Harbledown Lodge

Harbledown Lodge is a residential care home providing personal and nursing care to up to 56 people. The service provides support to older people who may be living with dementia in a large, adapted building. At the time of our inspection there were 40 people using the service.

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

People told us they felt safe living at the service. However, potential risks to people’s health and safety had not always been assessed. There was guidance for staff to mitigate risks, but this was not always consistent. Staff had not maintained accurate records about people’s care and support. There was a risk people had not received the care required to maintain their safety.

Medicines had not always been managed safely. People had not always been protected from the risk of infection; some areas of the service had not been maintained to reduce this risk. Checks and audits had been completed on the quality of the service, but these had not identified the shortfalls found at this inspection.

Staff were recruited safely and there were enough staff to support people and meet their needs. People and staff had been asked their opinion of the service and suggestions they may have. There were effective systems in place to protect people from abuse and discrimination.

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; the policies and systems in the service supported this practice.

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

Rating at last inspection

The last rating for this service was good (published 2 October 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

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

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

Enforcement

We have identified breaches in relation to record keeping and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Harbledown Lodge is a residential care home providing personal and nursing care to 56 older people. At the time of the inspection there were 46 people using the service, some of whom were living with dementia and conditions such as diabetes and epilepsy or with impaired mobility or more complex nursing needs. The home accommodates people over three floors all of which can be accessed by a lift.

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

People told us they felt safe and happy living at the service. Potential risks to people’s health, welfare and safety had been assessed. There was guidance in place to mitigate risks and accurate records about people’s care and treatment had been maintained.

Accidents and incidents were recorded and analysed. Action had been taken to reduce the risk of them happening again. The registered manager and staff understood their responsibilities to keep people safe from discrimination and abuse.

People’s medicines were managed safely. Staff monitored people’s health and referred people to relevant healthcare professionals and followed their guidance to keep people as healthy as possible.

People were supported by staff who had been recruited safely and received training appropriate to their role. Staff received supervision and appraisal to continue to develop their knowledge and skills.

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; the policies and systems in the service supported this practice.

People met with the registered manager before moving to the service to check that staff were able to meet their needs. Each person had a care plan that contained details about their choices and preferences. These plans had been reviewed regularly and updated when needed.

People were supported to eat a balanced diet and had a choice of meals. People’s preferences and dietary needs were catered for. People had access to activities that they enjoyed.

People were treated with dignity and respect. They were supported to be as independent as possible and express their views about their care and support. People’s end of life wishes were recorded where known. Staff worked with GPs and specialist nurses to support people at the end of their life.

The registered manager completed checks and audits on the quality of the service and acted when shortfalls were found. There was an open and transparent culture within the service, people were asked their views about the service and these were acted on.

Relatives told us they knew how to complain. The registered manager recorded all concerns raised and had investigated them according to the providers policy. People received information in formats they could understand.

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 28 August 2018) and there was a breach of one regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Harbledown 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 service is part of the Nicholas James Care Homes Group and is registered under Uniquehelp Limited. It is a registered nursing home for 56 older people. There were 42 people using the service during our inspection; some of whom were living with dementia and conditions such as diabetes or impaired mobility or with more complex nursing needs. It provides adapted accessible accommodation over three floors.

We last inspected Harbledown Lodge on 18, 19 and 20 April 2017. We rated the service as requires improvement in two key domains safe and well led. The breaches were in respect of the assessment and review of risk to people using the service and safe use of equipment and premises, maintenance of accurate records, and the development and use of effective quality assurance systems.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the service. We carried out this inspection as part of our programme of scheduled inspections; we checked that they had implemented the action plan. At this inspection we found that whilst improvements had been made to meet previous breaches in regard to management of risk; there was insufficient progress to meet outstanding breaches in respect of record keeping and effective audit processes. We have rated the service as Requires Improvement overall, this is the third consecutive time the service has been rated Requires Improvement.

At this inspection we found that inconsistencies remained in the completion of records of food and fluid intake for those nutritionally at risk, and also in repositioning records of those assessed as at risk of pressure ulcers. This information was important to enable monitoring that people were receiving the assessed level of care and support they required. Quality assurance checks to monitor records were undertaken but not completed robustly. A few people experienced distress that presented as behaviour that could be challenging, measures to reduce risk around this were in place but had not been recorded in risk information to ensure all measures had been implemented to safeguard people; we have made a recommendation around this.

There was a new registered manager in post, who is proactive, and shows enthusiasm and commitment to develop the service and given time address many of the previous shortfalls. We have taken this into consideration in our response to this continued rating of requires improvement.

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.

