Commissioning Group, those people deemed to require this level of support were found alternative accommodation. At the time of the inspection there were 23 people living at the service who required accommodation and personal care only.

There was no registered manager in place and there had not been one since February 2015. 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. There was a manager in post who started in August 2016 and whom had submitted her application to CQC for registration.

At the last inspection in August 2016 we found that a number of improvements were needed in relation to, meeting nutritional people’s needs, planning people’s care and support, the environment, identifying people’s health needs and monitoring the quality and safety of the service. We found the service in breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This inspection took place to establish what improvements had been made and whether the registered provider now met legal requirements. We found that there were on-going concerns and breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not kept safe from the risk of harm. Not all of the risks to people were assessed, reviewed or managed. This included the physical, medical, emotional and mental needs of people who used the service. Accidents and incidents were recorded but there was not always evidence of a follow up to ensure people's safety or to improve their care.

The registered provider had introduced a dependency assessment in order to demonstrate that they had the right number of skilled and experienced staff to meet the needs of the people who used the service. Out of the seven assessments reviewed three were incorrect and one had not been reviewed since September 2017. If assessments are not accurate there is a risk that staffing levels may not be adjusted accordingly.

There was a new chef in place who was carrying out a review of menus to ensure that people had a greater choice of meals and drinks. The chef had received advice and guidance from the dietetic service. People were observed to have a poor dining experience. Staff gave people the option to sit at the dining tables but this was not well organised and some people sat and waited for 50 minutes for their meal. During this time they became unsettled and uncomfortable. Tables were not laid with cloths, place mats or condiments. Menus were not available to help people make a choice or identify their meals and the menu board was not easy to locate or read.

The Statement of Purpose stated that the service can provide support to people living with dementia and also people with sensory impairment. We found that the accommodation, adaptations, stimulation and specialised support was not in place to support people with these conditions. This meant that staff could not meet people’s needs in an effective way and the environment did not meet their needs.

Staff had received training in the Mental Capacity Act 2005 (MCA) and were able to discuss this with us. However, care plans failed to address a person’s ability to make decisions about care and support or evidence where decisions had been made in a person’s best interest. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Some people who used the service were subject to a DoLS but the registered provider had not taken account of the conditions imposed within the DoLS authorisations.

People felt that the staff were caring and supportive and they expressed affection for them. Observations showed that some staff did not know how to support people who were distressed or may be seen to challenge others. We observed that some distressed behaviours were seen as ‘normal interactions’ and staff did not always manage or support people appropriately.

Staff were able to tell us about a person’s support needs and their likes/ dislikes. Some records indicated what was required of staff in order to provide. However this was not consistent those records lacked detail and did not reflect people's current needs especially around the monitoring of health conditions. This meant that people may not receive the care and support that was required to keep them safe.

Furniture, fixtures and fittings were in need of replacement or repair. There was a lack of cleanliness throughout the service and a malodour was present in some areas of the building. There were risks to a person’s safety as aspects of the building were deemed to be unsafe. Other concerns were identified in regards to infection control and increased risks to a person of acquiring an infection.

The complaints log was located and two formal complaints had been logged. The manager informed us that no other complaints had been made about the service. A response had been provided in each case but there was no evidence of how the complaints had been investigated in order to reach the identified outcome.

People and their families had been provided with the opportunity to express their views about the service though meetings and discussions with the registered provider. There were mixed opinions shared as to the confidence people had in the registered provider to remedy all concerns.

Whilst some improvements have been made to the registered provider's governance and auditing systems these were still not robust to ensure the safety of people was maintained. The registered provider had failed to ensure that the home had improved or sustained improvement in some identified areas. The registered provider had enlisted the services of an external consultant to better monitor the safety and welfare of people who used the service.The inspectors found no written action plans to evidence what remedial steps had been agreed and taken following these visits. The registered provider informed us that verbal actions had been agreed at the end of each visit. However, we found that some of the issues highlighted had not been resolved. This meant that there were inadequate processes in place to assess and monitor the quality and safety of the service.

Staff had confidence in the manager and said that it was good that she was trying to bring a consistency to systems, structures and record keeping requirements. The registered provider told us that he now had a better understanding of the requirements set out in the Health and Social Care Act 2008 and his responsibility within this. There was also evidence that he had a more regular presence within the home.

CQC were notified of key events which adversely affected people's safety and welfare. There was, however, a failure to notify the CQC of those persons subject to a DoLS.

The management of medicines had improved which meant that people would get the medicines that they required. Improvements had been made to ensure that medication was stored safely and in line with manufacturer’s instructions. Records in regards to medicines were accurate and there were care plans which provided staff with information to ensure that the right medication was given to the right person at the right time.

