Talbot Woods 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 inspection we rated this key question requires improvement. At this inspection the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People and their relatives told us staff were open and transparent with them; they trusted the service. Relatives told us communication channels were effective, and the service informed them if a significant event occurred. Accidents, incidents and events within the service, were recorded, and discussed to prevent reoccurrence. Staff told us about the actions they took in real life recent events. Opportunities for learning were consistently documented within people’s records. Accidents and incidents were recorded on the provider’s electronic systems. The registered manager was informed of each incident and undertook monthly reviews to identify trends.

The service 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 felt confident their needs would be met by staff and information would be shared to promote seamless care. Information about medical professionals was included within people’s care plans. Staff told us information was available to them if they needed to speak with external professionals about people’s support needs. This included, if a person had been admitted to hospital. People’s support needs were detailed within their care plans and risk assessments on the electronic system. A summary sheet was available if the person went into hospital or moved to another care home, this promoted continuity of care for people. Health and social care professionals were positive about communication with the service to aid people’s continuity in care.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at Talbot Woods Lodge, their relatives agreed. A relative said, “Our loved one is 100% safe here, they can always access support.” Staff told us they were committed to providing a safe homely environment for people. Staff understood how to identify signs and symptoms of abuse and harm; they told us the actions they would take to raise the alarm. Staff told us of various real-life situations where they had raised concerns, they were confident the registered manager and manager had acted immediately. We observed many kind interactions between people and staff. Safeguarding training was mandatory for all staff, was up to date, and had included regular updates. People were supported to understand how to raise concerns and reminded of safety considerations whilst away from the service. Records showed safeguarding referrals had been made as necessary and this included notifying CQC of certain events as required by law, which was an improvement by the service. All legal applications had been made in accordance with DoLS, this meant people’s rights were fully respected. The registered manager had oversight of DoLS applications, and any conditions were included within their care and support plans. Policies and procedures within the service provided a foundation for the practice and delivery of support.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people’s health and wellbeing had been identified, assessed and planned to support them to stay safe. Staff got to know people well and understood how risks could change as they moved through life. Records showed people were fully and regularly involved in assessments of risk. Plans were person centred and flexible to meet people’s changing needs. People had individual risk assessments in place for all activities and outside pursuits. The manager told us when completing a risk assessment, they visited the proposed place and assessed for hazards such as stairs, and accessibility, to ensure activities are safe. Risk assessments were completed on the providers electronic care planning system and were updated regularly or as things changed.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us they felt comfortable, and Talbot Woods Lodge was their home, each person had their own bedroom with all their favourite things. We observed the service to be kept in good order and checks maintained. Equipment and utility checks were in place and closely monitored to promote safety. Key staff members were responsible for maintenance within the service and undertook comprehensive checks and maintained records. There was a schedule of works and reminders of expiry dates. The service used external specialists and contractors to undertake some checks particularly where there was need for a specialism, such as gas, electrical and fire safety.

The service 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.

People told us staff were there when they needed them. People and their relatives told us there was enough staff on duty, and available to support their loved ones. Staff received training and support to ensure they could carry out their role effectively. Staff told us they felt supported fully by the registered manager and management team. Formal supervisions were carried out and staff told us they could access support at any time. We observed staff supporting people, the atmosphere was vibrant and fun. There was a process in place to measure people’s dependency and need which had informed staffing levels within the service. Staff were recruited safely, and recruitment records reflected this. Procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. Staff learning and development was in place to ensure staff were properly inducted into the service and their knowledge developed. The registered manager and management team had oversight of training within the service, this included accessing training and learning for career development and improved knowledge. A staff member told us, “The registered manager and manager provide informal coaching and trying to help us be the best and make sure everything is done.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us the service was clean and tidy, this included people’s own bedrooms. People were supported by staff to keep their living areas tidy. Staff received training in infection prevention and control. Dedicated staff ensured the service was clean. We observed the service to be clean and hygienic, this was mentioned positively to us by each person and their relatives. Personal protective equipment (PPE) was worn when necessary, by staff. Safe infection prevention and control procedures were in place, and this underpinned practices within the service. Infection control procedures and audits were in line with good practice guidance. Staff had plentiful supplies of cleaning materials, products, and PPE.

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

People received their medicines as prescribed. There were safe processes in place for ordering, storage, administration and disposal of medicines. Staff who were responsible for giving people medicines were trained and had their competency assessed. Staff told us they had robust ways of working in place to ensure medicines were safe. A programme of checks was in place to support safety. The provider’s electronic medicines system contained accurate recordings including administration and stock counts. The registered manager had oversight of the system. Medicines were stored at safe temperatures and checks were in place to ensure this was maintained. Guidance supported staff to ensure medicines taken occasionally were given in a consistent way. Medicines which required stricter controls were monitored and correct control measures were in place. Audits and checks were in place to ensure compliance. The service worked in accordance with ‘stopping over medication of people with a learning disability and autistic people (STOMP).’ STOMP is a national project to reduce prescribing and administration of mood-altering medicines. It is about helping people to stay well and have a good quality of life.