St Denis Lodge Residential 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 assessment we rated this key question Good. At this assessment the rating has remained Good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Accidents and incidents were documented and staff told us they felt confident to report their concerns to the management team. The management team undertook regular reviews of incidents to identify any themes or areas of improvement. These were then communicated to staff to aid learning and prevent reoccurrence.

People and their relatives confirmed they were confident to raise concerns and felt they would be listened to and actions would be taken. A relative told us, “I know I would be listened to, and action would be taken straight away. It doesn’t matter if the issue is bigger or smaller – if it matters to mum; it matters to them and they take it very seriously. They are absolutely brilliant at this.”

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 had detailed summaries of their needs, known as hospital passports. These contained information about their health conditions, care needs, family contacts and personal preferences. These were available in case of an emergency admission to hospital.

Care plans were developed collaboratively with people, their families, friends and relevant healthcare professionals. This meant people’s care record referenced input from healthcare professionals regarding treatments, appointments and outcomes. This information was shared with appropriate professionals, with the person’s consent. Should someone move to another service, or if their needs could no longer be met at St Denis Lodge, these records would also be shared with future care providers to support continuity of care.

A health and social care professional told us,” The team have always reached out for help when they have felt they needed it and maintained clear communication and provided any further information requested in a timely way.”

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.

There were clear processes in place to manage safeguarding events and the registered manager worked collaboratively with the local authority to support people safely. Staff had received safeguarding training and told us they understood how to recognise and report poor care and suspected abuse. A staff member told us, “If I felt somebody was being abused, I would go straight to the manager and deputy or in the staff room we have a number for the safeguarding team.”

Where people were subject to Deprivation of Liberty safeguards (DoLS) the service had made applications to the local authority and there was clear monitoring in place. DoLS ensure if a person is restricted in a way that deprives them of their liberty in a care home, it is only done when it is in their best interests, is necessary for their safety, and all other options have been considered.

Safeguarding, accidents and incident records viewed as part of the assessment, were consistent with information shared with CQC and other stakeholders, who commented that the provider communicated with them well.

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.

Staff balanced promoting choice with reducing risk and avoided overwhelming people, adopting a personalised approach to each individual. People were able to choose how they spent their day, including when and where they wished to spend their time. For example, some people preferred to get up early, to make their own way to the dining room and have breakfast before others. Staff would be on hand to help if assistance was required but promoted people’s choice and independence.

Risks to people’s health, safety and wellbeing were routinely assessed and reviewed. Key risk areas—such as fire safety, falls, skin integrity, and nutrition and hydration—were monitored closely. Staff told us they were kept informed about changes in people’s needs through effective communication, including signed information packs shared at handover.

Staff were trained in moving and handling techniques, and we saw them using equipment safely while communicating respectfully throughout the process. Risk assessments were in place, and people’s individual preferences regarding how they moved around the home independently were recognised and upheld.

The service did not always detect and control potential risks in the care environment.

We found the service had not identified all potential environmental risks. For example, an external door leading to the secure garden could not be opened from the outside, was not alarmed. The door was accessible to people. The registered manager responded to our feedback and organised for the door to be alarmed.

We found staff did not always close the door to the laundry room or kitchen when these were left unattended. The registered manager ensured all staff were reminded to close the door when they were not in the kitchen or the laundry room. Additional information was sent to all staff to ensure this was shared with everyone who worked at the service.

People had access to a call bell system, enabling them to request help in both emergency and non-emergency situations. Staff carried pagers to ensure they could respond to call bells quickly, regardless of where they were in the service. We observed staff responding promptly to call bells.

A review of the premises’ health and safety records showed regular servicing and checks were completed as required. Staff had undertaken training in health and safety and fire safety, giving them a good understanding of how to maintain safety within the service. During our assessment the service had their annual fire risk assessment completed by an external organisation. This meant the registered manager spoke with external professionals regarding fire safety of the service.

The provider sent regular updates to staff regarding fire safety. The service had up to date Personal Emergency Evacuation Plans (PEEP). These were kept within the service's emergency grab bag in an easy to reach area.

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.

We observed there were enough staff to meet people’s needs safely. Staff told us they had enough time to carry out their duties when fully staffed, “I feel there are enough staff to ensure the residents needs are met, and on the odd occasion where extra help is required management are seen to join the staff on the floor to assist.” There was a calm atmosphere, and people were not rushed. Staff received regular training although some staff reported supervisions were sometimes short and sporadic.

The provider supported staff with their learning and development. Some staff members were in the process of completing apprenticeships and were working towards diplomas.

The provider followed their recruitment policy, and pre-employment checks were completed on all prospective staff.

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.

The provider had an infection prevention and control (IPC) policy in line with current good practice standards.

We observed the premises were well maintained, appeared clean and there were no malodours.

Relatives told us they were all impressed with IPC and were happy with the standard of cleaning throughout the premises.

Staff completed training in IPC and had access to personal protective equipment (PPE) such as gloves. We observed staff using PPE appropriately. For example, when delivering personal care.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely as prescribed for them, including external preparations, time-specific doses and ‘when required’ medicines. If people looked after some of their own medicines, it had been assessed as safe for them to do this.

There were suitable arrangements for ordering, storage and disposal, and temperature monitoring, including for medicines needing cold storage and those requiring extra security.

Medicines care plans were in place, and risks were considered for people using higher-risk medicines such as anticoagulants, and flammable topical preparations.

Any errors or incidents were reported, so that systems could be put in place to prevent them recurring. Medicines audits took place to identify any improvements that were needed. Staff had regular training and competency checks to make sure they gave medicines safely. The registered manager was aware that some of the competency checks were past the recommended one-year review period and told us plans were in place to get these updated as soon as possible.