Middleton Lodge

People’s experience of using this service and what we found

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support: Equipment to ensure people received safe and correct care was not always in place. People did now access the local community much more, but activities to develop life skills and to meet objectives were not always in place. Care records did not always reflect people's preferences. Following our inspection, we saw a new care plan the provider had developed that was much improved, this needs to be put in place for everyone and for support staff to be given access and training on the new electronic system. People were not always assisted with their medication in a safe and appropriate manner. We did see that staffing was much more consistent and there was not a reliance on agency usage that we saw on our last inspection.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, systems in the service did not always support this practice and some best interest decisions were overdue for review.

Right Care: Care records including risk assessments were incomplete meaning staff did not always have the correct information on how to deliver safe care. Care was not always person centred, care records did not reflect people's goals and outcomes. Staff training and supervision was not up to date, but we saw a plan going forward was in place to address this and staff said they felt supported. We observed people positively engaged with the staff team.

Right Culture: Since our last inspection, the service had 2 different managers. Staff told us they had felt very unsupported during this time and morale had been "terrible." Management of the service was not robust, with incomplete records or documents such as care plans and audits that were not effectively reviewed and updated. An acting manager had been in post for 2 months and was committed and fully aware of the issues that needed to be addressed. Staff told us they felt supported by the new acting manager and were positive that they would continue the improvements made from when they started employment. The home’s garden area had improved since our last inspection and was now more accessible and homely, ongoing redecoration and furniture replacement was in place.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 January 2023.) There were 6 breaches of regulations. At this inspection we found the provider was in continued breach of 3 regulations. The service is now inadequate.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

The inspection was also prompted in part due to concerns received about safeguarding issues, staffing and management of the service. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report. The provider has taken action to address immediate concerns.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Middleton Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to medicines management, equipment, care records, staff supervision and training, person centred care, service quality and overall management of the service at this inspection.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Middleton Lodge is a care home providing accommodation for people who require personal care and nursing care to up to 10 people, some of whom may be living with mental health issues and or a learning disability. At the time of our inspection there were 10 people using the service.

People’s experience of using this service and what we found

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. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right Support

Care plans were not always up to date or contained the most recent information to support people with their care and support needs or one case dietary needs. People who required support with managing their diet did not have up to date plans to support this and some people had food and fluid monitoring records in place without a supporting care plan.

The service did not support people to have the maximum possible choice, control and independence over their own lives. People were not always encouraged to plan for aspirations and goals.

The service did not give people care and support in a well-equipped, well-furnished and well-maintained environment. Parts of the home were not maintained, well laid out or accessible to people to enable them to maintain their independence or gain independent living skills. There was a lack of soft furnishings and decoration to make the environment homely.

Medicines had not been managed effectively. Incomplete medicine records were found and systems to monitor medicines had not always been in place. Staff competencies to administer medicines were reviewed. People’s preferences were followed with their medicines in a way that promoted their independence and achieved the best possible health outcome.

Right care

The service acted to protect people from poor care. The service reported concerns to the appropriate places. Staff had training on how to recognise and report abuse.

The service did not always have enough appropriately skilled staff to meet people’s needs. People were not supported by person centred practices; care plans did not contain personalised plans or outcomes for people with achievable goals.

People were encouraged to take positive risks and risk assessments were in place, but these were not always reviewed. Some restrictive practices were in place for people without the appropriate decision making in place and records regarding accidents and incidents had not been completed consistently and we could not be assured people were receiving appropriate care and support.

Right culture

People did not always lead inclusive and empowered lives because of the ethos, values, attitudes and behaviours of the management and staff. The quality assurance processes in place were not always effective and failed to identify and address shortfalls in a timely manner.

People did not always receive good quality care, support and treatment because staff were not all trained to meet their needs and wishes. Safe recruitment processes were followed; however, a high proportion of agency staff were used, and this did not always ensure person centred support took place.

We have made a recommendation regarding care planning and recording people’s food and fluids.

