Archived: Bowland Lodge

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 the last inspection we rated this key question requires improvement. At this inspection the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

We found the provider was in breach of the legal regulation relating to maintaining a safe environment, safeguarding, medicine management, infection control, recruitment, staffing, staff training and good governance.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A proactive and positive culture of safety, based on openness and honesty was not in place. Lessons were not learnt or used to identify and embed good practice. In 2013 Tyne and Wear Fire Service prosecuted Bowland Lodge for breaching fire safety regulations. The learning from this had not led to any real changes in practices at the service and the fire authority continued to have concerns about how risk was managed. Accidents and incidents were not reviewed to identify themes or lessons, and staff were not encouraged to reflect on their practice or improve safety. There was no evidence that learning from incidents was shared or embedded to reduce the risk of recurrence, which increased the risk of avoidable harm to people and staff. Concerns raised at the last inspection in relation to medicine management, recruitment practices, risk assessments, cleanliness and upkeep of the building had not been addressed. The management team believed the service was well-run and therefore they had had not taken the actions needed to make improvements.

The management team did not always manage or monitor people’s safety. Systems to support safe pathways and transitions were not consistently effective. Risk assessments and care records did not clearly guide staff on how to manage known risks, including when people moved within or out of the service. Agency staff supporting people in the community were not provided with clear guidance, which contributed to unsafe outcomes, including people going missing. This showed a lack of coordinated and safe approaches to transitions. A staff member said, “A previous manager had a person's bedroom decorated for them, but they panicked when [partner’s son] came in and found out as they argued residents’ bedrooms should be kept plain so it's easier for them to move other residents straight in.”

Management did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. One person said, “Most of the staff make sure I’m alright.” However, the service had continued to fail to address ongoing issues with medicines, care plans and governance, which continued to place people at potential risk of harm. Staff had not received safeguarding training in the last year because the trainer’s fees not had not been paid.

Staff had not consistently sent in requests for Deprivation of Liberty Safeguard (DoLS) authorisations. People’s monies had not always been managed appropriately, and the new deputy manager was taking action to resolve this issue. Staff who had worked at Bowland Lodge for years understood safeguarding procedures, but safeguarding practice was not consistently effective. Safeguarding alerts were not consistently sent in when concerns were raised.

People were not always protected from abuse or avoidable harm, as risks within the service were not consistently identified or managed. Staff described experiences where their safety was not consistently protected, resulting in injuries that required hospital treatment. We were not assured that incidents were appropriately recorded or escalated, as staff told us they felt discouraged from reporting concerns. The service had not ensured staff were equipped with appropriate training or guidance to safely anticipate, prevent or respond to situations of heightened risk.

This meant risks were not appropriately escalated or managed.

People were not meaningfully involved in understanding or managing risks to their safety. Restrictive practices were used without clear legal frameworks or evidence of capacity assessments or best interest decisions, which limited people’s involvement and choice. Risk assessments were not fit for purpose and did not clearly describe how staff should support people in a safe and person-centred way. Often there were no risk assessments in place. For example, 2 people had accidentally set fires in their bedrooms. However, there were no risk assessments in place to cover this or show how staff were to manage this situation. When people became physically aggressive staff were provided with no guidance around how to manage this nor had any assessments to mitigate these risks been undertaken. No action was taken to determine if peoples’ needs could be managed.

The environment was not safe and did not support people’s wellbeing. The building was in a poor state of repair, with ongoing concerns about fire safety, water safety and maintenance. There had been repeated infestations of rats, which the service struggled to manage. There were repeated leaks, delays in hot water availability, and a lack of understanding of legionella control measures. Staff concerns about electrical and fire risks were not acted on promptly, increasing the risk of harm. A staff member said, “There was water leaking extensively through the rest of the building, including through the chandelier in the passageway. The leak from the chandelier was coming through from the walk-in wardrobe upstairs, which had a leak above that coming through the roof into a cupboard on the top floor. There are two cupboards upstairs that staff were expected to empty buckets from hourly however one of these cupboards had missing floorboards and unsafe electrics which I believe was a huge risk to staff, especially when carrying heavy buckets of water.”

Staffing arrangements were not safe or effective. There were times when there were not enough suitably skilled staff on duty to meet people’s needs, and rotas did not accurately reflect staffing levels. Recruitment practices continued to fail to meet legal requirements. Recruitment checks were incomplete and some staff files contained no information. Staff files did not contain the required recruitment information and checks were not completed to ensure staff on student visas or sponsorships with other organisations worked the correct number of hours.

On rotas and in the sign-in books confirmed some staff were deemed carers but were working as the administrator. This meant when there was supposed to be 1 senior and 3 carers on duty there were just 2 carers on duty. The activity coordinator had been made redundant, and the care staff were expected to both complete their tasks and provide activities. Staffing levels prevented staff from providing meaningful activities, supporting people to access the community or working in a person-centred manner. A staff member said, “A night staff member usually comes in on some of their days off to take some people out. This staff member was told that they were no longer allowed to come in to take residents out as they would not be paid.”

Staff did not have access to regular supervision or to mandatory or role-specific training, including de-escalation and breakaway techniques. A staff member said, “[Partner’s son] hasn’t paid the fees needed for us to go on the training app so none of us have been able to complete any training.”

This placed people and staff at risk of harm.

Infection prevention and control systems were not effective. Environmental issues, including leaks, inadequate hot water systems and poor maintenance, increased the risk of infection. There was a lack of oversight and understanding of required water safety checks, including temperature monitoring to reduce the risk of legionella. During the inspection the boiler was repaired but the hot water was slow to transition to the taps and people could be waiting 30 – 40 minutes for hot water in sinks, baths and 1 shower. This meant they could not adequately clean their hands. The service did not ensure that the service was adequately resourced to maintain a clean and hygienic environment. Essential supplies, including cleaning products and replacement linen, were not provided in sufficient quantities or in a timely way, despite staff raising concerns over a prolonged period. Some linen in use was worn and threadbare. These failures meant the registered person did not effectively assess or manage infection risks, and people were not adequately protected from the risk of infection.

Medicines were not managed safely. Medicines audits did not identify known risks, and returns were stored insecurely without appropriate records. There were not enough trained staff to complete required checks for controlled drugs, and staff did not always follow prescribing instructions, including for people who were supported on alcohol maintenance programmes. Some medicines were out of stock due to poor ordering systems, which placed people at risk of harm.