St Georges Lodge Residential Care 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.

At our last inspection we rated this key question good. At this assessment the rating has changed to 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. We identified 2 breaches of legal regulations in relation to safe care and treatment, and fit and proper persons employed.

This service scored 56 (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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Any incidents or accidents were documented and reported to the manager who discussed what had occurred with relevant people and staff. For example, following some unwitnessed falls by people in the lounge, a staff member was now present in this room, to ensure people remained safe. The manager understood and followed the provider’s duty of candour policy.

The provider did not always make sure there was continuity of care, including when people moved between different services. A healthcare professional told us that when people moved from St Georges Lodge Residential Care Home to a new home, information about their care and support needs was not always shared, even when requested, to ensure continuous care.

When a person moved into this home, the manager obtained an overview of their needs by talking with the person, their family and other care providers. This information was then shared with senior staff in preparation for when the person was admitted.

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 the home. One person said, “The staff are very kind. It makes me feel safe.” A relative added, “She won’t come to any harm.” A healthcare professional said, “From my observations, I am confident that residents are safe and well cared for.” Staff completed safeguarding training. One staff member told us, “It’s about protecting a person from abuse, what they want, making sure they are valued and cared for with dignity. If I had any concerns, I would report to a senior or the manager.”

The provider did not work well with people to understand and manage risks. People were put at potential risk of unsafe care because their risks were not always identified, assessed or managed safely.

We observed 2 staff transferring a person from their armchair to a wheelchair. The staff assisted the person to stand up by holding onto their walking frame. Both staff then guided the person round to sit in the wheelchair, but the brakes to the wheelchair had not been applied; this put the person at risk of a fall as the wheelchair could easily have moved. We saw brakes to 3 people’s wheelchairs were not applied for them when they were sat eating their lunch in the dining room. This meant the wheelchairs were not sufficiently stable for people as they ate a hot meal.

Some people had been prescribed medicines to thin their blood. One person had a history of falls and they were unsteady on their feet. People are at heightened risk of injury if they have a fall and also take blood thinning medication, but this risk had not been assessed. We discussed this concern with the manager who subsequently sent us a risk assessment which they had drawn up. However, this risk assessment which related to falls and blood thinning medication did not actually describe the risk, such as life threatening internal or external bleeding or bruising. This put people at risk of harm because staff had not received sufficient information to understand or manage this particular risk.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People spoke positively about the environment of the home. Their rooms were personalised and comfortable. A relative said, “The dining room is also very bright and welcoming.”

The manager undertook a daily walkaround the home and identified any issues that required attention. In addition to the environment, equipment such as slings, slide sheets, and pressure mattresses were also reviewed; any actions required were documented and completed.

People had personal emergency evacuation plans which described the actions needed in the case of an emergency. Staff completed fire training and practical elements in the use of fire extinguishers.

The provider did not always ensure that recruitment systems were sufficiently robust to ensure new staff were appropriately vetted and safe to provide care and support.

We reviewed 3 staff files and looked at a range of documents, including references, Disclosure and Barring Service checks, right to work in the UK, and employment histories. All 3 staff files showed gaps in their employment histories so the provider could not be assured they had the necessary skills and experience to undertake their roles. We discussed this issue with the manager who explained that 1 staff member had gaps in their employment history due to childcare. Another staff member’s employment history only showed 1 job they had worked in for 6 months, nothing else was recorded. The manager told us the information was probably held on the provider’s electronic systems, but this was not shared with us during the time of this assessment.

Staffing levels were sufficient to meet people’s needs, and we saw staff knew people well. Staff completed a range of training to enable them to undertake their role and responsibilities effectively. They received regular supervision from their line managers.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Housekeeping staff maintained a clean environment. One person said, “They come in every day and clean.” Another person told us, “They seem to be hoovering every day or every other day.”

Staff completed training in infection prevention and control. The manager told us, “We did have a situation with vomiting the other day, so we made sure the area was deep cleaned, and the person stayed in their room. All staff wore personal protective equipment when entering and coming out, monitoring to see if it was contagious. Because we acted quickly, we avoided the spread.”

The provider did not make sure that medicines were administered and managed safely.

We observed a staff member giving people their medicines at lunchtime. The staff member wore a tabard advising ‘Do not disturb’. Medicines were stored in a trolley that was wheeled into the dining room. The medicine for 1 person was placed in a small container, then the staff member signed the Medication Administration Record (MAR) to confirm the person had taken their medicine, although they had not. The person was upstairs in their bedroom. The staff member then returned to the dining room and checked with another person if it was all right to give them their medicines. This person was in the middle of their lunch but agreed to have their medicines. The staff member left their medicines in the pot next to the person’s lunch. The staff member later signed the MAR when they collected the empty medicines container, but they had not witnessed the person taking their medicines. The staff member did not sanitise their hands in-between giving each person their medicine; this is poor practice.

The stocks of 1 medicine for a person did not tally. The person had been prescribed a medicine for their high blood pressure, half a tablet to be taken in the morning. There should have been 6 tablets left in the pack, but there were only 2. There was a risk staff were giving more than half a tablet daily, although the manager told us they felt it was a recording error as the medicine stock had not been checked when the person moved into the home.

We checked the storage of medicines, including medicines that were kept separately and securely and medicines that required refrigeration. A bottle of eyedrops was out of date and should have been disposed of. Another bottle of eyedrops did not have the date of opening recorded, so staff could not be assured it was still safe to use.

We shared our concerns with the manager during the inspection. They stepped in and continued the lunchtime medicines round, assuring us the staff member would be spoken with and actions taken.

People told us they received their medicines as prescribed and that any changes were discussed with them. One person said, “They bring me my medicine every night and morning” and another told us, “Yes, they’re very good with that.”