Collington Park 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 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. Lessons were learnt to continually identify and embed good practice.

The registered manager had systems in place to monitor accidents and incidents with any themes or trends being identified, analysed and then acted on to minimise risk of future harm. For example, the number of night-time falls were evaluated, using charts and tables that showed the frequency, time and location of recent falls. As a result of analysing this information staffing numbers were reviewed on the different floors, action was taken and staff were moved between floors to cover the area that needed increased levels of monitoring and support; the number of falls then reduced. Information, and any required changes, were communicated to the staff via team meetings and shift handovers. Staff told us,” Changes in the home, done at handover at the start and end of shift, serious information is handed over verbally as well as written.”Correct procedures for reporting and recording risks were followed. The registered manager operated an open-door policy that encouraged all staff to discuss any safety concerns they may have with them at any time they were present in the home.

The registered manager 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 made sure they knew all care needs prior to people’s admission and liaised with families and the relevant healthcare partners to gather medical history and personal information that contributed to the care plan. Care plans were regularly reviewed and updated as required. Any healthcare staff already involved in people’s care and treatment were welcomed into the home, for example District Nurses treating leg dressings, and checking pressure areas acquired prior to admission, thereby continuing existing treatment plans. A professional said, “If a new resident needs urgent care, they will contact me and we will organise a separate visit as soon as possible.” People had a hospital passport, which was a summary of care and communication needs that could be printed out and taken with them in an emergency, or if they moved or visited a different healthcare environment; this maintained continuity between services as all recent needs were documented for other professionals to read. The registered manager and care team recognised the challenges in moving to a new environment and lifestyle and provided encouragement and understanding, with a person telling us, “It’s been a hard decision to leave my home, but I feel well supported.” Many people at the home were able to fully express their needs and wishes so could liaise with healthcare professionals themselves, but others were supported by staff to access any treatment and support they may need when visiting local services. Communication between the home and people’s families was positive and we overheard a call made to a relative to reassure them that the admission process had gone well and that the first words spoken had been “I’ve come home.”

The registered manager 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 registered manager shared concerns quickly and appropriately.

Care needs and risk assessments were completed prior to people moving in so staff were aware of any issues or areas of concern at the point of admission. Staff confirmed they understood the processes to follow should they wish to raise any concerns and many said they felt confident to do so, comments included,” If I felt something was wrong I would go to the immediate senior, or escalate if needed” and “go straight to management with any concerns, go above if about management.” Safeguarding training was provided to all staff, and the registered manager understood their responsibilities to share information and make referrals to the appropriate partners in a timely manner. A previous safeguarding matter was reviewed, and staff had completed the recommended training as detailed in the safeguarding report. This showed the leadership was responsive in its approach to keeping people safe. People told us they felt safe and well looked after, with one person saying,” I feel safe yes, completely, the home is pretty secure,”

Some people lived with dementia and could not make all decisions for themselves. The Mental Capacity Act 2005, (MCA), provides a legal framework for making decisions on behalf of people who may lack mental capacity to do so for themselves. Deprivation of Liberty Safeguards, (DoLS), were in place and had been applied for through the correct channels. DoLS ensure that people who lack capacity to make a specific decision about receiving care and treatment are protected and any restrictions placed on their freedom are lawful and in their best interest. Care plans reflected any mental capacity needs and focused on what decisions the person could make and when they would need support. Risk assessments reflected the person at the centre of decision making and often started with “I spoke with (the resident).” Staff were fully informed and kept updated on any changes. When needed best interest decisions had been made and documented, and we saw evidence of family involvement, and the care manager was clear about the procedures to follow and the individuals that needed to be considered for involvement in any decision meeting.Professional feedback was positive with a person telling us,” I have no concerns with safety or things happening that shouldn’t.”

The registered manager 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’s risk assessments were regularly reviewed and updated if any care needs changed. The registered manager told us they were supportive of people making informed decisions and taking positive risks, for example walking unsupervised in the garden despite there being some mobility risks; the staff accepted that people may wish to continue the things they liked to do and try to be as independent as possible, so put measures in place such as asking to be informed if people were going outside in the garden, so they could check after a suitable period of time that they had safely returned to their room. Levels of independence were encouraged to be safely maintained. A person told us, “They seem to want you to do things.”

