Archived: Lockermarsh Residential Home

Updated 22 March 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

The inspection was carried out by 2 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

Lockermarsh Residential Home 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. Lockermarsh Residential Home 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. Inspection activity started on 16 February 2023 and ended on 22 February 2023. We visited the location on 16 February 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals 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 4 people who used the service and 4 relatives about their experience of the care provided. We spoke with 5 members of staff including the registered manager and care workers. 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 a range of records. This included 5 people's care records and multiple medication records. We looked at a variety of records relating to the management of the service.

Updated 22 March 2023

About the service

Lockermarsh is a residential care home providing personal care for up to 24 people. At the time of our inspection there were 18 people using the service. Some people were living with dementia.

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

Systems in place to monitor the service remained ineffective. The governance systems failed to identify and action concerns. People did not always benefit from a positive culture which promoted person centred care.

Since our last inspection the provider had made changes to the medication system to ensure staff felt more confident. However, we continued to find medicines were not always managed safely. For example, we found concerns in relation to safe storage and recording. Protocols in place for people prescribed medicines on an as and when required basis, lacked detail.

Risks associated with people’s care were not always written in line with people’s current needs. Staff knew people well and could explain how risks were managed and we found no evidence people were harmed.

Since our last inspection the registered manager had been working with the local authority to address infection control. We found some improvements in this area, however, seating in the main lounge required attention and some storage rooms were cluttered. The provider was aware and was in the process of addressing these concerns.

The provider had a system in place to safeguard people from abuse. Staff were safely recruited. We found staff were responding to people in a timely way. However, there was no catering team, and this was impacting on the whole staff team. The registered manager was actively recruiting for these positions.

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.

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 rating for this service was requires improvement (published 5 August 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 26 June 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Lockermarsh on our website at www.cqc.org.uk.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to medication management and governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.