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

Rating at last inspection and update

The last rating for this service was good (published 11 December 2019)

Why we inspected

The inspection was prompted in part due to concerns received about the quality of care being provided to people. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

The provider acknowledged the shortfalls found during this inspection. They took some action following the first day of inspection to begin to address some of the shortfalls found regarding the environment.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Middleton Lodge on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to person-centred care, dignity and respect, medicine management, staffing, safe care and treatment, staff training, premises and provider oversight and monitoring at this inspection.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Visits to the service were taking place in line with national guidance. Visitors were required to test negative for COVID-19 and were screened appropriately with temperature checks and health declarations.

The service had ample supplies of PPE and all staff were observed to be wearing this appropriately. Used PPE was disposed of safely.

People and staff were regularly tested as part of the COVID-19 testing programme.

The service was clean and tidy throughout. A cleaning schedule was in place which included additional cleaning of frequently touched areas such as door handles.

The provider had robust policies and procedures in place to manage infection prevention and control.

Risk assessments were in place to support people and staff who were particularly vulnerable from COVID-19.

Management spoke positively about the hard work of the staff team, and the helpful support offered from the provider throughout the pandemic.

Middleton Lodge accommodates 10 people in one adapted bungalow. The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.” Registering the Right Support CQC policy.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Staff knew how to keep people safe and reduce the risks of harm from occurring. Staff had completed training in safeguarding and understood their responsibilities to report any concerns.

Robust recruitment and selection procedures ensured suitable staff were employed. Risk assessments relating to people's individual care needs and the environment were reviewed regularly. Medicines were managed safely and administered by staff trained for this role.

Staff received appropriate training and support to meet people’s individual needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to have enough to eat and drink and had access to healthcare professionals as and when this was needed.

People were supported by kind and respectful staff who valued people’s individuality and independence. We observed positive interactions between people and staff. People could make choices about how they wanted to be supported and staff treated them with dignity and respect. There was a welcoming and homely atmosphere at the service.

People received support which was person-centred and responsive to their needs. Person-centred is when people’s preferences are respected. Personalised care plans were in place which helped staff to know how people wished to be supported with daily living. People were involved in developing and reviewing their care plans and decisions about their care.

People were supported to take part in valued individualised activities including looking after the home’s pet rabbits to engage people and prevent social isolation.

People spoke positively about the registered manager and the wider management team. There was an effective quality assurance system in place to ensure the quality of the service and drive improvement.

There were systems in place for communicating with staff, people who used the service and their relatives to ensure they were fully informed via team meetings and newsletters.

Further information is in the detailed findings below.

Middleton Lodge is a residential home based in Middleton St George on the outskirts of Darlington. The home provides personal care for people with learning disabilities who also experience mental ill health. It is situated close to the local amenities and transport links. The service is registered to provide support to 10 people and on the day of our inspection there were 10 people using the service.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

We last inspected the service in April 2016 and rated the service as ‘Requires improvement.’ At this inspection we found the service was ‘Good’ overall and met all the fundamental standards we inspected against.

The atmosphere of the home was homely, warm and welcoming. People who used the service were relaxed in their home environment and visitors were welcomed.

People were supported on a daily basis in a person centred and caring way. Person centred is when the person is central to their support and their preferences are respected.

Visiting professionals offered praise of the service and how improvements had been made.

We spent time observing the support that took place in the service. We saw that people were always respected by staff and treated with kindness. We saw staff being considerate and communicating with people well.

People were supported to ensure they maintained their independence with one to one support.

Support plans were developed with people and not for people and these set out exactly how people liked to be supported.

People were encouraged to enhance their wellbeing on a daily basis by taking part in activities of their choice both at home and within the local community.

Staff told us they felt supported to carry out their role and to develop further and that the registered manager led by example, was supportive and always approachable.

Throughout the inspection we saw that people who used the service and staff were very comfortable, relaxed and had an extremely positive rapport with the registered manager and also with each other.

People’s support plans were written in plain English. They included personal history and described individual’s support needs. These were regularly reviewed; and people were at the centre of the process.

Support plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm.

People’s health was monitored and referrals were made to other health support professionals where necessary, for example: their GP, community nurse or optician.

People were supported by sufficient numbers of staff to meet their individual needs and wishes in a person centred way.

People were supported by trained staff. Who were supported to maintain and develop their skills through training, and development opportunities.

We viewed records that showed us there were robust recruitment processes in place.

Medicines were stored, managed and administered safely. We looked at how records were kept and spoke with the registered manager about how senior staff were trained to administer medicines and how this was monitored.

