Toby Lodge

Toby Lodge is a residential care home providing personal care for 10 male adults who had a forensic history, including mental health conditions and/or a learning disability.

Toby Lodge accommodates people in one building across four floors, with each person having their own bedroom with en-suite bathroom. There was also a communal living room/dining room, kitchen, quiet room and access to a small courtyard.

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

The inspection was prompted by information of concern regarding staffing levels and a poor culture within the service.

Although documentation confirmed that in November 2021 there had been a couple of occasions where staffing levels were below the provider’s recommended levels, we found no evidence during this inspection that people had been impacted by this and the issue was being addressed by the management team.

The senior management team were open and transparent when we discussed the concerns with them and acknowledged they had experienced some staffing issues at the end of the November, which was impacting the whole health and social care sector. They also explained some recent changes in company policies, including the legal requirement for staff to be vaccinated for COVID-19 as a condition of their deployment, had led to a turnover of staff.

The provider had been responsive to this issue and was in the process of recruiting new staff to ensure they had sufficient staff to meet people’s needs.

Throughout the inspection we observed a relaxed environment and people appeared comfortable in the presence of staff. A resident meeting on the first day of the inspection had a homely atmosphere, with discussions based around the upcoming Christmas and New Year plans.

We saw people were supported out in the community during our visit, with one person telling us they were going out for a walk to the local shop.

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 21 March 2018). We also carried out a targeted inspection looking at the Infection Prevention and Control (IPC) practices the provider had in place in February 2021. This was part of CQC’s response to care homes with outbreaks of coronavirus, to ensure that the IPC practice was safe and the service was compliant with IPC measures (published 5 March 2021).

Why we inspected

We undertook this targeted inspection to follow up on a specific concern which we had received about the service. The inspection was prompted in response to concerns received about alleged unsafe staffing levels and a culture of bullying and harassment. A decision was made for us to inspect and examine those risks.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Please see the safe and well-led sections of this full report.

We also 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 coronavirus and other infection outbreaks effectively.

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

Follow up

We will continue to monitor information we receive about the service. If we receive any concerning information we may return to inspect.

Toby Lodge accommodates people in one building across four floors, with each person having their own bedroom with en-suite bathroom. There was also a communal living room/dining room, kitchen, computer room and access to a small courtyard.

There was an outbreak at the end of December 2020 where nine residents and 11 staff members, including the registered manager, tested positive for COVID-19.

The local authority and infection prevention and control (IPC) leads at the Clinical Commissioning Group (CCG) were involved in follow up support, which included a number of meetings and two virtual tours between 8 January 2021 and 4 February 2021 to provide advice and guidance to the registered manager and staff team.

We found the following examples of good practice.

¿ There were robust protocols in place for visitors upon entry, with temperatures taken and a requirement to take a lateral flow device (LFD) COVID-19 test before entering the home. Staff also had to sign to confirm they were free from any COVID-19 symptoms and had not been in contact with anybody with symptoms or who had tested positive. Due to the recent outbreak, visits from relatives were currently suspended.

¿ The provider had been proactive in response to the feedback and advice from the local authority and the CCG. A number of posters, including easy read versions were displayed across the home and in people’s rooms to remind them about following guidelines to keep people safe and reduce the risk of infection. Easy read social stories had also been used to help explain the pandemic and the importance of social distancing to help people understand that it was fine if another person did not want to shake their hand, which helped to reduce one person’s anxious and distressed behaviour.

¿ Staff checked people’s temperature, oxygen levels and their ‘cough status’ three times a day, which was recorded on their digital care planning software. If this was not completed an alert was sent to remind the staff team to do this.

¿ The home used technology to support people to have video calls with their relatives and facilitate health and social care professionals meetings, such as service reviews, medicines reviews and virtual tours.

¿ The majority of recommendations had been actioned by the provider after the outbreak and the provider had also carried out a professional deep clean of the service on 7 January 2021. The registered manager told us they were having regular discussions with the staff team about following the guidelines and ensuring they followed best practice to make sure this was embedded throughout the service.

