Cumberland 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 good. This the first assessment since a new provider has taken over the service. At this assessment the rating has remained 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 registered manager 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. People could openly discuss concerns with the registered manager or with their identified key worker during meetings. We saw all concerns raised were taken seriously and investigated with any actions implemented and feedback provided to people in their preferred format. There was a culture of learning and empowerment for people living at the service. Communication and learning was shared with staff through regular updates, meetings and handovers. Staff were supported to identify and raise any safety events so that prompt actions could be taken to keep people and the service safe. Staff kept detailed records of safety events to monitor for themes or trends. Where improvements plans were needed these were put into place with timescales for completion. For example, where environmental issues were identified with fire safety the actions needed to make the service safe were documented and completed promptly. The work was then reassessed and another fire assessment completed to ensure people’s safety. Lessons were learnt to continually identify and embed good practice. The registered manager kept themselves up to date with any developments in the social care sector and shared this learning with staff.

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. The registered manager and provider had a robust procedure in place to ensure people could transition into and out of the service safely. The registered manager worked with people their relatives and health professionals involved in their care to establish a plan for care and support prior to people moving to the service. This included facilitating visits to the service by people and their relatives if involved and current supporting health professionals. If people liked spending time at the service a longer period was then arranged to allow for a settling in period and for people and staff to have time to get to know each other. The registered manager regularly met with people’s multidisciplinary team to ensure continuity of care and support. The registered manager arranged for people to have continued support with physical health and well being by registering people immediately with GP services, dentists and local mental health services.

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. Staff had received training in safeguarding people and ‘whistle blowing’ and felt confident to safeguard people and raise concerns. One member of staff said, “If I saw something of concern I would report it to my manager, if I felt it was not being dealt with properly, I would report it higher up to the owner of the company. If it still wasn’t being dealt with, I would call the police for any urgent matter or contact CQC and whistle blow.” People told us they felt safe living at the service. One person said, “I don’t feel endangered, it just feels normal, there is no pressure and nothing to be worried about or lead me to any concerns.” Another person said, “I feel safe here, I would not want to go anywhere else.”

The registered manager raised any safeguarding concerns with the local authority and worked with them to investigate these fully to keep people 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. People were involved in discussing their care plans and how they could be empowered to safely manage risks to them. Staff had guidance to follow in the form of risk assessments and care plans to keep people safe. Staff encouraged people to make decisions around their safety to promote their independence and support their wellbeing. Where one person was not confident to access the community independently staff had worked with them to develop their confidence so that they could still enjoy community activities. The registered manager supported working collaboratively with people to manage positive risk taking. One person had been supported to manage a specific risk. The registered manager worked with the person and their community treatment team to reduce risk‑related behaviours and help them stay safe. This demonstrated staff understood people’s rights to make unwise choices and support their decisions whilst continuing to work with them and their multidisciplinary treatment team.

Staff had received training on how to effectively respond to behaviour that communicates distress or emotion. Where one person was distressed staff were able to offer them verbal reassurance and redirected them to an activity, they found soothing and supported their emotional wellbeing.

The registered manager detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The registered manager had audits in place to monitor the environment to ensure this was safe for people to live. Staff had training in fire safety and fire drills were undertaken at the service. Each person had a personal emergency evacuation plan in place which showed what support people would need in the event of an evacuation. Where staff practiced fire evacuation with people, they were able to tailor their personal evacuation plan to show how they reacted during fire drills and what additional support they may require.

Fire risk assessments had been completed at the service and where issues had been highlighted with the environment these had been addressed promptly by the provider to ensure the environment met fire regulations.

People were involved in making decisions on how the environment was decorated and had been consulted on new furniture purchased. Where people invited us to see their rooms we saw they been able to decorate these how they wanted and had personalised their rooms with their own belongings and items that interested them.

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. People were supported by a consistent staff team and had a key worker to provide individual support. One person said, “My keyworker is [staff name]. I get on well with them they are nice.”

The registered manager recruited staff safely, applicants provided a full working history, references and undertook a disclosure and disbarring check (DBS), to ensure they were suitable to work with people who rely on care and support. New staff underwent a full induction, which included time to get to know people and their care and support needs whilst working shadow shifts with more experienced staff. New staff had regular probationary meetings with the registered manager to discuss their performance and any support or learning needs they may have.

All staff were supported with tailored training packages both face to face and through eLearning. The registered manager worked with a training provider to develop training packages that met the needs of the service and the people they supported.

All staff had completed the care certificate to include the new standards which had been added and to refresh their knowledge. The care certificate is an industry recognised set on training standards to equip staff with the knowledge they need to work in adult social care.

Staff told us they felt well supported at the service and were provided with the training they needed. One member of staff said, “We do train all the time, we love it though because we get so much knowledge, we can also ask management they are so supportive.”

Staff were being provided with regular supervision to discuss their performance, any training needs they may have and set goals. The registered manager held regular staff meetings. From minutes of meetings, we saw staff discussed the general running of the service, any lessons learned, safeguarding, policies and processes, the environment, training needs and looking forward.

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. Staff had received training in infection prevention control (IPC) and safe food handling level 2 and 3. The provider had policies in place to support IPC practices at the service. Cleaning schedules were in place along with regular audits to monitor the service. We observed the environment was clean and free from any odours. Personal protective equipment (PPE) was available for staff to use when needed. The registered manager told us that before any admission the room would be deep cleaned and redecorated and a new mattress provided along with bedding.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff had received training in medicine management and had their competency to support people with medicines checked. Medication documentation we reviewed was in good order and included clear directions for medicine prescribed as and when required (PRN).

The registered manager worked with people and other health professionals such as GPs and psychiatrists to regularly review people’s medicines, to ensure it was still effective and meeting people’s needs. People had been successfully supported to reduce medicines where appropriate under the principles of STOMP (stop over medicating people).

People were empowered to manage their own medicines safely when they wished to do this with the support of staff.