Tamarix Lodge - Care Home

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.

This service scored 53 (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. Staff recorded accidents and incidents, but records lacked evidence of follow-up actions, limiting opportunities for shared learning across the service. The provider reviewed service-level trends, but there was no evidence of local action to prevent recurrence.

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.

Systems in place to monitor people's health was not always maintained by staff. For example, we found gaps in record keeping for people who required daily monitoring of food and fluid intake, catheter care and repositioning. Information was available where people required additional support from health care professionals.

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.

The provider did not always share concerns quickly and appropriately. Staff were aware of their responsibilities to safeguard people. However, the provider failed to ensure risks to people were managed effectively. During the assessment it was identified that staff did not always feel listened to when they raised concerns about people's health and wellbeing.

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, supportive and enabled people to do the things that mattered to them.

The provider did not consistently assess or manage risks associated with individuals’ specific needs and health conditions. Care plans and risk assessments were not always in place for people’s specific health conditions. We observed that sometimes these records were incomplete and lacked sufficient detail to guide staff to provide safe and effective care, placing people at potential risk of harm. For example, on Day 1 of the inspection, we identified that individuals with catheters who were assessed as being at risk of urinary tract infections (UTIs) and water retention did not have appropriate documentation in place. Care records lacked sufficient detail to guide staff on how to effectively manage and mitigate these health risks. By Day 2, a full review of catheter care had been undertaken. Care plans had been updated to include additional information relevant to the management of catheter-related risks. However, despite these improvements, we continued to observe inconsistent record keeping regarding staff monitoring of these health needs. This meant there was not always clear information to ensure effective care delivery and risk mitigation.

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 provider had systems and processes in place to manage the safety of the service. However, staff told us that equipment needed to safely move people was not always available when required. A member of staff told us, "The ELK chair (lifting equipment for when a person is on the floor) has been broken for about a week and we need it at the moment to support [Person's name]."

A range of health and safety checks were undertaken incorporating electrical, gas and water safety. The premises were kept in good order and any identified issues were dealt with straight away.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervisionand development. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not deploy enough staff to provide people with the care and support they needed. People and their relatives felt there was enough staff at the service. However, we saw people sat in communal areas for long periods of time with limited staff interactions.

Staff told us they did not feel staffing levels were adequate to meet people's basic care needs. Comments from staff included, "We are really short staffed at the moment, we do have time to give people the care they need" and "There is not enough staff, I don’t have the time to do my job how I would like to do it."

Staff did not always feel supported. Where staff raised concerns about people's health and wellbeing, they told us they did not always feel listened to and appropriate action was not always taken by team leaders. Staff confirmed that they received regular supervision meetings and training was available to support them within their role.

Staff were recruited safely with all appropriate checks in place.

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.

The provider had effective systems in place to monitor infection prevention and cleanliness, including regular audits. Where issues were identified, prompt action was taken to address them. There was a sufficient supply of personal protective equipment (PPE) available at the service. Staff were observed using PPE appropriately, in line with infection control guidance.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

People received their medicines as prescribed. However, we found evidence that people received medicines that had passed their expiry date. Records relating to the administration of creams and topical medicines were not always fully completed by staff.

Risk assessments for individuals prescribed blood thinning medication were not completed. There was no documented risk assessment available to inform staff of the potential complications associated with this type of medication. We raised this example with the registered manager who stated that this would be addressed.