Franklyn Lodge 9 Grand Avenue

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 4 legal regulations. These were in relation to people being safeguarded from abuse and improper treatment, safe care and treatment, staffing and premises and equipment. The risks associated with people’s care were not always being managed and there were not always sufficiently qualified and trained staff deployed to support people in a safe way. Infection control was poor, and the provider had no oversight of the risk of the spread of infection. The provider had not ensured that the cleanliness of the service was maintained, and safeguarding concerns were not always recognised and raised to the appropriate authorities in a timely manner.

This service scored 44 (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.

The provider did not have a robust process in place to monitor or review incidents in the service. This meant it was not clear what actions were being taken to mitigate future risks to people and staff. The provider had not analysed incidents effectively to understand any underlying trends and themes. This meant they were not able to demonstrate how lessons were being learnt.

However, staff and people felt encouraged and supported in raising concerns because they knew they would be dealt with. One relative said, “I absolutely trust them, and I’m not worried to complain.”

The registered manager was aware of their responsibility to notify the CQC appropriately of incidents that had occurred.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service had not worked to ensure that one person’s care was fully reviewed, changes addressed, and they received the equipment they needed to support them safely with regards to their changing needs. The registered manager had raised this with the appropriate health care professionals however when there was no or little response from the relevant agencies, the manager had not adequately escalated their concerns and in a strong enough way to advocate for the person. This left the person at risk of falls, pressure sores and social isolation because they were being cared for in bed on the first floor of the home, unable to move to the communal areas of the home or to access the local community.

However, records evidenced people had been supported to access external health professionals appropriately and when needed. Relatives confirmed this, one relative said, “They [staff] let me know all of [relatives] appointments and the findings of those appointments.”

People who could not access the community for appointments such as opticians were offered home visits for routine annual eye checks.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

During the assessment one person was at significant risk of neglect of their social, emotional and physical needs yet this had not been recognised and raised as a safeguarding concern. This meant the provider was not always able to evidence how safeguarding concerns had been investigated and addressed to ensure people were kept safe.

The provider had applied for Deprivation of Liberty Safeguards (DoLS) authorisations for people. The people had been assessed, but the authorisations had not been received, and a significant period of time had passed since the assessments were undertaken. However, the provider was able to demonstrate that they had been regularly asking for the authorisations from the local authority.

Staff had been trained in safeguarding people from the risk of abuse, could tell us about the different types of abuse and to whom they should report concerns. One support worker said, “I would report to the manager or senior support worker if I was worried about anyone.”

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

People’s care and support records contained numerous risk assessments relating to aspects of the support they received, such as personal care, moving about the community, fire emergency and falls.

Some risk assessments were detailed and provided appropriate guidance for staff on how to mitigate the risks associated with people’s support. However, people had not been involved in identifying or mitigating risks, nor were they encouraged to take positive risks safely to develop and grow.

Other people’s risk assessments were not followed to ensure that the strategies outlined were effective in reducing the risk. For example, one person had been assessed as being at risk of choking on their food. The strategy outlined in the risk assessment to mitigate this risk was for staff to supervise and guide them whilst they ate so they didn’t rush their food. We observed lunch time, and no staff were present to supervise or guide the person.

We were not assured that risk assessments were always robust and individualised. Some mentioned another provider organisation, other people’s initials were sometimes used and some strategies used were the same, despite people’s different needs and physical presentations.

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 home was clean in some parts when we visited, however some areas were not clean and other parts were in need of maintenance and redecoration to ensure the environment was pleasant and homely for people.

There were malodours in some parts of the dining room and lounge areas. The furnishings in these areas were not composed of non-permeable, wipe clean fabric and these appeared not to have been adequately disinfected and cleaned appropriately.

While there were window restrictors on the first floor there were none on the ground floor. We did not see any risk assessments related to this.

Notwithstanding the above a relative told us, “It’s clean mostly when I’ve been there, it’s not the most modern. It’s a bit dated but it’s warm and carpeted.”

There were not always enough staff deployed to meet people’s needs safely and effectively. Staff did not always have the appropriate skills to engage people to meet their social, emotional and health needs.

There were not enough staff available to ensure that the strategies to mitigate risks to people’s safety that were outlined in people’s risk assessments were implemented effectively. For example, some people’s risk assessments noted they needed the support of two staff to ensure they were able to move about the local community safely. This was not available, and so people were not supported to undertake regular community activities or day-to-day errands such as shopping.

We observed that staff rostered on to provide 1:1 individualised support to people did not always engage them effectively. We observed one 1:1 staff member sitting and watching television instead of actively engaging the person they were supporting. The television show was not of interest to the person the staff member was supporting. They were not watching it but were instead pacing around the room.

One person with complex needs spent all of their time in their bedroom. Staff checked on them hourly but did not engage socially or carry out some form of social activities with them apart from supporting them with meals and with personal care. As they had significant mobility needs and their bedroom was on the first floor, they could not leave their room without staff support and there were not enough staff available to support them to do so. This left the person at significant risk of social isolation and unsafe care.

Support staff were also responsible for cooking and cleaning, which took them away from supporting people for periods of time.

The registered manager told us, and we noted in people’s support plans, that staffing levels were determined by the funding authorities’ assessment of people’s needs. However, we noted that the staffing levels were not sufficient based on our observations when we visited, nor was appropriate action taken to ensure that funding authorities were aware of when people’s needs had changed, and they required more staff to support them safely and effectively.

Staff told us they had been trained to provide safe support to people. A support worker said, “We have training every year. On Friday I did nutrition.” Another support worker told us, “We have lots and lots of training.” Staff training was up to date and covered a wide range of topics such as, learning disability and autism awareness, fire safety, continence care and infection prevention and control.

Support staff were also responsible for cooking and cleaning, which took them away from supporting people for periods of time.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. We were not assured that the home had robust infection control processes in place.

There were no facilities in any of the bathrooms and toilets in the building for drying hands. There was a lack of liquid soap in the toilet/bathrooms and in the few places where there was handwashing liquid, the content was watered down. We visited the service on three occasions over 2 weeks and on each visit the bathrooms and toilets remained the same with a lack of handwashing facilities.

There was also no hand sanitiser anywhere in the service. We were informed that hand sanitiser and hand wash were in the Control of Substances Hazardous to Health (COSHH) cupboard but when we looked, there were 2 containers, one with pine disinfectant and the other with no label on and we were told this was washing up liquid. There were COSHH data sheets but no supply of COSHH.

There was information and guidance for staff about supporting people to wash their hands after using the toilet, in people’s support plans, and posters on the wall showing people how to wash hands correctly. However we observed one person coming out of the toilet, there was no hand soap or paper towels available, and they were not supported to wash their hands.

The dishwashing detergent used in the kitchen was watered down which would have reduced its effectiveness to clean the kitchen utensils, the crockery and cutlery and prevent the spread of infection.

Daily checks of the service did not highlight the concerns we picked up and were therefore ineffective.

We spoke with the registered manager who told us they would order some hand soap, paper towels and hand sanitizer amongst other COSHH items.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff had not involved people in planning, including when changes happened due to their capacity, but relatives were kept informed of changes.

We saw medicines were stored and administered safely. When people had ‘as required’ medicines there was guidance in place for staff to follow. Staff administering medicines had received training and their competency was checked to ensure they were safe to administer these to people. Monthly medicines audits were carried out and yearly ones by the Pharmacy to make sure the management of medicines was safe.

One relative told us, “[Relative] only takes blood pressure tablets at the moment, they [staff] always do let me know of any changes.”

A staff member told us, “I oversee medicines in the home and make sure prescriptions go in and medicines are collected.”