Sands 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 legal regulation in relation to people’s safe care and treatment; this was because of failing to adequately manage risks in the environment and the care people received.

This service scored 62 (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.
When issues were identified, the service worked well to learn from incidents and accidents, for example when there was a medicines incident a robust investigation was carried out and measures put in place showing positive outcomes. The registered manager valued learning from lessons. They had created and delivered a medicines workshop with the staff team to go over lessons learnt, organised training and staff member’s competencies were completed as needed.

The provider did not always work well with people and healthcare partners toestablishand maintain safe systems of care. They did not always manage ormonitorpeople’s safety. They did not always make sure there was continuity of care, including when people moved between differentservices. We found some peoples care plans and risk assessments were not always complete or up to date.

This meant people were more vulnerable if being admitted to another establishment such as a hospital, as the information that went with them may not have provided an appropriate picture of their needs. For example, we found that peoples currently assessed needs such as modified diets were not up to date, and that risks were not always identified or mitigated. This risk could carry over to other establishments or provisions if people moved between services.

Whilst the providers documentation was not consistently reflective of people’s needs or potential risks, they did communicate well with other agencies such as community support services, GP’s and mental health teams. We saw evidence of good relationships with other partners.

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

We found circumstances of good safeguarding practices. Staff were trained and were able to tell us how they would safely handle specific incidences of abuse.

Where the registered manager identified concerns, these were handled appropriately, the relevant bodies were notified, and actions were always taken to keep people safe. For example, when there was a concern over finances for a person at the service, the registered manager was proactive in involving the relevant partners and working with the staff to increase awareness and knowledge. The registered manager had a financial advisor as a guest speaker for all the people at the service, this touched on topics of how to use money safely and keep your financial information safe and private.

Professionals who the provider hired for visits to the service such as hairdressers had relevant Disclosure and Barring Service (DBS) checks in place and these were current.

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 and supportive.

People with specific medical conditions did not always have appropriate documentation in place within their care plans or risk assessments to support safe management of their health. There was inappropriate guidance for staff regarding how to manage risks associated with specific medical conditions, the instructions went against best practice guidelines for example those at risk of choking. This demonstrated a failure to assess, monitor and mitigate a known risk.

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.

We found that risks in the environment were not always identified and mitigated, for example when we conducted our site visit significant works were being undertaken in the service. We found that these works had not been risk assessed nor had the provider sourced risk assessments or method statements from the contractor.

Storage equipment had not been installed correctly such as wardrobes not anchored to the walls.

Products subject to Control of Substances Hazardous to Health (COSHH) regulations had a designated safe storage space, however some products were left unsecured and were not adequately risk assessed.

The service operated a shared room model for some of their rooms. We found that these were not always suitably risk assessed. Risks to people were not always identified or mitigated.

We also found that not all equipment available for staff use had been adequately risk assessed and that staff had not received specific training for it. This put people at risk of avoidable harm if staff were to attempt to utilise this equipment unsafely.

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 found that there were suitable amounts of staff to support people and meet their immediate needs. Training was in place with a mixture of both E-Learning and face to face training as well as periodic workshops curated and delivered by the registered manager when potential gaps in knowledge were identified.

People told us they felt there was enough staff. One person said, “Yes, there are (enough staff). Yes, at the weekend there's the same.” Another told us, “Oh yes, there’s enough here. I have one particular key worker. [Key Worker] is my key worker. We’ve just been for a walk to the pier.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

There were good measures in place to manage infection prevention and control (IPC). Staff had a good working knowledge and there was annual knowledge checks conducted in the form of multiple choice questions, which all staff completed.

There were daily cleaning checklists for the home and the kitchen specifically. This included additional checklists that covered the cleaning of the service at night.

Staff told us that there was enough personal protective equipment (PPE) and if they needed anything specific, they could request this from management.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff received regular training in medicines administration and handling. Competencies were carried out regularly by the provider on all staff who administered medicines.

The provider made use of a digital system to manage medicines; we found that staff had a good working knowledge of the system and our checks showed no gaps in administration records. We found that all medicine stocks were accurate and reflected what the system showed. The system had built in safeguards for example, we observed when a person requested their medicines, not enough time had elapsed between the doses. The system flagged this and staff advised they would have to wait an additional 30 minutes for the safe administration of this medicine.

We found that good protocols for administering ‘as required medicines’ (PRN) were in place and these were completed by the Primary Care Network (PCN) Pharmacist. These had good levels of detail and covered all information needed to administer PRN medicine safely and effectively.