White Rose 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 66 (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 service demonstrated a positive learning culture where leaders and staff reflected on events and used audits and reviews to drive improvement. Falls information was reviewed through an accidents and incidents matrix and reflective practice was referenced when there were multiple falls, for example.

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 some systems to support safe care. However, we identified gaps in care documentation which increased the risks to people during their transition into the home. For example, 1 person did not have risk assessments or care plans for over 2 days after they moved to the home despite this person being a high falls risk. There was also evidence of inconsistency in the documentation of risk and people’s consent. For example, references to bed rails without clear recorded consent or best interest decisions being recorded. The provider confirmed documentation had been updated following our inspection visit. However, we were not assured these systems were consistently in place prior to our visit to ensure people were safe.

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.

The service had systems and oversight in place to help protect people from harm. Staff understood safeguarding responsibilities and responded appropriately to incidents. Safeguarding policies and reporting systems were accessible. Leaders demonstrated understanding of safeguarding processes and escalation routes.

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.

Although care plans referred to risk assessments, appropriate risk assessments were not always completed. For example, 1 person who smoked and another person with a catheter did not have specific risk assessments in place. Risks associated with these omissions were partly mitigated through detailed care plans. However, this did not provide assurance that risk management was consistent and effective. For example, people’s care plans did not always include enough detail about moving and handling equipment, such as the correct sling size. During observations, staff demonstrated they knew people well and used the correct equipment, but records did not consistently support safe practice.

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

The environment was well-managed to reduce risks, with routine safety checks and maintenance systems in place. Fire and water safety documentation including risk assessments and other routine environmental checks were recorded as fully completed.

The provider did not always 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 always work together well to provide safe care that met people’s individual needs.

The service had a robust recruitment process and used a dependency tool to monitor staffing levels. However, observations during some points of the day suggested staffing was limited and staff described frequently asking for support from leaders. Training compliance was generally high but we found 1 instance where a senior staff member did not have in-date fire drill training but had been deployed on shift for over 3 months. The registered manager confirmed following the inspection that all staff had been appropriately trained.

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.

There was active infection, prevention and control (IPC) oversight and good routine practices. During a recent outbreak of diarrhoea and vomiting, good teamwork and calm management was observed by senior leaders. During our inspection, domestic staff were observed thoroughly cleaning high-touch items such as call bells, which showed a commitment to high levels of cleanliness in shared areas.

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.

Medicines processes included structured administration systems, alongside regular audit activity to identify and address issues. Medicines audits identified some minor recurring issues. However, these were not found during the inspection, showing improvements had been made. A senior staff member confirmed medicines were, “Very well organised.”