We saw people were encouraged to eat and drink sufficient amounts to meet their needs. People were involved in planning the menus and choosing what they would like to eat and were involved in shopping and preparing food.

A complaints and compliments procedure was in place. This provided information on the action to take if someone wished to make a complaint and what they should expect to happen next. The compliments that we looked at were complimentary to the support staff, management and the service as a whole.

People had their rights respected and access to advocacy services if needed.

People were supported to play an active role within their local community by making regular use of local resources.

People were supported to be active in their chosen religion.

The service had been regularly reviewed through a range of internal and external audits. We saw that action had been taken to improve the service or put right any issues found. We found people who used the service and their representatives were regularly asked for their views about the support and service they received at meetings and via surveys.

Middleton Lodge is a residential care home based in Middleton St George on the outskirts of Darlington, County Durham. The home provides care for people with learning disabilities, physical disabilities and Autism. The home is situated close to local amenities and transport links. The home is registered to provide accommodation and personal care for ten people and on the day of our inspection there were six people using the service.

The provider had recently appointed a new manager who at the time of our inspection wasn’t yet registered. 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.

We spoke with a range of different team members; the chief operations manager, the regional director, the manager and care staff who told us they felt positive about the new manager and supported by them. Throughout the day we saw that people who used the service and staff were comfortable, relaxed and had a positive rapport with the manager and with each other. The atmosphere was welcoming. We saw that staff interacted with each other and the people who used the service in a friendly, caring, positive manner.

We observed how the service administered medicines and how they did this. We looked at how records were kept and spoke with the management team about how staff were trained to administer medication and we found that numerous medication errors had been made and administering process was being improved and audited to reduce errors occurring.

We looked at how the service looked after people’s monies and how they were kept safe. We found that the financial audits were not highlighting issues and we brought this to the attention of the manager.

From looking at people’s care plans we saw they were written in plain English and in a person centred way. A ‘person-centred’ approach focuses on the individual's personal needs, wants, desires and goals so that they become central to the care and support process. The care plans made good use of personal history and described individuals care, treatment, wellbeing and support needs. These were regularly reviewed by staff and updated by the manager.

Individual care plans contained risk assessments. These identified risks and described the measures and interventions to be taken to ensure people were protected from the risk of harm. The care plans we viewed also showed us that people’s health was monitored and referrals were made to other health care professionals where necessary for example: their GP, mental health team and care manager.

Although on the day of our inspection people who used the service were supported by sufficient numbers of staff to meet their care needs. However we could see from the previous staffing rotas that there had been recent issues where people who used the service were not supported by enough staff.

When we looked at the staff training records they showed us staff were supported and able to maintain and develop their skills through training and development opportunities. We found that some training was due to expire and staff would need to attend refresher training imminently.

When we looked at supervision and appraisal records we saw that these had not been carried out regularly. Care staff we spoke with told us they had recently started to get regular supervisions and appraisals with the manager, where they had the opportunity to discuss their care practice and identify further mandatory and vocational training needs.

We also viewed staff recruitment records that showed us there were robust recruitment processes and checks on new staff in place to make sure they were suitable to work with vulnerable people.

During the inspection we witnessed the staff rapport with the people who used the service and the positive interactions that took place. The staff were caring and attentive when communicating and supporting people.

People were encouraged to participate in activities but these were not always planned in advance to reflect people’s preferences. We saw staff spending their time positively engaging with people on a one to one basis. We saw evidence that people were being supported to go out but this was not always consistent.

We saw people were encouraged to eat and drink sufficient amounts to meet their needs. We saw people enjoying their meals. However the daily menu that we saw offered choices but these had not been devised with the people who used the service to incorporate their likes and preferences.

We saw a complaints and compliments procedure that was in place and this provided information on the action to take if someone wished to make a complaint and what they should expect to happen next. We saw evidence of complaints made and how these were taken up and they were recorded appropriately.

We found a quality assurance survey had taken place previously and we looked at the results. Relatives told us that they had been asked to take part in the surveys. The service had been regularly reviewed through an internal and external audits and there were actions identified that were on going to make improvements to the service.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. We found the service was working within the principles of the MCA.

During the inspection we found breaches of the Health and Social Care Act 2008and Regulations. You can see what action we told the provider to take at the back of the full version of the report.

