Cepen Lodge

Updated 7 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 3 inspectors, 2 medicines inspectors 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.

Service and service type

Cepen Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Cepen Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection -This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people and 3 relatives about their experiences of care and support. We spoke with 7 staff, the registered manager and regional director. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed care records and risk management plans for 6 people, 3 staff recruitment files, health and safety records and information, meeting minutes, training information, accident and incident records, multiple medicines records, quality monitoring information and quality assurance records.

Following our site visit we spoke with a further 7 relatives and 4 members staff on the telephone. We also contacted 2 healthcare professionals for their feedback about the service.

Updated 7 December 2023

About the service

Cepen Lodge is a residential care home providing accommodation and personal care to up to 63 people. The service provides support to adults over and under 65 years, people with physical disabilities and people living with dementia. At the time of our inspection there were 47 people using the service.

Accommodation is provided over 3 floors accessed by stairs and a lift. People had their own rooms with en-suite facilities. People also had access to communal areas such as lounges, dining areas and activity rooms. Access to the secure garden was from the ground floor.

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

This inspection was carried out in response to concerns raised about staffing numbers and the impact this had on people’s care. During our inspection we observed there were enough staff to meet people’s needs. However, when staffing numbers dropped to night staff levels, we observed people living in the dementia household were left with intermittent supervision at times. We have made a recommendation about this.

Improvements had been made to risk management plans and staff were reviewing them regularly or if people’s needs changed. Where people had been identified as being at risk, there was detailed guidance in place for staff to follow.

Medicines were managed safely. Staff had received training on medicines management and had their competence checked. Regular medicines audits took place which were carried out by staff and the local visiting pharmacist. Staff kept records of where they had applied topical patches and when they were changed. However, there was no record of any checks in between applications to make sure patches were still in place. We have made a recommendation about this. Staff worked in partnership with healthcare professionals to meet people’s health needs.

Health and safety checks were carried out regularly and the provider had a programme in place to make sure equipment was routinely serviced. During our inspection we observed the provider was carrying out planned refurbishment work. Risk management plans had been shared with us prior to the work starting.

People told us they were satisfied with the cleanliness of their rooms, and we observed the home was clean. Staff had access to personal protective equipment, and we observed them using it safely. Staff told us and records demonstrated training on infection prevention and control had been provided.

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. People and relatives told us people were safe and being cared for by staff who were kind and caring. We also observed very positive social interactions between people and staff demonstrating good relationships.

There was a registered manager in post who understood their regulatory and management responsibilities. Quality assurance and monitoring systems were in place to regularly check for quality and safety in all aspects of the service. Checks were carried out at service and provider level by various staff. Any areas for development or improvement were recorded on action plans and discussed at staff meetings. Action had been taken to make required improvements and we found the management team to be responsive to feedback shared during this inspection.

Opportunities were available for people and relatives to attend meetings at the service and share views and/or concerns. Feedback from people, relatives and staff about the registered manager and management team was positive. We were told the registered manager was approachable and listened to feedback and took action to address any concerns. Staff also had regular team meetings, supervisions and appraisals and felt able to share ideas.

Staff had been recruited safely and all told us they enjoyed their work. There were various ‘champions’ appointed amongst the staff team who took the lead in different areas. For example, there was a ‘speak up’ champion who staff were able to talk with regarding safeguarding or any other concerns. There were also dementia champions who had been given additional training to develop knowledge and skills so they could support other staff.

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 (report published 23 February 2022).

Why we inspected

We received concerns in relation to staffing numbers and the impact on people’s care and support. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We found no evidence during this inspection that people were at risk of harm from this concern.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

Recommendations

We have made a recommendation for the provider to include observations of practice and seek feedback from people when reviewing staffing numbers in the evening. We have also made a recommendation about medicines monitoring.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.