16 June 2022
During an inspection looking at part of the service
People’s experience of using this service and what we found
People were supported by staff who were familiar with their needs and were observed as being kind and responsive. People spoken with had some opportunity to go out and develop their independence with staff support.
Some people's needs had changed which meant they required additional support to stay safe. This was not reflected in the staff hours provided by the service. Three people had some one to one hours when staff supported them to go out or complete tasks within the service. Other people had shared support and staff had limited amount of time to spend with them.
Not all risks were appropriately assessed and monitored to ensure people were kept safe. People lived in a poorly maintained environment which made it more difficult for staff to keep clean. Facilities were poor.
Individual risks were not clearly identified and planned for. For example, staff did not keep fluid charts where people were prone to infection. Staff had not taken fully into account the recent hot weather and how this might impact on people’s general health and wellbeing.
People were not fully supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; For example staff had sought consent to keep the main fridge in the kitchen locked but had not documented the clear rationale for this or considered if this was the least restrictive option.
Medicines were safely managed but people even those who took their own medicines were required to go to the medicines room which was not a very person-centred approach. We have made a recommendation about monitoring the use of medicines prescribed to be administered when required.
People discussed their care needs with staff regularly, but daily care notes and monthly reviews did not clearly focus on people ‘s wellbeing and mental health or identify new or unmet need.
Governance and provider oversight was poor which had led to a lack of investment and quality improvement. The last CQC inspection to this service was on 4 October 2018. Although rated good safe was rated as requires improvement and we found robust actions were not taken to address our concerns. During a more recent inspection by the local authority in 2021 and a CQC review of the service in 2022 we found a continued lack of effective monitoring or action to address the issues found.
The registered manager was highly regarded by staff and people using the service and was engaging with health care professionals to get people’s needs reassessed where changes were noted in their physical and mental health exacerbated by the COVID 19 pandemic.
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 14 December 2018.)
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Why we inspected
This inspection was prompted by a review of the information we held about this service. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.
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.
You can see what action we have asked the provider to take at the end of this full report. 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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Adrian Lodge on our website at www.cqc.org.uk.
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 the environment, quality monitoring and assessing risk 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.