The service had a new manager in post. At the time of the inspection they were going through the registration process. The management of the home was good and we saw strong leadership in place and a positive environment for people and staff. Staff spoke highly of their manager and the support which they received.

We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Peoples care plans were person centred and provided information on what people liked/disliked, how people liked to be woken up of a morning and how staff should behave around them. Middleton Lodge uses a system called Caresys, where they update people's care plans on a monthly basis, log daily notes and any accidents and incidents.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care home. While no applications had needed to be submitted the home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards and there was evidence to show that this had been followed appropriately. Staff had received training in relation to these topics along with the safeguarding of vulnerable adults and had an understanding of the actions to take. This meant that people were safeguarded as required.

Middleton Lodge was clean and tidy; although the provider may wish to note that the communal bathroom boxed in area was bare wood, majority of carpets needed replacing or required a deep clean and the settee in the main lounge had a tear.

Is it caring?

The majority of people who lived at Middleton Lodge could not communicate verbally; there was information in the care plan about 'how I communicate.' Middleton Lodge had also devised a small communication booklet for one person who used the service. This was so that the person and the staff could communicate effectively. The manager stated that they are planning to do this for all people who could not communicate verbally.

Peoples care plans provided information on their medical and personal life history. The care plans detailed 'what I can do for myself,' 'what support I need' and 'how the home will meet my needs in this area.' Care plans were individualised and included people's preferences, interests, aspirations and diverse needs.

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People, who could communicate verbally, told us that they were happy with the care and support provided to them.

People who used the service were supplied with an easy read 'service user guide', Depravation of Liberties information and how to make a complaint.

Is the service effective?

Everyone had their needs assessed and had individual care records which set out their care needs. It was clear from our observations and from speaking with staff that they had a good understanding of the care and support needs of people living at the home and that they knew them well. Assessments included money management and behaviour that challenges.

People spoke highly of the staff and said that they were happy with the care that had been delivered and their needs had been met.

Is the service responsive?

There was clear evidence contained within people's care plans to show how they worked with other health and social care professionals. People told us that they knew how to make a complaint if they needed to. The home was responsive to people's needs, wishes and preferences.

One person who used the service had a 'coming home plan' for when they returned from a day centre. Every member of staff we spoke with, were aware of this plan and the reasons behind it.

People using the service and the staff, completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed with an action plan. The staff survey mentioned the need for a sensory room and money they received from a 'staff excellence' award had been used to purchase items for this.

Is the service well led?

We did see a cleaning schedule, but more robust audits needed to be in place to make sure this schedule was adhered to and was working. The manager told us that they have just employed a cleaner and were waiting the return of The Disclosure and Barring Service (DBS).

The service had records of quality assurance systems in place. Therefore the manager was protecting the people who used the service and others against the risks of inappropriate or unsafe care and treatment.

What people said:

People who used the service were very happy with the care they received. One person we spoke with said, "Everything is good about living here.' And 'I am going into town for lunch.' Also 'They (the staff) took me to see my mum.'

Staff we spoke with said 'I love working here, we are like one family,' and 'I get good job satisfaction,' 'I get loads of support,' and 'I get on with them all, I am very calming when people show behaviours that challenge.'

There were systems in place for checking the safety and quality of the service. We saw that people living at the home were involved as far as possible in the planning and cooking of meals and people's nutritional needs were monitored.

Care plans were written from the point of view of the person and peoples care and support were reviewed with them monthly by their keyworker.

There were enough staff on duty to meet the needs of the service and staff members on duty displayed a caring and supportive approach to people at the service.

We spoke to one person who told us that they liked living at the home and they were 'really happy'. They told us all about a visit that was planned to the local pantomime. They also told us how they go out in the home's minibus to the shops and also to the beach. They told us that the staff looked after them and kept them safe.

We contacted two relatives by telephone. One relative said that the care was 'brilliant' at Middleton Lodge. There had been problems in the past which had been addressed and they were 'quite happy'. They said their relative called it home and if anything was needed they just had to ask. They also said that their relative had been on holiday abroad several times with their carers.

Another relative we spoke to said they were 'happy' with the care at the home and that everything was 'fine'. Staff listened to them and their relative went horse riding which they loved.