Hawthorn Lodge Care Home

Hawthorn Lodge is a residential care home providing accommodation and personal care. The service is registered for up to 60 people. The service provides support to people aged 65 and over. The building is on two floors containing people's rooms and flats as well as a shared dining room and several lounge areas. At the time of inspection the service was supporting 42 people.

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

Governance systems and processes had failed to make sustained improvements since the last inspection. Quality assurance systems failed to identify and mitigate risks and left people at risk of harm.

People were not protected from environmental risks. Risks to people were not documented or mitigated effectively. The provider took action to mitigate risks highlighted once raised by inspectors.

Medicines were not managed in line with best practice. People who smoked and were prescribed flammable creams were not protected from the risk of severe burns or fatal harm. Action was taken by the provider to mitigate risks to these people once raised by inspectors.

People were not protected from the risk of infection. Areas of the service were not clean, had damage and wear and required repair.

Professional advice was not always sought or followed in a timely manner.

Potential safeguarding incidents were not consistently documented or reported to the local safeguarding authority for further review. Action was taken to improve these processes following discussion with the inspector and local authority.

People were not always supported to have maximum choice and control of their lives as they were not always supported in the least restrictive way possible and in their best interests. Systems in the service did not always support this practice. Relevant legal authorisations for Deprivations of Liberty for people were in place where required.

Most relatives felt engaged by staff and the registered manager. Staff felt the registered manager was approachable and felt able to raise concerns.

People and relatives we spoke with felt the service was safe. Staffing levels were in line with dependency levels. Staff were recruited safely.

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 requires improvement (published 07 October 2022)

Why we inspected

We received concerns in relation to infection control, safeguarding and medicines management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 requires improvement to inadequate 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.

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

Enforcement

We have identified breaches in relation to people’s health and safety, and governance 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 continue to monitor information we receive about the service, which will help inform when we next inspect. 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.

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 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.

Hawthorn Lodge is a residential care home providing accommodation and personal care. The service is registered for up to 60 people. The service provides support to people aged 65 and over. The building is on two floors containing people’s rooms and flats as well as a shared dining room and several lounge areas. At the time of inspection the service was supporting 40 people.

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

Risks associated with people's care and support were safely managed however, this was not always the case with environmental risks. The home was not always clean and hygienic and required some renovation work which had been started. The provider was not always following best practice guidance in infection control standards.

Safe recruitment practices were followed, and staff were trained and competent to carry out their roles. There were sufficient staff deployed across the service to meet people's needs and ensure their safety. This included support with medicines which were received, stored, administered and disposed of safely by staff trained and competent in this area.

Care plans contained personalised health information and people were supported with their health needs and had access to healthcare services. 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.

The registered manager was approachable, caring with good communication skills. The staff team were friendly, kind and respectful and understood people and their identified needs well. Opportunities to learn from incidents were shared across the staff team to ensure improvements in service delivery were made.

The provider and registered manager operated effective governance systems to ensure the quality, safety and improvement of people's care when needed. Audit systems were robust, and there were opportunities for people, relatives and staff to get involved in driving improvements.

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 inadequate (published 27 January 2022) and there were multiple breaches of 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.

This service has been in Special Measures since 27 January 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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.

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

We have found evidence that the provider needs to make improvement. Please see the safe section of this full report.

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

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.

Hawthorn Lodge is a residential care home providing personal and nursing care to 47 people at the time of the inspection. The service is registered with CQC for up to 60 people, however following changes, the registered manager informed us the service can now only support up to 52 people. We advised them to submit a new Statement of Purpose to CQC.

People were accommodated in one large building over two floors. Some of the accommodation was en-suite rooms, others were flats. There were communal areas and a garden for people to relax.

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

On the previous four inspections the service has been rated requires improvement. At this inspection there continued to be a lack of high-quality sustained improvements in place across the service.

The service was not clean and hygienic. Cleaning schedules had not been completed and cleaning audits were not up to date.

