Rook 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 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 people’s safe care and treatment and staffing.
 

This service scored 62 (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.

The provider maintained appropriate systems and policies to support learning from accidents, incidents, and complaints. Staff maintained comprehensive incident and accident logs, with actions taken and lessons learned recorded to support learning, reduce risks, and improve safety.

The provider shared lessons learned from incidents and accidents with staff to help reduce future risk. Staff confirmed learning was appropriately shared through team meetings and supervision. A member of staff reported, ‘‘Yes, if there is any incident, we have incident form, fill the form online so that the head office will know. The manager will address it and during staff meeting they will address it to minimise and manage the risk if we can’t prevent it 100 percent.’’

The provider made sure there was continuity of care, including when people moved between different services.

The service completed an initial needs assessment before people started using the service. People and their families, and other professionals where appropriate, were involved in the assessment process. The registered manager followed their referral process which included an assessment of needs and background information from the LA. The RM also told us they would speak directly with person during the assessment to understand their views, including whether they felt they were at risk, vulnerable, or had any concerns about their safety or wellbeing.
This meant a safe transition was in place for people moving into the service

We found that the provider involved people and their relatives to develop the care plan. People told us they felt involved in planning their care and were able to make decisions about how their care was provided. One person told us, ‘‘They asked for my opinion, and I was fully informed about my care. I was made aware of how I would be treated and what was expected of me.’’

The provider ensured that people were given a copy of their care plan to support their involvement in the delivery of their care and support. Care plans were also shared with staff to guide the delivery of care and support.
 

The provider shared concerns quickly and appropriately. Staff shared concerns promptly and appropriately with relevant authorities, including the local authority safeguarding team, and submitted notifications to CQC where required.

Staff reported they understood how to raise concerns and had received training in both adult and child safeguarding, enabling them to recognise signs of abuse or neglect. Staff members reported, ‘‘It's a process of protecting adults and children from risk of abuse, neglect exploitation, and harm, while promoting their health, wellbeing, dignity and right to live safely.’’ and ‘‘It is pivotal we work with vulnerable people, and we take steps to prevent abuse, even when the risk may come from friends or loved ones. Yes, I received training on safeguarding.’’

People reported they felt safe with staff and were aware of who to contact if they had any concerns regarding abuse or neglect. People reported, ‘[Family member] felt safe with the staff members.” and “Yes, they look after me. I use my key to go in. I feel safe.”

The provider had safeguarding and whistleblowing policies in place that were in line with best practice guidance. Where appropriate, people had Deprivation of Liberty Safeguards (DoLS) in place, which provided legal authorisation and safeguards to ensure any deprivation of liberty was lawful and, in the person’s, best interests.
 

The provider did not work well with people to understand and manage risks. 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. Staff did not always complete risk assessment forms in full, to ensure they contained sufficient detail in the required areas.

Where risk management plans were in place, these were not detailed enough to ensure staff had all the necessary information to deliver safe care and treatment to people. For example, the provider had not completed appropriate risk assessments on required specialist equipment such as wheelchairs.

Additionally, the provider had not completed appropriate risk assessments for risks associated with moving and handling, falls, choking, accessing the community, skin breakdown, diabetes management, skin breakdown, mental health and behavioural risks, and sensory impairments. This meant staff did not always have the necessary information to provide safe care and support or guidance on how to manage these risks safely. Failure to assess, monitor and mitigate risks placed people at increased risk of harm.

We spoke with the registered manager, who informed us that they would update the risk assessments forms to ensure they are accurate and complete.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care. The premises and flooring were kept clean, well maintained, and clear of any trip hazards.

Staff received appropriate health and safety training, including fire safety, to help them respond effectively in an emergency. The provide maintained records of daily health and safety checks, including environmental risk checks, fire evacuation drill records, and weekly fire alarm testing records, to help ensure the safety of people using the service, staff, and visitors.
 

The provider did always make sure staff received effective support, supervision and development. Staff were not supported through regular supervision, annual appraisals, or spot checks to assess their knowledge, skills, and competence. This meant the provider could not be assured that staff were receiving appropriate support, monitoring, and opportunities to develop and maintain the skills required to carry out their roles safely.

However, the provider followed safe recruitment practices, ensuring all required pre-employment checks were completed prior to staff commencing employment. The provider had completed Disclosure and Barring Service (DBS) checks or Right to Work checks appropriately prior to staff starting their roles. A DBS check is a record of a person’s criminal convictions and cautions. These checks help employers make safe recruitment decisions.

Staff had received mandatory training appropriate to their roles, including training on autism awareness, learning disability, dementia and manual handling, to support them in meeting people’s individual needs.

There were enough staff employed to meet people’s needs to ensure received care promptly and when they wanted it. People experienced continuity of care from a regular staff team who knew them well and understood their care needs. One person told us, ‘‘Yes, there are always enough staff around.’’
 

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 reported that they understood infection prevention and control (IPC) policies and wore personal protective equipment (PPE), such as disposable gloves and aprons, to help prevent and control the spread of infection. Staff reported, ‘‘I have completed training on it. We encourage handwashing and for us not be a carrier of infection. We use hand sanitiser and clean door handle.’’ And “We have training on cross contamination. In the kitchen, I put on my PPE and make sure things are kept separate. I don’t mix laundry together, and I follow hygiene procedures. We also use a mopping system, with the right mop for the right area.”

Staff received infection prevention and control training to ensure they understood safe working practices. Staff also completed food safety training to ensure they knew how to handle, prepare, and store food safely to reduce the risk of illness.
 

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.

The provider had a medicines management policy and procedure in place to support the safe management of medicines in line with current guidance and best practice. Staff received medicines administration training to ensure they had the knowledge and skills required to administer medicines safely.

The provider assessed staff competency to ensure they were able to safely administer medicines. We observed medicines administration records (MAR) had been completed in full, with no gaps, confirming people had received their medicines as prescribed and at the correct times. One person told us, “They give me my medicines and always give them to me on time.”

People received 'when required' (PRN) medicines when needed and the provider had PRN protocols in place. These helped to guide staff on when to administer these medicines and how to properly record their administration. Medicines cabinets were secured, and staff kept a record of the room temperature to keep medicines effective and prevent damage from heat or cold.