Priory Lodge

Priory Lodge is a residential care home providing accommodation and personal care to people who require support with their mental health. The service provides support to up to 18 people. At the time of our inspection there were 15 people using the service, 4 people were not in receipt of personal care.

People’s experience of the service and what we found:

Management did not have adequate oversight of the service and the provider lacked robust and effective governance systems to monitor the quality and safety of the service and improve care delivery. Incidents were not being reported correctly or investigated properly, and lessons were not learned.

The provider had missed some areas within the environment that posed a potential risk to people’s safety, and fire safety and infection control arrangements needed strengthening.

Staff were kind and considerate towards the people they cared for. However, care and support delivered were more intuitive than knowledge based. Staff had a basic understanding and awareness of people’s mental health needs. Care records contained insufficient guidance for staff to reduce risk, provide safe care and to promote and support people’s wellbeing. Improvement was needed in staff training and development to enable them to deliver care and support that is responsive, person centred and in line with relevant guidance and best practice.

Improvement was needed to demonstrate the service was working within the legal framework for making particular decisions for people who lacked capacity to do so.

We received positive feedback from the staff team about the management of the service. However, systems and processes needed to be reviewed to ensure that the registered manager could demonstrate that people’s individual needs were being met and staff were effectively supported to deliver safe care.

People we spoke with were happy living at the service. The atmosphere within the home was friendly and welcoming.

The registered manager was working closely with the local safeguarding and quality improvement team to reflect on the current practice within the home to ensure that lessons were learned, and to make improvements where needed.

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 24 December 2019). The service has been rated requires improvement for the last four inspections. The provider failed to complete and submit an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider had not made improvement and was in breach of regulations. The rating for the service has changed to inadequate.

Why we inspected

The inspection was prompted in part due to concerns received about management oversight and responsibilities, staff training, skill and competence and people’s care and support. A decision was made for us to inspect and examine those risks.

We undertook a comprehensive inspection to review all key questions.

Enforcement

We have identified breaches in relation to management and oversight, risk management and safety and staff training and support.

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

Follow Up

We will meet with the provider and 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.

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 registered manager had followed guidance on infection control procedures to safely support people living at the service during and after the pandemic. Priory Lodge accommodates people who are clinically vulnerable. Measures were in place to keep them safe and protect them from acquiring infections. This included, minimising close physical contact from people visiting the service using social distancing and isolation, when needed. One of the rooms had been left unoccupied to accommodate people being admitted to the service to minimise the risk of transmitting COVID-19 and protect people already in residence.

The registered manager had maintained a good stock of personal protective equipment (PPE). All staff had received training on how to properly use PPE.

People and staff were regularly tested for COVID-19 and where positive results had been returned the registered manager had acted quickly to mitigate the risks to others catching the infection. The service had one vacancy but had enough staff to manage future coronavirus and other infection outbreaks and winter pressures.

The service has a designated infection prevention and control lead. They have a specific interest in infection and control and was in the process of completing training to become the infection control champion for the service.

The premises had recently been refurbished. All areas of the service were clean and hygienic. Good cleaning processes were in place and records showed these were being sustained to prevent the spread of infection.

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

People told us that they were happy living in the service and staff were kind and caring.

Systems were in place for the supply and storage of people’s medicines, but these were not working effectively, and staff were decanting medicines into containers which increased the likelihood of errors. Action was immediately taken by the manager to address this and we saw the new system in operation on the second day of the inspection. We have made a recommendation about medicines.

Risk assessments detailed people's individual risks such as mobility and pressure care and there were arrangements in place to reduce the likelihood of harm. Safety checks were undertaken on the building and on the equipment to check if it was safe to use.

There were clear systems in place to recruit staff and ensure their suitability before they started work at the service. Staff received training to develop their skills and enable them to meet people’s needs.

The service was largely clean and there were no odours. Some of the flooring and seating was worn which made them difficult to clean but we saw that there was an ongoing programme of refurbishment and replacement.

When an incident occurred, this was investigated, and lessons learnt where appropriate. The service worked with external health and social care professionals to achieve good outcomes for people.

People told us that that they enjoyed the food, but mealtimes would benefit from being more interactive and collaborative.

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.

Care plans were in place which set out people’s needs and preferences. We have made a recommendation about enabling people to have access to their care plan.

People were supported by a consistent team of staff and most staff knew people well. People had a key worker with whom they met regularly to discuss their needs.

People had access to some social and learning opportunities, but further work is needed to encourage independence and help people to lead fulfilling lives. We have made a recommendation about improving access to community and mental health groups to reduce the risk of social isolation.

Feedback from people and relatives was considered through a range of systems such as surveys, care reviews and meetings.

The culture of the service was not fully person centred and the manager agreed to review some of the routines in place and assist people to access advocacy.

The provider had a framework to monitor performance and drive improvement. This included the collection and analysis of data as well as regular audits. These systems however had not identified all of the issues that we found at this inspection.

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 19 December 2018).

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Priory Lodge 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.