Infection control standards were poor due to the lack of effective cleaning and practice was not in line with current guidance. Staff and visitors did not always apply masks before entering the building. There was a lack of environmental checks in place.

Medicines management was not always safe. Medicines were not stored safely. There was a lack of guidance in place for ‘as required medicines. Two staff had out of date training in medicines. Bottles were not always labelled when opened.

Incidents and accidents were not always reported in a timely way. It was not clear if there was up to date analysis of incidents to identify patterns to learn lessons and prevent reoccurrence.

There was not enough staff. There were staffing vacancies and recruitment was ongoing. Staff and people living in the home told us there were not enough staff to spend time with people.

Staff meetings did not take place regularly, staff supervision and appraisals were not in place on a regular basis, this meant poor performance was not recognised and managed.

Care plans and risk assessments were not up to date, this meant staff may not have the latest up to date information to support people safely.

There were gaps across all staff training. Some mandatory staff training was not up to date, safeguarding, fire safety and manual handling. We asked for further clarification on training levels, but this was not received in a timely way.

Quality monitoring processes and systems were not up to date and there was a lack of oversight to allow ongoing improvements to be driven.

Processes to monitor people’s standards of care were not clear and we found gaps in recording that had not been addressed.

The registered manager worked with other organisations to support people; however, this support was not always consistent.

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 requires improvement (published 12 April 2019). There was a breach of Regulation 17. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We received concerns in relation to infection control and a missing person. As a result, 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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe 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.

During the inspection the registered manager and nominated individual agreed to take immediate action to mitigate some of the concerns we found.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hawthorn Lodge Care Home 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to Regulation 12 Safe Care and Treatment, Regulation 13 Safeguarding from abuse, Regulation 17 Good Governance and Regulation 18 Staffing at this inspection.

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

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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.

We found the following examples of good practice.

The provider ensured there were measures in place to reduce the risk of visitors catching and spreading infections. Lateral flow tests (LFT) were encouraged and provided to all type of visitors. The provider supplied all visitors with personal protective equipment (PPE), including masks and gloves.

People and staff were supported to use the home environment safely.

There were ample supplies of PPE available and hand sanitizing stations were available around the building.

The premises were clean and hygienic. Cleaning schedules were in place and there was a sufficient number of domestic staff to sustain frequent cleaning.

There was an Infection Prevention and Control (IPC) champion at the home. Their responsibility was to support the registered manager with IPC audits and spot checks on PPE practise and cleanliness.

The service had a registered manager in place at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

People’s experience of using this service:

People’s medicines were not always managed and administered safely, and we found some issues with staff practices that could impact on the control and prevention of infection. The provider’s quality auditing systems did not always highlight the concerns we found in these areas at inspection.

People felt safe at the service and the risks to their safety were well managed with clear strategies in place to reduce the risks for people. People were supported with appropriate numbers of staff. Their nutritional needs, and health needs were well managed.

People were supported by staff who had appropriate training for their roles. Staff gained people’s consent before providing care. 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. They were supported to express their views and opinions about their care. People had formed positive relationships with staff who knew their needs and preferences.

People’s dignity and privacy was maintained by a staff group who also encouraged people’s independence. There was a positive culture at the service and people and the relative we spoke with felt listened to, they could raise complaints or concerns and know they would be addressed by staff.

Rating at last inspection: The rating for the service at the last three inspections has been requires improvement with repeated breaches of regulations. Our last inspection of the service was 4 October 2017.

Why we inspected: This was a planned inspection based on the previous rating.

Enforcement; This was the fourth inspection where the service has been rated as requires improvement. We have asked the provider for an improvement plan to address the on going issues.

Follow up: We will continue to monitor the service and should we need to we will taken further action in the future.

During our last inspection in July 2016 we rated the location as ‘Requires Improvement’ and identified one breach of the Health and Social Care Act 2008.

There was a registered manager in post. 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.

People could not be assured that their medicines would be managed appropriately. The records of the medicines that had been administered to people were not always completed accurately by staff. The provider did not have a system in place to audit the management of people’s medicines.