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 home being newly built was well decorated, with facilities including a cinema room, a hair salon and a tearoom, plus numerous communal areas for sitting, socialising and relaxing; everywhere was clean and well maintained. Maintenance records were kept up to date with equipment checked and serviced as recommended, for example bath chairs in the communal bathrooms, and electrical appliance testing throughout the home. Fire exits were clear from obstruction and fire safety equipment was in place on each floor. A grab bag was easily accessible in the front entrance which contained People’s Emergency Evacuation Plans, PEEPS, and regular fire alarm tests and drills were completed. The home employed a full-time maintenance person to enable continuous monitoring and repairs throughout the premises. Some people lived with dementia, but everyone was integrated to promote an inclusive environment; to safely manage those who lacked capacity, the lifts had key codes. This enabled people that could use these codes to mobilise independently throughout the home but retained some security for those who needed support. The garden area was well thought out with good access for people requiring walking aids and wheelchairs, without it being obvious it was a care home environment. Professional feedback told us, “For everyone it is really safe” and “The environment is welcoming, organised and safe.”

The registered manager 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 were recruited safely with all the required pre-employment checks being carried out including a Disclosure and Barring Service, (DBS), check which identifies people with a criminal record or those who should not work with vulnerable adults or children. Prior to working on shift assisting people, new staff completed a week’s induction training and then 3 shadow shifts where they worked alongside experienced care staff to familiarise themselves with the routine and the people they were supporting. Staff told us, “Had lots of training to do, all completed now, all online.” The registered manager used a dependency tool, on a tracker, to determine staffing levels, but these could be flexible according to the needs of the home. There was additional oversite from a forecast chief of staff who sent prompts about changes in occupancy or staff numbers due to annual leave, so cover could be arranged and correct staffing levels maintained. All staff had access to training and development of skills via a digital training platform and at times face to face courses provided by trained staff, and this training was up to date. Additional visual competency assessments were completed in some areas such as medication administration; this confirmed staff knowledge was at the required standard. Feedback from families included positive comments on staffing such as, “They are all lovely, honestly couldn’t fault any of them.” We observed staff working together in pairs or as larger teams and heard good clear communication between colleagues. Staff worked confidently in different areas of the home. Staff told us, “I have found everyone lovely, the regional manager as well.” Daily allocations were completed first thing in the morning, and staff worked a “3 on 3 off” rota, tending to work on the same floor for their 3 shifts to promote continuity of care. Staff were observed supporting people with mobility aids and using equipment correctly. A person told us, “Staff are friendly, couldn’t do more,”

The registered manager assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All areas of the home were clean and well maintained, and we saw housekeeping staff continually working on each floor, making sure all rooms were tidy and clean. Cleaning schedules were in place, and cleaning products were stored securely. People told us the home was kept clean with comments including, “Very nice here, nice and clean.” The business contingency plan included guidance and actions for staff to take in the event of an outbreak of an infection, and the registered manager explained that they would lock down as early as possible to prevent the spread of any infection should 2 people become unwell with similar symptoms.People were supported to access booster vaccinations from their surgery when they were available and if they wished to have them. The staff team had access to Personal Protective Equipment, (PPE), and there were established donning and doffing stations, with hand washing facilities and wall mounted alcogel dispensers throughout the home for staff, people and visitors to use. All staff were trained in infection control and prevention, and we observed staff wearing aprons and gloves when preparing to assist people. The home had recently been awarded the highest rating of 5 from the latest food standards inspection.

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.

Care plans detailed people’s specific medication needs and their preferred ways to take them. Medicines were stored safely and securely in locked trolleys and medication rooms, with daily temperature checks recorded as required. There had been recent inspections completed by the home’s regular pharmacy and the MOCH team; the Medicines Optimisation in Care Homes, (MOCH), is a specialist team of NHS pharmacists who work to enhance medicine safety for care home residents. These had not identified any current concerns apart from high stock levels of one medicine which had low impact on people living at the home.

Record keeping was clear; the home used a digital E-Mar system to record daily administration, and all policies and procedures were in place and easily accessible for staff involved in the medication routine. When explaining the system and records to us senior staff spoke confidently and clearly understood the protocols and procedures to follow. PRN protocols, instructions for medicines that are not required all the time, were in place, together with a stock of homely remedies, which are medicines that can be bought over the counter and given whenever needed. Audits were carried out weekly and monthly, by senior staff and management, and night staff did daily checks; the stock levels we reviewed on the day of inspection were all correct.