Priory 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. Priory Lodge provides people with single or a shared room in an adapted building close to the centre of Colchester. At our last inspection of the service in January 2018, we rated the service as ’Requires Improvement’ overall but as inadequate in the key question of Well Lead. This was because we found deficiencies in the way the service was managed. We found that the provider was in breach of a number of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we took enforcement action cancelling the registered managers registration as we had concerns about their competency. The registered provider sent us an action plan setting out the steps they would take to address the concerns we raised. At this inspection we found that significant improvements had been made and the service was no longer in breach of the regulations. As a result, we have made a decision to remove the service from special measures. However, the overall rating remains ‘Requires improvement’ as further work is still needed in some areas to imbed some of the changes that have been made.

At this inspection the service did not have a registered manager. A new manager had been appointed but had not yet applied to register with CQC. 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.

Management and staff were clearer about how to keep people safe. The acting manager exercised greater scrutiny over accidents and incidents. Hazards were identified and managed. Equipment was serviced and checked to ensure it was safe to use. The service was clean and there were plans to adapt the building to improve the management of laundry and washing of equipment such as commodes. Since our previous inspection, the accommodation had benefited from general updating and more regular maintenance. The garden had been landscaped which meant that it more accessible to people. Communal areas were comfortable and homely.

Safeguarding was understood by staff and we saw that the acting manager followed the correct procedure when concerns were raised. Peoples medicines were safely managed.

There were sufficient staff available to support people and there were arrangements in place to check on staff suitability as part of the recruitment process. Staff had access to a range of training to equip them with the skills they needed to meet the needs of people using the service.

The Mental Capacity Act (MCA) 2005 provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The registered manager understood their responsibilities but some of the documentation regarding decision making could be strengthened.

People had choice of meals and access to health care and were supported to lead healthier lives.

People told us that they were happy living in the service and that they had a good relationship with staff. Care staff were caring and knew people well.

Opportunities to participate in activities had significantly improved since the last inspection. People regularly accessed the community as well as taking part in meaningful activities to assist with their overall wellbeing.

The service supports people with a wide variety of needs and while people’s primary needs may be around their mental health a number also had significant needs arising from other health conditions. The service was better equipped and to support people with differing needs and care was more person centred. Further work was needed to strengthen the care planning and review arrangements to ensure that people’s needs are met in a timely way and that they were being supported to fulfil their potential.

There was a system in place to address complaints. People, relatives and health professionals were asked for their view of the service at regular intervals.

There was visible leadership and the culture was more positive. The acting manager oversaw a number audits to check on the quality of the service but these would benefit from further development.

During an unannounced inspection in November 2016, we found breaches in Regulation 11, 12, 17 and 18 of the Health and Social Care Act 2008. The provider submitted an action plan to demonstrate how they would improve these areas of concern and during this recent inspection; we found that some improvements had been made.

However, the service was found to be in breach of Regulation 7, 9, 12, 13, 15 with a continued breach in Regulation 17. In addition, the service was also in breach of Regulation 18 of the Registrations Act 2009 for none reporting of other incidents to the commission.

Priory lodge residential care home 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, both of which we looked at during this inspection.

The care home accommodates up to 19 people in one building who are adults of working age and over 65, living with a variety of long-standing mental health problems. At the time of inspection, 17 people were living at Priory lodge.

At the time of inspection a registered manager was in place at the service, however we had concerns about the fitness to practice of this manager. Further meetings demonstrated that the registered manager lacked the competency and skills to ensure that the service was managed in line with the Health and Social Care Act, 2008. This is a breach of regulation 7 of the Health and Social Care Act, 2008, Registered manager requirements.

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.

Whilst we found that the service had improved in areas of concern previously found, we found the service required improvements in additional areas under each domain and the rating for the well-led domain was inadequate. The registered persons were not aware of their responsibilities to report safeguarding concerns to the relevant stakeholder, including the commission. This was a breach in regulation 18 of the registrations act, 2008.

The registered manager did not carry out robust investigations into incidents and accidents. They did not use information available to them to assess for and mitigate identified risks to people. This meant people were at risk of abuse and improper treatment. This was a breach in regulation 13 of the Health and Social Care Act.

There were insufficient infection control practices in place to safeguard people from risk of infection. When recommendations had been made by external companies, they were not always acted on. This was a breach in regulation 15 of the Health and Social Care Act.

During the inspection in November 2016, we found that the management of medicines needed improvement. We found that in this area there had been improvements and that medicines were managed safely and in line with best practice guidance.

Staff had previously not always been inducted in a safe way. We found that the HR/ Training manager had made significant improvements in this area.

The HR/ Training manager ensured that all new staff received a thorough induction, mandatory training, regular training updates and additional training to support them to meet peoples changing health needs. Staff were supported to undertake outside learning and given regular supervision.

Nutritional and fluid needs of people were met, and a choice of food was available. Where people needed additional support from other professionals, it was gained. However, care staff did not use any assessment tools to support them to identify when people were at risk of malnutrition, even for those with identified risk. Consequently, we could not be confident these needs would always be identified in a timely way. Previously identified at our last inspection of the service, this area of care continued to require improvement.

