Fixby 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 as good. At this assessment the rating has remained as good. This meant people were safe and protected from avoidable harm.

This service scored 81 (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 management team had good insight into the need to be open and honest and investigate and act upon concerns shared. They investigated, recorded and provided outcomes when incidents took place, and also ensured any lessons learned were shared to avoid future incidents. The staff told us they felt well trained, and meetings and handovers were effective, allowing for good teamwork and for them to feel confident and able to do their jobs well. They felt management would listen and act upon concerns shared with them. Accidents and incidents were recorded and reviewed regularly by the registered manager who analysed these for trends, patterns and commonalities. Complaints, incidents and safeguarding concerns were investigated with clear outcomes and lessons to be learnt identified. Actions were followed up by the management team. The service had robust procedures to ensure a positive learning culture.

The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care and had a robust pre assessment process in place including when people moved between different services. They initially looked at referrals and considered people's needs and whether the service was able to meet needs. They also considered the people who already live in the service and compatibility. The service had ensured all people had detailed communication passports which were in an accessible format. All people had detailed hospital passports in place. The service provides 24-hour staffing when people are in hospital and was recognised to be involved in a highly successful hospital admission previously, allowing staff to act as an advocate and share information ensuring the person was not discharged prematurely resulting in re-admission to hospital. The service ensured staff were available to act as an advocate and speak up to ensure people received safe and appropriate care whilst in hospital. The service actively used the urgent community response service to reduce the number of hospital visits and admissions for people living at the service.

The service 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 service shared concerns quickly and appropriately. Risks to people’s health, safety and wellbeing were assessed and regularly reviewed. Staff knew people well and took positive steps to support people to reduce distressed behaviours. Positive behaviour support plans were in place which highlighted person-centred and proactive strategies and offered guidance to staff on how to support people to maintain their wellbeing.

The service 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. Staff understood the risks to people and told us they were kept up to date with changes in people’s needs. Staff were attentive and responsive to people’s needs. Risks to people’s care were well managed and we observed staff following safe practises. The service managed risks to people’s health, safety and welfare. Risk assessments were person centred and provided detailed information and were regularly reviewed with the person. The service ensured staff were identifying, monitoring and responding to risks to enable people to live their lives in the way they wanted. We saw clear involvement of the person when able, relatives or advocates in any decisions made that impacted on their life.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People had individual spaces as well as communal areas for use. We found people had been involved with the decorating of individual spaces.

The service made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities. People were supported by a consistent and skilled staff team, who knew them well. We observed kind and caring interactions and a genuine focus on meaningful relationships. Recruitment was managed safely and staff received high-quality induction, supervision and training. They worked together well to provide safe care that met people’s individual needs. A staff member was recently nominated by people and staff for Kirklees Council care awards. The staff member was placed third and the wider staff team and people living at the service were involved in the nomination and support process throughout the event. The registered manager had recognised stress within the workplace and as well as an open-door policy, the staff had additional space in the summer house which provided a safe space with access to support counselling information for staff to have a break if feeling overwhelmed. Everyone spoke positively about the whole staff team and wider organisation. Comments included, “Staff are very kind and caring, not met any staff who are not, all staff appear to know everyone very well, observed staff being patient and kind.” “I would speak to any staff at the care home they are all good and they would, I am sure all listen and act upon complaints.” “I would know where to raise a concern, but I do not have any. All staff are brilliant, we all get along, we all get stuck in, teams work well together.”

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. Staff spoke about the importance of handwashing and effective wearing of personal protective equipment (PPE). They had a good understanding of appropriate waste disposal and the need to dispose of infectious waste appropriately. They also spoke about measures to contain infection. The management we spoke to were aware of the need to inform relevant professionals in the event of outbreak. We looked at completed daily cleaning schedules which included clear guidance on what required cleaning. We saw regular completed audits of hygiene and cleanliness standards in the building. The service had an up-to-date infection control policy.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People’s medicines were reviewed in line with STOMP (Stopping over medication of people with a learning disability, autism or both). They involved people in planning, including when changes happened. People were given their medicines safely and in a timely manner. This was recorded on their medicines administration record (MAR) and medicines were stored safely and securely. There were processes in place to ensure the safe and effective use of medicines. Instructions for medicines which should be given at specific times were available. Detailed guidance specific to each person on how to administer medicines prescribed as and when people required them, known as “PRN” was available to staff. There were records of people’s preferences to indicate how they wanted their medicines to be administered. Temperature records to ensure the safe storage of medicines were completed following national guidance. Records showed that management or staff carried out regular medicine’s audits. Staff had received medicines handling training, and their competencies were assessed regularly to make sure they had the necessary skills. There was a process in place to record any medicines related errors.