Rectory 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 requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

At our last assessment, we found no evidence of analysis of accidents and incidents which meant the service was not able to monitor themes and trends. Since our last assessment, the provider had made improvements for analysing accidents. They had ensured reporting processes for externally reporting accidents and incidents were in place. Safety was managed more effectively, and the new registered manager had introduced clearer processes such as forms to review medication errors and group supervisions, training and learning from any medication related incidents.

Staff were aware of processes to report accidents and incidents.

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.

Staff worked in partnership with other professionals such as GPs, dietitians and speech and language therapists (SALT) to support people to access healthcare when they needed it.

The provider had systems and processes in place for pre assessment of peoples’ needs prior to their admission to Rectory Lodge.

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.

At our last assessment, we found legal and regulatory requirements were not consistently met, such as failure to submit statutory notifications. The provider had also failed to report safeguarding concerns to the local authority. However, at this assessment we found the provider had made significant improvements to their reporting processes and working collaboratively with external agencies such as the local authority as well as CQC.

Staff had received training in how to safeguard people from abuse and understood how to report concerns. We saw evidence of safeguarding being discussed at team meetings.

People told us they felt safe. One person told us, “I am happy living here and can talk to staff.”

We observed people appeared to be comfortable living at Rectory Lodge and in the company of the staff supporting them. We observed positive interactions between staff and people.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last assessment we found inconsistencies around the information in people’s care plans and risk assessments. Since our last assessment, the provider had made improvements. For example, the provider had a SALT folder in the kitchen which showed each person’s needs around their SALT requirements with good levels of detail to help staff to mitigate any choking risks.

We reviewed care plans and risk assessments and found people were being more involved in their care planning and reviews. Some aspects of care plans were very detailed, but others would benefit from more information. For example, 1 person’s care plan contained lots of detail around emotional wellbeing, but their activities care plan had not been completed.

The provider was in the process of transitioning to an electronic care planning system and we discussed with the provider the gaps that we had identified to help ensure these were reviewed and completed.

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

Since our last assessment, the provider had made improvements to processes to monitor equipment and facilities. At the previous assessment we found that personal emergency evacuation plans (PEEPS) did not contain accurate information to protect people from harm in the event of an emergency such as a fire. At this assessment, we found there had been significant improvements to these and the risk to people had been mitigated.

We also found improvements had been made to fire safety checks. Fire extinguishers were in date and regular fire evacuation and fire drills were being carried out. There were monthly checks in place for fire equipment, emergency lighting and weekly checks being carried out on fire call points.

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 new registered manager told us they had increased the number of staff on duty to support people to access the community and other social activities. We observed enough care staff to support people. We received mixed feedback around the rota changes. Comments included, “People are doing things they did not do before such as going out more” and “Some shifts the staff will be in the office doing admin rather than supporting people.”

We reviewed training records and found improvements to the number of training requirements completed since our last assessment. The provider had updated the onboarding process to make sure new staff received the training and support they needed. They also ensured existing staff completed their refresher training on time so their knowledge stayed up to date.

The provider had recruitment procedures in place to ensure the required checks were carried out prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Since our last assessment, the provider had made improvements to their processes for monitoring infection prevention and control. We saw evidence of regular audits being carried out. The laundry room was clean, and people were encouraged to complete their laundry needs independently.

At our last assessment, we found some of the communal bathroom floors were stained and worn and in need of repair or replacement. These had been reported and the provider told us these bathrooms were not currently being used. These were still awaiting repair. There was one en suite with a strong malodour. We asked the provider about this and they confirmed this bathroom was still to be replaced and at present the room is not in use until the works have been completed.

Staff had received the appropriate infection prevention and control (IPC) training and staff were observed practicing good IPC during our onsite visit, including wearing appropriate personal protective equipment (PPE).

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

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Since our last assessment, the provider has improved how medication was stored by creating a dedicated medication room where medicines were stored securely. We saw improvements in documentation for medication. The provider now had weekly and monthly medication audits in place. Staff had received the appropriate training to support people with their medicines. We observed a staff member following safe administration of medicines being given at lunch time.