The 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 requires improvement. At this assessment, the rating has remained 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 safeguarding and staffing.

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. 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.

The provider did not consistently record, or review lessons learned from accidents or incidents, so they were unable to identify patterns that might reduce future risks. Although staff had ways to report concerns, the provider did not keep a record of organisational learning. They did not routinely hold or record structured discussions after incidents of restraint to understand what went wrong and what could be done differently to prevent similar incidents happening again. One staff member said, ‘We have informal chats after incidents, but never a formal debrief.”

They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not ensure essential information needed for people to safely transfer between services was current. Most hospital passports had not been reviewed for several years, meaning they did not contain up to date details about people’s needs. This lack of current information increased the risk of delays or inappropriate actions if a person required support from another service, such as a hospital. The provider planned to improve their systems for reviewing and updating hospital passports following our feedback.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

The provider did not have clear safeguarding systems, processes, or practices in place to protect people from abuse. The provider had not identified, assessed or managed the repeated use of restraint as a safeguarding risk, and did not recognise the potential for physical or emotional harm, abuse or improper treatment. There were missed opportunities to reduce restrictions and control over people. Incident reports did not always show what alternative strategies staff had attempted before they used physical restraint, and there was a lack of evidence of reflective practice, learning, or consideration of what could have been done differently. Although the provider had a policy for the use of physical restraint, this was not consistently applied in practice. There was no clear strategy to reduce the frequency of these interventions.The provider have acknowledged and have made changes to the recording of these incidents moving forward.

Not all staff had completed safeguarding adults training, which increased the risk concerns might not always be recognised or responded to appropriately. However, staff told us they felt confident to raise concerns with the registered manager and were assured appropriate action would be taken. One staff member said, “I will report it to management, who manage any safeguarding concerns.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is 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 assessments and applications had been made in line with the recommended procedures to support people to live the lives they chose.

The provider did not always work well with people to understand and manage risks.

Risks relating to people were not managed appropriately, there are positive behaviour support (PBS) plans in place for people and the risk is assessed. However, these are not always reviewed in the time frame required by the provider.

Risks that were documented were not always followed by staff. For example, it was risk assessed that staff were to check the water temperatures before people used the bath. This was not recorded. Therefore, this risk has not been managed accordingly. However, the provider has now started to follow this risk assessment and document bath water temperatures.

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

Regular checks were carried out across the care home to ensure the environment remained safe. Records showed routine monitoring of electrical systems, legionella, water temperatures and fire safety equipment. Personal Emergency Evacuation Plans (PEEPs) were stored in an accessible emergency grab bag.

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.

The provider did not ensure staff had completed the training needed to safely carry out their roles. Several staff had not completed required courses or had not refreshed their training in safeguarding adults and infection control, core training necessary to keep people safe. The provider also did not ensure all staff completed learning disability and autism training at a level appropriate to their role. This was despite the provider’s own training policy stating that staff must complete this training. The provider has shared improvements in their monitoring and reviewing of training since this assessment was completed.

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 provider had effective infection prevent and control measures in place. People were protected from the risk of infection because premises and equipment were kept clean and hygienic. The premises were tidy, and shared living areas were well maintained. Staff had access to personal protective equipment (PPE). Staff used safe practices, including wearing PPE properly, keeping areas clean, and maintaining good hand hygiene. Relatives told us, “It’s an incredibly clean home” and “It is always clean and tidy.”

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.

Staff did not consistently record the reasons for administering ‘as needed’ (PRN) medication or the person’s response, in line with the providers policy. This meant staff could not review whether the medication was required and if the medication had been effective for that person.

The provider did have a medication administration policy in place and did complete a yearly medication review for people.