Staff did not always receive regular supervision in line with the providers’ supervision policy. We have made a recommendation in the main body of the report related to the supervision of staff.

The providers’ quality assurance systems had not been effective at identifying or addressing shortfalls in the care and support that people received. The providers quality assurance systems had not identified that people’s medicines were not managed safely or that staff had not received regular supervision. This is the third inspection in a row that the provider has been rated as requires improvement. The provider has not implemented appropriate systems in order to achieve and maintain compliance with the Health and Social Care Act 2008.

Risks to people had been assessed and action had been taken by staff to minimise the known risks to people. People were supported by sufficient numbers of staff that had been subject to robust pre-employment checks.

Staff received the training that they needed to provide effective care to people. People were supported to access healthcare services when they needed to and to maintain a healthy and balanced diet.

Senior staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately. Staff understood the importance of obtaining people’s consent when supporting them with their daily living needs.

Staff knew people well and treated people with respect and dignity. People living at the service were encouraged to personalise their rooms and to feel at home.

People had detailed plans of care to guide staff in meeting their care and support needs. People had been involved in the development of their plans of care and received personalised care and support in line with their preferences.

The registered manager knew people well and was accessible to staff and people living in the home. The registered manager set high standards for staff to aspire to.

At this inspection we found the service to be in breach of one regulation of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014. The actions we have taken are detailed at the end of this report.

We carried out an unannounced inspection of the service on 12 and 13 July 2016. Hawthorn Lodge Care Home provides accommodation for persons who require personal care, for up to a maximum of 60 people. On the day of our inspection 50 people were using the service and there was a registered manager in place.

A registered manager was present during the inspection. 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.

During our previous inspection on 9 and 10 October 2015, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to; assessing and managing the risks to people’s safety, the safe management of people’s medicines, the environment people in which people lived, the care planning process and the management of the home.

During this inspection we checked to see whether improvements had been made. We found some improvements had been made in all areas, but further improvements were still required.

Improvements had been made to the premises but further work was required to ensure that the premises were safe for all people living at the home. The assessment of the risks to people’s safety were now carried out more thoroughly and regularly reviewed. Where people had been involved in an accident or incident at the home the incident had been recorded and reported to the registered manager and had been investigated. The processes for the safe management of people’s medicines had improved, but further improvements were required. This included the processes where people received their medicines ‘as needed’. There were enough staff to keep people safe. People were protected from the risk of harm because staff could identify the potential signs of abuse and knew who to report any concerns to.

Improvements had been made to the way people’s day to day health needs were met. However, people’s care records did not always reflect the care carried out by the staff, and in some cases, lacked specific guidance for staff when supporting people. The ground floor of the home provided people living dementia or other mental health related conditions, with assistance to lead independent lives. However more work was needed to support people in other areas of the home.

People were supported by staff who had completed a detailed induction and training programme. However staff did not always receive regular supervision of their work. The principles of the Mental Capacity Act (2005), including Deprivation of Liberty Safeguards, had been followed when decisions were made about people’s care. People spoke positively about the food provided at the home and we observed an organised lunch time experience.

People were treated with respect and dignity by staff, although we did see one negative interaction which impacted on a person’s right to be treated with dignity and to have their privacy respected. People felt staff were kind and caring. People’s records contained limited information about their life history; however plans were in place to address this. People were involved with decisions about their care and support needs. People were encouraged to lead independent lives. Information for people on how to access independent advice about decisions they made was easily accessible.

People’s care records contained detailed care plans which enabled staff to respond to their needs. People were supported to follow the activities that interested them. People’s diverse needs were respected, however some staff spoken with unaware of a person’s needs. People felt able to make a complaint and were confident it would be dealt with appropriately.

The registered manager’s auditing processes had improved since the last inspection, but further work was required to ensure the issues raised within this report were identified and addressed in a timely manner. The registered manager was aware of their responsibilities to inform the CQC of incidents that could affect people’s lives, but they had not always done so. People, relatives and the majority of staff spoke highly of the registered manager. People were encouraged to become involved with development of the service and were given the opportunity to give their opinions during ‘resident meetings’ and via questionnaires.

