Eastern 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.

This is the first assessment for this newly registered service. 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 the regulation relating to safe care and treatment particularly in relation to the management of people’s medicines.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service promoted a proactive and positive culture of safety. Staff understood their responsibilities to report accidents and incidents. These were recorded accurately and communicated to the management team in a timely manner.

The management team tracked accidents, incidents and other events, analysing them regularly to identify trends and underlying causes. This approach helped them take prompt actions when needed to make sure people received appropriate support. Lessons learned were shared with staff to improve practice. This demonstrated a commitment to continuous learning and improving safety.

The provider worked with people and health and social care 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.

The staff team made considerable efforts to gather and analyse information about people’s past experiences, including details of incidents from previous placements. They used this information to guide their approach to delivering care and support in a safe and effective manner. Historic care records were incorporated into current care plans that provided staff with clear insights to inform people’s care and support.

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.

Staff understood safeguarding procedures and knew how and when to report concerns. This helped ensure people were protected from harm. If they were to witness any form of abuse or neglect, a staff member told us they would “record it, report to manager and report to CQC if they [manager] don't take action”.

People and their relatives told us they felt safe at the service. A relative commented on the transparency of how the service managed a person’s finances, stating, “Nothing is hidden from me.”

The provider assessed risks to people’s care and wellbeing and provided guidance to staff on how to mitigate these risks. Risk assessments covered several aspects of people’s care, including mobility, eating and drinking, behaviour and health. However, while staff provided safe, supportive care that enabled people to do the things that mattered to them, there were discrepancies in care records.

Specific guidance on risk control measures was not always easy to locate within care records. Guidance was fragmented across different sections within people’s care records. This could make it difficult for staff to access relevant guidance swiftly, potentially delaying appropriate responses. For example, a person’s moving and handling risk assessment contained conflicting and out-of-date information, which could make it harder for staff to follow guidance and increase the risk of unsafe practice for the person. The provider acknowledged this issue and told us they would update the guidance.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. They ensured the premises and equipment were suitable for people, and staff escalated any concerns promptly.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service carried out appropriate recruitment checks to ensure staff were suitable for their roles. Staff recruitment files contained a range of checks including DBS checks (police check), staff employment histories, identity checks and employment references.

Staff received a range of training relevant to their roles, including regular refresher training. This ensured they remained up to date with best practice guidance. Staff were supported by their line managers through ongoing supervision and appraisals.

The provider assessed and managed the risk of infection. Staff followed infection control procedures and use personal protective equipment appropriately. People’s personal areas and communal spaces were clean. This reduced the risk of cross-contamination and supported people’s health and wellbeing.

The provider did not make sure medicines were managed and administered safely. We found multiple concerns in relation to medicines management, record keeping and oversight, which meant we were not assured people consistently received their medicines as prescribed.

Staff administered a person’s eye drops twice daily instead of the prescribed 3 times daily when required. There was no guidance for staff on when the medicine should be administered. While evidence later confirmed this was clinically safe, the arrangement had not been clearly documented and refusals of the third administration were not recorded on the medicine administration records at the time of the assessment. This provided limited assurances regarding medicines oversight and recording.

PRN (as required) medicines were not always managed safely. Some people did not have protocols in place to guide staff on when to administer them, and where protocols existed, some did not provide clear instructions. Discrepancies between PRN administration records and outcome logs for 1 person indicated a risk that PRN medicines were not always administered as required.

Medicines administration records did not provide assurance that medicines had consistently been given at the correct times. For 1 person receiving medicines via a PEG tube (feeding tube inserted into the stomach), while staff were trained in PEG and guidance was in place, appropriate arrangements for the safe management and clinical oversight of this delegated healthcare activity were not sufficiently evidenced at the time of the assessment. This meant we were not assured that medicines were being administered safely and in line with required supervision and governance arrangements.

Medicines audits were not always effective and the frequency at which they were undertaken gave limited assurance that issues would be identified promptly and addressed. The lack of robust oversight meant people were at risk of not having their medicines administered safely or consistently, as errors or gaps in practice could go unnoticed.

Medicines were received, stored and returned safely. People had medicines care plans that provided guidance for staff on the administration of their medicines. Following the inspection visit, the provider had started taking action to address the concerns and provided a service improvement plan. They had implemented and updated PRN protocols and told us they had strengthened their auditing systems.