Compassionate 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 is the first assessment for this service. This key question has been rated 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 premises safety. These failings placed people at risk of harm.

This service scored 62 (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 and lessons were not always learned from incidents to continually identify and embed good practice.

The provider was open and responsive when concerns were identified during this inspection and demonstrated a willingness to address issues. However, learning from previous incidents had not always been fully embedded into practice to prevent similar risks affecting other people.

For example, a person who had previously lived at the service had absconded through a window due to the absence of compliant window restrictors. Following this incident, some restrictors had been installed; however, they had not been fitted throughout the premises. This meant learning from the incident had not been consistently applied and other people remained at risk of absconding.

In addition, people were at risk of falling from windows above ground-floor level where compliant restrictors were not in place. This risk could arise accidentally, because of a confused mental state, or through deliberate actions, potentially resulting in serious injury or death.Following our feedback the provider purchased and installed window restrictors throughout the premises.

People and their relatives told us they felt they could raise any issues, and they would be taken seriously.

Staff told us incidents were investigated and learning was shared. One staff member told us, “Incidents are taken seriously. We fill out incident reports, discuss what happened, and have a debrief with the manager or senior staff so we can reflect on the incident, learn and improve.”

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’s care needs were regularly discussed in Multi-Disciplinary Team Meetings (MDTs) with relevant health and social care professionals to support continuity in care.

Staff told us how they monitored people’s health needs and how they worked with other professionals to raise any concerns. One staff member commented, “If I notice any concerns, I record them and report immediately to my line manager who will take up to the responsible professionals like the GP or mental health officials.”

Feedback from professionals about working with the service was positive. Visiting professionals felt staff worked well with them. One professional told us, “They have shown a commitment to maintaining people’s safety, responding appropriately to incidents, and engaging well with partner agencies to achieve the best outcomes for the people they support."

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 kept records of accidents and incidents and reported safeguarding concerns to the local authority when required. Learning from incidents was shared with staff and a safeguarding policy was in place to guide staff.

Staff understood what safeguarding meant, what signs to look for and how to escalate concerns to keep people safe.

Provider records showed staff completed safeguarding training and staff confirmed this.

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.

Staff knew people well and supported them in a way that was person-centred while promoting their safety in line with their assessments and risk assessments.

People told us how staff supported them to keep well while promoting their choice and control. One person told us, “Staff will support me to appointments and with personal care prompts because of my depression and forgetfulness.”

Professionals told us the service supported people around management of risks. One visiting professional commented, “The staff have demonstrated a proactive approach to managing risk and ensuring people’s needs are met.”

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

The provider had not maintained a consistently safe environment. We identified several environmental hazards which had not been adequately assessed or managed, exposing people to avoidable risks of harm. For example, hot water temperatures in communal bathrooms were excessively high. Regular temperature checks were not carried out throughout the service and there were no effective control measures in place to reduce the risk of scalding. Blind cords and loops had not always been secured or appropriately risk assessed. This exposed people to a risk of ligature harm. Compliant window restrictors had not been fitted throughout the building. As a result, people were at risk of falling from windows, which could result in serious injury or death. In addition, an uncovered heated towel rail was present in a communal bathroom. The risk associated with this had not been assessed, exposing people to the risk of burns from hot surfaces.

Following our feedback, the provider acted to address all environmental concerns identified during the inspection and provided assurances regarding the safety of the premises.

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.

Our observations found staff were always available throughout the service to respond to people’s needs. Staff completed training and they told us they felt confident in the application of their training.

People, their relatives and staff all told us they felt there were enough staff.

The provider carried out all required pre‑employment checks before staff started work. This included requesting references and completing criminal record checks through the Disclosure and Barring Service (DBS), which helps ensure safer recruitment.

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.

We observed staff using personal protective equipment (PPE) appropriately and following good hand hygiene practices.

People and their relatives told us the home was clean. One person said staff supported them to keep their room clean and they were happy with how it was decorated.

Staff commented on the home’s cleanliness and one staff told us, “The service is clean and tidy. Staff do regular cleaning tasks and encourage people to keep their own rooms clean as much as possible and also assist them to clean their rooms daily.”

During the inspection, the home appeared visibly clean and hygienic throughout, and cleaning schedules were noted.

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’s medicines were administered safely and ‘as required’ (PRN) protocols were in place for staff to follow.

Staff supported people to recognise when they needed to take their medicines. This helped promote better outcomes for the person as well as an increased independence around medication.

Medicines, including controlled drugs, were stored safely. Whilst no refrigerated medicines were being administered at the time of our inspection, a medicines fridge was available and daily temperature monitoring was undertaken to ensure it remained suitable for use. Managers completed regular medicines audits and monitored staff competency to support safe medicines management.