Lowgate Care Home

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• 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 good. At this assessment this key question has changed to requires improvement. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of the legal regulation safe care and treatment relating to medicines.

Medicines were not well managed. Not all care plans contained relevant, up to date information, which placed people at risk of not receiving the care and support required to meet their needs. Environmental safety was not always monitored, and the provider did not always assess and manage infection control risks.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The new management team had a proactive and positive culture of safety, based on openness and honesty. The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints.

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. Assessments were completed before admission to the service and staff gathered information about people's needs prior to them receiving care and support. However, care plans were not always up to date or reviewed regularly when changes in people’s needs occurred. The provider was working to address this.

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 felt safe. One person said, “I was completely terrified and wanted to run away as soon as I got here. I’m so glad I came here because within a very short time they made me feel safe.”

There had been a concern last year which involved several staff who have since left employment. Referrals to relevant safeguarding bodies, including the Disclosure and Barring Service had not all been made in a timely way. This has since been addressed. Staff were very aware of safeguarding procedures and would have no hesitation to report any issues arising. The manager told us staff were to attend the local authority safeguarding training, although this had not been booked at the time of the assessment.

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. One relative said, “They asked me what my [relative] likes and how they like to be helped. They have asked them as well.” Where people had equipment in place to manage risks to their skin integrity there was insufficient guidance for staff, including what setting specialist mattresses should be placed on and this information was not monitored or included in care plans.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care as there was no dedicated maintenance operative in place. Weekly and monthly checks on the premises and equipment were not always up to date. The provider was in the process of recruiting a new maintenance operative.

The provider took steps to ensure there were enough staff. However, staff had not always had regular and effective support, including supervision and appraisal sessions. Staff told us the new management team were now listening, and they felt more supported and settled. Safe recruitment practices were in place. However, DBS best practice guidance had not always been followed during staff disciplinary processes. This was addressed immediately.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Staff continued to place personal protective equipment (PPE) over handrails when this had already been highlighted by the local authority via their monitoring visits as inappropriate. Staff entered kitchen areas without changing aprons which had been used elsewhere. Staff had received training in infection, prevention and control and policies and procedures were in place to support staff. The provider was in the process of addressing these issues.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found a range of concerns, including ‘as required’ medicines protocols not always in place. These protocols provide staff with information on when and how to administer these types of medicines which are often for pain relief. The controlled drugs cabinet was not secured as legally required. Thickeners were not secured. Thickeners are usually powders added to foods and liquids to bring them to the right consistency/texture for people with swallowing difficulties. Medicines which were covertly administered to people were not fully recorded and were without the correct authorisation in place to do this.