Archived: Lake and Orchard Residential and Nursing Home

Lake and Orchard Residential and Nursing Home is a care home providing personal and nursing care to 47 people aged 65 and over at the time of the inspection, including those living with dementia. The service can support up to 90 people.

The care home accommodates people across two separate units each has separate adapted facilities. At the time of our inspection, the provider was not using one of the units.

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

The provider had failed to make and sustain improvements following the last inspection. The service did not provide a good level of safe care for people. People were at risk of avoidable harm because risks were not recorded accurately, monitored or managed. People were not safeguarded against the risk of abuse. Staff had not identified or raised concerns we identified in relation to administration of medicines, people’s care, including pressure area care. We raised safeguarding concerns for three people as a result of the inspection, as we could not be sure their care had been managed appropriately and sufficient action put in place to keep them safe.

Health and safety was not well managed. This put people at risk of potential harm. Sufficient planning and preparations had not been made to support the safe evacuation of people in the event of a fire. We contacted the local fire service to request a visit to the service and support the provider.

Medicines were not managed safely. We could not be sure people received their medicines as prescribed. Medicines were not always returned to the pharmacist when no-longer required.

There were not always enough staff to give people the care and support they needed. The provider had not staffed the service in-line with people’s assessed dependency levels.

Audits were ineffective. They had not identified the issues we found, including with health and safety and staffing. The provider had not always worked openly and acted on requests made by the Care Quality Commission (CQC).

People had been moved to a different unit in the service or in some cases, moved floors without consultation. The moves were poorly planned and carried out, causing significant distress and upheaval for people. People, relatives and staff feedback about this experience was negative.

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 overall rating for this service was requires improvement (report published 16 March 2020). 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 not enough improvement had been made and the provider was still in breach of regulations. The service has been rated requires improvement or inadequate for the last eight consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about management of people’s pressure areas, catheter care, medicines and care needs. A decision was made for us to inspect and examine those risks. We carried out a focused inspection to review the key questions of safe and well-led only.

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. Rating from the previous comprehensive inspection for those key questions were used in calculating the overall rating at this inspection.

The overall rating for this 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.

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 as 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 person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, good governance and staffing.

Because of the serious concerns relating to people's welfare and safety we have taken enforcement action to prevent the provider from operating a regulated service at this location.

Lake and Orchard Residential and Nursing Home is a residential care home providing personal and nursing care to 45 people aged 65 and over at the time of the inspection. The service can support up to 90 people.

There are two separate units within the home divided into nursing care and residential care. At the time of our inspection, the provider was not using one of the units.

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

People remained at significant risk of unsafe care. The provider had failed to make changes following previous inspections. There was limited or no action to improve the safety of people. People did not always receive adequate nutrition and hydration, putting their health at risk. Pressure area management was not effective to prevent people’s skin integrity breaking down. The provider had failed to learn from people’s previous experiences of care and safeguarding concerns to prevent reoccurrences.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last overall rating for this service was inadequate (report published 19 August 2020). 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 not enough improvement had been made and the provider was still in breach of regulations. The service has been rated requires improvement or inadequate for the last eight consecutive inspections.

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about people’s eating and drinking, skin integrity, infection control and staffing. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

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.

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.

After our inspection of 22 July 2020 we took action to prevent new admissions without the express written approval of the CQC.

We have identified breaches in relation to safe care and treatment, safeguarding, premises and equipment and staffing.

Because of the serious concerns relating to people's welfare and safety we have taken enforcement action to prevent the provider from operating a regulated service at this location.

Lake and Orchard Residential and Nursing Home provides nursing and personal care and support up to a maximum of 90 people. There are two separate units within the home divided into nursing care and residential care. At the time of our inspection, the provider was not using one of the units. At the time of this inspection 27 people were accommodated.

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

Despite service users with more complex having moved to alternative accommodation, we continued to identify risks relating to service users’ nutrition and hydration needs being met, poor pressure area care, failure to provide effective personal care, poor moving and handling practices, inadequate infection prevention and control and failure to support people appropriately to manage their health conditions.

For more details, please see the full report which is on the Care Quality Commission's (CQC) website at www.cqc.org.uk

Rating at last inspection and update:

The last overall rating for this service was inadequate (report published 19 August 2020). There were multiple breaches of regulation. We took action to require the provider to seek the express written permission of the Care Quality Commission (CQC) for any new admissions to the home. At this inspection not enough improvement had been made and the provider was still in breach of regulations. The service has been rated requires improvement or inadequate for the last eight consecutive inspections.

Why we inspected

We undertook this targeted inspection to check on specific, ongoing concerns we had about people’s eating and drinking, skin integrity, infection prevention and control and staffing. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

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.