We identified one continued breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of this report.

If you wish to look at our findings in detail please see the full report.

Is the service safe?

The environment was clean. The premises were secure from anyone entering unannounced, and care records were only accessed by authorised staff. People told us they felt safe. There were sufficient numbers of staff on duty to meet the needs of the people in the service. Staff members were confident to raise safeguarding concerns to the manager. Procedures for the correct administration of medicines were being followed.

Is the service effective?

Each person had a care plan that described their individual care needs. Staff had a good understanding of people's needs and risks. One relative told us, "The staff are very kind here.' There were sufficient infection control measures in place. Staff were knowledgeable and received good training and were supported appropriately by senior staff.

Is the service caring?

Our observations throughout the visit were positive. Staff showed a great deal of patience and good humour when they were assisting people. One staff member told us, 'We work as a team to do what we can for people.' Questionnaires sent to people's families were complimentary. People in the service were not rushed, and a relative told us, 'It's lovely here.'

Is the service responsive?

People's care needs were assessed before they were admitted. Care plans and risk assessments reflected people's individual needs and were updated promptly when necessary. People and their relatives were invited to meet with their keyworkers each month to review their care plans. However, people did not currently have individual, structured activity programs in place because there was no activities coordinator currently in post.

Is the service well-led?

There were systems in place to monitor the quality of the service being provided. These included feedback by the use of monthly audits, complaints received and questionnaires issued. All findings were addressed in a timely way. Staff received a good level of training, were well supervised and had a good understanding of the aims of the service. Care records were up to date and all risks had been assessed.

An external healthcare professional told us, 'The service is ok; people are cared for. Staff communicate well with my team and they're willing to listen and learn.'

We saw person centred information which met individual people's needs in two out of the three care plans we looked at. Care plans and risk assessments for identified care needs were in place.

We spoke with two relatives of people who used the service. They told us, 'My relative is safe,' and, 'I've got no concerns about the staff.'

Staff told us who they would report or have reported issues to if they had safeguarding or whistle blowing concerns.

Since our last inspection, effective systems had been put in place to reduce the risk and spread of infection. The manager and provider of the service had taken action to address the issues found at our last inspection and had implemented measures which minimised the risk of infection.

A relative of a person who used the service said, 'The cleanliness has improved.'

Appropriate arrangements were still not in place in relation to the recording of medicines. Medicines were not always handled appropriately and procedures for the correct administration of medicines were not followed.

During our inspection we found that work to improve the premises and building had been started but further work was still needed. The provider acknowledged this and had identified an on-going programme of works and maintenance to ensure the premises were both safe and suitable for the delivery of care to people who used the service.

One person who used the service told us, 'I've got no complaints.'

A relative of a person who used the service said, 'The home's well run. The manager sorts things out if things aren't right.'

People who used the service, their relatives and staff members were able to discuss and raise issues with the manager.

Three people told us the service was clean, one person said, 'Reasonably clean.' During our tour of the premises the environment did not smell clean. Our observations meant that people may not always be cared for in a clean, hygienic environment.

Appropriate arrangements were not in place in relation to the recording of medicine. The medication administration record (MAR) charts we looked at were not fully completed. Medications had been given but the administration of those medicines had not been recorded and staff had not signed the relevant section of the MAR charts. A recent provider audit identified issues with this standard.

Two relatives of people receiving care told us, 'The building needs attention.' During our tour of the premises we observed that the interior and exterior environment was dated and required redecorating and some repair.

Two people told us there were enough staff to support them. One relative told us, 'Staff numbers are ok. Staff work well with the numbers they have.' We did not see evidence of insufficient staffing levels during our inspection.

One person told us they had made a complaint and the service had responded appropriately. A complaints procedure was in place and contained appropriate detail.

Records were kept securely. Nobody raised any concerns regarding the security of records at the service.