Derwent 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 safe care and treatment and fit and proper persons employed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service promoted a proactive and positive culture of safety based on openness, learning, and improvement. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff said they felt comfortable raising issues with management and told us that incidents were discussed at team meetings. Lessons learned were communicated with staff.

A duty of candour policy and an accident and incident policy were in place and accessible to staff. Incident forms were completed and analysed for themes. A duty of candour letter was seen.

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.

People experienced safe care, with effective systems for managing risks and transitions. Referrals to partners were made in a timely way.

People visited the service prior to moving into the service. A relative said, “I visited once by myself to check whether the home was suitable as [my family member] was unwell in hospital at that time. I then went again with [my family member] so [they] could see the home.” Clear information was received from partners prior to a person moving into the service. This allowed the registered manager and other staff to put initial care and support plans in place which were further developed as they got to know the person using the service.

Systems were in place to provide information to healthcare partners in the event of an emergency admission to hospital. Care plans were reviewed if people’s needs changed following discharge from hospital. Care records included information from hospitals to support these reviews.

A professional commented, ‘I have found their service to be professional and supportive, particularly in relation to assisting patients who are in the process of moving from an inpatient setting to the community and require some adaption/adjustment to day-to-day routines and general functionality.’

People were protected from abuse, neglect, and discrimination. Staff had completed safeguarding training and safeguarding policies were in place.

People felt safe. A person said, “I do feel safe in the home.” A relative said, “Yes, it feels safe. I have no problem with [my family member] living there.” Another relative told us they had been satisfied with a safeguarding outcome involving their family member.

Staff understood their safeguarding responsibilities. They were able to explain the actions they would take if they suspected abuse.

Safeguarding records were in place which included referrals to the local authority and notifications to the CQC.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). A DoLS policy was in place. No people currently living at the service had an authorised DoLS in place.

The provider worked with people to understand and manage risks.

A relative told us that their family member’s risks were well managed. They said, “The home had [external professionals] involved to assess their risk and then they came back to re-assess the risk after staff had monitored [my family member]. I really like the fact that they reviewed [the risk] as this has ensured normalcy for [my family member].”

Risk assessments and support plans were in place to manage risks. Staff completed training regarding the management of risks including de-escalation and first aid training; however, no moving and handling training had been completed at the time of the assessment.

Documentation was completed when people showed distress and these events were analysed to minimise the risk of reoccurrence. Staff said they always involved people as much as possible in decisions about their care.

Systems were in place to ensure equipment and the premises were monitored as required, however they were not fully effective.

We identified concerns with the environment which included poorly functioning doors, windows that were difficult or not possible to close, issues with water temperatures and heating, damage to some walls and ceilings. Some equipment used to help monitoring health required calibration.

Not all environmental and premises issues identified by internal and external audits had been addressed promptly. Staff told us that the response to some maintenance issues had become slower since the maintenance function had been centralised by the provider.

There was a smell of smoke in the dining room. Smoking was not always taking place in the designated area and people were smoking outside the building but directly under a dining room window. This area had not been cleaned and was also next to a gas barbecue. This put people, staff and visitors at risk of harm.

The provider had started to take action to start to address some of these issues before they were brought to their attention during the assessment visit, however, some of these actions could not be immediately completed and we will continue to monitor completion.Evidence was provided following the assessment visit demonstrating work taken to repair walls and ceilings, address issues regarding smoking and actions taken in response to external audit findings. We were also told that actions had been taken to address all doors, windows and heating issues. Additional checks had been put in place to identify and action potential environmental and premises concerns.

A relative told us that they did not feel that their family member’s belongings were fully secure in the home and told us that an important family belonging had gone missing. They had raised this with management but the item had not been found by staff.

Health and safety policies were in place and staff completed health and safety training and fire warden training.

The provider had not made sure there were enough qualified, skilled and experienced staff at all times. Staff recruitment records were not easily accessible.

A person said, “I do think they have enough staff at the home.” However, a relative told us that they were concerned that staff appeared to almost always be in the office. They were also worried that there was no cook and care staff were doing the cooking which might have an impact on the amount of time they spent interacting with people who used the service.

While we did not observe people waiting a long time for support from staff; on both days of our assessment visit there was no domestic staff member or cook. Care staff were covering those roles.

Care staff told us that they had sufficient staff to meet people’s needs, however, a staff member felt that there needed to be more domestic staff. The provider employed one domestic staff member to work from 9am to 1.30pm from Monday to Friday only. We identified a number of cleanliness concerns during our visit.

We were told that two staff were being recruited though it was not clear what their roles would cover.

Staff told us that they felt supported and we saw that they received induction, training, supervision and appraisal. However, moving and handling training was not in place for staff though plans were in place to provide this. Staff told us that they were not supporting people to move, though, it was recognised that people’s needs might change in the future.

We requested staff recruitment files during this assessment but did not receive all of the information requested within the timescales set. Recruitment information was held centrally and there were delays in providing it. We requested information regarding agency staff members and this was not available. This meant that there was a greater risk that people were not supported by staff that were safely recruited.

Risks of infection were not managed and controlled. Parts of the home and equipment were not always clean. Monitoring systems had not been effective in identifying and addressing the concerns we saw during our inspection.

This included stained bedclothes, clinical waste not being appropriately managed, unclean shower chairs, unclean toilets and bathrooms. Access to the kitchen and clinical waste containers was not restricted at all times.Evidence was provided following the assessment visit demonstrating extra systems in place to ensure access to the kitchen and clinical waste containers was restricted at all times and the home and equipment were kept clean.

Staff felt that there needed to be more domestic staff. The provider employed one domestic staff member to work from 9am to 1.30pm from Monday to Friday only. Domestic staff were not present in the home on either day of our assessment.

A person said, “I think the home is kept clean in the communal areas and my room is cleaned once per day.” A relative told us that the home was clean and their family member’s continence needs were well managed by staff.

An Infection prevention and control (IPC) policy was in place. Staff had completed IPC training. Cleaning schedules were in place. IPC audits were completed by staff. We were told that a further IPC audit had been completed since the assessment visit to identify and action any additional areas for improvement.

Medicines were managed safely and effectively. Staff received training and their competency was assessed. A medicines policy was in place.

People were satisfied with medicines management at the service. A person said, “I do get support with medication, this is for my physical and mental health.” Another person said, “I am provided support with my medication 3 times per day, this is for my [mental health condition].”

We reviewed medicines documentation and storage and found medicines were managed effectively. However, body maps were not in place to support staff on where to apply creams and the signature sheet for staff administering medicines was not complete. We were told that these would be addressed. Evidence was provided following the assessment visit demonstrating that body maps had been put into place and the staff signature sheet was now complete.

Medicines audits were completed; medicines errors were investigated and lessons learned shared with staff. Evidence was provided following the assessment visit demonstrating extra systems in place to document and note actions taken following any identified gap in medicine administration records.