Care staff were caring and knew people living at the service very well. In times when people became distressed, staff acted in a compassionate and dignified way to support them. People’s confidential information was kept securely.

Staff felt cared for by the management team. The HR / training manager supported staff who wanted to access outside opportunities for learning and development.

Whilst care plans had improved, there was not always enough information to support staff to meet peoples identified needs in a person centred way. People at the service were not given sufficient opportunities to engage with the wider local community, or to promote their own independence. This was contrary to the provider’s statement of purpose and best practice and was a breach in regulation 9, of the Health and Social Care Act.

The service did not provide people with rooms that they could lock which was contradictory to the providers statement of purpose, and had previously be highlighted during the last inspection report.

Whilst improvements had been made following the previous inspection, we continued to find concerns around safeguarding people, the lack of robust governance in place, planning for the future of the service. Poor governance systems in place was a breach in Regulation 17 of The Health and Social Care Act, 2008.

Consequently, whilst we found areas of good practice and improvement, there was a lack of sufficient governance and over sight of the service from the registered manager and registered provider. They did not identify challenges to the service, changes in practice and legislation, nor did they provide the service outlined in their statement of purpose. The general lack of understanding of the registered manager regarding their own legal responsibilities and best practice for supporting people living with mental health difficulties, has resulted in a breach of regulation 7, of the health and social care act. This has resulted in an inadequate rating within the well led domain.

Where a service has been rated as inadequate within a domain, we aim to return to the service within six months of publication to ensure that they have taken the appropriate steps to make the necessary improvements.

However, we have noted the improvements made and maintained by the HR/ Training manager and dedicated care staff.

You can see what actions we took at the end of the report.

The service had a registered manager. 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.

Staff understood the principles of keeping people safe, but in practice these had not been followed. We found some risk assessments in place to meet their needs, but for some people relevant risk assessments were not found or up to date. This meant there were risks associated with people's care which staff were not aware of.

The environment had not always been maintained to a safe standard.

Sufficient recruitment checks had not been carried out before staff started work to ensure that they were suitable to work in a care setting.

Medicines were administered and stored safely. People were supported with their medicines but correct guidance was not in place when people were given medicines as needed (as and when required).

Staff had a basic knowledge of the Mental Capacity Act 2005 but this had not been properly followed or put into practice. This meant people did not have their mental capacity assessed and restrictions had been placed on people without their agreement or being in their best interests as authorised by proper processes.

There was a training programme in place for staff but this did not cover all the areas needed, which meant staff did not always have the knowledge to meet people's needs.

People enjoyed their meals and were offered a choice at meal times. People were supported to access a range of health professionals.

People did not always have their needs planned in a personalised way which reflected that their choices and preferences had been considered. This meant staff may not always have the best information on how to meet an individual's needs and preferences.

People were not always supported to engage in activities and individual interests were not always accommodated.

There were systems employed to monitor the quality of the service, but they had not effectively identified concerns which impacted on the quality of care that people received.

We considered the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; Is the service safe, Is the service effective, Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a member of staff asked to see our identification and asked us to sign in the visitor's book. This meant that appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access the service. The member of staff also went through the fire safety evacuation procedure, so we were aware of what to do in the event of an emergency.

People told us they felt safe, protected and their needs were met.

Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, we saw that policies and procedures were in place. The manager confirmed that relevant staff had been trained to understand when an application should be made, and how to submit one. This ensured that arrangements for safeguarding people were in place.

Records seen confirmed that staff were booked onto upcoming or had received training in safeguarding vulnerable adults from abuse, the Mental Capacity Act (MCA) 2005 and DoLS. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

People told us they received their medication as prescribed and intended. Medicines were correctly stored and disposed of and records seen were accurate. Staff received medication training and managed medicines in a safe way.

Records seen confirmed health and safety was checked in the service and equipment was maintained and serviced.

Is the service effective?

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Records showed that staffing levels were based on the level of dependency and needs of the people who used the service.

Staff supervision and training was planned and delivered as required. This meant that staff had the support and skills to deliver care effectively.

Is the service caring?

Staff interacted with people who used the service in a caring, respectful and professional manner. People told us they were happy with the care they received and their needs were met. One person told us, 'The staff are good. They can't do enough for you, they are very attentive, kind, and all round decent people .'

Staff had a good understanding of the people's care and support needs and knew them well.

Is the service responsive?

People's choices were taken in to account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor, district nurses, mental health teams and chiropodists.

Is the service well-led?

There is not a registered manager at this service. The provider advised us that the manager of the service will be submitting their registration application to the Care Quality Commission

Staff told us they were clear about their roles and responsibilities and were supported and trained to meet people's needs.

People's care records and risk assessments were accurate and up to date.

The provider had systems and procedures in place to monitor and assess the quality of the service provided. There were records to identify shortfalls in the service and how they had been addressed.

Feedback from people who used the service about their experiences was valued, taken into account and influenced the running of the service.

Staff that we spoke with told us that they had access to a good range of training that provided them with the necessary skills to meet people's assessed needs.

People that we spoke with told us that they felt the staff who supported them understood their care needs well, and always supported them in a understanding and respectful manner.