Cheybassa Lodge Rest 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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At the previous assessment the service was in breach of legal regulation in relation to safe care and treatment and staffing, the provider had made the required improvements and is no longer in breach of these regulations.

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.

Following our previous inspection improvements had been made. Where care had not gone as planned, records were detailed and contained information about the actions provided to keep people safe. The provider used this information to review incidents, identify patterns and implement processes to reduce the risk of future harm. For example, having identified a person was at high risk of falls, the provider determined what time of day falls were more likely to occur, increased staff presence at that time and implemented equipment to prevent the person falling.

Lessons learnt following safety events were shared with the team. People’s care plans had been updated to reflect these changes and the team were supporting people to meet their needs. This reduced the risk of harm through similar incidents occurring.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

Staff knew how to protect people from abuse and who they would report any concerns to, both internally and externally. The service shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies.

Where required, Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise, restrictions placed on people to keep them safe.

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.

Risks associated with people's health and wellbeing were effectively assessed, monitored and mitigated. Risk assessments contained sufficient detail to guide staff in reducing the risk of harm. For example, 2 people identified as being at high risk of falls had clear information about how risks should be managed. Some people displayed behavioural and psychological symptoms of dementia; their risk assessments provided staff with appropriate strategies to support them. Behaviour monitoring records showed a decrease in emotional distress.

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

Environmental risks had been considered for those that lived there. For example, heated hand towel rails, hot water pipes and radiators were covered to prevent the risk of burns. The stairs were not accessible to people assessed as being a high risk of falls, to prevent injuries.

People’s specialist equipment was serviced regularly and in good working order. Environmental checks were completed regularly including gas safety, electrical safety, fire safety equipment, water safety and manual handling equipment, this reduced the risk of harm.

Staff had a robust understanding of the actions they would take in an emergency and there were regular fire evacuation drills. This reduced the risk of harm to people in the case of an event such as a fire, water safety or gas leak.

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.

Staff conduct had not always been checked during the recruitment process as the provider’s policy was to obtain 2 references. However, the risk to people was mitigated because the provider ensured new staff did not work alone until they were assured staff could work safely and effectively, as part of the recruitment processes enhanced disclosure and barring checks were made. Following our inspection the provider has updated their recruitment policy to ensure conduct is checked during the recruitment process in line with legislation.

Staff all told us they felt the training was good and gave them the knowledge and skills they required to meet people’s needs. Staff received regular support and supervision meetings and yearly appraisals.

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.

The home was free from malodour and was clean. There were effective systems to prevent infections spreading. For example, high touch points were frequently cleaned, bins contained bin bags, and furnishings and fittings were in a good state of repair and could be easily cleaned. Staff had access to personal protective equipment (PPE), and this was stored safely. Clinical waste was handled and stored appropriately. The laundry room was clean and well organised, clean and dirty laundry were stored separately.

Staff wore PPE correctly during mealtimes and when assisting people. Staff had a good understanding of their role in preventing infections. This decreased the risk of infectious diseases being spread.

The provider did not always make sure that medicines and treatments were safe and met people’s needs.

Medication errors were not always detected, and medication was not always administered as prescribed. For example, a person who was prescribed medication for a short period of time, staff had not reduced the dose or stopped the medication as directed by the person’s GP. The provider was responsive and ensured lessons were learnt to prevent a similar error in the future.

The medication trolley was not stored in the medication room. The room temperature where it was stored was not routinely monitored; therefore, the provider could not guarantee the medicines were stored at safe temperatures. The provider was responsive to our concerns, installed a thermometer and regularly monitored the room temperature.

Shortfalls were identified with some medicine’s documentation, including the completeness and detail of instructions for medication prescribed at variable doses. For example, for a person’s eye drops, the instructions for staff did not include which eye needed the medication or the situations where more than 1 eye drop was required, however staff showed good understanding of the dose required in different situations.

Medicines were stored securely and only administered by staff who were suitably trained.

People’s PRN (as required) protocols contained sufficient detail to enable staff to administer medicines safely.

There were effective systems in place for the receipt and return of medicines. Staff recorded when medicines were opened, meaning they knew when the medication needed to be disposed of.