Archived: Shore Lodge - Care Home Learning Disabilities

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 inadequate. 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 continued breach of legal regulation as potential risks had not always been assessed, guidance was not always available to staff informing them how to keep people safe. The service was in continued breach of legal regulation as sufficient numbers of skilled and experienced staff to meet people’s assessed needs had not been deployed. The service was in breach of the legal regulation as staff had not always been employed safely.

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 listen to concerns about safety and reported safety events. Lessons were not always learnt to continually identify and embed good practice. The provider had a lessons learned log, however, it was not clear that there was a robust learning culture. This was because lessons learned from incidents and accidents were not always documented. For example, a person’s death had not been recorded, another person’s head injury was not recorded. A person’s choking incident was recorded on the log but the review into what happened was not robust. The provider had not identified that the person had been given food that their care plan showed they did not like and should not eat. Lessons had not been learned from the incident as they were still given this food despite their care plan and risk assessment saying they don’t like it and they find it difficult to swallow. The person’s relatives also told us, “[Person] doesn’t like pork, I think it is because he finds it chewy however it is cooked. He will tend to eat around 3 mouthfuls and then won’t eat any more.”

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. There had been no new admissions to the service since we last inspected. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, support was in place as well as hospital passports. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital. People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken, people had support from those who they knew well to understand what was happening. The manager explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. This included ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP and other health professionals when needed. A relative said, “The hospital consultant recommended that [person] has Vitamin D. The GP was slow in sorting this so [manager] went down to the surgery in the car and got it sorted out; he is having the vitamins now.”

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 had been trained and knew the signs to recognise potential abuse and how to report any concerns. Staff felt confident that any concerns they raised would be acted on and followed the provider’s policy and procedure. A staff member said, “I have done safeguarding training, I would report any abuse concerns, check injuries, report and fill out a body map. It would be taken seriously and acted upon. They are always reminding us. We know people well and can notice changes and we must report them.” The manager understood their responsibilities to report any concerns promptly to the relevant external agencies. Records showed that concerns had been investigated, and safeguarding had been discussed with the staff team during handover meetings, staff meetings and in supervisions. Information was available around the service for people and staff on abuse and staying safe. Relatives told us their loved ones were safe.

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. A person’s care and support plan showed they had an epilepsy sensor on their bed which was to be used when they were in their bed to enable staff to know if the person had a seizure. We observed staff had not recorded that this equipment was used when the person went to bed for a rest in the afternoon on the first day of the assessment. This meant staff were not following their care plan and risk assessment to monitor the person’s safety. We observed staff not following care plans and risk assessments in relation to moving and handling risks, this was usual practice, and they confirmed this. Moving and handling risks for 1 person were not well managed, this put the person and staff at risk of harm. We reported these concerns to the physiotherapist who had put together the moving and handling guidance and the person’s care manager, as well as reporting this to the management team. Another person did not have a risk assessment and care plan in place regarding use of a specialised piece of mobility equipment.

At our last assessment, epilepsy care plans and risk assessments were in place to provide guidance, however, 1 person’s care plan did not include ensuring their safety in relation to bathing, or the procedure to follow if they had a seizure while sitting in their wheelchair. Guidance and explanation around the risks of sudden unexpected death in epilepsy (SUDEP) were not included. At this inspection we found this had been updated. However, we found that risks were not always well managed.

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 environment within the service had been improved and renovated so was more inviting, items that could cause harm were safely locked away. Some areas of the service were closed off, with the heating shut off because the number of people living at the service had reduced. This included the area with an assisted bath. The manager told us the bath was not used by anyone. However, maintenance records showed unused water outlet testing had not been carried out in accordance with Health and Safety Executive guidance ‘Managing legionella in hot and cold-water systems’ and the provider’s legionella risk assessment had not been followed. Records showed only one infrequently used water outlet had been flushed when the service had multiple empty rooms and bathrooms. Since we last inspected the service, the fire service had carried out an inspection. They served the provider a deficiency notice and told the provider to make improvements to the fire safety. The provider had engaged with contractors to assess the work, at the time of our assessment, some of the work had been undertaken.

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. Staff recruitment records contained gaps in employment, 2 out of 3 staff files had issues with dates not matching the application. We found employment references were missing. Character references had been undertaken.

Training records showed some staff had received training and rotas showed this training was continuing. Only 76% of staff had completed moving and handling practical training, despite all people at the service requiring physical support. Not all staff had completed emergency epilepsy medicines training. This included staff who took out people who required this medicine into the community and night staff. This meant there had been no trained staff on shift at night which put people at risk of harm if they had a seizure and required this medicine at night. We observed untrained staff completing medicines administration on the first day of our assessment. Training records did not show that staff had completed training to support them to work with people in distress or that staff had attended training in learning disability and Autism. Staff told us they had regular supervision.

There were suitable numbers of staff on shift during the assessment, however this was not always the case. Reviews of records submitted as part of the provider’s conditions of registration showed that 4 staff were on shift during the day and 2 staff were on shift at night consistently. A relative said, “There used to be loads of staff, now there are not so many, but I don’t suppose they need as many with less people there and 1 wing closed."

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. People were protected from the risk of infection. Relatives told us they felt the service was clean and free of odours. A relative told us, “It is clean, they have cleaned it all up.” Observation showed the service was clean and staff wore the appropriate personal protective equipment (PPE) and had access to a variety of PPE throughout the service. Staff had been trained and followed the provider’s policy and procedure in relation to infection control. Day and night staff followed a schedule of cleaning tasks which included deep cleaning. Risks of infection and cleaning records were reviewed and audited by a member of the senior management team.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff who were responsible for administering people’s medicines told us they liked the electronic system they used for recording medicines management. Some people had been prescribed ‘when required’ (PRN) medicine for times such as, being in distress or for pain relief. Staff followed PRN protocols including guidance from the prescribing health care professional. Guidance and legislation were followed for anyone requiring ‘covert medication’. This involved administering medication in a disguised form, such as in food or drink, without the person’s knowledge or consent. However, 1 person’s covert medicines protocol showed a medicine was being put on yoghurt. This was not being taken in line with manufacturer guidance. This medicine should not be taken with lactose containing drinks/food or other medicines and it clearly stated this on the prescription label and patient information leaflet.

A person’s medicines administration record (MAR) from August 2024 to February 2025 showed a medicine had been given daily at the same time as other medicines, this was not administered according to the prescriber’s instructions. Other medicines records showed people had mostly received their medicines as prescribed. However, a person’s MAR showed they had been given PRN medicine for a seizure on 09 November 2024, we were told the person had not had seizures for a considerable time. On the same day another person did have a seizure and PRN medicine for this which was recorded in their MAR. Staff had incorrectly recorded the administration of this medicine against the wrong person. This recording error had not been picked up in medicines audits undertaken by the management team.