Beech Lodge – Thames Ditton (Beech Lodge) is a care home providing accommodation and personal care for up to nine people with learning disabilities and mental health needs. There were eight people living at Beech Lodge at the time of our visit.

The inspection took place on 17 November 2016 and was unannounced.

The service had a registered manager. 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.

We previously carried out an unannounced comprehensive inspection of this service on 15 November 2015. At that inspection, seven breaches of legal requirements were found in respect of the effectiveness of staffing, safe care, cleanliness of the service, the provision of person centred support, treating people with dignity and governance. As a result the service was rated Requires Improvement and seven requirement actions for the service to improve were set. Following that inspection, the provider sent us an action plan which identified the steps they intended to take to make the required improvements. This inspection found that the provider had taken the action they told us they had in respect of each of these areas and as such each requirement action had been met.

The culture and leadership of the service had significantly improved since our last inspection. The management team and provider had responded positively to the changes that were needed and worked hard with staff to improve the way people were supported and the service was run. Monitoring systems had been embedded which had enabled the service to self-develop and operate in accordance with the principles of reflective learning.

People were now placed at the centre of the service and received a more personalised level of support that was responsive to their individual needs. People were actively involved in making decisions about their care and encouraged to lead fulfilling lives and reach their maximum potential.

People were supported to maintain good health. The service worked in partnership with other health care professionals to ensure people kept healthy and well. People had a good range of nutritionally balanced meals and were supported to follow dietary advice given to them. Medicines were managed safely and there were good processes in place to ensure people received their medicines as prescribed.

There were systems in place to ensure staff were safely recruited and suitable to work with people whose situation and needs made them vulnerable. Staff were better trained and supported to work with people and understood their specialist needs. A new local office facility had enabled staff to attend face-face training and discuss ways of working in a more open and proactive way.

The way staff were deployed better suited the needs and interests of people and provided greater opportunities for people to take part in more individualised activities that were meaningful to them. People were now more engaged with their daily lives and spent their time doing things that both interested and developed them.

Positive role modelling and coaching from the management team had improved the way staff interacted with people. Staff took active steps to promote people’s privacy and dignity and provide support to people in a genuinely caring and empathic way. People felt listened to and their concerns were acted on.

Risks to people were managed in a proactive and enabling way. People were supported to understand risks so that they could develop their independence. Environmental risks were now appropriately assessed and actioned safely. Significant work had been undertaken to comply with the requirements of the fire service. Similarly, standards of maintenance and cleanliness across the serv

Beech Lodge – Thames Ditton is a care home providing accommodation and personal care for up to nine people with learning disabilities and mental health needs.

The inspection took place on 10 November 2015 and was unannounced.

The home did not have a registered manager. 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 current manager had been working in the home since June 2015 and was in the process of applying to be registered.

We found that people were placed at unnecessary risk because hazards in respect of the environment and fire safety had not always been appropriately managed. For example we found that fire exits were not always kept free from obstruction and there were not adequate plans in place to demonstrate how people would be safely evacuated in the event of a fire. We reported our concerns to the local fire safety who visited and conducted their own inspection which resulted in requirements being made under The Regulatory Reform (Fire Safety) Order 2005.

The home was unclean and some areas were in need of refurbishment. Whilst a part-time cleaner was employed, the majority of cleaning was left to the people who lived there and they received minimal support and supervision in respect of this. Our shoes stuck to non-carpeted floors as we walked around the home and surfaces in communal areas were sticky to touch. In some of the bedrooms, people’s shelves and units were thick with dust and sinks heavily stained. Communal toilets were soiled and unpleasant to access.

Whilst people received most of their medicines as prescribed, the systems in place for checking medicines were appropriately disposed of had failed. We found a number of stock medicines that were out of date and other items that had been opened and not discarded after use. There were no guidelines in place for the use of homely remedies such as paracetamol and cough medicines despite there being a stock of these being held. People were otherwise supported to maintain good health and had regular access to a range of healthcare professionals.

Staffing levels were sufficient to meet people’s needs, but were not always deployed appropriately. Not all staff had the specialist skills and experience to support people effectively. The training programme in place for staff did not include key areas such as how to support people with mental health needs. The result of this was that some staff did not engage appropriately with people and motivate them to participate in meaningful activities.

Care plans were personalised and well documented, but were not always followed in practice. Staff were not always good at instinctively giving people choice and control over their lives. For people who did not have their own aspirations, there was a lack of engagement and development.

Staff took appropriate steps to maintain people’s privacy and dignity and were respectful of their personal space and belongings. The language used in supporting some people with behaviour that challenges was not always respectful. One person told us that they felt they were sometimes treated as child and we heard other people talking about the need to be “Good” or “Quiet.”

There was choice in respect of mealtimes, but this was offered reactively rather than as a matter of course. Whilst people had the capacity and ability to make their own decisions about meals, they felt obliged to seek permission or were heavily supervised in the process. It was not clear how the staff supported people to maintain a sufficiently varied and balanced choice of meals. We have made a recommendation to the provider about this issue.

