Stanway Green 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.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders listened to people and acted upon any concerns relating to people’s safety.

The provider had systems in place for recording individual incidents and accidents. However, the management team had not always ensured all incidents relating to people’s falls were robustly monitored and reviewed. During the inspection, we found inconsistencies in how falls were being recorded and this meant the circumstances of the fall were not always clearly documented. Where the provider had investigated incidents relating to falls, these investigation reports were not always sufficiently detailed to demonstrate how lessons were being learnt to mitigate future risks. The provider’s falls audits had not identified these issues prior to the inspection.

Following our feedback, the provider immediately implemented a new falls monitoring audit to ensure any shortfalls in reporting were promptly identified and addressed.

The provider worked in partnership with people, relatives and relevant health professionals to establish and maintain safe systems of care. This included when people were admitted into the service and when they were admitted and discharged from hospital. The provider shared information appropriately and made sure there was continuity in people’s care as they transitioned between services.

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 had a safeguarding policy and process in place for staff to follow and staff knew how to respond to and escalate any concerns around people’s safety. One member of staff told us, “If I had a safeguarding concern about the service, I would report it straight away to the manager and senior staff or the local safeguarding team if needed.”

The management team told us they had liaised with the local authority to support their understanding of safeguarding thresholds for reporting. They told us this had led to improvements in their safeguarding processes and partnership working.

The provider had not always ensured all risks to people’s health and safety were monitored effectively. During the inspection, we found some contradictory information relating to people’s health risks recorded across their care plan and risk assessment documentation. Where management audits had identified potential concerns relating to people’s changing health needs, such as their weight and nutritional intake, care plans and risk assessments had not always been updated promptly to ensure staff had clear guidance in place about how to support people safely.

People’s personal emergency evacuation plans (PEEPs), detailing how to support them to evacuate safely in the event of a fire, did not always contain all relevant information. The PEEPs were not always easily accessible in the event of a fire.

Despite these concerns, people were supported by an established and consistent staff team who knew them well. Staff were knowledgeable about people’s personalised risks and knew how to minimise these. People and their relatives told us staff supported them safely. Comments included, “[Person] is completely safe” and “Absolutely, [person] is safe and feels safe.”

Following our feedback, the management team responded immediately to update the PEEPs documentation and ensure this was always accessible. They told us they were also reviewing people’s care plan and risk assessment documentation to ensure information was up to date and accurate.

The provider had processes in place to detected and control potential risks in the care environment. Equipment servicing and equipment safety checks were being completed appropriately and a refurbishment plan was in place to modernise and improve décor. However, during the inspection, we identified a communal bathroom where large items were being stored which could pose a risk to people if they were to fall. We also found an unlocked staff toilet room with an unrestricted window. This could pose a potential falls risk. The provider responded immediately during the site visit, securing both rooms and arranging for the removal of the items. They told us they would also review the frequency of the environmental checks on all rooms to ensure safety and security were more closely monitored.

People and their relatives told us staff were knowledgeable and experienced. Comments included, “I’ve no concerns about the knowledge of the staff, they do know what they are doing” and “They know how to help [person] and give them what they need.”

Staff told us there were enough staff on duty to support people safely and they worked together well to provide safe care which met people’s individual needs. Comments included, “I am proud to be part of a team that supports and pushes each other to be better every day” and “I am proud of the positive relationships we build with the people we support and how well we work as a team.”

People’s relatives told us there were usually enough staff available to support people as and when required, although some told us more staff appeared available during the week than at weekends. Comments included, “They seem a bit low on the weekends”, “I believe that there are enough staff, they don’t seem to be rushed off their feet and you don’t have to look very far to find staff” and “They are busy, sometimes they are a bit short of staff I think.”

The provider completed a dependency tool to determine the staffing levels required on shift. This did not always evidence how timings had been decided and did not include allocations for people’s activities. Despite this, people told us they did not feel rushed and we observed staff spending time sitting with people and doing some group activities. Following our feedback, the provider told us they were reviewing and amending their dependency tool to include more detail.

The provider had completed appropriate recruitment checks to ensure staff were safely employed. Staff received relevant training to support them in their role and the management team completed observations of staff practice to ensure training was embedded.

The provider had systems in place to monitor cleanliness and manage infection prevention and control. However, we found these systems had not always been implemented effectively. During the site visit we found some issues with cleanliness in communal bathrooms and a build-up of cobwebs in communal hallways. We found these issues had also been identified in an external infection prevention and control audit and in concerns shared by people’s relatives. However, the provider’s cleaning schedules and infection prevention and control audits had not identified any concerns. Following our feedback, the provider told us they had spoken with staff and were reviewing their auditing processes to ensure checks were completed more robustly.

People’s medicines and treatments were safe and they had been reviewed with relevant health professionals to ensure they were appropriate to people’s needs. The provider had a medicines policy in place and staff told us they had received appropriate training and support in understanding how to administer medicines. However, the provider’s processes for monitoring the safe administration of people’s medicines were not always implemented effectively.

We found people’s medicines administration records were not always clear and legible. Staff were not always recording why as and when required [PRN] medicines were being given and there was not always an up to date PRN protocol in place to provide staff with guidance on when to administer these medicines. Medicines stock checks were not always completed frequently to ensure any inaccuracies were promptly identified.

Despite this, we identified no concerns with the administration of medicines observed during the inspection and people’s relatives told us staff managed medicines safely. Comments included, “Staff watch [person] take their medicines”, “I’ve no concerns” and “It’s managed well.”

Following our feedback, the provider stated they were amending their processes to ensure a running total of medicines stock was completed and confirmed all PRN protocols were now up to date.