Toby Lodge is a ‘care home’. 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. Toby Lodge accommodates 10 male adults in one building across four floors, with each person having their own bedroom with en-suite bathroom. There was also a communal living room/dining room, kitchen and access to a small courtyard. At the time of the inspection the care home was supporting 10 people who had a forensic history with mental health conditions and a learning disability.

There was a manager in post at the time of our inspection who was also a registered manager at another service managed by the provider. 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 and their relatives felt comfortable approaching the management team, who had a visible presence throughout the service. Staff felt valued and spoke positively of the open and honest working environment and the support they received from management, which led to a strong sense of teamwork across the whole team.

During a period of refurbishment at the home people had been supported to stay at a holiday home to minimise the negative impact it could have had on their day to day lives. People enjoyed the experience and staff spoke positively about the support from management during this period.

People’s risks were managed safely and care records contained appropriate and detailed risk assessments and emergency plans. Staff had a good understanding of how to manage behaviours that challenged the service and worked closely with health and social care professionals for advice and guidance.

People and their relatives told us they felt safe using the service and staff had a good understanding of how to protect people from abuse. It was discussed regularly with people who used the service and all staff were confident that any concerns would be investigated and dealt with immediately.

People who required support with their medicines received them safely from staff who had completed training and been observed in the safe handling and administration of medicines. Staff completed appropriate records when they administered medicines and these were checked daily by staff to minimise medicines errors.

Staff had access to training to support them in meeting people’s needs effectively. New staff shadowed more experienced staff before they started to carry out care tasks independently and received regular supervision from management. They told us they felt supported and were happy with their input during the supervision they received.

People received support to make choices about their food and drink and staff were aware of nutritional needs relating to people’s culture, religion and medical needs.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The provider was aware when people had restrictions placed upon them and notified the local authority responsible for assessment and authorising applications. Best practice information was available in an easy read format to help explain the process to people who used the service.

People had regular access to healthcare services and staff were aware when people’s health and medical appointments were due. Health and social care professionals confirmed they were always updated if people’s health conditions changed or needed any further guidance and support.

People and their relatives told us staff were kind and compassionate and knew how to provide the care and support they required. We observed positive interactions between people and staff throughout the inspection and saw people felt comfortable in the presence of the whole staff team. We saw that staff treated people with respect and kindness, respected their privacy and promoted their dignity and independence.

People were supported to follow their interests and staff were proactive and encouraged them to take part in a range of activities to increase their health and well-being and reduce social isolation. People and their relatives were involved in planning how they were cared for and supported. Care records were person centred and developed to meet people’s individual needs and discussed regularly during key work sessions.

The provider had an accessible complaints procedure in place which was regularly discussed with people and relatives knew they could speak with staff if they had any concerns. There were surveys in place and monthly residents meetings to allow people the opportunity to feedback about the care and support they received.

There were effective quality assurance systems in place to monitor the quality of the service provided and understand the experiences of people who used the service. The management team followed a daily, weekly, monthly and annual cycle of quality assurance activities and learning took place from the result of the findings.

At our previous inspection on 10 and 11 December 2015 a breach of legal requirements was found. After the inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to notifications.

We undertook this focussed inspection to check that they had followed their plan and to confirm that they now met the legal requirements in relation to the breach found. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Toby Lodge’ on our website at www.cqc.org.uk’

There was a registered manager in post at the time of our 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.

Toby Lodge provides care and support for up to 10 male adults with a learning disability and forensic history. At the time of our inspection they were providing support to nine people in the home, and one person was being supported in hospital.

At our previous inspection we found that the provider did not always notify the CQC of notifiable incidents.

At this inspection, we found that improvements had been made.

The provider was aware of the type of incidents that they were required to notify the Care Quality Commission (CQC) of and had reissued the regulations to the registered manager and staff team with immediate effect. Notifications were discussed and monitored at management meetings.

Toby Lodge provides care and support for up to 10 male adults with a learning disability and forensic history. All of the bedrooms are for single occupancy and at the time of this inspection the service was providing support to eight people.

There was a registered manager in post at the time of our inspection. 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 told us they felt safe living at the service and relatives confirmed this. All staff had received training in safeguarding adults from abuse and had a good understanding of how to identify and report any concerns. Staff also felt confident that any concerns would be investigated and dealt with.