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 safety, staffing, cleanliness and maintenance of the premises and safeguarding of people from abuse at this inspection.

Because of the serious concerns relating to people’s welfare and safety we have taken immediate enforcement action to prevent the provider from operating a regulated service at this location.

Lake and Orchard Residential and Nursing Home is a care home providing personal and nursing care to 64 people aged 65 and over at the time of the inspection, including those living with dementia. The service can support up to 90 people.

The care home accommodates people across two separate wings, each has separate adapted facilities. One of the wings specialises in providing nursing care.

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

People did not receive good quality care. The provider had failed to make improvements and act on recommendations made by professionals following the last inspection. We met with the provider during this inspection to outline the improvements required and to seek assurances of their commitment to making improvements at this service.

We found no evidence people had been harmed but they were at risk of avoidable harm due to the ineffective governance arrangements in place. For example, risks, accidents and incidents were not always managed and monitored effectively to keep people safe and prevent reoccurrences. Medicines were not managed safely due to shortfalls in administration arrangements and records. The environment had not always been properly cleaned and maintained to keep people safe and prevent infection. Care records did not always show checks, including pressure area checks, had been completed to evidence people’s care needs were being met. Improvements were needed to records kept about people’s care and support.

People’s needs were not always met in a timely, responsive way because the provider had not ensured sufficient staff were on shift. Staffing arrangements did not support the delivery of high-quality, dignified care. Feedback from relatives and observations showed us there were times when people had to wait extended periods for support. For example; people did not always receive timely or effective support to eat and drink. The provider reviewed their staffing levels following our inspection and agreed to increase staffing levels.

People were not always offered choices about their care. Family members were not always involved in the care of their relatives. People were therefore not supported to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were not always suitably trained or supported to meet people’s needs. For example; staff needed more knowledge in end of life care. All of the staff we met were motivated to provide the best care possible for people and felt frustrated that they were not able to deliver the care and support in a more person-centred way because of the poor staffing levels. The provider’s responsiveness following inspection and commitment to increase staffing levels should enable staff to work in a more person-centred way.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (report published 8 February 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last seven consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to person-centred care, safe care and treatment, premises and equipment, good governance and staffing. Please see the action we have told the provider to take at the end of this report.

The provider had also failed to ensure statutory notifications were submitted to the CQC. This is a breach of regulation Full information about CQC's regulatory response to this is added to reports after our process outside of inspection has been concluded.

Follow up

We wrote to the provider to request an improvement plan to address the shortfalls we found on inspection. We will meet with the provider after publishing this report 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.

Lake and Orchard Residential and Nursing Home is registered to provide residential and nursing care for up to 99 older people who may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Accommodation is provided across two units ‘Lake’ and ‘Orchard’, both spread across two floors. Lake provides residential care, whilst Orchard provides nursing care. Both units support people who may also be living with dementia. At the time of our inspection, there were 61 people using the service; 30 people living on Lake and 31 people living on Orchard.

The registered manager had left the service shortly before our inspection. A new manager was in post who told us they were going to apply to become the registered manager. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A ‘peripatetic manager’ had also been working at Lake and Orchard Residential and Nursing Home since our last inspection and they were supporting the new manager during their induction period. The management team were also supported by a regional area manager and two deputy managers; one who worked on Lake, and one who worked on Orchard.

At the last inspection completed in April 2018, we rated the service requires improvement overall with inadequate in well-led. We identified three breaches of regulation relating to person-centred care, staffing and the governance of the service. Following the inspection, we met with the provider and asked them to take action to make improvements, and this action has been completed.

Work was ongoing to improve the service. Significant progress had been made since our last inspection, but further improvements were needed to achieve a good rating.

Sufficient staff were deployed, but improvements were needed to the way staff were organised, supervised and deployed at busy times and to support with meals on Orchard.

There remained some inconsistencies in staff’s approach. Some staff did not always offer people choices and worked in a more task orientated way. Greater supervision and leadership was needed to monitor and address these inconsistencies and to promote good person-centred care.

Areas of the service were tired, worn and in need of redecoration. There were other environmental and maintenance issues throughout the service that needed to be addressed. The manager and peripatetic manager were aware of these issues and outlined the plans in place to address this. Renovation work was taking place at the time of our inspection to improve the dementia nursing unit, but further improvements were needed.

The overall rating for this service is ‘requires improvement'. Whilst this is the sixth consecutive time the service has been rated inadequate or requires improvement overall, the continued improvements and trajectory showed positive leadership. The provider had made significant progress since the last inspection and was now compliant with the fundamental standards of quality and safety. This progress demonstrated an ability and ongoing commitment to improving the service. We will continue to work with the provider to monitor progress and support improvement to achieve at least a good rating overall.

We received positive feedback about the new manager and the positive impact and changes being made. The provider was embedding a more robust system of audits.

