Updated 13 December 2023
Filsham Lodge provides nursing care and support for up to 56 older people, some of whom are living with dementia. At the time of this assessment there were 55 people living at the service. We carried out this assessment between 6 and 16 February 2024. This assessment was prompted in part due to concerns received about safeguarding and culture at the service. We looked at 9 quality statements; Safeguarding; Involving people to manage risks; Safe and effective staffing; Infection prevention and control; Independence, choice, and control; Person-centred care; Equity in experiences and outcomes; Shared direction and culture; and Governance, management, and sustainability. The provider's processes and procedures had not always been effective which meant some people were at risk of harm. We were not assured that the infection prevention and control processes were robust enough to keep people safe. The managerial oversight of this was lacking and the issues we identified had not been addressed through quality assurance processes. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This evidenced that the safe domain was not consistently good. Staff were trained and deployed effectively to meet people’s needs. They clearly knew people well and promoted their independence and individuality. There had been improvements to the management of risk and staff were confident in identifying and reporting any safeguarding concerns. They spoke positively of the culture becoming more open and transparent, something which the new manager was working to embed in the service. We observed staff interacting with people in a warm and caring manner.