Amberwood 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 inspection we rated this key question good. At this inspection 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 service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had an electronic system to record, review and analyse incidents and accidents. The registered manager told us they shared learning from events which had occurred in the service.Records showed staff were informed of relevant incidents and lessons learnt through handovers, team meetings, reflective practice and supervisions.

Staff were given the opportunity to reflect on their practice during a particular incident or event, to identify areas for development. People’s care plans and risk assessments were updated following incidents if required.

Relatives told us they knew how to raise concerns and report any issues about the care of their family members. A relative said, “We feel we would be listened to, and any concerns would be addressed.”

The service 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.

People had summaries of their needs, known as hospital passports, available in case of an emergency hospital admission. The registered manager confirmed staff would attend with the person if they were admitted to hospital. This supported safety and continuity of care.

Health and social care professionals were complimentary about the service.A health and social care professional told us how the service worked with them to ensure continuity of care for a person who required treatment.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 service shared concerns quickly and appropriately.

People told us they felt safe living at the service.

Staff told us they knew how to raise concerns with the registered manager. A staff member said, “I do believe the clients are safe due to having a responsive management team and a very efficient maintenance team. All staff are trained in health and safety and have robust safeguarding, first aid, infection control and safety intervention.Safeguarding concerns are always taken seriously and reported quickly and dealt with rapidly.”

We observed staff working in safe ways, for example, when providing emotional support to people.

The provider had a process they followed to ensure people were protected and concerns were reported to the local authority without delay.  Staff received training in safeguarding, and the provider had a safeguarding policy in place.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. All legal applications had been made in accordance with DoLS. This meant people’s rights were fully respected. The registered manager had oversight of DoLS applications.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Although some risk assessments had not been reviewed within the documented timeframe, the registered manager had a structured process in place to ensure all risk assessment documentation was reviewed and outstanding actions were completed.

Staff knew people well and explained how to support them safely. We observed people being supported in a safe manner, for example during mealtimes.

When people communicated their needs, emotions or distress, staff supported them in positive ways. This had protected their rights, dignity and ensured people experienced positive outcomes while remaining safe.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff told us they knew how to report concerns relating to the environment. A staff member said, “We report maintenance and environmental issues to our in-house maintenance team. They are addressed as soon as is possible and if it is out of the remit of inhouse staff a call out is made and it’s normally completed quickly.”

The service had up to date Personal Emergency Evacuation Plans (PEEP). These were kept within the service's emergency grab bag in an easy to reach area. PEEPs provide staff and emergency service personnel with critical information on the evacuation needs of each person in the event of an emergency.

The provider used external contractors to service the fire system and undertake some checks, including in relation togas and electrical safety.

Safety measures were in place throughout the service including radiator covers and window restrictors.

The service 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.

A relative told us, “Most staff have been there a long time, and these staff members are lovely, professional, reliable and try their best.” People told us they liked staff members and we observed kind interactions between people and staff.

Staff had regular supervisions and attended team meetings. Staff told us they felt part of a team. Training records confirmed staff completed training to ensure they had the, skills and knowledge to carry out their roles. The provider offered additional training when required, for example in response to changes in people’s needs. Records showed staff’s competencies were spot checked.

We observed staff supporting people in a person-centred way, for example when supporting them with activities.

Recruitment procedures were in place to ensure checks were carried out on staff before they commenced 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 service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the service to be clean during our inspection. People and relatives had no concerns about the cleanliness of the service. People’s rooms were well maintained, clean and when possible, people were supported to look after their living space.

Personal protective equipment (PPE) was available for staff to use when needed. A staff member told us, “We are provided gloves, masks, aprons, hand soap. PPE is in various locations within the site; they are topped up throughout the day.”

At the time of the inspection the service held a food hygiene rating of 5 which meant hygiene standards were very good and fully complied with the law.

The service had an up-to-date infection control policy in place and staff received training in infection control.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Staff confirmed they received training and had competency assessments to support the safe management and administration of medicines.A staff member told us, “Within my job role I administer medication and have competency completed.”

The registered manager responded to our feedback by introducing new systems to prevent a recurrence.

The provider responded quickly and in line with their policies when medicines errors occurred. Incidents were investigated, lessons learnt, and changes were made to safeguard people in the future.

We observed staff supporting a person to take their medicine. Staff followed person’s care plan.

We found 4 recording omissions when staff had not signed to confirm medicines had been administered. Medicines audit failed to identify and assess shortfalls in recording of medicines.In response to our findings, the registered manager introduced a new system to help to prevent a recurrence.