Manor 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 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, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Accidents and incidents were recorded so any patterns or trends could be identified, and action taken to reduce the risk of reoccurrence and learn from lessons. The registered manager reviewed incident records to identify any action needed to ensure people remained safe as far as possible.

We saw learning from incidents took place and appropriate changes were implemented. Staff were kept informed of the outcomes of any investigations.

There was an on-call system where a member of the management team was available to advise staff in the event of an emergency.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Before a person started using the service, an initial assessment of their needs was carried out which involved them, their relatives and other health professionals where appropriate. From the assessment, a care plan was developed, and this covered aspects of the person’s care such as, personal care, communication, mobility, behaviours, medicines and eating and drinking. This helped to ensure staff had the relevant information to be able to safely meet the person’s needs. This also helped the registered manager to decide if they could meet people’s individual needs effectively.

People were safeguarded from abuse or harm and staff understood how to keep them safe. People told us they felt safe at the service and did not raise any concerns in the way staff supported them. A person told us, “Yes, I do feel safe.” A relative said, “[Family member] is safe, I have no concerns. They would tell me if something was not right.”

Staff knew what their responsibilities to report any abuse was and they were able to tell us the actions they would take if they witnessed or suspected any abusive or neglectful practice. A member of staff told us, “I will inform the manager of any safeguarding concerns.” Staff had received safeguarding training and were aware on how to escalate any concerns that they might have to external agencies.

There were policies and procedures to protect people from the risks of harm or abuse. Staff had received safeguarding training in this area.

The registered manager was aware of their responsibilities on how to protect people from abuse. Records showed safeguarding concerns had been reported to the local authority and these were investigated internally.

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 worked with people to understand and manage risks by thinking holistically so that care met their needs in a way that was safe and supportive and enabled them to do the things that matter to them.

Potential risks about people’s safety were assessed to ensure they were supported to remain as safe as possible.

Risk assessments gave staff clear guidance on how best to support people in different situations; for example, the management of falls or when people were going out in the community. This helped to ensure care and support was delivered in a safe way.

Risk assessments were reviewed regularly to ensure they were accurate. This meant staff had clear guidelines to enable people to take risks as part of everyday life safely. Staff knew of potential risks to people and ensured they were safe when carrying out any task.

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

The provider had a system to ensure equipment at the service was maintained and serviced for the safety of people, staff and visitors.

The provider had also assessed the risks around the premises to ensure people lived in an environment that was safe for them. For example, there was a fire risk assessment in place and weekly fire safety checks were carried out.

Equipment used by staff were regularly checked to ensure they were functioning properly. The temperatures of the hot water were checked regularly. However, during our visit, we noted that the hot water temperature was above the recommended level of 43 degrees. This issue was rectified immediately by the handyman.

The registered manager informed us that there was a fault with one of the fire panels. This had already been reported to the maintenance team, and this was fixed on the day of our visit.

We noted the provider carried out a health and safety risk assessment of the premises to ensure people, relatives, visitors and staff remained safe.

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.

At our last inspection, we recommended the provider followed best practice guidance for adequate staffing levels for homes of this size to ensure people receive the support they need at all times. During this assessment, we found there were enough staff to meet people’s needs. Any shortfalls, due to sickness or leave, were covered by existing staff, and this helped with consistency.

The staffing numbers were kept under review to respond to people’s choices, routines and needs. For example, when people had appointments in the community, more staff would be working to accompany them.

People were protected from the risk of receiving care from unsuitable staff. The provider had a safe recruitment process in place. Appropriate checks had been carried out such as criminal records, proof of identity and references before staff started work.

People and their relatives felt staff had the knowledge and skills to look after people who used the service. A person said, “The staff are good.” A relative told us, “The staff know what they are doing, they look after my [family member] very well.”

People were supported by staff who had received appropriate and relevant training. Staff had attended various training programmes related to their roles, such as safeguarding adults, medicine management, infection control, moving and handling, and health and safety. Staff commented that the standard of training they had received was good and informative.

There was an induction period for new staff. Staff would shadow an experienced member of staff until they were competent to work on their own. The induction covered their familiarisation with the service, the people who used it and the policies and procedures of the provider.

Staff received regular supervision and support, which helped to ensure they were able to provide effective care. They were given an opportunity to discuss any work-related issues, such as any training needs as well as needs of people in the service. This helped the management team to monitor staff’s performance and identify any shortfalls.

The provider had an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance.

The provider had systems to ensure people as well as staff were safe regarding the spread of infection. Staff were provided with personal protective equipment (PPE), such as gloves and aprons. They had received training in infection control and knew what their responsibilities were, such as proper hand washing procedures.

There were daily cleaning schedules in place.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they received their medicines when they needed to have them. The service had a medicine policy, which outlined the safe handling of medicines. Where people needed assistance to take their medicines, there was guidance in place on how staff must support them.

Staff had received appropriate training to ensure they were competent to administer medicines. Medicine administration record (MAR) sheets were completed correctly to evidence medicines were administered safely and there were no missing signatures.

The registered manager carried out regular audit of medicines, including people’s medicines administration records. Medicines were stored appropriately in a lockable metal cupboard. There was guidance in place on managing 'when required' medicines for each person.