Shore Lodge - Care Home Learning Disabilities

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At this assessment we found there were continued breaches of regulation relating to safe care and treatment. The provider had failed to act on the warning notices issued following our last assessment. People continued to be at risk of harm and had not been kept safe from physical harm. The provider had failed to investigate thoroughly and act on incidents and accidents, to keep people safe and reduce risk. There had been no improvement in the level of support people were receiving. Staff training had not been improved and staff did not always have the skills to support people safely. Safeguarding concerns had not always been identified and reported. The provider had started to make some improvements to the environment.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they were not always safe at the service. When people did verbalise their needs they were not always listened to and the needs of staff and the service were put first. A person had recently moved to a bigger room, they said, “I went through hell getting that room. I’ve got room for my chair now”. This was raised by the person at the last assessment. We were told by an anonymous whistle blower that the person had continued to ask to move to a bigger room and was told they could not as an interim manager was staying in there while they were working in the service. We told a senior manager about this before the assessment visit. Staff told us the person had been told not to keep asking as the room was in use and were told if they kept asking, they would be given notice to leave. The person said to us during our assessment visit, “I don’t want to go to a down and out home”.

We did not see any changes in some staff’s approach to people even though we had raised concerns during our last assessment visit. We had to raise our concerns again at this assessment visit. Although some staff told us there had been some positive change since the last assessment visit, such as having a permanent manager now, other staff did not think positive changes had been made. Some staff said although the registered manager had returned to work, they were not able to make any changes as “their hands are tied”. Some staff told us there continued to be a poor culture among staff, who did not raise concerns or report incidents and did not treat people in a caring way.

Robust systems were not in place to ensure that incidents were reported and used as an opportunity to learn and improve. When incidents occurred, the documentation of the incident was poor, and was not always fully reflective of what happened. The provider could not be assured all incidents were reported by staff and could not be assured of the accuracy of incident reporting. The registered manager told us they did not think the account given by staff of a recent incident where a person had slipped from their wheelchair had been accurate. The registered manager had requested CCTV be installed in communal areas to provide assurance of people’s safety. The registered manager told us the provider had not agreed to their request. Records used when people had experienced distress, to record what led up to the incident, how the person had been supported and the outcome, had not been monitored to provide information to update people’s care plans and risk assessments and to learn lessons to prevent further occurrences. Care plans and risk assessments had not been updated following incidents. This placed people at risk of avoidable harm.

Staff told us they now supported people when they were receiving care in hospital, however, staff and leaders did not support people to access the care they needed, or as advised by healthcare professionals, such as oral health care, providing the correct, safe equipment, or appropriate health checks. There was a reliance on external bodies to prompt changes to people’s care based on their changing needs.

Healthcare professionals involved in supporting people living in the service continued to tell us staff were not pro-active in getting the best care for people. GP’s had previously carried out annual healthcare checks with people over the telephone or video link. Most people were not able to verbally communicate or use a telephone or computer camera, which meant they could not fully take part in the appointment. Staff had not provided advocacy to change this arrangement. People were undergoing annual health checks during this assessment. This time, the GP was visiting people in their home, face to face.

People’s care records had not changed in relation to how staff supported people to access the appropriate health care and how to make sure their voice was heard when they did. People’s health action plans were not fully completed. Information was lacking, which meant staff did not have crucial guidance to ensure people received the health support they needed when they needed it and that preventative healthcare was accessed.

Although staff we spoke with told us they had a good understanding of safeguarding and had received training, we found staff did not raise or did not feel comfortable to raise when alleged abuse had occurred. Staff frequently contacted CQC during the assessment to raise their concerns but told us they had not raised these with managers and if they did they did not feel anything would be done. One staff told us, “We don't believe the people here were unsafe, but we have to see it from your point of view” (regarding the outcome of the last assessment). However, CQC have continued to be contacted by whistle blowers raising concerns about the way people are being supported.

We observed and heard poor bullying interactions between staff and people. One member of staff who was providing 1:1 support with a person, was standing in the front of the lounge double doors where the person was sitting on the floor, to prevent them leaving the room. A member of staff was heard to say to a person, “If you are good, I will phone (relative), if you aren’t, I won’t”. One person told us, “(staff member) says the next move is Broadmoor, I don’t know if they are joking or not” We also heard the person asking the Registered Manager “I don’t have to go Broadmoor, do I?” The registered manager was very reassuring to the person and told them they do not, and that Shore Lodge is their home. We observed some good interactions, 2 staff members were trying to work out what a person was asking for as they became a little agitated, a staff member figured out the person was asking who was working on the sleeping shift that night. The person visibly relaxed once they knew.

