The 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.

This is the first assessment for this newly registered service. This key question has been rated 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 safe care and treatment.

This service scored 59 (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 did not always have a proactive and positive culture of safety. Staff listened to concerns about safety and investigated and reported safety events, however lessons were not always learnt to continually identify and embed good practice.

Whilst the provider had good processes and systems in place for reviewing accidents and incidents, we did find there were some areas where it was not always clear that there had been continued learning.One person’s care plan we reviewed identified that some information had not been updated to reflect their current needs. Despite this, staff told us they were kept informed between shifts regarding people’s needs. One staff member told us, “Urgent updates are communicated promptly as they arise.”

The provider was open to feedback and took appropriate action to ensure gaps identified were updated. We saw no evidence of anyone being at immediate risk of harm.

The provider did not always ensure and establish safe systems of care. They did not always manage or monitor people’s safety.

We identified concerns around some of the shared equipment audits and gaps within some care plans and risk assessments. We found faulty wheelchairs which had not been placed out of action but were still in the home. The provider reviewed this practice, and all faulty equipment is removed from the building to avoid potential risks of harm to people.

Some people had experienced changes in their care needs during a recent hospital admission, and not all information had been updated in a timely manner. This meant the transition from hospital back to the home could have placed the person at risk of harm. The provider ensured this information was reviewed and updated following our feedback during our onsite inspection.

We did receive positive feedback from relatives around the transition of their relative into the home from their previous residence. The family told us their relative’s falls had stopped since moving to The Lodge and that they were well supported with their mobility needs.

Staff worked in partnership with other professionals such as GP’s and District Nurses. We received positive feedback around partnership working.

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.

The provider submitted notifications in line with their regulatory requirements and raised concerns with the local authority where appropriate.

The provider had safeguarding policies and procedures in place, including a speaking up policy. We reviewed staff training records in relation to safeguarding training and found no concerns. Staff we spoke with understood how to safeguard people from abuse and understood how to report concerns. Comments included, “I know I am free to speak up about any issues I need to raise.”

People and their relatives told us they felt safe at The Lodge. One relative told us, “It’s so nice to see [relative] happy, the pressure has been taken off the family as [relative] is so happy here.”

During our onsite inspection we observed people appeared to be comfortable living at The Lodge and we observed interactions were positive.

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.

We reviewed care plans and risk assessments during our onsite visit. Whilst some aspects contained a good level of information, we did find gaps in some areas of the care plans reviewed. For example, 1 person’s care plan and risk assessments we reviewed did not have sufficient information around risks related to their catheter care or blood thinning medication. We fed this back to the provider, who updated and reviewed the care plan and risk assessments.

Despite this, feedback from staff was positive around information sharing and they felt any change in needs were communicated well amongst the staffing team. Comments included, “I feel I am always well informed of how each person is.”

Staff confirmed they received daily handovers about people including changing care and support needs.

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.

The provider had appropriate checks in place relating to the environment such as fire safety. Necessary safety certificates were in place to support safe environments in areas including gas safety and electricity checks. Systems were in place to ensure the water quality was maintained to reduce the risk of water-borne bacteria (like legionella).

However, we found inconsistencies with equipment checks relating to the shared wheelchairs. It was not clear which risk assessment related to which wheelchair and when checking the wheelchairs, we found one with a brake that was not working properly and another wheelchair that was out of service with a flat tyre, but there did not appear to be a clear audit trail as to which wheelchair related to which risk assessment or which person. One person’s care plan we reviewed stated they used a wheelchair; however, they did not have an associated risk assessment in place, and their care plan lacked detail around their use of a wheelchair

Staff were aware who to report any maintenance concerns to.

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 reviewed training records and found no concerns around staff training. Staff we spoke with confirmed they received regular training and supervisions. Comments included, “I feel the training provided is more than adequate in keeping staff development and knowledge at the standard required in delivering the highest standard of care,” and “We are given the required training where professional trainers attend the home to train us on specific topics. Additionally, managers and seniors provide informal training as and when required.”

We did not receive any negative feedback around staffing levels.

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 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 clean and tidy with no malodours. Relatives we spoke with were positive with the cleanliness of the home and the overall environment. One person told us, “The home is always clean.”

The gardens were well maintained and provided a welcoming outdoor space for people to enjoy.

The service had a policy and procedures in place for infection prevention and control, and regular audits were completed by staff.

Staff had received the appropriate infection prevention and control (IPC) training, and we did not observe any concerns around poor practice of IPC during our onsite visit. Staff were observed wearing appropriate personal protective equipment (PPE) and this was available throughout the home.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Staff recorded the administration of medicines on Medicines Administration Record (MAR) charts. These records showed that people received their medicines as prescribed. However, during our onsite inspection we reviewed records relating to medication administration and found discrepancies around stock. We found the stock number of medicines were recorded, but actual balances of medicines were incorrect. We addressed this with the provider at the onsite inspection, and the registered manager took appropriate action to resolve the discrepancies and has since confirmed further actions taken to ensure the issue was resolved.

We reviewed the medication fridge temperature records and found some recent gaps in recording, which was addressed with the provider at the time of the inspection. The provider had a medications policy in place and controlled drugs were stored securely. Staff had received training in medication administration and competencies had been completed.