Staff training had been updated and staff told us that they now felt better able to carry out their role. Staff had received supervision and felt able to go to the manager or one of the senior staff if they had any concern. This meant that people were supported by staff that had improved skills and knowledge to carry out their roles effectively.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’.

The service 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.

Atherton Lodge is a privately owned two-storey detached property that has been converted and extended into a care home.

It is registered with Care Quality Commission (CQC) to provide accommodation for up to 40 older people who require personal and nursing care. Some people were living with dementia. At the time of the inspection there were 40 people living at the service.

At the time of our inspection there was no registered manager in place and there had not been one since February 2015. 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 registered provider had employed a number of managers since February 2015 however they left their post before being registered with the Commission.

At the last inspection on 16 November 2015, we found that a number of improvements were needed in relation to: meeting nutritional people’s needs, planning people’s care and support, identifying people’s health needs and monitoring the quality and safety of the service. After the inspection, we issued requirement actions in relation to breaches of the Health and Social Care Act 2008 which we identified.

Following the inspection the registered provider sent us an action plan stating that they would meet all the relevant legal requirements by 4 January 2016. During this inspection we found that the registered provider had not met these legal requirements and we found further significant breaches of the Health and Social Care Act 2008.

CQC is now considering the appropriate regulatory response to the breaches we found. We will publish our actions at a later date.

People were not kept safe from the risk of actual or potential harm. Risks to people were not properly assessed, reviewed or managed. This included the physical, medical, emotional and mental needs of people who used the service. Staff did not always recognise safeguarding incidents and therefore action was not always taken to ensure that people were kept safe. Accidents and incidents were not always recorded or followed up to ensure people's safety or improve their care.

There were insufficient staff available to meet the needs of people. We found that many of the lounge areas were left unattended and people did not always get the support they required. The registered provider could not demonstrate how he was assured that the right numbers of skilled and experienced staff were available at all times to meet the needs of the people who used the service.

The management of medicines was not safe which meant there was a risk that people did not get the medicines that they required. Medicines had not always been available and medication which was signed for as given was found on the floor or tables. Medication was not always stored securely or in line with manufacturer’s instructions. Records in regards to medicines were not always accurate and did not provide enough information to ensure that the right medication was given to the right person at the right time.

People did not have a choice of nutritious meals and drinks. Some people's diets were very poor placing them at risk of malnutrition but these risks had not been identified. Advice from professionals such as a dietician had not been followed. People had a poor dining experience. Staff did not give some people the option to sit at the dining tables and other people did not get the support they required at mealtimes.

At the time of the visit the service provided support to some adults with functional mental illness which is not in accordance with their Statement of Purpose. Additionally some people were under 60 years of age. Staff did not have the skills and knowledge to support these individuals.

The Statement of Purpose also stated that the service can provide support to people living with dementia who require personal or nursing needs and also people with sensory impairment. We found that the accommodation, adaptations, stimulation and specialised support was not in place to support people with these health conditions. This means that staff could not meet people’s needs.

Staff were not familiar with the principles of the Mental Capacity Act 2005 (MCA) when working with people who lacked the mental capacity to make decisions. The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Some people who used the service were subject to a DoLS but the deputy manager could not tell us if all the authorisations were still valid as some appeared to have expired. Following the inspection, the local authority confirmed they had renewed the authorisations in question.

Whilst people felt the majority of staff were caring and supportive, observations showed that some staff did not know how to manage behaviours which distressed people. Staff responses to this did not always respect people’s dignity. People and their relatives commented that they had at times found it difficult to communicate with staff because there had been a language barrier.

People did not receive personalised care which met their needs and some people did not have a care plan in place for their identified needs. Care records lacked detail and some were out of date so did not reflect people's current needs. People had access to health and social care professionals as required, however staff did not always follow advice given by them. People were also at risk of missing health appointments.

Furniture, fixtures and fittings were in need of replacement or repair. Linen and towels were dirty and threadbare. There was a lack of cleanliness throughout the service and a malodour was present throughout the building. There were insufficient bathing facilities available for the number of people who lived at the service. Adequate checks were not carried out on pressure relieving mattresses to ensure that they were working and correctly set.

Staff training was not kept up to date and some staff had not completed training deemed essential for their role. Staff had used moving and handling equipment which they had not been trained to use.

Care staff had been supervised; however supervisors had failed to act upon concerns which staff raised during their supervisions. There was a lack of clinical supervision and oversight of the practices of the registered nurses. This meant that there was risks that people were supported by staff who did not have the skills and knowledge to carry out their roles effectively.

The complaints log could not be located and the deputy manager informed us that no complaints had been made about the service. This was despite family members informing us that they had raised a complaint. There was no evidence of these complaints and how they had been investigated or resolved.

People and their families were not provided with the opportunity to express their views about the service, for example, through meetings or discussions with the registered provider. Staff meetings had not been frequent or well attended.

