Welcome House - Nickleby 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 Requires Improvement. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, unsafe premises and equipmentand safe staffing.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The majority of people being supported at Nickleby Lodge were described in the providers documentation as experiencing extreme distress, confusion or anxiety on a regular or daily basis as a result of their mental health diagnosis. The provider had not formally recorded these instances for a number of years for some people on the basis of this being normal for that person. There was no clear analysis or monitoring of people’s mental health to identify learning or ways staff could effectively promote people’s wellbeing. For example, by looking at what may have triggered a person’s mental health to deteriorate, or whether strategies or techniques staff have used in response were effective. The provider had accepted people as frequently becoming distressed or upset as normal without challenging this or considering if they reflected an unmet support needed.

Incidents were not always recorded or investigated appropriately. We saw one incident where a person had threatened to “beat” other people they lived with and staff. There was no further information recorded around this including what further action had been taken to explore why this had happened or how to prevent it in the future. Where incidents did occur there was no detailed analysis to identify any themes or trends to improve people’s outcomes.
 

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.

In some cases we saw prompt action was taken to make referrals to wider health and care providers, to seek specialist input in response to people’s deteriorating or changing health needs. For example, one person had recently been extremely unwell and a stakeholder involved in their care told us, “The care home contacted us in timely manner without any delay as soon as problem was noted so there was no delay in care”. People were also supported by staff to access regular appointments to manage their physical and mental health.

However, this was not consistently the case. One person had been assessed as being at risk of choking which was increased by them not always wearing their dentures, the provider had not made a referral to Speech and Language therapy to ensure they were able to safely support this person to manage their nutrition and hydration. Another person had lost a significant amount of weight in the last year. Whilst they had appointments with their GP to explore if this could identify a concern with their physical health, they had not proactively made a referral to a dietician to look at how they could encourage this person to eat and prevent the risk of malnutrition. Neither was there any guidance or plan for how staff would prevent this.

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.

Staff had all received training in safeguarding and were able to demonstrate a good understanding of this. One staff member explained “This is protecting people from abuse or neglect, and we have a policy on safeguarding which I know where to access. I could also follow the whistleblowing policy if I needed on how to report concerns to external bodies”. Safeguarding referrals were being made appropriately where there were concerns raised that identified abuse or neglect may have occurred.

There was not always a clear or robust plan for how the provider would protect people from the risk of this happening. For example, one person would regularly decline to take their medication which placed them at greater risk of self-neglect. Their care notes demonstrated this was a regular occurrence, and yet there was no guidance on how the reasons for this had been explored, or strategies or techniques that use to support them in taking their medication. Other people were at risk through self-harm or suicide ideation, and the care plans in place to manage this did not provide any clear guidance on how this had been explored to reduce these risks posed to people during a mental health crisis. Where people were assessed as lacking capacity, mental capacity assessment to review this were not robust in determining how care provided was the least restrictive way.

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 at the service were living with significant risks to their physical and mental health, in the majority of cases, there was no detailed plan of how staff would work with them to mitigate these risks. Where people were at risk of becoming distressed or physically or verbally aggressive, the plans in place for staff to follow were not robust and provided no clear strategy of how de-escalate.. For one person the mitigation in place if they were to become distressed was simply to tell them to “calm down” and asking other people to leave the room. For another person, staff were told to “avoid making the situation worse” without any guidance as to what they should avoid doing. This risked causing the person further distress and putting them and staff at risk of harm. Neither case showed a holistic approach to protect people from becoming distressed or how staff could respond to minimise this if it happened. The information for staff on people’s triggers for distress or how staff should respond was not robust or person centred. We identified multiple people had a history of harming themselves intentionality or threatening to take their own life, yet despite this in some cases their risk assessments stated there was no risk around self-harm or suicide.

Some people had complex conditions without any care plan or risk assessment, meaning staff were providing care without any clear guidance. This included around the risks of malnutrition, constipation and recurring urinary tract infections. In other cases the guidance in place was minimal, and was responsive rather than proactive in considering how staff could actively help people manage their own health needs. For example, where people were at higher risk of being incontinent there was no guidance around how staff could help prevent this. Although staff could explain how they would support people, the provider could not be assured this was in line with their wishes or aligned with best practice. The lack of guidance meant there was a risk of people not being consistency or safely supported, and that staff less familiar with people’s needs would not have the information they required.
 

