Hawthorne Lodge is a care home providing personal care. It can accommodate 25 older people. The home is owned by Stirrupview Ltd. The accommodation is a mock Tudor style building located in the Bootle area of Liverpool. Due to its location there is good access to public transport and many local facilities are a short journey away.
This was an unannounced inspection which took place over two days on 7 and 8 January 2015. The inspection team consisted of an adult social care inspector and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
The service did not have 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. The service has been without a registered manager since April 2014.
When we spoke with people living at Hawthorne Lodge and their relatives they told us they felt safe. People spoken with said, “I feel very settled here”, “I’m generally happy and settled here at the moment’’, “I’m very settled here now, I have no regrets about coming to live here.’’ People were observed to be relaxed in the environment. The staff we spoke with could describe how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. All of the staff we spoke with were clear about the need to report through any concerns they had.
At our last inspection in July 2014 we had found the home in breach of regulations relating to staffing. At that time, levels of care and support staff, including domestic and kitchen staff, were not sufficient to ensure people received a consistent level of care. On this inspection we asked about staffing at the home. We found that people living at the home and their relatives felt staff were more settled and delivered safe care. There was now settled staff working in the kitchen. Domestic staff hours were still under review. People spoken with felt more could be done in terms of the amount time staff spent actively engaged with people socially. We fed this back to the acting manager in terms of service development.
We looked at how cleanliness and hygiene was managed in the home. Overall we observed the home to be generally clean. We did, however, observe an example of a lack of consistency. One bedroom we saw was not clean although the person in it told us it had been cleaned earlier by care staff. We also had a concern before our inspection from a relative that ‘standards had deteriorated since the last manager left’, citing a lack of cleanliness on occasions in their relative’s bedroom. A recent audit by Liverpool Community Health [LCH] [infection control] also highlighted some issues that needed addressing.
You can see what action we told the provider to take at the back of the full version of the report.
We looked at how staff were recruited and the processes to ensure staff were suitable to work with vulnerable people. We looked at four staff files and asked the manager for copies of appropriate applications, references and necessary checks that had been carried out. We found the information required was missing or inadequate on some staff files. These did not provide adequate checks to ensure staff suitability to work with vulnerable people.
You can see what action we told the provider to take at the back of the full version of the report.
We looked at how medicines were managed in the home. We found that people were receiving their medicines but there was risk that that errors could occur. This was because some medication records were confusing and lacked clarity. The audits carried out by the staff had not identified these. There was also a lack of available policies and procedures relating to medication administration for staff to reference. We discussed these anomalies with the acting manager and staff. Staff felt that the current risk was low in terms of any medication errors as they were familiar with the people living at the home and their different medicines. We did not find any evidence that people had not received their medicines. The medication administration records did not support a safe practice however.
You can see what action we told the provider to take at the back of the full version of the report.
Some arrangements were in place for checking the environment to ensure it was safe. For example we saw some documented evidence that regular checks were made including nursing equipment and fire safety. A ‘fire risk assessment’ had been carried out and this included personal evacuation plans [PEEP’s] for all of the people living in the home.
We observed staff provide support for people and the interactions we saw showed how staff communicated and supported people in a positive manner. Staff were able to explain each person’s care needs and how they communicated these needs.
People we spoke with and their relatives told us they were happy with the access to medical support when it was needed. One person told us they had been into hospital recently for treatment and had just returned. When we looked at the person’s care file we saw the care plan had not been updated to reflect the person’s changing care needs. We discussed the need to update care plans to reflect changing care needs, so that any short term care needs could be adequately monitored. This also included details of care for people with specific medical conditions so that staff would have a more detailed reference to carry out care.
We looked at the training and support in place for staff. Following our last inspection in July 2014 we found the provider was in breach of regulations because staff morale was low and there was a lack of organised training in place. The provider had sent us an action plan which said they disagreed with the findings of the inspection and that ‘training is organised and provided to all staff’. The breach remained in place however.
On this inspection we asked for training records for staff but these were not available at this time. The manager told us they had completed an audit of staff training needs and was aware of what training was needed for staff. They said, for example, ‘’Quite a few staff needed to do infection control training.’’ We were told ‘most’ staff have completed training in moving and handling. The manager was not able to tell us whether staff had completed key training in abuse awareness and safeguarding processes. There was no overall training matrix available for the manager or staff to access. The manager said they monitored staff training through supervision. We were told all staff had attended one supervision session to date. There had been no formal appraisals carried out since the new owners had taken over the company in April last year.
Following the inspection the manager sent us a training plan for the forthcoming six months. This identified and plotted training for staff in ‘statutory’ subjects such as moving and handling, medication, safeguarding, infection control and fire awareness. In addition three staff are to undertake training with respect to the care needs of some of the people living at the home who may be living with dementia.
We asked about basic qualifications of staff which could evidence knowledge to carry out effective care. The manager told us that some staff had a qualification in care such as NVQ [National Vocational Qualification] or Diploma. All of the senior staff [four in total] had such a qualification. In total, however, out of 22 staff on the duty rota only eight had such a qualification [although three staff had recently started a course].
