Appleby Lodge

We found the following examples of good practice.

The building was clean, and there were appropriate procedures to ensure any infection control risks were minimised. All communal areas had safe distancing seating arrangements.

Clear signage was displayed around the service on what PPE was required to protect people and if any person living in the service was at higher risk.

The registered manager was communicating with people, staff and family members regularly to make sure everyone had an understanding of procedures and precautions being taken, and how to keep people safe. The registered manager worked with the care staff team to ensure infection prevention and control measures were followed. This included introducing an in-house ‘Track and Trace’ system to monitor which staff member had been working with a person living in service. Therefore, if a positive test was confirmed the registered manager could deal with the situation promptly.

Cleaning and infection control policies and procedures had been updated in line with Covid-19 guidance to help protect people, visitors and staff from the risk of infection. The registered manager kept up to date with appropriate training in infection control. The registered manager arranged training for staff to ensure they knew how to keep people safe during the COVID-19 pandemic and outbreak in the service.

The registered manager ensured people living in the service, and staff, had access to additional support, including one-to-one meetings and contact by phone, to offer any emotional support needed.

During the summer months some families had met with their relatives in the garden and new arrangements were in place for families to meet in a safe area of the home during the winter months. Staff helped people to stay in touch with family and friends through phone and video calls.

The staff were following up to date infection prevention and control guidance to help people to stay safe. The registered manager ensured staff and people who used the service understood why every measure was in place.

People at high risk and those wishing to remain in their own rooms were supported by staff to occupy themselves. Staff provided activities whilst maintaining people’s safety. Some people living with dementia found it difficult to understand the safe distancing rule. However, staff were quick to intervene if people got too close and diverted them elsewhere, without causing distress to either party.

Further information is in the detailed findings below.

People’s experience of using this service:

People and staff told us the service was well managed. People said they were treated with kindness and compassion and felt respected. Staff showed a true fondness for the people they cared for and there was a warm, friendly and welcoming atmosphere. People’s wellbeing was promoted.

There were positive working relationships with external professionals and a passion for continuous learning and improvement.

People were kept safe and protected from avoidable harm and abuse, and people now had their medicines safely managed. New processes had been put into place to ensure a more robust oversight. People now lived in an environment which was fully assessed for safety.

People received personalised care and support, and had their human rights protected. Staff were competent in their roles and were well supported. Quality monitoring systems had been further developed. However, we have recommended the provider takes action to continue to strengthen their overall governance systems, because the system had not identified that some records were not always in place, or up to date.

More information is in Detailed Findings below.

Rating at last inspection: Requires Improvement (published 21 March 2018).

Why we inspected: This was a planned inspection. At this inspection we rated the service Good.

Follow up: Going forward we will continue to monitor this service and plan to inspect in line with our reinspection schedule for those services rated Good.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

We told the provider to make improvements to ensure people’s medicines were managed safely, that the environment was checked to ensure it kept people safe, and risks associated with people’s care were recorded. We also told the provider to ensure staff had the necessary training to be able to safely and effectively support people, that people’s human rights were protected in line with the Mental Capacity Act (MCA) 2005, and that people’s care records showed their involvement in decisions relating to their care. As well as being kept up to date and in line with their wishes and preferences. Action was also required to ensure people had enough to stimulate their social and cognitive needs, and that people’s privacy and dignity was respected, particularly at the end of their life. In addition, we requested the overall management, leadership and culture of the service should be improved and asked the provider to implement an effective monitoring process, to help capture people’s views and identify when improvements were required.

Immediately after our inspection, the provider told us they would stop new admissions to the service, in order for them to put things right. We also contacted the local authority safeguarding team who took prompt action to ensure people's health, safety and wellbeing.

The Commission considered its enforcement policy, and took enforcement action, which was to impose a condition on the provider's registration. This meant on a monthly basis, the provider was requested to carry out an audit of people’s care plans and risk assessments, the management of people’s medicines, and equipment and environmental maintenance. Submit a summary of their findings to the Commission, and demonstrate what action was being taken to improve the service and to meet regulation. Since October 2017 the Commission had been receiving and reviewing the provider's monthly returns, which had demonstrated ongoing improvement at the service. However, during our most recent inspection although we found some improvements had been made, our findings relating to people’s care plans, risk assessments and medicines management showed the information which had been provided had not always been fully accurate. This demonstrated the providers auditing systems had not always identified where improvements were required and continued to require adapting.

During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures, but further improvements are still required. The Commission also made a decision to remove the providers imposed condition of registration.

We carried out an unannounced comprehensive inspection on 29 January 2018 and 08 February 2018.

Appleby 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 provides accommodation for up to 18 older people who require personal care. The provider also operates a day centre offering meals and companionship to local people. The service is on one level. There are shared bathrooms, shower facilities and toilets as well as a lounge and dining area. There were 15 people living at the home at the time of our inspection and one person using day care facilities.

Since our last inspection the manager had now registered with the Commission and was now the registered manager of the service. 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.