People, relative’s and staff said they found the new registered manager approachable; she was a visible presence in the service. Some health and social care professionals thought the service was improving. Staff told us that they felt well supported, they were provided with appropriate induction and training to give them the skills and knowledge needed for their role, they had opportunities to express their views. The registered manager used a dependency tool to help determine how many staff were needed; this was kept under review. People, staff and relatives told us there was enough staff.

People were supported with their religious beliefs. Staff demonstrated values of kindness compassion and commitment in their day to day practice. They were respectful of people’s privacy and dignity. They were not familiar with the providers stated values and lacked understanding of their responsibilities around Duty of Candour. These are areas for improvement. Staff however, understood how to recognise and respond to abuse of service users and to escalate their concerns if they needed to. People and their relatives felt confident to express their views and concerns. People and their relatives were invited to meetings and sent surveys to ask for their feedback, these were analysed and people were kept informed of the outcomes from survey results.

Medicines were safely managed. Staff understood how to protect people from harm and abuse and knew how to escalate concerns. People’s consent was sought by staff in delivery of their daily care. Staff understood and supported people in accordance with the principles of the Mental Capacity Act 2005.

People were offered choice around the food they ate, and their preferences and specific dietary needs were taken into consideration to ensure their nutritional needs were met. People’s health needs were supported and referrals to health professionals were made on their behalf as and when needed. End of life care needs were managed appropriately so that people remained comfortable and their wishes were adhered to.

People had individualised care plans that reflected their needs and how they wished these to be supported. People and relatives were involved and consulted about care plan content and review.

Staff encouraged people to be involved and feel included in their environment. People were offered varied activities and participated in social activities of their choice. Staff knew people and their support needs well.

The premises were clean and well maintained, servicing of equipment was undertaken at regular intervals to protect peoples safety. The premises were accessible; it had been adapted to meet the physical care needs of people with mobility issues. Equipment to help mobilise people was available and serviced regularly. Fire systems were serviced and staff attended fire drills several times each year so that they knew how to evacuate the premises. Contingency plans were in place to inform staff how to manage emergency events and staff was provided with out of hours on call support from senior managers. Accident and incidents were recorded appropriately and actions taken to minimise recurrence.

We have made one recommendation in regard to behavioural risk assessments.

We have made a recommendation about accessible information.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Harbledown Lodge is registered to provide personal care and accommodation for up to 56 older people. There were 42 people using the service during our inspection; some of whom were living with dementia and conditions such as diabetes or impaired mobility.

Accommodation is set over three floors and upstairs bedrooms can be accessed by a passenger lift. There is a communal lounge, activities room, dining room and quiet room on the first floor and a lounge on the second floor. The home has extensive grounds and a part of the garden is accessible and secure, with a seating area. An onsite activity centre and hydrotherapy pool facility was being refurbished and nearing completion.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Registered persons have a legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People and relatives gave mainly positive feedback about the service. We found some aspects that were not safe and required improvement to address them.

Some risks to people had not been properly reduced. The risk of falls was not always proactively managed and incidents and accidents were not always managed appropriately to avoid recurrences. Some pressure relieving air flow mattresses were not on the correct settings to provide people with appropriate relief from pressure on their skin. Statutory safety certificates were not present for all equipment used at the service and oxygen cylinders were not safely stored.

Records of people’s care and treatment were not always up to date or meaningfully completed and, although audits were regularly undertaken, they did not always identify shortfalls they were intended to.

A survey of people living in the service found they felt safe. Assessments had been made about environmental risks to people and actions had been taken to minimise them. Staff knew how to recognise signs of abuse and how to report it.

There were enough staff on duty to support people, and proper pre-employment checks had taken place to ensure that staff were suitable for their roles.

Staff had received training in a wide range of topics and this had been regularly refreshed. Supervisions and appraisals had taken place to make sure staff were performing to the required standard and to identify developmental needs.

People’s rights had been protected by assessments made under the Mental Capacity Act (MCA). Staff understood about restrictions and applications had been made to deprive people of their liberty when this was deemed necessary.

Healthcare needs had been assessed and addressed. People had regular appointments with GPs, health and social care specialists, opticians, dentists, chiropodists and podiatrists to help them maintain their health and well-being. Medicines were well managed and people received them when needed.

Staff treated people with kindness and respect. Staff knew people well and remembered the things that were important to them so that they received person-centred care.

People had been involved in their care planning and care plans recorded the ways in which they liked their support to be given. Bedrooms were personalised and people’s preferences were respected. Independence was encouraged so that people were able to help themselves as much as possible.

Staff felt that there was a culture or openness and honesty in the service and said that they enjoyed working there. This created a comfortable and relaxed environment for people to live in.

Systems were in place to encourage feedback from people, relatives and staff and were subject to continuous review.

People’s safety had been protected through cleanliness and robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had been serviced regularly.