Staff spoken with said they felt supported by the manager and the training provided. They told us that they had had a supervision session with the manager and there were support systems in place such as staff meetings and provider representatives attended.
We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. People living at the home varied in their capacity to make decisions regarding their care. We saw examples where people had been supported and included to make key decisions regarding their care; for example when being admitted to the home, and also when reviewing care in the home. The home had a copy of the MCA Code of Practice available for reference.
We were told, at the time of our inspection, of a person who was on a Deprivation of Liberty Authorisation [DoLS]. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. We found the manager and senior staff we spoke with aware regarding the process involved if a referral was needed.
People reported that the food in the home was varied, nutritious and plentiful. They said, “The food here is good. It’s made fresh in the kitchen every day and there is enough choice of what I like for me, ‘’The food here is alright. They always offer me something I like for my main meal.’’
During the inspection we observed the lunchtime meal in the dining room. People were observed to be supported to eat and lunchtime was a pleasant and social occasion.
People living at the home and their relatives spoke well of the staff and commented that they were kind and caring. Comments included: “Yes, the staff are very good; they look after me very well”. “The staff are very kind and helpful, they are always telling me to be careful’’, “The staff here are very kind and helpful”, “The staff always treat me with respect”, “The care is fine, but it could be better with more staff”, “The staff here are really good with mum, she needs a lot of physical care and they treat her with respect and kindness.’’
Throughout the inspection we observed staff supporting people who lived at the home in a dignified and respectful way. When staff interacted with people there was warmth and staff had patience and understanding.
People told us they felt they were listened to and generally staff acted on their views and opinions. This inclusion was not always reflected in the care planning records which only gave sporadic evidence that people had been consulted regarding their care.
The majority of activities in the home centred on the daily routine and were undertaken on a communal basis. There was little evidence of a ‘person-centred approach’ [by this we mean looking at people’s preferences for activity on a more individualised basis] to the care of the people staff supported. We spoke with staff who told us that they spent time with people when they could and certain members of staff had set activities that they provided when on duty. For example karaoke, quiz and arm chair exercises. We were told these were not planned as such. We were told that previously [before the running of the home changed] there was more emphasis on planned activities with [for example] an art group up and running. We fed this back to the acting manager in terms of further development of the service.
People said they had no concerns or complaints about the home, and would either speak to the manager, or ask their relative to intercede with the manager on their behalf. People said “I have no complaints, but I’d tell my daughter if I had any worries” and “If I had any concerns I would talk to the manager, but there has been nothing major so far.’’
At our last inspection in July 2014 we found the provider in breach of regulations regarding the management and running of the home in that there was lack of formal processes to audit and monitor standards in the home and a lack of clear management direction. On the visit we checked to see if improvements had been made.
We met with the acting manager. We were told they had been in this position for approximately three months and had worked in the home as a carer for longer. We asked the acting manager about plans for further developments in the home. They said that the provider had plans to develop some of the fabric of the building but could not give any further information as to any further development of the service.
On the first day of the inspection we met with a representative of the provider and we were concerned that some information relating to health and safety had not been passed on effectively to the acting manager. The acting manager had not seen a recent infection control audit report. There was, therefore, a concern the acting manager and staff could not responded to appropriate professional and expert advice in a timely manner.
We asked the acting manager about their role and how this related to the provider in terms of areas of work and accountability. We were unable to get clear picture of this. The acting manager advised us they currently had no specific job description and was not able to identify clear parameters to their role. The role of the provider in providing ongoing support to the acting manager was also not clear. This lack of clarity impinged on the acting manager’s awareness and knowledge of the running of the home. For example, much of what we asked for in terms of regulatory requirements, policies, procedures and records could not be produced for the inspection at the time.
From the interviews and feedback we received, the acting manager was seen as open and receptive. Staff told us they received going support.
A process was in place to seek the views of people living at the home and their families so this could inform service development. A survey had been sent out in May 2014 and the results showed positive feedback.
We enquired about other quality assurance systems in place to monitor performance and to drive continuous improvement. The acting manager told us about weekly health and safety audits they had conducted but these could not be located at the time of our visit and were sent to us later by the provider. We were shown how accidents and incidents were recorded. The manager advised us these were not audited. This meant there was no assessment and analysis of these to inform any overall patterns or lessons that may need to learn for the home.
On this inspection we found there were breaches of regulations covering infection control, requirements relating to staff employed at the home and medication management. We were concerned that the home’s current auditing and monitoring of these had not effectively identified any shortfalls or improvements needed.
We found on inspection that issues requiring the home to notify the Care Quality Commission had not been made. These included an injury to a person living in the home, a person being on a DoLS authorisation and two safeguarding investigations. The acting manager said they would notify us retrospectively and would seek to review the regulations and guidance available regarding notifications.
You can see what action we told the provider to take at the back of the full version of the report.