South Haven Lodge Care Home

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 remained 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 the ways people’s medicines were managed at the service and good governance.

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 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. There was a new management team in place who were working to ensure lessons were learnt to identify and embed good practice. A staff member told us, “Management wasn’t in place prior to the new management starting. Now I am using the poor experience to help guide how I manage situations. The new management structure has taken a big turn for the positive.” The new management team needed time to embed the changes they were making into practice.

The manager told us they received safety alerts from the government, local authority and CQC which informed them of risks as well as themes and trends to ensure the provider could take appropriate action to mitigate these risks. They told us they check to see if they affect the service and print them off for staff to read and sign to ensure everyone is aware.

The provider was developing plans to ensure they worked well with people and healthcare partners to establish and maintain safe systems of care. Systems had been developed to manage or monitor people’s safety. The provider needed time to embed this into practice.

The manager told us when people transition in or out of the service the initial assessment is really important as well as speaking to the person and their friends and relatives. The manager told us if people go to hospital they printed out key information to form a hospital pack to go with the person to ensure continuity of care.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They had not always concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider had not always shared concerns quickly and appropriately. The new management team were working to improve this for people. Documents demonstrated the provider was now sharing concerns quickly and appropriately. The provider needed further time to fully embed this into practice.

Mental capacity assessments, best interest decisions and Deprivation of Liberties Safeguard (DoLS) applications had been completed where required which meant we were assured staff protected people's human rights in line with the Mental Capacity Act (MCA).

People and their relatives told us they felt safe living at the service.

At our previous 2 assessments we found concerns in relation to risk management and mitigation. At this assessment although we found some improvements had been made, we identified continued shortfalls in this area.

We could not be fully assured people at risk of developing pressure damage had been repositioned as highlighted within their care plan. For example, 1 person’s repositioning records stated, ‘Turning and positioning – 2 hourly – 2 hourly turns,’ we found this person had not always been repositioned as described. This placed this person at risk of experiencing skin damage.

We found some discrepancies in people’s care records, for example, 1 person’s blood glucose target was recorded differently twice in their diabetes care plan and differently a third time in their eating and drinking care plan. We spoke with the clinical lead about this who was responsive and made the required changes immediately. Staff were able to accurately describe the person’s correct target blood sugar levels.

We spoke with the manager about some of the discrepancies we found in people’s records. They told us they have implemented new systems and processes to mitigate the risk of this occurring again in the future. They told us they were implementing more robust systems and processes which included team leaders taking more accountability. These new systems and processes require time to be embedded to ensure they drive sustained improvement.

We observed some people in bedrooms were not always able to easily reach their drinks. The manager told us people who were nursed in bed were checked on a regular basis and supported with drinks as required. We reviewed fluid charts for these people. We found people received fluids in line with the target level detailed on their fluid charts.

People had access to call bells. Where people had been assessed as unable to use call bells, additional checks were in place.

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

We found fire doors were checked regularly and action taken to address any concerns noted. We found bedrails were secure. The service was clutter free with good access to fire doors.

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. We observed sufficient staffing levels to meet people’s needs and documents confirmed this. Most people’s relatives told us there were enough staff to meet people’s needs. One person commented they would appreciate more time to spend speaking with staff whom they said often appeared busy.

The provider followed safe recruitment practices. Where agency staff were used, the provider had agency profiles in place to demonstrate these staff had appropriate Disclosure and Barring Service (DBS) checks in place. All agency staff had undertaken an induction.

We reviewed a copy of the training matrix and found there had been improvement in attendance rates; However, this was an ongoing process, and further work was required to ensure all staff had received the training required. For example, the provider had not quite achieved 90% compliance in all training, as required in their service improvement plan. However, we could see improvements were being made. Competency checks of staff practice had been incorporated into the providers processes.

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. People and relatives told us they were happy with the cleanliness of the service, and we observed it to be clean. The provider had an up-to-date Infection Prevention and Control (IPC) policy. Staff attended IPC training. We reviewed cleaning schedules which were consistently completed.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. This was the sixth consecutive inspection where shortfalls relating to medicines had been identified. Staff did not always involve people in planning. The service had made a number of improvements since the last inspection. We saw examples of good care planning which supported staff to meet people’s needs. However, further improvement was required in some areas. For example, for 1 person at risk of seizures; triggers and type of seizure and potential risks had not been assessed or clearly documented. This meant the person was at risk of possible harm. For people nearing the end of their life who had been prescribed anticipatory ‘just in case’ medicines; prescribing information about when and how to initiate treatment were not readily available in administration records or care plans. This created a potential delay in treatment and avoidable distress. Information about how people liked to receive their medicines, was not accessible within the electronic administration records for staff to access when administering medicines.

We were not assured from training records provided, that all staff had completed medicines training or had their competency assessed to administer medicines, in line with best practice. This meant there was a risk people may not receive their medicines as prescribed or in a safe manner.

We observed some medication cupboards, holding prescribed creams in a number of bedrooms, had keys either still in the lock or dangling by the side of the medication cupboard attached by a chain and some were left open. We spoke with the manager about this who was responsive and made all medicines cupboards safe. They told us they would identify a safe place to keep the medicines cupboard keys.

We saw people were not inappropriately given medicines to manage emotions and behaviours. People’s health needs were monitored and reviewed appropriately, with detailed records kept of interactions from visiting healthcare professionals.