St James's 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 provider and registered manager were in breach of the legal regulations relating to consent, safe care and treatment and governance.

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 service did not have a strong learning culture. Incidents and accidents were recorded, but there was no evidence of analysis or lessons learnt to prevent recurrence.

Staff told us, “No, when things go wrong it is never discussed with staff or any lessons learnt.”

Feedback from residents’ meetings was not actioned or analysed, and staff reported concerns raised were not followed up.

The provider did not have established systems to maintain safe care.

They did not always ensure they had robust records to support continuity of care, when people moved between different services. Pre-admission checks were incomplete, with missing details such as allergies and date of birth for new residents.

The providers systems did not identify all the concerns we found at this inspection.

The provider 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 understood safeguarding and could describe escalation routes, including external bodies. One staff member told us, “If no action was taken it would be Plymouth Council and CQC and we have those numbers available.” However, staff reported feeling unsupported when raising concerns, and there was limited evidence of the management team acting on issues.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and hospitals, this is done through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005 (MCA). We checked whether the service followed the principles of the MCA and how it managed DoLS. Although the service had applied for DoLS authorisations, people’s capacity had not been assessed and recorded in line with the Mental Capacity Act 2005.

No individual safeguarding concerns were identified during the assessment. While we did not identify anyone who had come to harm, this contributed to a breach of the regulation in relation to consent and governance.

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.

People were not consistently involved in managing risks. Care plans lacked guidance on safe support, for example one person’s care plan did not provide guidance on how staff should support a person to minimise the risk of skin breakdown.

A staff member said, “We never even get a chance to read the care plan… we don’t have time.”

This contributed to the breach of the regulation in relation to safe care and treatment.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care.

Environmental checks were mostly completed, however, fire doors were not always closed where required. Fire drills had not taken place since 2017 despite being identified as necessary. The fire risk assessment had not been reviewed since 2022 and was due to be reviewed in September 2024.

One staff member told us in the event of a fire they would not know what to do and there would not be enough equipment to support everyone to safely evacuate the building. Staff highlighted hazards, saying, “There are wires coming from the beds… they are a death trap.”

This contributed to the breach of regulation in relation to good governance.

A relative told us, “I do think the furniture could be updated, but you can’t put a price on the fantastic care that (Person’s name) receives. She is happy, and I am happy”.

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

Staff and relatives reported the service was regularly short of staff, which limited opportunities for social interaction with people and providing person-centred care.

One staff member said, “We are understaffed… residents are made to get out of bed even if they have said they want to stay in bed.” Another commented, “The morale of the staff… I know some of them are not happy and we are overworked and overtired.”

Training compliance was poor in key areas, and competency checks for nurses to ensure they were administering medicines safely were missing.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

Safe recruitment practices were being followed. Staff had references, and Disclosure and Barring Service (DBS) checks, as required. DBS checks help employers make safer recruitment decisions by identifying criminal convictions or cautions. Nurses working within the service had valid and up to date PINs. PIN checks show who can legally practise as a nurse or midwife in the UK.

The provider did not always assess or manage the risk of infection.

There were gaps in kitchen cleaning logs. Cleaning records did not identify when equipment needed to be cleaned or had been cleaned.

We received mixed feedback from relatives in relation to the odour and cleanliness of the home. Comments included, “The home always smells like faeces”, and “I think the home is kept clean and tidy”.

We observed some unclean moving and handling equipment. Some carpets within the lounge area needed to be cleaned, however we discussed this with the provider who was working with an external company to clean them.

Most staff had completed training for Infection Prevention and Control (IPC), and personal protective equipment (PPE) was available and used appropriately. Staff confirmed, “We wear aprons, gloves, and use red bags so the IPC is really good here.”

The provider did not always make sure medicines and treatment were safe.

Controlled drugs were not administered in line with the service’s policy and NICE guidance. Discrepancies were found between controlled drug records and medication administration records. These issues increased the risk of errors and compromised safe practice.

This contributed to the breach of regulation in relation to safe care and treatment and governance.

Relatives told us the staff administered medicines, and they had no concerns in relation to the administration of medicines.