Foresters 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 our last assessment 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.

The service was in breach of a legal regulation in relation to the way in which people’s medicines were managed.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Managers recorded, tracked and analysed accidents, incidents and risks. However, these processes did not always effectively reduce or prevent recurrence of concerns or drive consistent improvement across the home. Audits, a risk register, incident investigation and regular monitoring took place, with daily meetings to address emerging risks. However, governance and audit processes had failed to identify and manage some of the shortfalls found during this inspection. Managers told us they would learn from this, and we found some issues had been resolved by the second day of inspection.

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 provider assessed people’s needs when they moved to the service and developed care plans which identified risks and guided safe care. Professionals described care plans as supporting continuity and making transitions smoother. One professional told us, “I do like the care plans. Their care plans really do help us to get a good picture of what is happening [and] makes transitions smoother.” The service worked with community professionals when needs changed, including contacting relevant clinicians to support care planning and review.

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 how to raise safeguarding concerns and were confident action would be taken. Safeguarding referrals and notifications were made as required, to the relevant organisations. Relatives and people knew who to speak to if they felt unsafe, typically naming the registered manager or senior staff.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had risk assessments in place. However, practice did not always align with assessed risks or as identified in people’s care plans. Care records did not always evidence how staff managed repeated refusals of care, and medicines and repositioning were not always recorded as planned. This meant people were not consistently supported to understand and manage risks in a way that matched their assessed needs and choices.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider completed equipment and maintenance checks, and staff described equipment as in good working order. However, parts of the environment were not consistently well maintained or safely managed. There was signs of wear requiring redecoration, some rooms cluttered with equipment, and the inconsistent use of the stair guard, despite risk assessments being in place. Environmental safety risks were also noted, including combustible materials stored at the bottom of a stairwell and a laundry cupboard left unsecured with linen obstructing a smoke. Managers took action to address the issues identified during our inspection.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Feedback about staffing levels and responsiveness was mixed from people, relatives and staff. Staff told us they did not always have time to speak with people and call bells could go unanswered when staff were stretched. This was observed throughout the first day of the inspection. One staff member said, “We have safe numbers [of staff], but it would be nice to spend more time with people.” Managers described recruitment and retention challenges. Staff were recruited safely.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff used appropriate personal protective equipment and there were good stocks of these. However, infection prevention and control (IPC) systems were not consistently effective in practice. Cleaning schedules were in place, yet some weekly tasks were regularly recorded as not completed and we observed areas requiring cleaning. People were not supported with hand hygiene before eating, which increased the risk of infection transmission. We also observed poor practice of storing creams inappropriately in toilet areas. Managers had previously identified similar concerns but took immediate action to review and address the issues identified during our inspection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not always managed safely, and shortfalls in oversight increased the risk of avoidable harm. Inspectors found medicines were not always stored securely, expired prescribed items were present, and required gaps between doses were not always followed. Key supporting systems were not consistently in place. For example, guidance for people who were prescribed medicines on an as and when basis was not always in place or was inconsistent. People who were prescribed transdermal patches did not have appropriate records of where these had been placed. Whilst this had been identified during the most recent medicines audit, which took place shortly before the inspection visit, this was not in place at the time of our inspection. One relative reported they had observed poor practice, telling us, “A couple of times there have been a couple of tablets left on [Name]’s table. I’ve raised it and it got dealt with.” Following our inspection the registered manager has provided assurances the concerns identified have been actioned.