Staff were safely recruited. They were trained to recognise and respond to safeguarding concerns, and told us they felt confident the new manager would listen and respond to any concerns they had. Risk assessments were regularly reviewed and updated. They contained relevant information about risks and how these should be managed. The manager was developing systems to help audit accidents and incidents to identify patterns and trends. Medicines were managed safely.

Staff completed regular training. We received mixed feedback about supervisions. Work was ongoing to embed a system of regular supervision and appraisals.

The food provided looked and smelt appetising. Staff weighed people regularly and worked with professionals to make sure people’s nutritional needs were met.

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. Staff had taken appropriate steps to assess people’s mental capacity and make best interest decisions when necessary. Appropriate applications had been made to deprive people of their liberty.

People gave positive feedback about the kind and caring staff who supported them. Staff encouraged people to maintain their independence. They understood the importance of treating people with respect and worked to maintain people’s privacy and dignity.

Care plans contained more person-centred and detailed information to guide staff on how best to meet people’s needs. They were regularly reviewed and there were systems in place to make sure staff had up-to-date information as people’s needs changed.

Improvements had been made with activities and there were more opportunities for meaningful stimulation.

People told us they felt able to raise any issues or concerns. Action had been taken to respond to complaints about the service.

Lake and Orchard Residential and Nursing Home is registered to provide residential and nursing care for up to 99 older people who may be living with a physical disability or dementia. The service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service is purpose built and accommodation is provided in two units ‘Lake’ and ‘Orchard’ spread across two floors. Lake provides residential care; Orchard provides nursing care. Both units support people who may also be living with dementia. At the time of our inspection, there were 59 people using the service; 24 people were living on Lake and 35 people were living on Orchard.

The service had a registered manager. They had been the registered manager since February 2018. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported by a regional area manager and two deputy managers; one worked on Lake, the other worked on Orchard.

At the last inspection in January 2017, we rated the service Requires Improvement overall. We identified four breaches of regulation relating to safe care and treatment, premises and equipment, staffing and the governance of the service. We asked the provider to take action to address our concerns. At this inspection, we identified ongoing concerns about the quality of the care and support provided.

Staff did not consistently provide safe support with moving and handling. Care and support was not always person-centred and staff did not always provide effective care to meet the needs of people living with dementia. The care and support provided on Orchard was task-based. At times there was little or no interaction, activity or meaningful stimulation for people. Records did not evidence people were regularly engaged with meaningful activities.

Staff profiles and records of induction were not always available for the agency staff who worked at the service. The provider requested updated information to ensure agency profiles listed the correct dates of training completed, included previous experience and confirmed their professional qualifications and registration were up-to-date. Permanent staff raised concerns about the impact of using agency staff. Agency staff lacked supervision and direction and did not consistently provide safe, effective or caring support to meet people’s needs. This showed us sufficient numbers of suitably skilled and experienced staff had not been deployed to meet people’s needs.

Records were not always well-maintained. Care plans were not always kept up-to-date and did not consistently provide clear person-centred information about how people’s needs should be met.

Whilst some improvement had been made and the breaches of regulation relating to safe care and treatment and premises and equipment had been met; this was the fifth consecutive time the service has been rated Inadequate or Requires Improvement overall. It was the third consecutive time we have found breaches of one or more regulation. This showed inadequate governance. The provider had not operated effective systems to monitor and improve the quality and safety of the service. It showed a failure to provide a consistently good service to meet people’s needs.

There was a new breach of regulation relating to person-centred care and continued breaches of regulation relating to staffing and the governance of the service. You can see what action we told the provider to take at the back of the full version of the report. We will also meet with the provider and commissioners to address the ongoing concerns about the care and support provided at Lake and Orchard Residential and Nursing Home.

We made a recommendation about further developing a dementia friendly environment.

Medicines were managed safely, although improvements were needed to the records relating to medicines prescribed ‘when required’ and topical medicines such as creams.

The home was clean and well-maintained. Checks were completed to ensure equipment was safe to use. Action was taken to minimise the risks associated with a fire.

Some people told us staff were caring. There were inconsistencies in the caring support staff provided. Some staff provided kind, compassionate and very caring support to meet people’s needs. However, staff did not consistently involve people in decisions. The support provided was not always caring and dignified.

People provided positive feedback about the food and staff supported people to ensure they ate and drank enough. Consent to care was sought in line with relevant legislation and guidance on best practice.

Staff received regular supervisions and annual appraisals.

The provider had a system to manage complaints.

Lake and Orchard Care Centre offers accommodation for up to 99 older people living with dementia and/or with a physical disability requiring nursing or rehabilitation services. The centre is divided into two units named Lake and Orchard. There were 64 people resident on the day of our inspection: 42 people in Orchard and 22 in Lake.

