Hatherley 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. This was our first inspection of this service. The service has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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. The registered manger and deputy manager shared learning from incidents, accidents, complaints and safeguarding concerns with staff at team meetings. Team meeting minutes confirmed and a staff member told us that a recent accident had been discussed and measures were put in place to reduce the likelihood of the same thing happening again.

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. Assessments of people’s needs and risks were regularly reviewed to ensure they were reflective of their current needs. Information was available and shared with other health care services such as hospitals when this was required. For example, people had hospital transfer records which outlined their care and support needs for professionals.

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.

There were safeguarding and whistle blowing procedures in place. Staff told us they had received training on safeguarding adults from abuse, and they felt confident any concerns they raised would be managed appropriately. A staff member told us, “I am fully aware of how to whistle blow and if I ever felt there was bad behaviour from a staff member, I would report to my manager and to the local authority and CQC if I felt nothing was being done about it.”

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of liberty Safeguard (DoLS) authorisation was applied for through the relevant local authority. All legal applications had been made in accordance with DoLS, this meant people’s rights were fully respected. The registered manager and deputy manager had oversight of DoLS applications, authorisations, and any conditions. Training records showed that all staff had received training on the Mental Capacity Act (MCA) and DoLS.

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.

People had individual risk assessments relating to their mental health and medical conditions, eating and drinking, falls, self-neglect, medicines and smoking amongst others. People received safe care from staff who understood and managed risks effectively. Staff told us they had received training on people’s mental health conditions; they followed people’s individual risk assessments and sought the support from the community mental health team when it was necessary.

The provider detected and controlled potential risks in the care environment. The provider made sure the environment and equipment used was safe and regularly serviced, for example, on the fire alarm system, emergency lighting, portable appliances and gas safety. People also had individual emergency evacuation plans in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency.

We noted a window restrictor on a skylight had been dethatched and that a window restrictor in a person’s bedroom was not fit for purpose. We brought these to the attention of the deputy manager. They reattached the window restrictor on the skylight and immediately arranged for a maintenance person to make safe the window restrictor in the person’s bedroom. They showed us a maintenance record confirming that the window restrictor in the person’s bedroom had already been reported for repair.

We noted that the carpet on the stairs and landing was worn and needed replacing. The deputy manager showed us a maintenance/refurbishment plan for the service. Some people’s bedrooms had been decorated to the colour scheme they chose and there was ongoing work to do all the bedrooms. There were plans to replace the carpet on the stairs and landing. A person using the service showed us around their bedroom and told us, “I chose this lovely green colour for my room. I am very happy now that my room is decorated the way I want it.” Another person told us, “My bedroom is nice and cosy, they are going to decorate it soon.” A relative told us that the service provided a much needed safe, clean and stimulating environment that met their loved one’s complex needs.

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.

People using the service and staff told us there was always enough staff on duty to meet peoples care and support needs. A staff member told us, “The day-to-day staffing levels are quite good. We have time to spend with the residents; we do lots of activities and can plan outings. During a weekday we have 3 staff, to cover for when there are planned activities or medical appointments.”

All necessary pre-employment checks were completed before staff commenced employment at the service. Records included application forms, checks on employment history, right to work in the UK checks, health checks, references from previous employers and Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Training records indicated that staff had completed training on mental health awareness, diabetes, Parkinsons disease, learning disability, equality and diversity, fire safety, health and safety, first aid, basic life support, food hygiene, infection control, moving and handling, safeguarding adults, the Mental Capacity Act 2005 (MCA) and Deprivation of liberty Safeguard (DoLS) amongst others. A staff member told us, “The human resources team make sure we do our training; they tell us when we need to do a refresher. I have recently done training on Parkinsons disease, mental health training and the Oliver McGowan training which was amazing.” Records confirmed that staff had been receiving regular supervision from the deputy manager.

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 service employed a domestic staff member to clean the service for 3 hours each day. This staff member was on leave when we visited so care staff were responsible for keeping the service clean. We observed the service was generally clean however noted that one toilet had a strong odour and the toilet and floor was soiled. We reported this to staff who subsequently cleaned the toilet. Following the first day of our inspection the deputy manager discussed the current cleaning arrangements with the provider. As a result of their discussions the domestic staff members hours were increased to 30 per week and systems were put in place for using contract cleaners to cover annual leave and sickness.

Staff told us they were provided with personal protective equipment (PPE) when they needed it. We saw records from infection control audits carried out by the provider. Training records confirmed that all staff had received training on infection control.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us they received their medicines safely and as prescribed. One person said, “The staff help me with my medicines, they make sure I take them on time.” Medicines were stored safely and administration records (MAR charts) were completed accurately by staff, with codes for non-administration where appropriate. PRN (as required) medicines protocols were in place to guide staff on when to administer these medicines. Medicines were administered by trained staff who had completed up-to-date medication competency assessments. Regular monthly audits of medication practices were carried out to make sure medicines were managed safely.