Overall, people’s medicines were now managed safely. However, people who required medicines at particular times did not always have care plans in place for staff to follow, to help ensure they received these in line with prescribing guidelines. People, who had pain relief patches applied to their body, did not have records in place to detail where they had been applied. Meaning, people may not always receive consistent medicine support. The registered manager and provider had introduced a new audit to help highlight where improvements were required. Whilst the use of this audited had seen a positive impact in driving improvement, it had failed to identify where some improvements were required.

Overall, people now lived in an environment which was assessed to ensure it was safe. Fire checks were being carried out as required. However, some risks had not been assessed to ensure people’s safety, for example hot water in two bathrooms and in one person’s bedroom was found to be very hot.

People's accident and incidents were recorded which helped to provide a good overview of when a person had experienced unavoidable harm, so themes could be identified to help minimise it from occurring again. However, when a theme had been identified people’s care records were not always updated. This meant the person may not receive consistent care because the information had not been recorded for staff to read.

People told us they felt safe living at the service. People were protected from abuse because the provider’s processes and procedures kept people safe. People were supported by suitable numbers of staff to ensure their needs were met. People’s call bells were answered promptly and the provider had created a new staffing dependency tool which would help to assist with ensuring there were, enough staff to be able to meet people’s needs safely.

People lived in a clean and odour free environment. Staff received infection control training and implemented their knowledge and training. Whilst, laundry was handled in the correct manner the laundry area was found to be cluttered with flooring which could not be washed easily.

People now received care from staff who had undertaken training to help meet their individual

needs. Overall, people’s human rights were protected, but when someone did not have the mental capacity to make certain decisions, such as in respect of their care this was not always detailed within their care plan to enable the person to be supported effectively. People's consent to care was now obtained and was documented in care plans and people were asked for their permission prior to being supported.

People’s individual communication needs were known by staff and staff knew people well. However, the recording of this information was not always detailed in people’s care plans to help ensure a consistent approach.

Overall people were pleased with the food. The chef told us there was always flexibility and people could have what they wanted. People’s like and dislikes were now recorded, and the menu had been re-created by taking account of people’s preferences. People were supported with their nutrition, and now had care plans in place to help guide staff to deliver the correct support. People were supported to live an active life, but many chose not to.

People received a co-ordinated approach to their care. Health and social care needs were assessed on an ongoing basis, to help ensure their care and support needs were being met in line with best practice. The GP who visited the service was complimentary of the care provided.

People lived in a service which was adapted to meet their needs. The provider had recently replaced the dining room chairs so they were easier for people and staff to move, whilst they were seated.

People's privacy and dignity was now respected. Staff spoken fondly of the people they supported and used sensitive and appropriate language to describe people’s care needs. People and their families, told us staff were kind and caring. People told us they were now satisfied with the laundry service.

People’s individual equality and diversity needs were known, and respected. People’s care plans now demonstrated how people were being actively involved in making decisions about their own care and support.

People now had care plans in place to help provide guidance and direction to staff about how to meet their needs. Care plans were reviewed when changes occurred in people’s care and/or on a monthly basis.

Overall, people would be supported respectfully at the end of their life, because staff had received training in palliative care. However, people’s end of life care plans were not individualised to help ensure staff knew what people may specifically wanted.

The registered manager helped to reduce people’s social isolation by consulting with people about what they wanted to do. People’s comments and complaints were respectfully listened to, and used to help improve the service. The provider’s complaints policy may not have been in a suitable format for everyone to understand.

The provider now had more of an active role and was visible within the service. The registered manager told us they received good support, and that the provider was at the service on a day to day basis, speaking with people and staff to ensure they were satisfied with the service.

People lived in a service whereby the registered manager and provider were continually learning which helped to adapt and improve the service. The registered manager and provider kept their professional knowledge up to date. They also told us they kept up to date with regulatory changes by

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.

We carried out a previous comprehensive inspection on 09 September 2015 and 11 September 2015 and the service was rated Good.

We have since carried out an announced comprehensive inspection on 12 June 2017 and 15 June 2017. Prior to our inspection the Commission had received concerns regarding the leadership of the service, the recruitment of staff, staffing levels and the management of people’s medicines. During our inspection we looked into the concerns which had been raised.

Appleby Lodge provides accommodation for up to 18 older people who require personal care. The provider also operates a day centre offering meals and companionship to local people. The service is on one level. There are shared bathrooms, shower facilities and toilets as well as a lounge and dining area. There were 15 people living at the home at the time of our inspection and two people using day care facilities.

People told us they received their medicines when required, however people’s medicines were not always managed and stored safely.

People lived in an environment which had not been assessed to ensure it was safe. Weekly fire tests were not always carried in line with the provider’s policy. People had personal emergency evacuation plans in place (PEEPs), however these had not been updated to reflect people’s changing care needs. PEEPs help to give a summary of people's individual needs for the emergency services in an event such as a fire. Following our inspection, because of concerns identified, we contacted the fire authority.

People were not always protected from risks associated with their care. People did not always have risk assessments and care plans in place relating to their individual care needs, and when these were in place, they were not reflective of people’s current care needs. This meant staff did not have the most up to date recorded information to enable them to know how to support people safely. However, whilst information was not documented, staff did know people well and communicated with each other about how to meet people’s needs at staff handovers and through-out the day.

