Avondale Castlemount 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. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

There were robust systems in place to learn from any incidents, which were focused on analysing contributory factors, and how incidents might reflect an unmet support need or relate to person’s previous life history or emotional trauma. After each incident there was an in-depth de-brief with staff members to support their wellbeing, as well as explore what had occurred and how ongoing learning could be taken to support people have the best outcomes from their care. One staff member explained, “There are always welfare checks and a debrief after incidents. These allow me to take stock and see where we are with somebody’s care, discuss what happened openly and take learning going forward. These are really valuable”.

Incidents were analysed to look for themes and trends and were discussed at team meetings and used to inform focused work with people to support their wellbeing. For instance, following incidents between some individuals, targeted work was carried out to strengthen learning and understanding around supporting individuals to maintain healthy and safe relationships while sharing communal space. There were also debriefs with people after instances of distress or anxiety to explore what caused them to feel that way. As a result, staff understood times or situations that were more likely to result in reduced emotional wellbeing and could pre-empt these by redirecting people towards meaningful and positive activities.

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 provider ensured there were clear plans to support people with key transitions, such as joining the service, accessing health services and moving to more independent care in the future. There were regular and comprehensive reviews of people’s care with partner organisations to design multi agency plans of how to support people’s physical and mental health. For example, with people who may have emotional difficulties in interacting with health services for fear of judgement, staff worked with them to support them in doing so in a way that was safe for them. This was facilitated using debriefs, hospital passports and reflective practice to support people in accessing the care they need.

Guidance was regularly updated and reflected current best practice guidance to support people safely. There was a stable and consistent staff team who knew people well and could advocate for them effectively when moving between services. Other agencies who worked with Castlemount Lodge spoke positively about how they engaged with them when people were at important or difficult points in their lives. One stakeholder told us, “They were proactive in seeking input when the person I worked with required additional support, and they used creative, person-centred approaches to help them engage and feel comfortable. Overall, they came across as a service that genuinely wants to get things right for the people they support”.

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. The provider shared concerns quickly and appropriately.

Both the provider and staff were knowledgeable about the risks to each person and had detailed plans in place to safeguard them from abuse and neglect. Where abuse or neglect did happen, the provider worked in partnership with the local authority and others to put in place plans to protect people.

Staff were appropriately trained could confidently explain how they would identify signs of abuse and their responsibilities to safeguard people from the risk of harm. One staff member told us. “Abuse could be physical, financial, sexual or emotional. I have had training and we are constantly looking out for signs something might not be right. If I was concerned, I would report to the manager or other agencies. I would make sure I carefully document my concerns, communicating what I am doing with the person involved and work on a safety plan together”.

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.

There were detailed and robust risk assessments in plan that set out a clear and person-centred strategy for how staff would work together with people to manage risks to their physical and mental health. These were regularly reviewed with people to ensure they remained up to date, and that people knew how the staff who worked with them would protect them from harm and support them to live healthier lives.

There was clear and detailed guidance for staff which was shaped by input from other professionals where relevant. When people’s health needs changed, referrals were made to wider health and care services where appropriate, to ensure guidance continued to reflect their needs and additional support put in place if required. Staff explained they had time to regularly review people’s care plans to ensure they had an up-to-date knowledge of how to support people, and that where people’s needs or care plans changed this would be shared with them in a timely way.

For example, when people may be at risk of becoming distressed and putting themselves at risk of harm, there was clear guidance setting out how staff might recognise this and how they should respond to help relieve this distress and supporting ongoing mental wellbeing. They worked with mental health services to put in place long terms plans of supporting rehabilitation and recovery. One health and care professional who worked with the service told us “They always seem highly aware of risk assessing, and the need for clear and robust risk assessment and safety plans for individuals. They actively contributed in our own risk assessments with those we support”.

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.

There were systems in place to monitor the safety of the environment. This included around fire safety, regular safety checks on electrical and gas supplies and safe storage of hazardous chemicals. The building was largely well maintained and was a bright and pleasant space decorated with artwork created by people, as well as resources and tools to document their journeys and achievements specific to their own mental health.

However, in a minority of instances, monitoring systems hadn’t been effective in identifying and removing risks. For example, tap temperatures in the building were consistently too high and not all radiators had covers, meaning there was a risk of people burning themselves. Both issues were quickly resolved once raised with management. We also identified a disused fire escape at the rear of the building which needed to be secured to prevent access to the roof.

The provider did not always ensure robust recruitment practices were in place, however there were sufficient numbers of staff employed who were knowledgeable and trained in people’s needs. They received effective support, supervision and development.

Feedback from people, relatives and staff confirmed that there were sufficient numbers of staff throughout the day to support people’s needs safely. One staff member told us, “Yes we have enough staff. However, there is always additional support if needed. We have an SOS system which we can use at any time, and somebody will sit on the phone with me or come out to the service if needed”. A relative explained “There are usually 5 members of staff working in the day, which I think is enough as people are quite independent”.

Staff received ongoing support and development and were fully trained to meet the needs of the people they supported. This included enhanced and ongoing training around mental health and learning disabilities and autism which met the Oliver McGowan Code of Practice. This a national requirement ensuring people with a learning disability or who are autistic are supported by sufficiently trained and knowledgeable staff, who are aware of barriers faced by these groups in wider society. Staff told us if they felt they needed any additional training to support people this was always available if they requested it. There were regular supervisions and appraisals to identify staff performance and ensure they maintained a strong and up to date knowledge of people’s needs.

However, the provider needed to ensure a robust process was in place around Disclosure and Barring Service (DBS) checks. A DBS check is used by employers to make safer recruitment decisions. In a minority of cases people had started employment a short time before the outcome of this check was received, and the provider had not ensured a robust risk assessment was in place for such circumstances to be confident that this was always a safe and appropriate course of action.

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.

The service was visibly clean, and all staff had received training around how to protect themselves and the people they supported from the risk of infection. There were regular audits and checks in place which demonstrated routine cleaning was taking place. This was reflected in feedback we received with one relative explaining, “The home is always clean”.

People were actively empowered and involved to be in control of their own cleaning to help them develop life skills to support them with living independently in the future. For people who may be reluctant to maintain their own personal hygiene, staff worked with people creatively to explore the reasons for this linked to previous traumas or significant life events. They put in place strategies and focused work to help people regain pride in their personal appearance, and reduce the risk posed to them by developing infections.

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.

There were robust systems in place to ensure people received the medication they needed, when they needed it, and that it was administered in a safe manner in line with relevant guidance. Regular audits were taking place which were effective in identifying any medication errors, and appropriate learning was taken in such instances such as refreshing staff training. All staff administered medications and there were robust checks on their competence to ensure they were sufficiently knowledgeable and could do so safely.

People were supported to have regular reviews of their medicines to ensure they remained appropriate. The service followed the principles of STOMP (Stopping over medication of people with a learning disability and autistic people). STOMP is a national programme focused on reducing inappropriate prescribing of antipsychotic medications to control behaviour and focuses holistically on people’s support needs and how they can be met through less restrictive means. Staff worked with people to monitor these medications and if they remained appropriate for each person.

Some people made choices to not always take their medicine and staff had respected everyone’s right to do so but also worked with people to explore the causes of this and developed plans with people to support them to develop safer routines. This included supporting people move towards managing their own medicines who aspired to live independently in the future.