Charnwood 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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. For example, there were systems in place to review safety events, to understand why a person had become distressed or an incident had occurred. A staff member told us, “We have a positive, open culture here and staff are given time to reflect on what we did, what worked and what we could have changed. Managers make sure de-briefs always happen after incidents so we can share learning and make sure we are consistent.” A second staff member described how the providers’ positive behaviour support specialist met with staff to provide support. They told us, “We meet and bounce ideas or suggestions around with them. It helps to have a fresh pair of eyes to support with reviews to make sure approaches are working for people.” This approach helped to prevent further incidents and embed good practice.

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. Staff worked with external agencies collaboratively to ensure people were safe and involved in their care. Care plans provided examples of joint working, including assessing for potential moves to more independent living and working with health professionals to identify strategies for people to enable them to engage in health appointments and screening and stay healthy.

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 and worked collaboratively with professionals to protect people from harm. Staff completed training and were aware of potential indicators of abuse or neglect. They told us they knew what to do if they were concerned about a person through changes in their responses or behaviours. A staff member told us, “People are safe as there is always someone around to support them and people get their allocated 1-1 staff. If I had any concerns, I would go to the managers and 100% they would listen and respond.” Relatives told us they felt their family members were safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Staff supported people to take risks to achieve a good quality of life through a positive risk taking approach. Staff were skilled and proactive in supporting people experiencing distress and were alert to emotional communication. People had individualised and detailed behaviour support plans which incorporated positive proactive strategies for staff to follow. Restrictive interventions were only used where authorised and as a very last resort. These were reviewed regularly and after each incident of distress to assess if approaches remained effective and necessary. A staff member told us, “We work closely with people and assess what upsets or calms them. For example, [Name] will hold their head before they become distressed if the environment becomes too loud for them. We know this and can intervene at an early stage by prompting them to go to a quieter area which calms them and prevents their distress from escalating.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Changes and adaptations had been made to the environment to meet people’s sensory and physical needs. For example, some people had their own apartments where they could prepare and eat meals to develop their independence and reduce potential negative interactions with others. People were able to access a sensory room for therapy and had access to extensive grounds and surrounding woods with staff to promote a healthy lifestyle. People’s care plans included plans to support staff to evacuate them safely in an emergency. For example, a person with a hearing impairment had an extra loud sounder in their room to enable them to hear the fire alarm. The provider undertook routine and specialist safety checks to ensure the premises and equipment remained safe for people, staff and visitors.

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. There were sufficient staff to meet people’s needs and staffing was deployed flexibly to ensure where people required constant supervision, this was in place and to support people to go out when they wanted to. There was an effective programme of staff training, including a detailed induction, to ensure staff were sufficiently skilled and knowledgeable to meet the needs of autistic people and people with a learning disability. A relative told us, “The current staff members are the best ever, they understand my family member and their needs and requirements. I have every confidence in all of them.” The provider followed robust recruitment processes to ensure staff were safe and suitable to work in the service.

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. Staff followed safe practices to protect people from the risk of infection and keep the environment safe. We saw the environment was clean and free from clutter. Cleaning schedules and IPC audits were carried out to ensure standards were upheld.

The provider had systems and processes in place so that medicines and treatments were safe and met people’s needs, capacities and preferences. However, we found these were not always followed or consistently understood by staff. We found staff had not completed appropriate and ongoing training in safe oxygen storage and use; and oxygen was not stored securely. Medicines administration records (MAR) were not always completed accurately as we found errors around people’s as and when required medicines and excessive stocks of some medicines. Additionally, we found staff were not accurately recording fridge temperatures to ensure medicines were being kept within the required temperature range. These errors could affect how the medicines worked and their suitability. We raised these concerns with the registered manager who took immediate action to make address these, including staff training, which mitigated risks. They also introduced more robust oversight and monitoring to ensure improvements were embedded in staff practices. Restrictive practices involving chemical restraint were only used as a last resort once staff had supported people in different ways which were detailed in care plans. People’s medicines were regularly reviewed to ensure they were effective and suitable.