Grove 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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.

Staff reported concerns appropriately around accidents and incidents and these were investigated by management. Lessons learned were recorded, to prevent safety concerns from happening again and to reduce concerns about safety. A staff member told us “any learning points are discussed in team meetings. For example, after a fall, we might review mobility support and add extra equipment”.
 

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.

Pre-assessments were completed prior to people moving into Grove Lodge and formed the basis of their care plan. People’s information was kept up to date by being regularly reviewed. A guide and hospital passports were in place to support with transitions between services.
 

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.

Staff knew who they would report any concerns to both internally and externally. Safeguarding systems and processes were in place to identify, report and investigate concerns. Staff were trained in safeguarding, and the provider had a safeguarding policy. However, the safeguarding policy was not reviewed recently and did not contain all required contact information for the local authority safeguarding team. During the assessment following our feedback, the provider updated their safeguarding policy.
 

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.
Risk assessments were in place where required for people, for example around falls and absconding. Risk assessments were reviewed regularly to take account of any changes in people's needs. Staff told us they were provided with all the information they needed to support people safely and they were informed when risk assessments were updated.
 

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.

The provider had environmental risk assessments in place, for example for the kitchen and first aid requirements. Equipment such as hoists were regularly checked. However, the fire risk assessment completed by a competent person, had not been regularly reviewed. The home did not carry out fire drills and had not assessed the risk of this. There was no water hygiene risk assessment in place and cold water temperature checks had not been completed. Following our feedback, the provider booked a water hygiene risk assessment to be completed and implemented a cold water temperature check. This placed people at risk of harm from exposure to potential dangers within the environment.
 

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.

Staff competency assessments took place for medication and moving and handling. However, staff had not completed all training required for their role. For example, end of life care, falls, care planning and oral care. Not all staff had received training in how to support people with specific health conditions, such as diabetes. This meant that people were at risk of being supported by staff who were not trained to meet their needs safely.
Staff supervisions appeared to be a tick box exercise rather than an engaging and participant focused experience. The provider shared a supervision document that had not yet been used for the staff members whose files we looked at. The provider told us they would use this document going forward. This meant that staff were not receiving the support they needed to perform their job roles.
We found enhanced Disclosure and Barring Service (DBS) checks for adults were in place. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, references were not in place for 2 of the 3 staff files we looked at. There was a risk assessment in place around this, which did not reflect current ways of working. For example, staff were now lone working whilst supporting people. This meant that staff were not always recruited safely.
 

The provider assessed and managed the risk of infection.

The provider had an infection prevention and control policy in place. Staff had completed training in infection prevention control.We observed the service was visibly clean.
Relatives told us that they felt the home was clean.

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

We found risk assessments were in place for emollient creams and around medicine refusal. PRN (as and when required) protocols were in place. However, they did not provide clear direction to staff about when to administer PRN medicine and how to determine the dose of medicine to administer. This meant that people were at risk of not receiving their medicines when they needed them. Following our feedback, the PRN protocols were updated to include this information.

Best practice guidance was not followed for the use of transdermal patches. For example, the record of application did not include recording the specific location on the body where the patch had been applied. Continual use of the same area of application may cause irritation or skin breakdown. Following our feedback, the provider implemented a body map document for staff to record the specific location for the administration and removal of patches.

Staff recorded the running balance of controlled drug medicines after they had administered the medicine. However, the provider did not complete regular stock amount checks of controlled drug medicines and the medicines policy in place did not provide guidance for staff around how this should be carried out. This meant that people were at risk of harm of medicines errors occurring and remaining undetected.