Archived: Lucy Lodge

Updated 25 June 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection of Lucy Lodge took place on 28 April 2016 and was unannounced. One Adult Social Care inspector carried out the inspection. Information had been gathered before the inspection from notifications that had been sent to the Care Quality Commission (CQC), from the local authorities that contracted services with Lucy Lodge and from people who had contacted CQC to make their views known about the service. We had also received a ‘provider information return’ (PIR) from the registered provider. A PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We spoke with four people that used the service, two staff and the registered provider. We looked at care files belonging to three people that used the service and at recruitment files and training records for three staff. We looked at records and documentation relating to the running of the service, including the quality assurance and monitoring, medication management and premises safety systems that were implemented. We looked at equipment maintenance records and records held in respect of complaints and compliments.

We observed staff providing support to people in communal areas of the premises and we observed the interactions between people that used the service and staff. We looked around the premises and saw communal areas as well as people’s bedrooms, after asking their permission to do so.

Updated 25 June 2016

The inspection of Lucy Lodge took place on 28 April 2016 and was unannounced. At the last inspection on 3 July 2014 the service met all of the regulations we assessed under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These regulations were superseded on 1 April 2015 by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Lucy Lodge is a traditional property in a residential area close to the centre of the seaside town of Bridlington. Its situation offers easy access to the local community and public transport, being within walking distance of local shops and facilities. The service supports up to 16 people who may have mental health needs. At the time of the inspection there were 13 people using the service. All bedrooms are for single occupancy, and there is one lounge, one dining room and an enclosed external smoke room. Bathroom facilities are shared, but designated to male and female use. There is a small garden area for people to use in the warmer months, which is separated from the small car park to the rear of the property. Extra parking is available on the street, but this is time limited due to parking restrictions.

The registered provider was not required to have a registered manager in post, as the registered provider was a registered partnership. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. On the day of the inspection the registered partners were jointly managing the service. One of the partners had the National Vocational Qualification Level 4 in Advanced Management in Care and 29 years’ experience working with people with mental health needs. The partners had employed a registered manager previously but this person had left their position in December 2015.

People were protected from the risk of harm because the registered provider had systems in place to detect, monitor and report potential or actual safeguarding concerns. Staff were appropriately trained in safeguarding adults from abuse and understood their responsibilities in respect of managing potential and actual safeguarding concerns. Risks were also managed and reduced on an individual and group basis so that people avoided injury of harm.

The premises were safely maintained and there was evidence in the form of maintenance certificates, contracts and records to show this. Staffing numbers were sufficient to meet people’s needs and we saw the staff recorded on the rosters were on duty. Recruitment policies, procedures and practices were carefully followed to ensure staff were suitable to care for and support vulnerable people. The management of medication was safely carried out.

People were cared for and supported by qualified and competent staff that were regularly supervised and had their performance appraised. Communication was effective, people’s mental capacity was appropriately assessed and their rights were protected. No one required any Mental Capacity Act 2005, Deprivation of Liberty Safeguards referrals to restrict their lifestyles, as people were free to come and go and voluntarily agreed to any proposed behaviour modification plans. The Mental Health Act 1983 was the legislation most likely to be used at Lucy Lodge.

People received adequate nutrition and hydration to maintain their levels of health and wellbeing. The premises were suitable for providing care to people with mental health issues and their general environment was that of a family home.

We found that people received informative and friendly care from kind staff and that staff knew about people’s needs and preferences. People were supplied with the information they needed at the right time, were involved in all aspects of their care and were always asked for their consent before staff undertook any support tasks.

People’s wellbeing, privacy, dignity and independence were monitored and respected and staff worked to maintain these wherever possible. This ensured people were respected, that they felt satisfied and were enabled to take control of their lives.

We saw that people were supported according to their person-centred care plans, which reflected their needs well and which were regularly reviewed. People had the opportunity to engage in some pastimes and activities if they wished to, as activities were offered when staff had time to do so. People made good use of their community facilities and often accessed these alone or in twos and threes: not everyone required the support of staff to access community services. Some people had good family connections and support networks.

There was an effective complaint procedure in place at Lucy Lodge and people were able to have any complaints investigated without bias. People that used the service, relatives and their friends were encouraged to maintain relationships by frequent visits, telephone calls and sharing of each other’s news.

We saw that the service was well-led and people benefited from this because the culture and the management style of the service were positive. There was an effective system in place for checking the quality of the service using audits, satisfaction surveys, meetings and good communication.

People had opportunities to make their views known through direct discussion with the registered provider or the staff and through more formal complaint and quality monitoring formats. People were assured that recording systems used in the service protected their privacy and confidentiality as records were well maintained and were held securely on the premises.