Priory 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 inadequate. 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 safe care and treatment.

This service scored 50 (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. Lessons were not always learnt to continually identify and embed good practice.

We saw evidence the provider responded to concerns and complaints and logged accidents and incidents however, we found that there were not always sufficient actions taken when an incident occurred. For example, we found in 1 person’s care plan, they had experienced an episode of choking, however no choking risk assessment/guidelines were in place for staff about what they should do if they suspect the person is choking. The provider confirmed a referral had been completed to the SALT speech and language therapy team, but it was not clearly documented within the care plan. This meant staff did not always have the specific information needed to reduce the risk of similar incidents occurring.

We saw evidence the provider did discuss lessons learned with the staff team during staff meetings and staff confirmed they were kept informed between shifts regarding people's needs. Comments included, “I’m kept in the loop regarding any health updates or changes to care plans” and “We are kept informed of updates to clients’ health needs and care plans via handovers and other communications, which helps to ensure consistent and continuous care.”

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 in partnership with other professionals such as GP’s, district nurses and advanced nurse practitioners. Feedback we received from professionals was positive. One professional told us, “The home are very prompt to seek help and support.”

Relatives we spoke with told us they were kept up to date with their loved one’s health needs. Comments included, “If [relative] has been unwell the manager of the home contacts us by telephone and keeps us updated with their treatment.”

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.

The provider submitted statutory notifications and raised safeguarding concerns with the Local Authority.

The provider had safeguarding policies and procedures in place and staff had received training in how to safeguard people from abuse and understood how to report concerns. One staff member told us, “We receive updates in key areas such as safeguarding.” We saw evidence of safeguarding being discussed at team meetings.

People told us they felt safe. One person told us, “I am quite happy here, I can talk to the staff or manager if I am worried about anything.”

We observed people appeared to be comfortable living at Priory Lodge and in the company of the staff supporting them. We observed positive interactions between staff and people.

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.

We found that people did not always have the appropriate risk assessments in place to reduce the likelihood of harm occurring. We found one person had no risk assessments in place and they had a significant number of health needs. One person’s care plan we reviewed had not been updated to reflect their recent health decline and increase in care needs. We also identified gaps in some areas of peoples care plans. For example, one person's needs section was blank, and we also found conflicting information around one person’s diabetes needs which meant we could not be assured staff had the correct information to safely support people.

However, feedback from staff was positive and they felt any change in needs were communicated well between the staffing team via handovers, meetings and in house communication systems. Comments included, “I feel well informed about health changes and risks associated with residents’ care plans” and “Clear communication is shared daily, and any changes to a person’s health or care needs are always passed on during shift patterns and reports.”

The registered manager acknowledged these failings during the inspection and reviewed, updated or created the relevant risk assessments and care plans.

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.

During our onsite inspection, we found that checks relating to fire safety were up to date such as emergency lighting and fire doors, however when reviewing Personal Emergency Evacuations Plans [PEEPS], we found they did not always contain sufficient detail to ensure people’s safety in the event of a fire. We also found one person did not have a PEEP in place which placed them at risk of harm in the event of a fire. The registered manager acted on our feedback and ensured the PEEP was completed and in place and updated the PEEPS for other people to ensure they were up to date, accurate and contained the relevant information.

We found wardrobes were secured to the walls and necessary window restrictors were in place.

Necessary safety certificates were in place to support safe environments in areas including gas safety, electricity and legionella checks.

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, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We reviewed training records and found staff had completed core training, however training specific to certain health needs was not always recorded or evidence. For example, we saw no evidence of staff receiving training around dysphasia, despite a person being at risk of choking.

We addressed this with the manager, and they confirmed staff had received the appropriate training around catheter and stoma care via the district nursing teams. We discussed ensuring any additional training is logged on the training matrix, so it is clear what training has been done and dates completed/due for refresher.

Staff told us they felt they received sufficient training and were positive about the induction process. Staff received sufficient supervision. Comments included, “Management provides support to staff development through supervision, appraisal and competency assessments.”

We did not receive any negative feedback around staffing levels and people told us staff were available to help when needed. Comments included, “I don’t need staff support to go out but they are here if I need anything.” We observed enough care staff to support people.

The provider had recruitment procedures in place to ensure the required checks were carried out prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

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

During our onsite inspection, we found improvements were required around infection prevention and control (IPC) of the environment. We found in the communal bathrooms build-up of limescale, skirting boards were dirty and staining on walls. There were a number of cobwebs observed in areas such as the conservatory. One of the stairwell carpets was ill fitting and dirty and the chairs in the lounge area were worn and the leather was degrading. We found out of date food in the fridges and identified concerns around appropriate storage of food and stock rotation. The provider had audits in place for cleaning schedules and IPC; however, these had failed to identify these issues. The manager did confirm that new chairs were due to be purchased for the lounge area and discussed plans to redecorate the home.

Staff had received the appropriate infection prevention and control training. Staff had access to personal protective equipment (PPE), and we saw staff wearing PPE appropriately. Despite our findings, feedback from relatives was positive about the environment. Comments included, “The home does appear to be clean and well maintained in the communal areas.”

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

During our onsite inspection we reviewed records relating to medication administration and found discrepancies around stock. We found the stock number of medicines were recorded, but actual balances of medicines were incorrect. We found one person’s eye ointment was out of date which could mean the ointment would be ineffective and place the person at risk of harm. We observed incorrect medication administration practices. We reviewed the PRN – ‘as required’ protocols and found they did not contain sufficient information such as signs and symptoms to look for that may identify that a person potentially needs their PRN medication, and we found they were not dated. It was unclear when these were due to be reviewed or if people had been involved in developing the protocols. We also identified some medications in stock that were not listed on the medication administration record (MAR). We did not identify that any harm had come to people, but these issues placed people at risk of harm.

The provider had medication audits in place and staff competency checks had been completed, however, these had failed to identify issues around stock management and administration practices.

The provider had a medications policy in place and controlled drugs were stored securely and we found no stock discrepancies for controlled drugs.