Eastern 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 newly registered service. This key question 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 managers investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

When incidents or accidents had occurred, these were recorded and appropriate measures taken. Lessons were learned after each incident and mitigation was put in place. We saw evidence of previous mitigation which had been implemented after previous incidents and accidents. For example, for one person who was at high risk of falls, the service had put in a sensor to alert staff when they got out of bed and their care plan was updated with known times they were more likely to have a fall.

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.

Prior to people moving into the service, a pre-admission assessment was carried out to ensure the service could meet people’s needs. The manager effectively shared information when people were admitted to hospital or when people’s needs changed. External professionals were very complimentary about the service. One professional told us, “When I have raised concerns with staff, these have always been acted on appropriately.”

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.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found people had Deprivation of Liberty Safeguards (DoLS) where required and records of mental capacity assessments along with best interest decisions were held on file.

People were safe and well cared for. One person told us, “I feel very safe; staff look after me very well.”

The provider investigated safeguarding incidents and shared concerns quickly and appropriately with the relevant authorities. Staff had received safeguarding training and knew how to identify and report abuse. One staff member commented, “People are definitely safe living here.”

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.

Care plans and risk assessments guided staff on how to manage risk and keep people safe. A variety of records associated with care and treatment were accurate, current, and recorded sufficiently. These included records for assessing and managing known behaviours and risks. One person was identified as having episodes of agitation. Documented strategies on how staff would support this person to remain safe were clear. Staff could tell us how they supported the person to manage the risk effectively.

Risk assessments were in place, this included for the use of CCTV in the communal areas. Daily checks were completed by staff and included monitoring of the environment, checking the handover book, cleaning and laundry duties. Systems of accountability and governance to ensure safety was maintained.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff had good knowledge of fire safety procedures, and every person had a personal emergency evacuation plan (PEEP). The purpose of a PEEP is to ensure all people can evacuate the building safely and promptly in the event of an emergency, regardless of their level of mobility or other health conditions. Where people were not mobile, the PEEP described the measures to keep them safe until emergency services arrived and their rooms were located close to exits. This was to mitigate the risk of only 1 staff member being at the service on a night shift. The service further mitigated risks overnight by not allowing agency staff to work on night shifts. This was to ensure only staff who were familiar with the service were alone with people living there.

Equipment was available and maintained regularly to meet people’s needs. We saw evidence fire equipment, lifting equipment and electrical safety checks were completed as required by regulations such as Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

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.

The provider followed recruitment procedures to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

There were appropriate staffing levels to make sure people received safe quality care and, when commissioned, 1 to 1 care.

Staff told us they were well supported by the management team and praised their compassion. Staff had regular supervision and appraisals, they said these were useful and enabled them to discuss training, their performance, and any concerns they had.

We discussed with the manager including moving and handling competency assessments alongside medication and dignity competency assessments.

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.

Staff wore personal protective equipment (PPE) when required and the environment and equipment was clean. The service was waiting for a new food hygiene inspection. Staff were observed following required standards and practise when storing foods.

People praised the cleanliness of the service. One person told us, “It’s always nice and clean.” Another person commented, “It’s clean here, it never smells anyway!”

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

People received their medicines safely and as prescribed, administered by staff who knew them well. If people were prescribed medicines on an “when required” basis, written instruction to help staff identify when these should be administered was available for people.

Staff involved people in planning, including when changes happened and promoted people’s independence. People needed physical support with having their medications, although they had the mental capacity to understand their medications and what they were for.

Appropriate arrangements for the ordering and disposing of medicines were in place and known by staff. A variety of regular medicines audits were carried out, and any shortfalls were identified with actions taken to minimise the risk of re-occurrence.