Shore Lodge - Care Home Learning Disabilities

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At this assessment we found there continued to be a breach of regulation relating to consent and the warning notice had not been met. There had been a decline in the quality of care and support people received. Staff still did not understand their role in recording how decisions had been made when people did not have capacity. Staff continued to not follow the principles of the Mental Capacity Act 2005. There had been no improvement in the assessment of people’s needs and review of their care plans.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they understood what people’s needs were, but we found evidence that only physical needs were being managed. People’s emotional needs were rarely considered and if they had communication needs staff did not try alternative communication methods to ensure they were able to make their wishes and feeling known.

People had personal care plans however these were not up to date or regularly reviewed. There was no evidence that people’s assessed care needs were known by staff. Following serious incidents between people living at the service, updates to people’s needs were not completed or recorded which placed people at risk of harm as staff did not have all the information necessary to provide good and safe support.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

Staff told us they asked for consent when supporting people and giving them choices regarding food, or clothing. However, staff did not understand people’s ability to make decisions for themselves. The staff who had completed mental capacity assessments did not provide enough details to ensure the assessments were accurate and reflected people’s wishes.

Following the previous assessment, CQC issued a Warning Notice regarding mental capacity assessments. We found no improvement at this assessment. Records of peoples’ ability to decide for themselves lacked detail and we were not assured the assessments had been fully completed, the dates of assessment were not clear, and the principles of the Mental Capacity Act 2005 were not followed. The provider’s service improvement team had recorded that mental capacity assessments were updated, and relatives and others were involved to agree decisions taken in people’s best interest, however records did not show appropriate involvement. There were significant delays between the recorded assessment and consultation with people’s loved ones. For example, one person had 13 mental capacity assessments completed in 1 day. The person’s representative was not involved until almost 3 months later. This questioned the validity of the assessments and best interest decision making process or that staff and people’s representatives were acting in their best interest.