There was a lack of sustained leadership in the service and staff found it difficult to adapt to ever changing systems, structures and record keeping. The registered provider's governance and auditing of the service had been weak and ineffective. They had been reliant on others and did not demonstrate personal accountability. There had been repeated lack of action where the registered provider had failed to improve or sustain identified areas of improvements.

There was no robust system of quality assurance in place which the registered provider could monitor the safety and welfare of people who used the service. The registered provider did not have a good understanding of the requirements set out in the Health and Social Care Act 2008 and their responsibility to this.

There had been a failure to operate the service in an open and transparent way or in accordance with the law. Significant events which adversely affected people's safety and welfare had not been reported to the CQC as required.

The overall rating for this service is ‘Inadequate’ and the service is therefore once again placed into ‘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

Is the Service Safe?

We found people were not protected from the risks associated with medicines because the provider did not have effective processes in place to make sure medicines were managed safely. We looked at records about medication and medication for 14 people who were living in the home on the day of our visit and we found there were some concerns about medicines or the records relating to medicines for all of those people.

We found medicines which were no longer needed were not stored securely. We found that appropriate arrangements were not in place in relation to the recording of medicines. We found that medicines were not administered safely. We found that arrangements made to give people their medication as directed by the manufacturers, especially with regard to food were poor. We found there was no information available to guide nurses as to how to give medicines which were prescribed to be given when required. We also found that there was no information recorded to guide nurses or staff as to where to apply creams.

We found appropriate arrangements had been made in relation to obtaining medication.

This is a summary of what we found.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLs) and the Mental Capacity Act 2005. We found one DoLs application was in the process of being submitted and proper policies and procedures were in place. We discussed this with the deputy manager who understood when an application should be made, and how to submit one.

The people we spoke with said they felt safe living at the home. Comments from them included; "I have no concerns. I feel very safe here" and "I feel as safe here as I did at home".

Is the service effective?

People told us they were happy with the care provided and their needs had been met. Our observations and discussions with staff showed they were knowledgeable about the people they supported and what people's care needs were. One person told us; "They are very good to me here. I have no complaints".

Is the service caring?

During our observations on the dementia unit in the morning, we saw staff helped people to make floral display's. In the afternoon, we saw staff sitting and talking with people who used the service. We observed that staff spoke to people in a caring and compassionate manner. When people became confused and upset, staff dealt with the situation calmly and were attentive to people's needs. We conducted a period of observation in the lounge area of the unit that provided nursing and personal care. We observed that staff spoke to people in a caring and compassionate manner. One person told us; "If I feel down, they help me and I feel better then".

Is the service responsive?

We saw that before a person started to use the service, an assessment of their needs and abilities was undertaken. The care plans showed how the needs of the people who used the service were to be met, including any risks to their well-being. Each person was allocated a key worker and reviews of each person's care took place on a monthly basis or sooner if required. People's personal preferences such as their daily and bedtime routines were also taken into account. This had been done with the involvement of the person where possible as well as their relatives.

Is the service well led?

A new manager had recently been appointed at the home. Staff and people who used the service spoke highly of him and said they were listened to when concerns or suggestions were made.

We saw the service carried out monthly audits of various aspects of the service's operations such as medication management, care planning, people's finances and the homes environment. Where concerns were identified, processes were in place to enable appropriate changes to be made.

Before our inspection we examined our records and found the service did not have a manager that was registered with us. The current manager had been in post for eight weeks prior to our inspection. The manager agreed to start the registration process without delay as his probationary period with the service had been completed. We discussed this with the provider before our inspection. They told us they would ensure the manager would start the registration process immediately so that the service was not in breach of the conditions of its registration with CQC.

We spoke with two relatives of people that used the service. Comments from them included: 'There is nothing bad to say about the care here. They talk to (my relative) about his time in the army. He responds to this which is key for him' and 'The staff are brilliant. I'm thrilled to bits.'

We found the home to be very clean throughout. All of the bathrooms we examined were in a good state of repair. In addition to this the carpets and flooring were in very good condition.

We looked at five staff files during our inspection. We found that Criminal Record Bureau(CRB) disclosure checks were completed for all members of staff. We found that before any member of staff began employment with the company they required two references.

We found there was an effective system in place to deal with complaints. It was evident there was a detailed audit trail of how concerns were managed and dealt with to the complainants satisfaction were possible.

Three of the care plans we looked at identified people who were at risk of falls. We found that regular safe and well being checks had been undertaken and recorded.

We did not speak with people who used the service during this visit as people we spoke with on our previous inspection were happy with the care they received and considered that they were well looked after. Relatives we spoke with at our last inspection said that their relation's health had improved since coming to live at Atherton Lodge.