People enjoyed their meals; any risks of malnutrition had been adequately addressed. There were a range of activities.

The registered manager was widely praised by people, relatives and staff for their commitment to improving the service. There was an open, transparent culture amongst staff and management.

People knew how to complain if they needed to; most complaints were addressed in line with the services’ policy.

We found a number of breaches of Regulation. You can see what action we told the provider to take at the back of the full version of the report.

We have also made the following recommendations:

We have made a recommendation about the frequency of review for high risk skin care concerns and the review of the continuing clinical need for catheters following admission from hospital.

We have made a recommendation about practice and facilities to ensure dignity and privacy is promoted at all times.

We have made a recommendation about handling of verbal concerns.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

This helped us answer our five questions:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Most people told us that people were always treated with dignity and respect by the staff. However, we saw some examples which showed that this was not consistent throughout the staff team. One example was a member of staff who placed grapes in two people's mouths, without asking if they wanted any or giving them the opportunity of taking their own fruit.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to treating people living with dementia with dignity and respect at all times.

Visitors said that they felt that their relatives were safe living at the home. Safeguarding procedures were in place and staff understood how to safeguard the people they supported.

Staff received regular training to ensure that they had the necessary skills and experience needed to support the people living in the home.

There were safe systems in place for the receiving, administration and disposal of medicines. However, the storage of medicines was not safe.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to the storage of medicines.

The Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The home had proper procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager had submitted one application and told us that they would be submitting more applications to safeguard the people who lived in the home in the near future. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

Most people that we spoke to told us that they were happy with the care that was delivered and that it met people's needs. This was also evidenced in responses to questionnaires. Where people were not satisfied with all aspects of care, they were confident that the home manager listened and would take the appropriate action.

People's health and care needs were assessed with them and/or their representative and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required and they reflected people's current needs.

Staff had a good understanding of people's care and support needs and knew them well, including information about people's family and past lives.

Staff had received training in key areas so that they could meet the needs of the people who lived at the home. Nurses had received specialist training in specific areas and all staff had received training in dementia care.

Is the service caring?

People were mostly supported by kind and attentive staff. We saw that staff stopped to talk to people who were confused to give assurance. We found an exception to this when a staff member did not answer a person's query about their medication in a patient and understanding manner.

At lunchtime we saw that people were able to eat at their own pace and were not rushed.

People's preferences and interests were recorded in detail in their plans of care and staff demonstrated that they understood people's individual needs and preferences.

Is the service responsive?

People's needs had been assessed before they moved into the home. This included people's needs with regards to their nutrition and hydration. Where people had been assessed as at risk of poor nutrition an action plan was in place to minimise the risk.

People were assigned a key worker, who took a specific interest in their care and welfare.

People had access to activities and one to one conversations with the activity coordinator. However, as there was only one coordinator for the 50 people who lived in the home, there were times when people had limited stimulation.

People were supported to maintain relationships with their friends and relatives. Visitors told us that they were always made welcome.

Visitors knew how to make a complaint if they were unhappy. They said that the manager listened to their concerns and took action to try and address them.

Is the service well led?

The service had a quality assurance system, which consisted of internal audits and an external audit from a member of the company. This included all aspects of care, such as care planning, staff training, health and safety, medicines management and the environment.

People completed survey questionnaires about their level of satisfaction with the service. The last time this was done, most people were positive about the support given by the home. Comments included, 'Mum seems to be happy with staff and is comfortable in their presence'; and, 'Staff are always friendly and welcoming when we visit.'

Staff told us they were clear about their roles and responsibilities.

Since our last inspection the provider had sent us an action plan showing how they intended to improve the service and achieve compliance. A new manager had been recruited and started work at the home two weeks before our visit.

People and staff told us that they had noticed an improvement in the service. One staff member told us, "It's so much better, the place is cleaner and we know what we are doing before we arrive for work." One person who used the service told us, "it is much cleaner." We found that the premises was well maintained with on- going improvements identified.

The service was clean and tidy with correct infection control procedures in place. We found people's medication was stored appropriately and administered safely.

People who used the service and staff we spoke with felt there was sufficient numbers of staff on duty to meet people's needs. We saw that there was at least one member of staff in each area of the home at any one time.

We found that in the clinical room there were systems in place to make sure the correct procedures were followed for infection control. However other areas of the home were not clean, therefore people were not fully protected from the risk of infection. We saw that there were areas of the home that had not been adequately maintained to promote the wellbeing of people who used the service.

We found records and care plans up to date and people had consented to their care and treatment. We saw that all safety checks and services on equipment were undertaken regularly. There were effective systems in place to make sure people and staff were asked their views of the service. Records were kept securely and in good order so that confidentially was maintained.