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Inspection Summary


Overall summary & rating

Good

Updated 30 January 2019

We rated Sanctuary Lodge as good because:

  • The ward environment was safe, clean well equipped, well furnished, well maintained and fit for purpose. The manager had completed a risk assessment highlighting any ligature anchor points. Managers kept clear records of environmental risk assessments, incidents, complaints and safeguarding concerns.
  • The service had enough nursing and medical staff, who knew the service and staff had completed their mandatory training. The service had a system in place to monitor mandatory training and supervision compliance. The service employed a range of staff disciplines who worked together as a team to benefit clients. The service had effective working relationships with external organisations.
  • Staff kept detailed records of clients’ care and treatment. Staff completed and updated risk assessments for each client and used these to understand and manage risks individually. Staff knew how to protect clients from abuse and the service worked well with other agencies to safeguard them. Senior managers engaged with staff and clients on how to improve the service through surveys and staff meetings.
  • The service had appropriate arrangements in place for managing medicines. The nurse completed medication audits each month and discussed errors with the team. Staff followed National Institute for Clinical Excellence and Department of Health guidance for treating alcohol and drug dependency. The service utilised complementary therapies and improvements to the environment to support recovery.
  • The service treated concerns and complaints seriously. Managers investigated all complaints and they shared learning from these with all staff. The service had received a high number of compliments. Managers measured the performance of the service and collected data to inform service development. Staff knew which incidents to report, how to report them and shared learning from incidents in meetings.
  • Staff treated clients with compassion and kindness and supported clients to make decisions on their care for themselves. Clients told us staff supported them with activities outside the service, such as local visits and family relationships.
  • Staff felt respected, valued and supported by the team and their managers. The provider was developing staff through extra training to provide a better service.
Inspection areas

Safe

Good

Updated 30 January 2019

We rated safe as good because:

  • The environment was safe, clean well equipped, well furnished, well maintained and fit for purpose.
  • The manager had completed a risk assessment highlighting any ligature anchor points and actions needed to mitigate risks to clients who might try to harm themselves.
  • The service had enough staff from each discipline, who knew the service.
  • Eighty-three per cent of staff had completed their mandatory training and the manager monitored training rates.
  • Staff completed risk assessments for each client and used these to understand and manage risks individually. Staff updated risk assessments regularly and after incidents.
  • Staff knew how to protect clients from abuse and the service worked well with other agencies to safeguard clients and others.
  • Staff kept detailed records of clients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • The service had appropriate arrangements in place for managing medicines. A nurse audited medicines management each month and fed any errors or discrepancies back to the team for actions.
  • Staff knew which incidents to report and how to report them. Managers shared learning from incidents in team meetings.

Effective

Good

Updated 30 January 2019

We rated effective as good because:

  • Staff assessed the physical and mental health of all clients on admission.

  • Staff followed National Institute for Clinical Excellence and Department of Health guidance for treating alcohol and drug dependency.

  • The service employed a range of staff disciplines. This included a registered nurse, support workers, and therapists. Managers ensured the service employed staff with skills needed to provide high-quality care.

  • Staff from different disciplines worked together as a team to benefit clients. They supported each other to make sure clients had no gaps in their care.

  • The service had effective working relationships with outside organisations.

  • Staff supported clients to make decisions on their care for themselves. They understood the principles of the Mental Capacity Act 2005 and assessed and recorded clients' capacity clearly.

Caring

Good

Updated 30 January 2019

We rated caring as good because:

  • Staff treated clients with compassion and kindness. They respected clients’ privacy and dignity, and supported their individual needs.

  • Staff involved clients and those close to them in decisions about their care, treatment and changes to the service.

  • Staff gave clients opportunities to make requests and raise issues at a weekly community meeting.

  • Staff provided regular updates to family members and involved them in the planning of their relative’s care with the client’s consent.

Responsive

Good

Updated 30 January 2019

We rated responsive as good because:

  • Waiting times from referral to treatment and arrangements to admit, treat and discharge clients were in line with good practice.

  • Staff supported clients with activities outside the service, such as local visits and family relationships.

  • The service had arrangements for people requiring physical mobility access. There were ground floor bedrooms and a lift to allow clients to access upstairs therapy rooms. The manager could request an interpreter or have written documentation translated into another language to meet the needs of clients whose first language was not English.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. The service had received a high number of compliments.

Well-led

Good

Updated 30 January 2019

We rated well-led as good because:

  • Managers measured the performance of the service and collected data to inform service development.
  • Staff knew who senior managers were and said they visited the service.
  • The provider was developing the staff to provide a better service with additional training.
  • Staff felt respected and valued and supported by their team and managers.
  • The service had a system in place to monitor mandatory training and supervision compliance.
  • Staff knew which incidents to report and how to report them.
  • The provider audited staff compliance against organisational policy on topics such as medicines and client files.
  • Managers kept clear records of environmental risk assessments, incidents, complaints and safeguarding concerns.
  • Senior managers engaged with staff and clients on how to improve the service through meetings and surveys.
  • The service utilised complementary therapies and improvements to the environment to support recovery.