People told us they felt safe living at Appleby Lodge. People were supported by sufficient numbers of staff to meet their needs. People’s needs were taken into consideration in determining staffing levels. People’s call bells were answered promptly. Recruitment checks were carried out to ensure staff working with vulnerable people, were suitable. However, gaps in an employee’s previous employment were not always scrutinised.

People did not always receive care from staff who had undertaken training to be able to meet their individual needs. For example, skin care, dementia, end of life and moving and handing. We were also unable to determine what training staff had undertaken because training certificates did not match the providers overall training records.

People’s human rights were not protected. When someone did not have the mental capacity to make certain decisions, this was not always detailed within their care plan to enable the person to be supported effectively. People’s consent to care was obtained, however this was not always documented.

People told us they liked the meals and people were supported to eat and drink when necessary, however people’s care records were not always reflective of the care and support they required. This meant staff did not always have up to date information about the best way to support people in order to meet their individual needs.

People’s likes and dislikes were not recorded to help ensure people received meals which met with their preferences. However, staff told us they knew people well and that people were able to tell them what they liked and did not like. People were not always offered a choice for their main meal and the menu had not been created by involving people/and or their relatives. The manager told us they had already recognised improvements were needed, and action had been taken to appoint a new member of catering staff who had been tasked with making the necessary changes.

People and/or their loved ones were involved in making decisions about their care and support. However, this was not always recorded so the manager was taking action to rectify this, by speaking with staff, people and/or their families. People had access to external health and social care professionals. People’s records showed GP’s, community nurses and specialists had been involved in their care.

People’s privacy and dignity was not always promoted. People’s bedroom doors were left open but it was not detailed in their care plans if this was their choice. People’s care needs were not always discussed respectfully by staff. People told us they regularly received the wrong clothing back from the laundry.

People who were being cared for at the end of their life were not being cared for in an environment which took into consideration their dignity, privacy and respect. People being cared for at the end of their life, were not always cared for by staff who had undertaken training. People did not always have end of life care plans in place to ensure staff were aware of their wishes.

People and their families, told us staff were kind and caring. Some people told us there was not always enough to do, to keep them occupied. The manager told us they had already recognised social activities were not always suitable and plans were in place to gather people’s views and to make changes. People’s cultural and spiritual needs were being met by religious events, and Holy Communion was held at the service on regular occasions.

People told us they would feel confident about raising concerns. People’s complaints were used to improve the service.

People were not protected by the provider’s systems and processes to help ensure the quality of their service was monitored. As a consequence of this, the provider had failed to recognise the service had been deteriorating.

Since our last inspection there was a new manager in post. At the time of our inspection the manager had been in post for two weeks and was already working hard to make changes.

The provider did not have robust governance system in place to help capture people’s views and drive continuous improvement.

People were not protected by the provider’s policies and procedures. The provider’s policies were out of date and did not always reference changes in new legislation.

The provider and manager demonstrated an open and transparent approach throughout our inspection, for example showing us what they had identified themselves as already requiring improving. This demonstrated their understanding and recognition of the Duty of Candour. The Duty of Candour means that a service must act in an open and transparent way in relation to care and treatment provided when things go wrong. The provider had displayed their latest rating in line with legislation.

As a result of our inspection the provider told us they would voluntarily stop any new admissions to the service to give them time to make the necessary improvements.

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.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Five people all told us how happy they were living at the home and that they felt very well cared for by the staff of Appleby Lodge. They told us, 'I am looked after far too well, I have not a care in the world' and ' The things that are important to me are all done by the staff ".

There was a low staff turnover and this meant staff knew people's needs well.

Further monitoring of medicines practice was needed to ensure all areas are safe.

The acting manager undertook some recruitment checks for new staff. Further checks were needed to be undertaken and recorded to ensure that people continued to be cared for safely.

The care provided, environment, care planning and medication were all monitored by the acting manager to maintain the quality of the service though this had not covered all aspects of safety in the service. They demonstrated that they were responsive to people's views and were developing social activities.

Records relating to people's care were personal to ensure that people's choices and preferences would be met by staff.

We talked with nine people who lived at the home. Comments from people who lived at the care home included,

'This is a wonderful home, you really can't fault it in any way and I am a very fussy person ', 'They help me get up when I am ready and I can go back to bed when I want to ', ' when you ring the call bell, they soon come', 'This is the best home around here' and 'The food here is excellent'.

We pathway tracked four people who use the service. Pathway tracking means we looked in detail at the care four people received. We spoke to staff about the care given, looked at records related to them, met with them and observed staff working with them.

All of the people we spoke with said that they felt safe and would feel able to complain if they needed to.

We saw that the home had a comfortable homely feel and that the home was clean and had no offensive odours.

We looked at the systems in place to check the quality of the service. We found that auditing systems had been put in place and efforts had been made by the management to monitor the service and address any problem they found. By doing this, they could develop and improve the service they were providing.