The provider had a range of audit tools in place, but these were not always effective in identifying quality issues within the home. The manager was seeking to effect change as a result of concerns raised in a recent survey completed by people, but more was needed to provide adequate leadership and development to staff.

Appropriate checks were undertaken when new staff were employed and staff understood their safeguarding responsibilities. People’s legal rights were protected because staff routinely gained their consent and understood that each person had the capacity to make decisions for themselves.

Equality and diversity was managed well and people were supported to follow their own religious and cultural preferences. We saw that people who wished to attend church were supported to so and consideration was given to the attendance at religious festivals and carnivals.

We found a number of breaches of regulations. You can see what action we asked the provider to take at the back of this report.

This was a follow up inspection to ensure that the provider had taken action following our inspection in April 2014. During that inspection we found a shortfall in the outcome related to quality monitoring. The provider had failed to address shortfalls identified in the questionnaire that people who used the service had completed. The newly appointed manager had not seen the questionnaires and was not aware that there were shortfalls.

Since our inspection the provider had distributed a new questionnaire and an action plan had been completed.

Our inspection of this care home helped answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People are treated with respect and dignity by the staff. People told us they felt safe.

The service was clean and hygienic. Equipment was maintained and serviced regularly therefore not putting people at unnecessary risk.

The manager maintained the staff rotas, they took people’s needs into account when making decisions about the numbers, qualifications, skills and experience of staff required during the daytime shifts.

The emergency plan was not available to us on the day of inspection. It had since been made available to us via email.

Is the service effective?

There was an advocacy service available if people needed it. This meant that when required people could access additional support.

People’s health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. People we spoke with all commented, “The staff were very kind to us.” One person said “The staff are beautiful.”

People who used the service completed an annual satisfaction survey. Where shortfalls or concerns had been raised, these had not been addressed. The manager was unaware of the survey or shortfalls.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

We have asked the provider to tell us what they are going to do to meet the needs of the people who used the service related to their comments in the annual survey.

Is the service responsive?

People completed a range of activities in and outside the service regularly. The home shares a company minibus, which helps to keep people involved with their local community.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. Reviews by social services for people who used the service are currently underway. For those that had taken place we saw that the completed review documents were available in people’s care plan folders. We saw evidence to show people had contributed to the reviews.

We reviewed the service’s quality assurance records which demonstrated that identified shortfalls from the previous inspection had been actioned. As a result the quality of the service was continuingly improving.

This was a follow up visit to review improvements related to the environment; home manager recruitment and the arrangements for training and supervision for staff. During the inspection we identified a shortfall with the provision of night staff cover and a lack of risk assessments for people to cover night arrangements.

People who used the service were happy to speak with us. People confirmed they liked living at the home and that the staff were kind to them. We were told about the lovely Christmas that they had enjoyed in the home and their lunch was cooked well.

We spoke about staffing with the manager who told us they provided one member of staff who would sleep overnight at the home with no waking staff. There were no risk assessments in place that detailed night arrangements when the staff member was asleep.

We found that the provider had not completed a written refurbishment plan. This would allow CQC to see future plans for the home. We saw that no further work had taken place since our last visit in October.

We saw records that showed us training had now taken place and other training had been planned for the year. All staff had benefitted from a supervision session in December 2013.

We found that records held by the home were not up to date.

The provider had recruited a home manager. It was confirmed by him that the registration process had begun.

This was a follow up visit to check whether the provider had taken the action needed to ensure that they were meeting standards of safety and suitability of the premises. We also checked whether people were cared for by staff who had received adequate training and support following our previous visit on 2 August 2013.

We spoke with people who said they were happy and they liked some of the changes, such as the new bathrooms. We saw that there were improvements to the premises but some areas were still in need of improvement, for example the toilets on the first floor.

Staff told us that they felt well supported and enjoyed their work. However, we saw that although supervision and appraisal had improved, some staff had not received the essential training required to carry out their work safely.

The service still did not have a registered manager in place although we were given assurance that a new manager had been appointed.

There were nine people at the home when we visited.

We spoke with three staff during and four people who used the service and carried out observations throughout our visit.

People told us that they were treated with respect by the staff and expressed satisfaction with the staff and with the support that they received.

People told us that they were well cared for. One person said “The staff support me.” Another person said “I love it here.”

People were happy with the meals and the choice of food and were involved in selecting what to eat.

The service was in the process of upgrading the home, but there were some areas that were unsafe and unsuitable for people’s needs. For example, the ground floor bathroom.

Staff told us that they felt well supported and enjoyed their work. However, we saw that staff were not regularly supervised and saw that some training was overdue.

There were nine people living at the home when we visited. During our visit we spoke with five people and also made observations throughout the visit.

People who used the service were very positive and told us they were treated with respect. Each person commented that they were happy to live at the home. One person said “I like it here.” Another person said “I feel very happy here.”

People we spoke with told us that they had good relationships with staff and made positive comments about staff.

People told us that they felt safe in the home and were able to talk to staff if they had concerns. They told us that they felt involved in the decision making in the home and some people said that they had participated in regular meetings about the running of the home.