We last inspected this service on 9 and 10 November 2015 and found a breach of regulation in relation to the management of medicines. We asked the provider to take action to make improvements and this action had been completed.

At this inspection we identified that risks to people's health and safety had not always been identified and managed, there were not enough staff working at the service, the environment did not meet people's needs and the systems in place for monitoring the service were not consistently effective. You can see what action we told the provider to take at the back of the full version of the report.

The perimeter fence was not secure on day one of the inspection but this was made safe the same day.

Risks to people's health had not always been identified which could have resulted in harm.

There was a registered manager employed at this service at the time of the inspection. They have since made an application to have their registration removed and no longer work at the service. 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 had employed a second manager for the Orchard unit. This person had started work at the service following their induction several weeks prior to the inspection. The registered manager was not available for this inspection and so the manager of Orchard and the regional manager made themselves available throughout the two days.

The risk of infection was minimised for people who used the service because staff were using appropriate measures to monitor and clean the service.

Safe recruitment procedures were in place to ensure suitable staff were employed to work with people at the service. There were not sufficient staff to meet people's needs. The registered provider has already reviewed this and was making changes to meet the needs of people at those times.

Accidents and incidents were recorded, analysed and trends identified.

Medicines were managed safely.

The service had only minimal signage in place to encourage people to find their way around. Although some people's bedroom doors were personalised the service had more to do in order to make the service fully dementia friendly.

Staff knew the people they cared for and were well trained. They worked within the principles of the Mental Capacity Act 2005. Deprivation of Liberty Safeguard (DoLS) authorisations had to be resubmitted in order to ensure that people were not being detained without authorisation.

People's nutritional needs were met.

The service was caring. From our observations during the day, we saw that staff knew people well and saw that staff approached and spoke with people kindly and with respect. Staff lacked expertise and confidence when caring for one person because of their very complex needs. Staff were supported by the community mental health team and the care coordinator from the local authority was aware of this person.

People received compassionate care at the end of their life.

Care plans were person centred and were regularly reviewed. Activities were provided. A new activity person was joining the team which would allow more time to be spent providing activities for people and reduce the risk of social isolation.

There was a complaints policy and procedure and people knew how to make complaints.

There was a quality assurance system in place, which used audits in each area of the service so that there was a consistent approach to improvement. Some areas had not been identified. The manager made plans to deal with each issue as soon as we highlighted them.

Staff were happy in their work and were positive about the support they received from management.

The service worked with health and social care professionals to improve the outcomes for people at the service. They had links to other organisations for support and networking.

People we spoke with told us they were satisfied with their care and treatment. We looked at their care records and found they accurately outlined the support people needed.

We spoke with staff and they were knowledgeable about the people they were supporting. We observed interactions and saw that people were treated with dignity and respect on every occassion.

We spoke with several people who used the service and they told us that staff always helped them when they needed assistance. One person said 'The girls can be cheeky but I like that'. Another person told us 'They look after me ok'.

We looked at the systems in place for the safe handling of the medicines and found that people were receiving their medication in line with the prescriber's instructions.

Although people we spoke with told us they were satisfied with their care and treatment we found inconsistencies between some people's care plans and the care and support that they received.

People we spoke with told us they felt safe at the service. We saw that where there were any concerns regarding the safeguarding of adults appropriate referrals had been made to the local safeguarding authority.

We spoke to three people who used the service about the support with medicines that they received from staff. One person said 'I think they are very good here'. Another person said 'They are not bad you know. Sometimes they forget to give my medicines'. A third person said 'I get well looked after. I am better than I was'. One person's relative said, 'I have seen them being given tablets. I have seen this regularly.' Overall we found medicines were not always safely handled and improvements were needed.

Staff we spoke with told us they felt supported. The introduction of a new training programme prevented us from making a judgement about the current training completed by staff.

We saw that systems were in place to monitor the quality of service provision.

We found that work had started on improving levels of involvement in planning care but this was still underway and was not being monitored. We found that there were improvements in staff interactions and general wellbeing of the people who used the service.

We looked at care plans and various types of assessments and saw that these had been started but were not yet completed.

Previously we had identified some issues with infection control previously and that the home had tackled these issues since the last inspection. They had made improvements in both the cleanliness and hygiene of the home and also in the monitoring and audit of these areas.

We found that there had been limited progress in the general quality assurance undertaken at the home and this still required work.

We observed care to help us understand the experience of people who we could not talk to us directly about their experiences at the home. We spoke with staff and with healthcare professionals about the care and well being of people who used the service. We also gathered evidence of people's experiences of the service by reviewing care records and quality assurance documentation.

We found that although the home had systems in place these were not effective in promoting people's safety and welfare.