The provider did not 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.

There were regular checks undertaken to monitor the safety of the physical environment, but these were not always effective at identifying risks to people or taking prompt action to remedy them. We identified all emergency call bells in the bathrooms were either too short or had been tied up, meaning they would not be able to be accessed if a person was to fall onto the floor. This placed people at potential risk of harm as they may not be able to access help when needed. All radiators in the building were unguarded, and the water temperatures were consistently outside of the recommended safe temperate range, placing people at an increased risk of burning themselves at times when their perception of risks was reduced such as during a mental health crisis. There had been no risk assessment to determine if this was safe. We also identified the shed was unlocked with access to sharp implements such as saws, despite the service supporting people with a history of self-harm.

Checks had taken place to ensure that utilities such as electricity, gas and water were safe. There were also robust business continuity arrangements of how the service would ensure continuity of care in the event of an emergency situation such as loss of utility or extreme weather. Fire safety checks were regularly taking place including fire drills. However, one person was at risk of choosing not to evacuate during a fire, which was not reflected in their personal emergency evacuation plan . These documents are used by staff and fire crews to support with evacuation, meaning in the event of a fire there was risk they would not have up to date information about how they could safely support this person. This was updated once we raised the concern.
 

The provider did not always make sure that staff had sufficient knowledge or training. They did not always make sure staff received effective support, supervision and development.

Staff were working with individuals with complex and profound mental health needs, meaning there was an increased importance of supervision both to ensure staff remained an up to date knowledge and to monitor their wellbeing. Despite this, records showed that 3 members of staff had gone a period of 6 months without a supervision and another for 4 months. The provider did not have robust systems for monitoring staff competency. Staff were being assessed as competent to support people with medications including controlled medicines, but the provider did not have a checklist or system to conduct or record this assessment. This meant the provider could not be assured that staff were able to do so safely.

In the majority of cases we found staff had appropriate levels of training to manage the needs of people safely, and were knowledgeable about the people they worked with. Feedback from staff, people and relatives were that the numbers of staff in place were sufficient to support people safely. There was a system in place to regularly review this. Staff were safely recruited including use of Disclosure and Barring Service (DBS) checks. A DBS check is used by employers to make safer recruitment decisions.
 

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

One person was living in a room which had an overwhelming odour of urine. This was a deeply unpleasant, undignified and unsanitary environment for this person to reside in. The provider had failed to take urgent action to rectify this and we saw replacing the carpet which was the source of odour had been on their maintenance list for several weeks, without considering how profoundly unacceptable it was for a person to live in these conditions for any period of time. We raised this with management and following the inspection action was taken the next day to replace the carpet with more acceptable flooring for this person’s needs which would be easier to clean.

Some areas of the environment were badly degraded which meant staff would not be able to effectively clean them, and increased the risk of them harbouring infections. This included the work surface and cupboard doors in the kitchen and some areas within bathrooms where surfaces were in a poor state of repair and degraded to their base material. We also identified some items of personal protective equipment (PPE) had expired and therefore may not be as effective against preventing the spread of infections.

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

There were gaps in recording how “as and when” (PRN) medications were managed. The protocols for when to offer these were unclear meaning we could not be assured people would receive these consistently to manage complex health conditions. When they were given, staff were failing to monitor the outcomes of these and if they had been effective in relieving the condition they were prescribed for in accordance with good practice guidance. For example, one person was being prescribed an antipsychotic medication to be used as a last resort during extreme distress or anxiety. These medications have a high toxicity and a sedative effect, there was no clear recording of why they had been given or whether they were effective. Staff were guided to document each instance this medication had been given to describe how other less restrictive options had been exhausted first, however were not doing so. Therefore, it could not be established that these were always being managed appropriately.

The provider were supporting people with a learning disability or who were autistic, however failed to demonstrate awareness of STOMP (Stopping over medication of people with a learning disability and autistic people). STOMP is a national programme focused on reducing inappropriate prescribing of antipsychotic medications to control behaviour and focuses holistically on people’s support needs and how they can be met through less restrictive means. As detailed above, some people were regularly being given antipsychotic medication with little oversight or governance to ensure this was always appropriate or that holistic approaches had been used first.

We were informed staff had been assessed as competent to administer medication, however the provider had not documented how they had determined this and could not demonstrate a robust process for how these assessments were undertaken.