People were not protected from the risk of abuse. At the last assessment visit safeguarding concerns were not always investigated, and when they were, these were not sufficient to find the root cause, take appropriate action, and to learn lessons. We found the same at this assessment visit. When investigations were completed, they were not sufficient to find the cause of the incident and to enable the registered manager to put in place steps to avoid them happening again. This led people to be at ongoing risk of avoidable harm. We were also made aware of further incidents from external stakeholders and whistle blowers which we had not been informed of or had not been raised as required to local authority safeguarding teams. A person had taken a glass photo frame from their wall when they were in their bed. The frame had broken, and glass was in the bed and on the floor. Night staff reported the incident to day staff during handover and said they had cleared the glass and made sure the person was safe. However, day staff found the person had received cuts from glass and glass was still in the bed. The incident had not been referred to the local authority safeguarding team until a CQC inspector contacted the registered manager when they had been informed of the incident by local authority staff. The registered manager then raised a safeguarding referral but not until they were advised to by CQC.

Staff told us they were managing people’s risks around dysphagia better since the last assessment. A member of staff said, “I am a (dysphagia) champion, chef signs and champions sign off mashed food”. Agency staff we spoke with told us they had not seen any risk assessments for the person they were providing 1:1 support to, including crucial records in relation to the risks the person posed to themselves and others. When inspectors showed agency staff the person’s care file with all care plans and risk assessments, they confirmed they had not seen this. Staff did not have access to plans intended to support people when they were experiencing distress. Individual plans had been developed but they were not in people’s care files. Staff had not been given the opportunity to understand what the signs of people’s distress may be, what the triggers were, and how to support people to avoid becoming distressed. Staff could not support people to be safe from harm as individual plans were not available to them.

We observed a person receiving 1:1 support spent most of their time on their own with a staff member in a lounge area. During our assessment visits we saw clear differences in relation to how staff interacted with the person. One staff member focused on the person, engaging them in conversation and activities. Other staff were seen to stand in the lounge doorway or sitting in the lounge area not engaging with the person. This increased the risks of the person becoming bored and therefore distressed, which represented a risk to the person and to other people. We saw instances where people became distressed, shouting out or were straight faced and unsmiling, when some staff were on shift. When the shift changed, we saw a change in people’s demeanour, where they were not shouting out, or were smiling and taking notice of what staff were doing. We had noticed similar differences between staff shift changes at the last assessment. We shared this with the management team again during this assessment visit. Risks around the changes in peoples’ reactions to different staff had not been picked up as a continued risk by the management team, which increased the risks to people’s well-being and of continued incidents of distress.

Individual risks were still not identified and assessed to make sure people were safely supported to mitigate risks. The provider had not made any changes to peoples’ individual risk assessments since our last assessment, where we raised concerns about risk. One person was at high risk of choking, but their choking risk assessment had not been reviewed or updated since January 2024. A senior member of the management team told us this should have been reviewed monthly due to the high-risk score. Serious incidents had occurred, and risks had not been identified, reviewed or updated following the incidents. Some people were at risk to themselves and to others due to their distress, and the risks had not been carefully assessed and mitigated against to assure people they were safe. At our last assessment, epilepsy care plans and risk assessments were in place to provide guidance, however, these did not include ensuring the safety of people in relation to bathing, or the procedure to follow if they had a seizure while sitting in their wheelchair. Guidance and explanation around the risks of sudden unexpected death in epilepsy (SUDEP) were not included. During this assessment, we found 1 person’s care plans and risk assessments had been reviewed and updated with the missing areas. However, the care records of other people who had epileptic seizures had not been reviewed or updated. One person always used a wheelchair, and their epilepsy care plans, and risk assessments continued to not include guidance for staff in relation to the person having a seizure while sitting in their wheelchair. There was a risk staff would not know how to support the person safely in this situation.

Staff told us cleaning products were now always locked away since the last assessment to keep people safe. We checked cupboards and doors and found them to be locked. However, staff and leaders continued to have a poor understanding of environmental risk. Because of this people had been harmed, and were at on going risk of physical and psychological harm. Staff and leaders had failed to notice dangerous items and unsafe equipment in all other areas (including having a glass frame within a person's reach in their bedroom). In addition, leaders and staff lacked understanding about how environments can impact people's safety in terms of psychological harm.

People’s living environment continued to be poor, although the provider had started to decorate the service, people’s bedrooms continued to be bare and impersonal. Communal areas were uninviting and institutional looking. A bathroom was still out of use and being used as a storeroom, meaning people did not have full access to facilities. The bathroom used as a storeroom was being used by decorators to store their equipment. This included items such as tins of paint, open boxes and packets of powder used by decorators as filler, and some tools, including a hammer. The bathroom door was unlocked, open and next door to a person’s bedroom. The person was independently mobile and was placed at risk of harm by the products and equipment left unattended and in an open space. People continued to be using equipment such as chairs and shower chairs they had not been assessed for to ensure their safety and comfort. Some people continued to share equipment that neither person were assessed as safe to use.

