Our inspection team was made up two inspectors and a specialist clinical advisor. We spoke with some of the people who used the service, the manager, the clinical lead, nursing staff, care staff and one visiting professional. We also observed staff supporting people with their daily activities.

Ami Lodge can accommodate up to 27 people. There were 19 people using the service at the time of our inspection. Most people had fractures and were experiencing reduced mobility. Many were admitted from hospital for occupational therapy and physiotherapy. The aim was for people to return home after a period of rehabilitation.

We considered our inspection findings to answer questions we always ask:

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found:

Is the service safe?

The service was safe. Practices in the service generally protected people using the service, staff and visitors from the risk of harm.

Systems were in place to make sure that managers and staff learned from accidents and incidents, concerns, complaints, whistleblowing and investigations. This reduced the risks to people and helped the service continually improve.

Each person had a care plan detailing their support and care needs. We saw that there was guidance for staff to follow to reduce risks and implements strategies to make sure people were as safe as possible.

Is the service effective?

The service was effective. People told us that they were happy with the care that had been delivered and that their care needs were met. One person we spoke with told us, “It’s lovely; it is a really nice place. They look after you”. Another commented, “The staff are very helpful”. We saw that staff were attentive to people using the service and responded promptly when needed.

Staff support was consistent and structured. We found that staff were properly trained, supervised and appraised.

People’s health and care needs were assessed with them and /or their representatives. We found that care plans were regularly reviewed to reflect any changes in a person’s needs.

Is the service caring?

The service was caring. People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People we spoke with said they felt staff respected their privacy and dignity and staff were polite and caring.

The majority of people we spoke with felt that staff responded to them in a timely manner and most people said they did not feel rushed. One person we spoke with said the staff were, “Very kind and did their best” and another commented that staff were, “Always kind and always there for me”.

Is the service responsive?

The service was responsive. People told us that they were happy with the service. One person we spoke with said that carers attended promptly to their needs. It was clear from observations and from speaking with staff that they had a good understanding of the people's care and support needs.

We saw records to show that the service worked closely with health and social care professionals to maintain and improve people's health and well-being.

People knew how to make a complaint if they were unhappy. They told us that if they had any concerns they would speak to the manager. They were confident that their complaint would be taken seriously and acted on. We looked at some of the complaints that had been received by the service and found that responses had been open, thorough and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service was well led. There was a clear management structure in place and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities and that they felt supported by the management team. Systems were in place to ask people who used the service, relatives and staff for their views about the service.

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Ami Lodge is operated by Raj & Knoll Limited. The service has 28 beds. The building for Ami lodge was not purpose-built and had been modified to provide rehabilitation care. Ami Lodge is split over two floors, has 27 rooms and can accommodate 28 patients. All rooms with the exception of four, has ensuite facilities.

The service provides rehabilitation and support for patients in a residential setting who have just come out of hospital. This service is commissioned by a local NHS trust.

We inspected this service using our comprehensive inspection methodology.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated the service as inadequate overall.

• The service did not have managers at all levels with the necessary experience, knowledge, and skills to lead effectively, and provide high-quality sustainable care. Managers were not always aware of the risks, issues and challenges in the service. Leaders are not always clear about their roles and their accountability for quality.

• The service did not proactively identify where quality improvements could be made to the service and to patient care.

• The service did not have a clear governance structure. There was a lack of clarity for roles and responsibilities and a lack of accountability to support good governance. We found limited structures, processes and systems in place to support the delivery of good quality, sustainable patient care.

• The service did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

• The service did not routinely collect, manage and use information to support all its activities.

• The service did not always manage patient safety incidents. The service did not have an incident reporting policy. The service lacked organisational learning, and made no changes to issues identified from incidents.

• Patients were not adequately monitored for the risk of deterioration. We found the service did not learn from patient transfers and therefore did not make improvements to the service as a result.

• The service did not have a clear or formal eligibility criteria to admit people to Ami Lodge from the commissioning NHS trust.

• Staff did not consistently keep appropriate records of patients’ care and treatment. Records were not always legible, and there were gaps in the documentation. Nursing records were kept separately to the main patient records.

• Safety checks provided false assurance, as they were not fully accurate or contemporaneous.

• The service did not formally collect safety performance data. The service did not discuss safety data in meetings or use it to drive improvements to the service or patient care.

• The service provided mandatory training in key skills to all staff but did not ensure everyone completed it. The data provided to us showed that staff had only achieved the completion target of 80%, on two out of 15 occasions.

• There were processes to protect patients against cross infection. However, these systems were not always effective. There were limited formal systems for monitoring staff compliance with infection prevention and control practices.

• The service did not have systems that monitored the effectiveness of care and treatment. Information about the outcomes of patient’s care and treatment was not routinely collected and monitored.

• There was a lack of auditing to ensure compliance with policies and clinical practice. Audits that were in place, either lacked an action plan or where action plans were available, there were no timescales or people accountable for making sure the actions were implemented.

• The systems and processes for policy development and review were not effective. We found that some policies either did not have a review date or were out of date.

• The service did not have an adequate process to ensure people’s concerns and complaints were listened to and used to improve the quality of care. Complaints were not monitored over time, and the managers did not monitor complaints for trends and themes, or to identify areas of risk.

However, we found the following areas of good practice:

• Staff cared for patients with compassion. Feedback from patients confirmed staff treated them well and with kindness.

• Staff provided emotional support to patients to minimise distress. Staff were on hand to offer emotional support to patients and were very happy to offer a listening ear. Patients told us they felt able to approach staff if they felt they needed any aspect of support.

• Staff involved patients and those close to them in decisions about their care and treatment.

• Patients told us they were kept informed and included in their care decisions and treatment.

• Patients told us they were given time, could ask questions, and felt included in the decisions about their care.

• There were systems and processes to assess, plan and review staffing levels at the location, including staff skill mix.

• Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse, and they knew how to apply it.

• The service gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.

• Staff gave patients enough food and drink to meet their needs. Nutritional assessments were completed on admission.

• Staff monitored and assessed patients regularly to see if they were in pain. Patients told us that staff would ask them regularly if they had pain, and would offer pain relief medication.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide care. Staff respected their colleague’s opinions.

• The service took account of patient’s individual needs.

Nigel Acheson

Deputy Chief Inspector of Hospitals