Chapel 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 changed to 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 infection prevention and control.

This service scored 53 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice. Accidents and incidents were recorded and analysed to identify trends and patterns. The registered manager included lessons learnt discussions as part of daily huddles and discussed key lessons for the team and changes to improve practice. However, throughout the inspection we identified areas where lessons learnt exercises had been completed but changes in practice had not been sustainable. Following our inspection the registered manager and provider took action to improve. This included adding specific duties to the registered manager’s daily checks.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. The service had an electronic care planning system which generated a hospital pack so information could be passed between services when appropriate. However, care records did not always accurately reflect people’s current needs. For example, staff were assisting 1 person to use the hoist, whilst their care plan stated they could walk independently using a walking aid. This was not always conducive in providing continuity of care.

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. Staff received training in safeguarding and understood how to recognise and report abuse. Staff were confident action would be taken to keep people safe. One staff member said, “I would report suspected abuse to the home manager. I am confident that the management team would take appropriate action but if not, I would either escalate it to the area manager or use the whistleblowing approach.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the management team and staff understood the principles of the MCA and were working in line with guidance. One staff member said, “In practice the MCA helps to protects and empower people aged 16 and above who may lack capacity to make specific decisions for themselves.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans did not always give clear information regarding the use of moving and handling equipment. For example, 1 person's care plan stated they needed a medium sling and a separate section stated they required a small sling. The sling in the person's bedroom was a large sling. Care plans did not always record the loop configuration to use to ensure safe transfers. This placed people at risk of unsafe care. Staff knew people well which minimised some risk, but the home used agency staff who would be reliant on care planning documentation. Daily monitoring charts did not always reflect the information contained within people’s care plans. For example, 1 person’s food and fluid records did not consistently document what meals had been consumed. Where entries had been completed, they were often vague, using descriptions such as “had lunch, ate all,” without sufficient detail. There was also a lack of evaluation of fluid intake. Information relating to weight loss was inconsistent, with contradictory information recorded in different sections of the care plan. Although people identified as experiencing weight loss had been placed on nutritional monitoring, food chart entries lacked detail and contained gaps where meals or snacks had not been recorded, with no explanation provided for the missing information. This put people at risk of unsafe care. We raised these concerns with the registered manager who sent us an action plan detailing how they would improve.

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. The registered manager told us they had a new fire risk assessment in place. Fire doors throughout the home had been identified as requiring work to ensure they were effective. The provider completed a fire door survey, and all doors had failed to meet requirements. The provider had an action plan in place to address this issue and we liaised with South Yorkshire Fire and Rescue Service who offered reassurances. The registered manager requested a timescale from the provider to ascertain when this work would be completed. We also identified other areas of the environment which needed attention, such as the corner unit in dining room upstairs was not secure to wall and 1 dining chair was unsafe as the arm was broken. This was moved immediately by the unit manager.

The provider did not always make sure there were enough qualified, skilled and experienced staff. However, staff told us they received effective support, supervision and development. Most people and relatives we spoke with felt there were insufficient staff available to meet their needs. We observed staff were constantly busy, but still people had to wait a long time to receive support. One relative said, “It is a lovely home with caring staff doing their best. But 3 staff, sometimes less, is not enough.” We raised these concerns with the registered manager and were informed they used a dependency tool kit to align staff numbers to the dependency of people. We identified this was accurate, but staff deployment could be improved. The provider had a recruitment policy which was used to ensure suitable staff were employed. Pre-employment checks were carried out prior to staff commencing employment. The provider had an induction program which included mandatory training. Staff told us the management team were supportive but commented that appraisals did not always take place. One staff member said, “I have not had a formal appraisal, but the manager is supportive and approachable.”

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. Many areas of the home required cleaning effectively and some areas required repair so items could be cleaned. We identified issues such as shower chairs were unclean underneath the seat, storerooms required cleaning and tidying, continence wear was not stored effectively with opened packets found on the storeroom floors. Skirting panel coming away from the wall in several parts of the home and was unclean and gathering dust and debris. The curtains and cupboards in the upstairs dining area were unclean. This put people at risk of cross infection. Following our inspection the registered manager sent confirmation these issues had been addressed. However, improvement in practice was required to ensure cleaning programs in place sustained the cleanliness of the service.

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. We identified 2 missed signatures on the medication administration record for 1 person. Some people were prescribed medication in a patch form, and some body maps were not in place to record the site they had been applied to. We also identified some minor issues with stock check. The management team took swift action to address these concerns. Staff told us they received training in the safe administration of medicines and had their competencies checked to ensure they administered medicines safely.