There continued to be no effective processes in place to make sure people’s individual personalities and needs were considered when designing and improving the living environment. Processes that were in place were not effective in recognising or rectifying shortfalls within the environment. Managers walk arounds took place and audits were undertaken but they failed to pick up on the issues, such as the unsafe items stored in a bathroom, to improve safety. People’s well-being had not been considered by staff, or in the auditing process, to take into account the risks to people’s well-being and positive outcomes by making simple improvements to their living environment.

Agency staff working with people during our assessment visit told us, “I had 1 day training here”. However, we found that agency staff had not been properly inducted, as they had not been shown or had access to people’s care records. A staff member said, “My first 3 shifts were my induction, gave me everything I needed”. We found that not all staff had completed the necessary training to understand and support people with a learning disability or autism well. Another member of staff told us, “I need to do Equality and Diversity training by Thursday, I can do it quick on an iPad doing a 1:1 with (person supported)”.

Although we were told there were sufficient staff by the management team and by staff, we observed that there were insufficient staff to make sure people could go out when they wished. We saw staff taking people out into the garden or for a quick walk in their wheelchair, however, people did not get the opportunities to explore individual activities in the community to enhance their day and support their well-being. One person was receiving 12 hours of 1:1 staff support through the daytime hours. The person went out infrequently even with this level of support. In a 4 week period they had only been supported to go out 4 times. These trips out included a bus ride, a visit to a local shopping centre and to a fast-food restaurant. No consideration had been given to effectively using the 1:1 staffing hours to plan activities that provided access to new interests. We saw some staff engaging very well with people and people looked happy and relaxed in their company. We also saw staff who did not engage well with people and people were not smiling or making eye contact in their company. We had raised this with the management team during our last assessment and we found staff had still not received training or coaching to be able engage with and support people with a learning disability.

Staff had not received the training necessary to ensure they had the skills and ability to support people with a learning disability and/or autism, or to support people with distressed behaviour safely. An agency staff member’s profile showed they had not completed training in relation to supporting people with a learning disability, or autism. Another agency staff member did not have a completed induction record to evidence their introduction to people and the service. The provider had adopted a specific training regime for staff who supported people who experienced distressed behaviour. All staff had not completed this training. 13 out of 25 staff on the rota had not completed the full training. Agency staff providing 1:1 support for a person who experienced distressed behaviour had not had this training. Incidents had happened where people had been hurt. Not all staff had completed nutrition and hydration training or basic food hygiene training. All staff cooked meals and prepared drinks for people. We found there were enough staff present during our assessment visit. However, following our visit we received feedback from local social service teams who visited the service that they had concerns about staffing levels. One member of agency staff was allocated to work 1:1 with a person who required constant supervision to support the safety of themselves and others. The agency staff member was alone with their allocated person, plus 2 other people in a communal lounge. These people could not receive the appropriate support and were placed in an unsafe position where they could experience harm. The registered manager and a senior manager were present in the service at the time. Although the training matrix, which details which modules the staff have completed, was updated, we were not assured that this training had been effective.

All staff were responsible for cleaning the service. Tasks were allocated at the beginning of a shift, though there were no checks to make sure the standard of cleaning was acceptable. However, this process took staff away from supporting people with their daily activities, one to one support and this caused some people distress.

Although the service was reasonably clean, there was no evidence deep cleaning had taken place. This included areas such as window sills, skirting boards and frequent touch points such as door handles. This placed people at risk of infection.

There were no systems in place to ensure the building including communal areas and people's bedrooms were deep cleaned. The provider had not assessed how staffing levels would be affected by care staff cleaning and doing the laundry. Staff were required to cook people's meals, however, there was no system in place to make sure staff who had been cleaning did not then cook during the same shift. The provider had not identified and acted on the infection risk posed by people sharing equipment such as shower chairs. Staff allocations for cleaning and laundry were recorded on the handover record. Night staff were responsible for some areas of cleaning. There were no systems in place to check these tasks were being completed. Staff had access to appropriate PPE and cleaning products and there were sufficient stocks.

Staff who were responsible for administering people’s medicines told us they liked the electronic system they used for recording medicines management. However, staff and leaders had failed to ensure people's rights were always upheld when they took their medicines: some people had medicines covertly administered without their knowledge and without the right legal process being followed.

An electronic system was used to record the administration of medicines and the management of the medicines stock. The system worked well. We did a random count of stock and numbers of medicines tallied with the numbers recorded as being left in stock on the system. PRN protocols, to give guidance to staff about medicines that were prescribed by the GP to be given as and when needed to people were in place. Medicines were appropriately stored and checks such as room temperatures, to preserve medicine efficacy were completed. However, records of how decisions had been made about how people's medicines were administered, had not followed guidance. We could not be assured people's right to refuse was being upheld.