Suffolk Lodge

Updated 22 September 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 4 and 5 September 2018 and was unannounced. The inspection team included one inspector on both days and an expert by experience on the second day. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, the registered manager completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We looked at the PIR and at all the information we had collected about the service. This included previous inspection reports, information received and notifications the registered manager had sent us. A notification is information about important events which the service is required to tell us about by law.

During the inspection we spoke with 14 people who use the service, seven of them in depth, plus one visiting relative. We spoke with the provider's nominated individual, deputy head of regulated services, the registered manager, deputy manager, the administrator, activity staff, two domestic assistants and maintenance staff. We received feedback from nine care workers. We observed interactions between people who use the service and staff during the two days of our inspection. We spent time observing activities and lunch in the dining rooms. As part of the inspection we requested feedback from 23 health and social care professionals and received responses from three.

We looked at four people's care plans, monitoring records and medicine administration record sheets, five staff recruitment files and the staff training and supervision logs. Medicines administration, storage and handling were checked. We reviewed a number of other documents relating to the management of the service. For example, utilities safety check certificates, equipment service records, the legionella risk assessment, the fire risk assessment, staff meeting minutes, audits of the service and the complaints, compliments and incidents records.

Updated 22 September 2018

This inspection took place on 4 and 5 September 2018 and was unannounced.

Suffolk Lodge is a care home without nursing that provides a service to up to 40 older people living with dementia and/or a physical disability. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is split into 5 smaller units of seven to eight bedrooms. There are three units on the ground floor and two on the first floor. One of the two first floor units was closed with all people living in the other four units. At the time of our inspection there were 29 people living at the service.

There was a registered manager as required. A registered manager is a person who has registered with the 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. The registered manager and deputy manager were present and assisted us on both days of this inspection.

We last inspected the service on 22 and 23 August 2017. At that inspection we found the service required improvement. This was because improvements were needed to the safety of the premises, the safe storage of medicines and to ensure the premises were more suited to those living with dementia. We also found the provider had not established an effective system to enable them to ensure compliance with the fundamental standards. 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 key questions of safe, effective and well-led to at least good. At this inspection we found the provider and registered manager had done all they said they would do and had improved the service to an overall rating of good, with a rating of good in all key questions.

Extensive work had been done on the safety of the building to ensure the premises were safe. Medicine storage had been addressed to ensure medicines were stored at safe temperatures. Work had been completed in response to health and safety inspection concerns, recommendations from a legionella risk assessment and work required following an inspection by the local Fire and Rescue Service.

The registered manager and the entire staff team had been involved in carrying out an audit of the premises to see where changes could be made to improve the 'dementia friendliness' of the premises and enhance the lives of the people living at Suffolk Lodge. The findings from the audit had been implemented, resulting in an environment that enhanced people's wellbeing and aided their independence. The provider had introduced a system that was successful in enabling them to monitor and ensure the service was compliant with the fundamental standards.

People felt safe living at the service and were protected from risks relating to their care and welfare. Staff knew how to recognise the signs of abuse and were aware of actions to take if they felt people were at risk.

People were protected by the provider's recruitment processes. Safe recruitment practices were followed before new staff were employed to work with people. Required checks were made to ensure staff were of good character and suitable for their role.

People received care and support from staff who knew them well. Staff training was up to date and staff felt they received the training they needed to carry out their work safely and effectively. People received support that was individualised to their personal preferences and needs. Their needs were monitored and care plans were reviewed monthly or as changes occurred.

People received effective health care and support. Medicines were stored and handled correctly and safely. 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.

Meals were nutritious and varied. People told us they enjoyed the meals at the service and confirmed they were given choices.

People were treated with care and kindness. People's wellbeing was protected and all interactions observed between staff and people living at the service were respectful and friendly. People confirmed staff respected their privacy and dignity.

People and relatives were aware of how to make a complaint. They told us they could approach management and staff with any concerns and felt they would listen and take action. They benefitted from living at a service that had an open and friendly culture and from a staff team that were happy in their work.

People living at the service and their relatives felt there was a good atmosphere and thought the service was managed well. Staff also felt the service was well-managed. They told us the management were open with them and communicated what was happening at the service and with the people living there.