Amber Lodge Nursing Home

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment of this location under a new provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had not always ensured a proactive and positive culture of safety. Staff did not always report concerns about safety and therefore we were not assured all safety events were investigated. However, the provider was working towards embedding a lessons’ learnt approach to help to continually identify and embed good practice.

Staff responded to an incident between 2 people however, there was no completed incident form for this event. This meant not all incidents were reported for the provider to review and identify whether any further actions were needed.

When incidents were investigated, the provider had done so openly and transparently. The provider had identified areas of the service that needed improvements and was working towards an action plan to achieve these.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People received support from other services as needed. For example, speech and language therapists and there was regular involvement of primary care services such as from the GP and community matron.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Amber Lodge Nursing Home. One person told us, “Yes, I feel safe, there are staff around all the time, and they ask me if I am okay.” Relevant guidance had been followed to ensure any restrictions necessary for people’s safety were applied for as legally required under the Deprivation of Liberty Safeguards and monitored.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff worked to ensure pain was monitored well. However, whilst risk assessments were in place these were not always followed to ensure risks to people were well managed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Not all risks in the environment had been identified and mitigated. For example, not all wardrobes were securely fixed to walls which caused a potential risk to them toppling over. However, other risks in the environment were mitigated, for example a fire risk assessment had been completed, and window restrictors were in place.

The provider had not always made sure all staff had the necessary skills and competencies to provide safe care. We observed staff did not always follow good practice principles for moving and handing and assisting people with their meals. One person told us, “I did walk when I came here but I prefer to be hoisted, though sometimes it digs in and hurts a lot.” Not all staff had completed the training the provider had identified as required for their role and there had been no training provided for one person’s specific care needs. Not all staff were able to provide assurances that diets for people with dysphagia, and those requiring fortification were prepared and served in accordance with recognised standards. One relative told us, “There are a lot of new staff, and I think they need more training.”

We saw there were enough staff to meet people’s needs on the day of the inspection. However, people told us they thought staffing could improve. One relative said, “There is not enough staff, and there are always different faces.” One person told us, “There is not always enough staff,” while another person told us, “If you call someone at night you often have to wait a long time.”

The provider did not always assess or manage the risk of infection. We found some furniture had chipped and as such was hard to clean and some items were heavily stained. A dining chair had splits in the fabric and others had food residues on them. People did not have personalised slings when they were transferred with a hoist which increased the risk of cross infection. One person told us, “It’s fairly clean, sometimes at weekends the bins don’t get emptied.” A relative told us they had given feedback on cleaning and had seen some improvements in the cleanliness of the bathrooms and toilets.

The provider made sure that medicines were managed and stored safely. However, we were not assured all positive behaviour support principles were followed before ‘as and when’ needed medicines were given.

On the day of the inspection medicines were administered in accordance with good practice principles. Medicines were stored securely and in accordance with recommended temperatures. However, one person had medicine given when their behaviour could be a risk to themselves or others. Records did not show other positive behaviour support strategies had been tried and were unsuccessful before staff administered medicine. This meant the provider was not able to demonstrate medicine had been used in line with least restrictive principles.