Archived: Sonia 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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, medicine management, environmental safety, staff training and staff recruitment.

This service scored 25 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

When people were upset or distressed staff used ABC forms to monitor any incidents. The purpose of these forms is to assist staff to understand the triggers and patterns for incidents and identify more effective strategies to support the person. However, records were very poor and would not support staff to improve people’s care. For example, dates and times were missing meaning staff could not identify if there was a patten to when a person was distressed and adjust their care to ensure staff were responding appropriately to support people’s wellbeing.

When people needed medical attention following an incident people told us they received this. For example, one person had fallen and told us they had seen medical staff following the fall. Staff confirmed this was the case.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The advice received from health care professionals was not always followed and this increased the risk of people coming to harm. For example, some people had been prescribed a modified diet to reduce the risk of choking. Staff were not following the guidance for how to prepare these foods or for what foods should be provided. For example, people were served peas when the advice was to avoid these. This increased the risk to people from choking and limited people’s choices.

Information of concern was not always shared with partners. For example, some people had lost a significant amount of weight, health care providers were not always informed about this, and they should have been. One person had continued to lose weight and was underweight but had not been referred for support with nutrition prior to the inspection.

When people went to hospital the provider told us a member of staff usually went with them. However, one relative told us this was not the case and their relative was sent alone and they found them wandering about the hospital confused.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The majority of staff had completed training in safeguarding adults. Staff told us they would raise concerns where these were identified. Where safeguarding concerns had been identified these had been reported and action had been taken to reduce risk. Staff told us, “We need to protect our residents from abuse, any kind of abuse, I will report to management and then if they do not do anything I will then report to CQC.”

However, people were not always well protected from the risk of poor practice. People told us they felt safe living at the service. However, one relative did raise concerns, and we identified a number of areas where safety did need to be improved. There were areas where practice was not safe and staff had not whistleblown to raise concerns regarding this. For example, staff had not raised concerns about the lack of training in some areas or staff not following people’s prescribed diets. One relative told us about a safeguarding incident which had occurred in the last year, and the provider had failed to notify CQC of this incident. We asked the local authority to confirm if they had received a notification and they told us they had not.

Where people had been deprived of their liberty the appropriate legal authorisation to do so was in place or had been applied for.

Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

One person had lost a significant amount of weight in the months previous and was still losing weight. There was no real strategy in place to provide support to the person to maintain their calorie intake. Whilst the provider did improve the information in the person care plan during the inspection, information was still limited and there was no evidence staff were providing this support. For example, the care plan guided staff to provide high-calorie, high-protein foods. The provider told us the person usually ate better in the morning. There was no guidance around this to ensure staff were offering more calories earlier during the day. We observed staff went to remove lunch from the person when it was not clear they had finished their meal. We raised concern about this, and the person’s food was returned. The person carried on eating. The provider did put a food diary in place after we raised concerns. However, this didn’t evidence a strategy was being followed to reduce the risk from weight loss.

One person was at risk from retaining urine and had a catheter in place. They had previously removed this catheter. During the inspection the person’s trousers were soaked in urine. Staff did not identify this until the inspector raised concerns. The deputy manager told us the person had disconnected their catheter during the night but there was no evidence this had been shared with staff working during the day. The person’s fluid intake and output needed to be monitored to ensure they were still not retaining fluid. However, records were poor leaving the person at increased risk.

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.

During the inspection we saw tools were left about the service unattended. The provider told us this was only when maintenance staff were taking a break. However, we saw tools in multiple places at multiple times. Staff walked past tools which were left unattended and accessible to people and did not act to address the potential risk.

There was no clear plan to support people to evacuate if there was a need to do so during the night. For example, if there was a fire. The provider has not assessed how many people would need to be moved to a safe area if there was a fire, where people needed to be moved behind two fire doors. People had personal evacuation plans in place. However, these did not include any information on how to support people if they became distressed.

There were areas where the service needed maintenance. For example, one person’s headboard was very loose and covers in place to protect people from radiators had holes in the covers meaning people were at higher risk of burning themself.

People were protected from the risk from utilities such as gas and electric. The provider had undertaken the checks required such as ensuring electrical wiring was safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were a large number of new staff at the service. A number of staff had not received the training they needed to provide safe and effective support to people. For example, staff had not completed face to face training in manual handling or basic life support. One staff told us, “We have not done any face-to-face training yet, but I did in the care home previously to here.” The training provided was primarily short online courses for staff to complete. The provider told us staff learning was enhanced through discussion. However, staff did not always demonstrate they knew how to support people well. We observed staff also stood over one person when supporting them to eat rather than sitting next to them and providing positive encouragement. We asked one member of staff what they would do if a person was choking as there were people at risk living at the service. They told us they did not know. Another member of staff was not able to provide a response. We asked for evidence kitchen staff had completed training in supporting people with diabetes and modified diets. No evidence was provided and there were people with both these needs living at the service.

Safe recruitment process had continued to not always be followed. The provider had not ensured that staff had complete recruitment files. The provider did not have employment histories for some staff so they knew where the person had worked previously and explained any gaps in employment. There was not always evidence the provider had checked potential staff’s Disclosure and baring records (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

The provider used a dependency tool to plan staff numbers. People and staff told us there was enough staff to support people. However, the provider had not taken sufficient action to assess if 2 staff was enough at night to support people to evacuate in the event of a fire. We referred the service to the fire service following the inspection visit.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

There were areas of the service which were not clean or well maintained. This increased the risk of infections being harboured. For example, one shower floor was torn and needed replacing. One person’s bedding was not clean and had stains. Clean bedding was stored in a cupboard with unclean bedding which smelled strongly of urine. Where there was a risk people could get urine on the floor, their bedrooms had carpeted floors and there was a very strong smell of urine some people’s bedrooms, in corridors and in the lounge. One toilet brush holder was half filled with faeces-stained water. When we checked later the water had been emptied out but the holder was still unclean and still smelled.

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.

Some people were supported with medicines which needed to be administered at specific times. Staff were not recording the time the medicines were administered to enable this to be monitored. This increased the risk of harm to people.

Medicine returns were not always stored safely. Staff told us they stored medicines to be returned in an old toilet next to the manager’s office, which was not locked. Other medicines were stored safely in a locked medicine cabinet in a locked room.

Medicines were in date and stock totals matched people’s medicine records. Where people used patches such as pain patches there were body maps in place to guide staff on where to place the patch.

Where people had ‘as and when’ medicines (PRN) there was guidance in staff such as information about when to offer this medicine and how often the medicine could be taken