Delamere 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.

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.

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 learning from incidents and feedback. There were systems to review accidents and incidents. Logs were rated to highlight themes, such as falls, and we saw evidence that staff raised safeguarding concerns and submitted statutory notifications when required.

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Systems in the home did not always support continuity for people. Care records did not always have all the required details such as mental health conditions and how these can present.

The home supported people with mental health needs but did not have this service user band listed with CQC at the time of inspection. A service user band defines the specific group of people the provider intends to provide care and support to. We found care plans for people with mental health conditions did not describe early warning signs of deterioration or clear relapse indicators. The provider took immediate action to rectify this during and after our inspection.

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.
Safeguarding systems and training were in place and staff felt able to raise concerns to prevent and promptly address any signs of abuse.

Staff across different roles were confident in describing types of abuse, how to recognise concerns and the process for reporting them. They told us they would report to the manager, seniors or to the local authority. Staff told us, ‘We are encouraged to report any concerns,’ and said they would whistleblow if they saw poor practice.
 

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 learning from incidents and feedback. There were systems to review accidents and incidents. Logs were rated to highlight themes, such as falls, and we saw evidence that staff raised safeguarding concerns and submitted statutory notifications when required.

The provider did not always detect and control potential risks in the care environment. They did not always make sureequipment,andfacilities supported the delivery of safe care.

Fire safety arrangements were not always effective. The home had anup-to-datefire risk assessmentandevacuation plans for individuals. Records showed routine fire drills and alarm tests, but there were gaps including a missingnight‑timedrill which had also been highlighted by the fire and rescue service. Action plans wereupdated toaddress this following our inspectionto include these drills.

The provider did not always make sure staff received effective support, supervision and development to provide care that met people’s individual needs. Staffing levels and skills were often sufficient to meet people’s needs, and staff described a supportive culture, but gaps in supervision and training were seen.

Training records and audits showed that staff received training in areas such as moving and handling, safeguarding, dementia and staff described additional training for specific needs. However, there was no specific mental health conditions training at the time for a service supporting people with varied mental health needs.

Supervision and appraisal arrangements were not always in place. Audits highlighted gaps and some staff told us they had not had regular one‑to‑one supervision. Following our inspection a supervision planner was put in place and several staff described supervisions that they found “useful,” but it was too early to be confident that this was sustained.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

On the first day of our visit, we found ground floor bathrooms and toilets in poor condition. Personal items and towels were left in sinks and on shower chairs, toilets required cleaning, there were no bin liners in waste bins, and a clinical waste bin had wipes and other items placed on top. There was no hand gel available at sinks. In the ground floor lounge, we observed stains and drips on the walls behind chairs, consistent with liquids being spilled, and these had not been effectively cleaned. We observed a staff member not using appropriate personal protective equipment when supporting a person.

Relatives gave detailed accounts of poor cleanliness and hygiene on the ground floor over several months. One relative described corridor floors that were “filthy and sticky.”

Following our feedback, domestic staff promptly cleaned identified areas, and a refurbishment plan was implemented to redecorate the ground floor lounge to address the staining on walls.

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.

Staff completed medicines administration training and regular competency assessments. Staff told us competencies were checked every 6 months and that they felt supported by the local medicine’s optimisation team, who visited to carry out checks and provide guidance where appropriate.