Archived: Pathfields Lodge

Updated 4 February 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 16 and 19 November 2015 and was unannounced. The inspection was undertaken by one inspector and a specialist advisor, who was a qualified mental health and learning disability nurse and a mental health act commissioner.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also reviewed information we held about the service including statutory notifications that had been submitted to the Care Quality Commission (CQC). Statutory notifications include information about important events which the provider is required to send us by law. We also received feedback from the local authority that commissioned the service.

We spoke with six people using the service and three visiting relatives. We also spoke with the manager, the area manager, five care staff, one agency nurse and one team leader.

We reviewed the care records for four people using the service. We also reviewed four staff files that contained information about their recruitment, induction, training, supervision and appraisals. We also looked at other records relating to the quality monitoring the service.

Updated 4 February 2016

This inspection took place on 16 and 19 November 2015 and was unannounced.

Pathfields Lodge provides personal care with nursing for up to 48 people. People who use the service have learning and physical disabilities and some people who have early onset dementia. At the time of our inspection there were 35 people were using the service.

The service had been without a registered manager for over 12 months. 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. A new manager had been appointed by the provider; they had submitted a registered manager application to the Care Quality Commission (CQC), which was in progress.

Risk assessments and personal emergency evacuation plans (PEEP’s) were not always updated when people’s needs and capabilities had changed.

Records relating to the monitoring of people’s food and fluid intake did not follow the providers’ policy.

People did not always have a care plan put in place by the provider on admission to the service. Some of the care plans lacked clarity on how people’s current needs were to be met.

The quality assurance management systems were not sufficiently robust in detecting when people’s needs had changed and care plans in need of updating.

Staff employed at the service were familiar with the safeguarding and whistleblowing procedures, however qualified agency nursing staff working at the service were not as knowledgeable of the procedures.

There were sufficient numbers of staff available to meet people’s care and support needs, although there was currently a high reliance on the use of external agency staff. The staff recruitment systems ensured that staff were safe to work with people using the service.

Appropriate systems were in place to order, store, administer and dispose of people medicines. Although people who sometimes required essential medicines to be crushed did not have the method for administering medicines clearly recorded in their medicines administration record (MAR) or care plan.

Staff received regular training which provided them with the knowledge and skills to meet people’s needs. They also received supervision and support from their line supervisors.

Staff sought people’s consent before they provided care and support. All staff and management had a good understanding of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) and were knowledgeable about the requirements of the legislation.

People were treated with kindness and compassion and their privacy was respected. Their needs were assessed and their care plans gave guided the staff on how people wanted to be supported. People and their relatives were involved in the on-going reviews of their care. People’s privacy and dignity was respected. Relatives and visitors were made welcome.

People had opportunities to pursue their interests and hobbies and to choose what activities to have available at the service.

The service had a complaints procedure in place and the provider had responded appropriately to complaints.

We identified that the provider was not meeting regulatory requirements and were in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.