South Lodge Care Home

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

The provider had systems and processes in place to safeguard people from the risk of abuse. Staff received training and understood their responsibilities to safeguard people. The provider had systems in places to manage risks to the quality of the service and protect people from the risk of abuse and neglect. However, the systems were not always implemented effectively and as a result, not all risks were assessed adequately. Following our feedback, the provider took immediate action to mitigate the risks we were concerned about. The equipment and facilities were well maintained. Staff had received training about environmental risks and understood their responsibilities.. Staff were recruited safely and received ongoing training and support within their roles. However, not all staff supervisions were up to date. The acting manager was in the process of addressing any gaps in staff supervision. Staff managed medicines and treatments safely and met people’s needs. Some medicine records were not always detailed for medicines taken on an 'as required' basis. Action was taken promptly to address this during the assessment process.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people said they felt safe and could raise concerns with staff. One person gave us an example of when they had reported not feeling safe and staff had taken action to resolve the concern. Another person told us were concerned when they found a bruise and staff took action to investigate how it had occurred.

People were protected from the risk of abuse. Policies and procedures were in place and staff had the relevant training. Staff were able to describe how they would recognise abuse and how they would report it. This included reporting outside of the service to relevant authorities.

We observed people seeking support and they appeared comfortable in doing so. Staff responded to people in a kind and caring manner. Staff provided reassurance to people and helped to create a calm atmosphere within the service. Staff demonstrated a good knowledge of people's individual choices and preferences.

Staff had training and understood their responsibilities to safeguard people from abuse. Investigations and root cause analyses were completed by the management team. All incidents of suspected abuse were reviewed by senior managers through their reporting system and were reported to appropriate agencies such as the Local Authority, the CQC and the police.

People told us staff knew how to use equipment and keep people safe. One person said about staff, “They always know what to do.” Another person said, “They are really safety conscious" and gave examples of how staff used moving and handling equipment correctly.

The regional support manager and acting manager told us they had identified all care plans and risk assessments which required review. They assured us action would be taken and shortly after our site visit, updated care plans and risk assessments were provided. Staff were knowledgeable about the risks identified such as the risk of falls and how to use assistive technology to keep people safe. Some staff felt there were not always enough staff to follow these plans to mitigate risk and keep people safe.

Staff knew people well and communicated with them effectively. Staff were observed supporting people when they requested it. People had a choice of where they wanted to be and staff supported this.

All accidents and incidents were reported and reviewed by senior managers. Daily meetings were held with all heads of department to discuss and communicate safety concerns or changes in needs. People were supported to take informed risks and their freedom and choice was respected. Risk was assessed and care plans were in place to manage each identified risk. However, care plans lacked the detail staff required to manage risk and keep people safe. Care plans and risk assessments were electronic and alerted staff when care plans were not followed. However, staff did not always follow the information detailed within care plans. Following our feedback, the provider took immediate action to mitigate the risks we were concerned about.

Most people said they thought the service was well maintained. 2 people raised concerns about the standard of cleaning in their rooms. However, the areas of the service we looked at which included all communal areas and some people's bedrooms were visibly clean and fresh.

The management team told us they were aware of an issue with the front door not providing enough security. Action was taken shortly after our site visit to address this. Staff told us there were known faults with the fire panel which was being replaced. This had not caused any additional risk as there were supplementary sensors in the affected areas. Staff had training about environmental risks and were able to tell us about the actions they would take to reduce risks to people.

The equipment and facilities were well maintained. We saw mattresses used as crash mats where people were at risk of falling out of bed which was not appropriate. The area manager took immediate action and replaced these with the correct equipment during our visit.

The service had a maintenance team who carried out or arranged all appropriate routine maintenance and safety checks. A home audit was carried out by the estates manager and maintenance manager and included all premises and safety procedures. Action plans were followed as required. A fire risk assessment was carried out twice a year, any deficiencies were followed up with an action plan. There was a ‘stay put’ policy in the event of a fire as a sprinkler system was in place. The area manager was seeking further advice regarding evacuation information required. Following the estates audit, refurbishment and redecoration required was identified and had commenced.

Most people we spoke with told us there weren't always enough staff. One person said, “Occasionally there aren’t enough staff. It means things are a bit later done.” A relative told us their family member sometimes had to wait for up to half an hour for support. Everyone one said staff were competent and knew how to carry out their roles. Following our site visit the acting manager provided assurances regarding staffing numbers. A new rota was issued with increased staffing numbers. Staff deployment was reviewed and updated to ensure staff were aware of their responsibilities. Staff were reminded about responding to call bells in a timely way.

Managers used a dependency tool to calculate the numbers of staff required based on people’s needs. The acting manager and area manager told us staffing numbers had recently been increased following a recent recruitment drive. The acting manager had reviewed the staff rotas and told us the deployment of staff had improved. They told us all shifts had been covered with the correct amount of staff. However, some staff did not feel last minute absences were always covered or that there were always enough staff to keep people safe. Staff told us they had all the training they required to do their jobs. Following our site visit the acting manager provided assurances regarding staffing numbers. They said a new rota was issued with increased staffing numbers and staff were reminded about responding to call bells in a timely way.

Staff appeared to know people well and communicated with them effectively. We saw people receiving support when they asked for it. Mobile call bells were left with people so they could call staff if they required support or assistance. We observed one person was unsupported in the garden area who was at risk of falling.

Safe recruitment practices were followed so checks were carried out before new staff were offered employment. Staff received induction training and ongoing training. Compliance with required training was mostly above 90% however some training rates were lower such as moving and assisting people, hydration and nutrition and pressure ulcer prevention. Staff supervision was not up to date, the acting manager was taking action to address this and to ensure every staff member had access to supervision with a senior member of staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People told us they got their medicines at the right time and in the right way. One person said, “They always bring me a little pot with my tablets in and always ask if I need anything for pain.” Another person told us they had seen the doctor because they had been sleeping a lot and their medicine was being adjusted to get the right balance.

Staff supported people with their medicines in a safe and appropriate way. The staffing team had training and competency assessments to ensure they were safe and competent. Staff told us they felt confident managing people’s medicines. They were knowledgeable and knew what to do in the event of a medicine error.

People mostly received their medicines in a safe way. The provider had policies and procedures in place for staff to follow regarding managing people’s medicines. Medicines were stored securely, including medicines requiring refrigeration, and records were accurate and up to date. Medicine prescribed for distress had not been administered on 2 occasions because there was no stock available. The provider had identified this error and had improved processes for stock checks of medicines to reduce the risk of this happening again.