Sandiacre 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 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 legal regulation in relation to safe care and treatment at the service.

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 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. Staff understood their responsibilities to report any concerns. We found accidents and incidents had not always been thoroughly investigated, the provider had also recognised this. We saw improvements had been made as recent incidents had been fully investigated and determined the actions required to reduce the risk of reoccurrence.

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. The registered manager told us of how they assessed people’s needs and compatibility prior to them using the service. We found key information had been sought from relatives and external professionals involved in people’s care, and this was used to develop their plans of care. People also had hospital passports in place which can be used to share important information between services about a person to aid their continuity of care in the event they needed to attend or be admitted to hospital

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 were protected from abuse. Staff confirmed they had regular safeguarding training and demonstrated their knowledge of how to recognise signs of abuse and how to safeguard people if they had any concerns. Relatives told us their family members were safe using the service, we observed people to be familiar and comfortable with the staff supporting them.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks which affected people's daily lives, were documented and known by staff. We observed staff to demonstrate a good understanding of how to support people positively with their known risks and records evidenced people regularly took part in activities they were interested in. We found care plans had not always been regularly reviewed, however the registered manager demonstrated systems were now in place to ensure this happens consistently. Relatives spoke positively about how their family members were supported with their interests. One relative told us, “[Person] loves the outdoors even in bad weather, the staff are so good they wrap [person] up gloves and a hat and take them out even if it’s just a walk around the block, this makes [person] happy”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. CQC does not regulate the premises, as the responsibility for the building lies with the landlord. This means that while the CQC assesses the quality of care and support provided, the physical environment and tenancy arrangements remain outside of our remit. However, the systems in place to monitor the safety of the premises and to report and progress tenancy matters were not always effective. They did not consistently identify shortfalls in the environment or ensure that these issues were addressed in a timely manner, which created risks to maintaining a safe service. We identified fire safety concerns that had not consistently been identified in the providers audits. Some of these issues had been reported but had not been acted upon. Following our assessment, the provider took immediate action to ensure the issues were rectified.

The provider did not make sure staff received effective support. The provider had deployed staff in a way that placed people at risk of harm.We found that some staff were scheduled to work consecutive 12‑hour shifts during both the day and night. In addition, some staff were required to attend training immediately after completing a waking night shift. We were not assured that training delivered under these conditions was fully effective. This placed people and staff at risk of harm. We asked the provider who was also the registered manager to address this.We found staffing levels reflected the hours people were commissioned. However, these did not always provide enough staff to meet people’s assessed needs safely. For example, the provider’s assessment had identified a person required the support of 2 staff in an emergency, however only 1 staff member was on duty during the night. We raised this concern with the provider and the local safeguarding team. The provider informed us following our assessment a review of the person’s care package had been scheduled to take place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and understood how to share concerns with appropriate agencies promptly. The provider had an infection, control and prevention policy in place and systems and processes to ensure infection, prevention and control measures were regularly audited. Personal protective equipment (PPE) was readily available, and staff confirmed there was always an adequate supply of this.

The provider did not always make sure that medicines and treatments were safe and met people’s needs. We found one, ‘as and when’ medicines protocol lacked detail around when staff needed to administer the medicine. The registered manager had also identified this and was seeking clarity from the person’s GP. During our assessment, we also found a temporary protocol had been put in place instructing staff to prepare a medicine in advance without administering this. We raised this as it is unsafe practice the registered manager confirmed this had not been followed and was no longer in place.Medicines were administered by trained staff who received regular checks and direct observation of their practice. Stock levels corresponded with the records in place and audits of medicine administration records were conducted regularly by the staff and provider. Relatives spoke positively about the support their family members received with their medicine. One relative told us how staff had positively supported a person with an acute health condition which was now resolved.