People’s risks were managed and well monitored. The care plans included risk assessments which all staff could access via a digital device and any changes could be updated straight away. The service had a robust recruitment process and staff had the necessary checks to ensure they were suitable to work with people using the service. There were sufficient staff so that people could be supported to go out and access the local community.

People received their medicines safely and staff had received training in the safe handling and administration of medicines, which was refreshed annually.

People were supported by staff who had the necessary skills and knowledge to meet their needs. Staff had completed an induction programme and received regular supervision from management. People consented to the care they received and staff understood their role with regards to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People were supported to maintain their health and well-being through access to healthcare professionals, such as GPs, social workers and the Community Learning Disability Service. The information provided from these appointments was updated into people’s care plans.

People received support to make choices about their food and drink and staff were aware of nutritional needs relating to people’s culture, religion and medical needs.

People and staff were relaxed throughout our inspection. There was a warm and friendly environment and people told us they enjoyed living in the service. Staff put people at the heart of their work and focused on them and their needs rather than tasks. Positive relationships between people and the whole staff team had developed as staff displayed a kind and compassionate attitude towards people.

Staff were knowledgeable about the people they were supporting and respected their privacy and dignity, along with their cultural preferences.

People received personalised care and staff involved people, their relatives and health and social care professionals when reviewing their needs and how they would like to be supported. People were supported to follow their interests, take part in social activities and maintain relationships with relatives and friends that mattered to them. For example, during the inspection one person was supported to visit a relative.

The service had an accessible complaints policy and people and those who mattered to them knew how to raise concerns and make complaints. There were also surveys in place to allow people and relatives the opportunity to feedback about the care and treatment they received.

The registered manager had a visible presence within the service and was described by relatives and health care professionals as kind, caring and committed. Staff spoke highly of management and told us they were very supportive and approachable.

There were effective quality assurance systems in place. The registered manager followed a monthly and annual cycle of quality assurance activities and learning took place from the result of the audits. However the registered manager failed to notify the CQC about a serious incident and a safeguarding concern that had been raised which is a legal requirement.

We identified one breach of Regulation in relation to notifications. You can see what action we told the provider to take at the end of the full version of this report.

As part of this inspection we spoke with all five people who lived at Toby House at the time of our visit. We also spoke with four members of staff and a member of staff at the NHS trust responsible for the treatment of one person who lived at the home. We reviewed records relating to the management of the home which included three care plans, daily care records and records about how the home monitors its own performance and quality of care.

Below is a summary of what we found. The summary describes what people using the service and staff told us, what we observed during the visit and what we saw in the records we looked at.

Is the service safe?

There were enough staff on duty to meet the needs of people living at the home on the day of our visit. Staff working at the home had suitable experience to enable them to support people. We saw that the provider had carried out checks to ensure staff were of a suitable character. All the staff had undertaken safeguarding training which was refreshed regularly. Staff understood the risks involved in providing support for people and there were plans in place for dealing with other foreseeable emergencies.

CQC monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. A number of people were subject to restrictions imposed under mental health legislation. Safeguards were in place to ensure people were protected from the risk of undue restriction on their liberty.

Is the service effective?

People told us that they like living at Toby House. One person said "it's good here; the staff really help me." The care plans we looked at showed that support was provided in line with people's assessed needs. We saw that people were meeting their goals and making tangible progress towards their goals. Other professionals involved with the care of people living at the home spoke of improvements they had observed in people's health, wellbeing and ability to care for themselves.

Is the service caring?

Staff spoke to people with courtesy and respect. People living at the home were comfortable in the company of the staff on duty on the day of our visit. Staff respected people's individual personal and cultural needs and paid close attention to details important to individuals living at the home.

Is the service responsive?

We saw that staff were responsive to the needs of people living at the home and the choices they made. Staff helped to identify and arrange activities which helped address the needs of people on an individual basis. People were encouraged to make decisions about their own care wherever possible. Care plans were regularly reviewed and updated to take account of needs as they emerged.

Is the service well led?

The service was led by a manager who was actively engaged with staff and proactive in the care of people living at the home. There was a strong focus on devising bespoke care and support and there were effective systems of quality control to ensure the service provided effective care.