Filsham 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

People were not always safe and protected from the risk of infection. Some staff lacked knowledge on barrier nursing and how to do this effectively to minimise risks to people. The oversight from management regarding infection control 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. We were provided with some immediate assurances regarding a plan of repair to aid better infection control. Staff were trained and confident in recognising the signs of abuse. They knew what steps to take if they saw something of concern. Policies and procedures were in place to support staff with managing safeguarding. There were enough staff with the correct skills to support people effectively. Staff were recruited in a robust and safe way.

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.

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.

The provider had a relevant and robust safeguarding policy in place. Staff demonstrated a good awareness of this and of their responsibilities to safeguard people from abuse and any discrimination. Staff were aware of the signs of abuse and how to report safeguarding concerns. There was a good Deprivation of Liberty Safeguards (DoLS) policy in place and staff were confident in applying this in practice, including working with people in their best interests when appropriate.

People felt safe living at Filsham Lodge and expressed that staff cared for them well. One person told us, “I feel safe here, I can walk around, and staff look after me. All staff are kind.” Another stated, “I am only here for a short stay, but I am safe.” Relatives also felt their loved ones were safe. One said, “I ring up daily and they put me through to the nurse and then to [person]. Staff could not be doing more, all doing their best to keep [person] safe, no sign of any form of abuse.” People and relatives received a welcome pack when joining Filsham Lodge which provides details on safeguarding and the complaints procedure.

Staff had received training with regards to safeguarding and felt confident in being about to identify and report any concerns. One staff member told us, “I received safeguarding training a few weeks ago. If safeguarding is raised, I receive positive feedback which is good to know any outcomes and areas of concern.” Another staff member said, “I could talk to a senior nurse or manager if I needed to, they would listen and help. I have not witnessed any abuse; I would report it and any form of discrimination.”

People were treated with kindness and care by staff. Staff spoke respectfully to people and showed a good awareness of people's individual needs and preferences. People were relaxed and cheerful in the presence of staff. People who became distressed were supported with diversional tactics. People who walked with purpose and approached staff continuously were treated kindly and listened to whilst being supported by staff to drink and rest.

Processes to identify and manage risks were in place but not always robust. For example, fluid records were not clear or specific to the person the referred to. It was not documented what actions had been taken when people had consistently not consumed the recommended amount of fluid. We saw some people were sat on their hoist slings throughout the day, this was raised with the manager who agreed to review whether the hoist slings were appropriate and safe for this to continue. Pressure wounds were closely monitored and analysed so risks could be minimised. Falls were documented and care plans and risk assessments detailed how to minimise these. People who had repeated falls were referred to GP and falls team.

People and their relatives spoke positively about how risks were managed in the home. One relative told us, “Any risks associated with his medication, blood thinners and cholesterol are managed. He is not as mobile now due to previous falls, he also has a catheter bag, but staff deal with it very well.” Another stated, “GP and staff listened to me and responded to address the problem and adjusted her care as necessary”.

Staff were able to demonstrate a good knowledge of risks and how these are managed and reduced. One staff member told us, “I have received regular health and safety training plus fire training. We keep a personal emergency evacuation plan (PEEPs) folder which lists the exits and way out.” Another added, “If I witness a resident having an accident or fall, I write down what I saw, we receive training to help minimise risk with falls, diabetes and epilepsy.”

Observations of practice were largely positive, but we did see some areas which needed improvement as practice was not always in line with NICE (National Institute for Health and Care Excellence) guidance. For example, we saw a staff member assisting someone with their breakfast in bed. The staff member did not lower the bedrails to sit alongside the person but instead stood over them spooning them food. This was highlighted to the manager to be addressed. Other observed practice was more positive, especially regarding moving and handling. One person was being hoisted to a chair to reposition, 2 staff did this safely; asking for consent and explaining what they were going to do before doing it. They took their time and were not rushed.

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

Staff deployment had ensured people’s needs were met in a timely manner and in a way that met their preferences. One staff member told us, “During my induction I shadowed a member of staff, this applies to agency as well. I have monthly supervision which is helpful, I get good feedback and support.” Another said, “We have good training; it is all on offer and available. This helps improve my work.” A further staff member stated, “We are well staffed, I think better than it was. We have to take breaks at certain times now, we get plenty of training and it’s all up to date. I get supervision, it was a bit bumpy getting a new manager but it’s getting there.”

Staffing levels were stable, and the skill mix was appropriate to support people safely. The rotas were reviewed regularly by the manager and confirmed suitable staffing. For example, there was always 2 registered nurses on duty supported by trainee assistant practitioners, senior care staff and care staff. Staff were recruited in a safe and robust way, with appropriate checks carried out, including with the Disclosure and Barring Service (DBS).

People were comfortable with staff and spoke positively about them. One person told us, “I have a staff with me all the time.” Relatives also felt there were sufficient, well-trained staff to keep their loved ones safe. Comments included, “I think there are enough staff, they are all very patient with some challenging residents to care for”, "Always staff around, I think the staffing levels are good. When I visit, I am met at the door and staff are vigilant” and "Staff are very good I think, they keep me informed and when I visit they look after me as well."

The staffing levels enabled staff to give people the care they wanted and needed. Good practice was observed when staff were assisting people in the lounge. We observed 2 good transfers where people were being supported from wheelchairs to chairs in the lounge. 2 staff were in attendance, with an additional carer to engage with people and encourage them to drink.

Staff had received infection prevention and control training however some were unsure regarding the use of barrier nursing. At the time of the assessment, the service had an outbreak. Some staff were unclear as to which parts of the building had been affected, and why additional measures had only been put in certain areas. This had improved by the second day of the inspection.

The provider did not have robust quality assurance processes in place to promote sufficient infection control. The last audit made available to inspectors was completed in May 2023. Quality assurance processes had not identified or addressed the issues found during the site visit. The manager was receptive to this feedback and provided a plan of repairs to be completed to promote good infection control.

People and their relatives spoke positively about the cleanliness of the home. One person told us that they felt the cleaners did a good job. Relatives spoke of being made aware when there were any infection control issues, one said, “They rang to tell me about the diarrhoea and vomiting so I could choose to stay away for a couple of days.”

Throughout our observations, we were not assured that effective infection prevention and control was being completed in the service. The overall cleanliness of the home was difficult for the housekeepers to manage as parts of the building needed repair and renewal. This included carpets, sluices, and upstairs bathrooms. Communal areas however were clean and comfortable. We were not assured that the provider was promoting safety through the layout and hygiene practices of the premises. Bedrail bumpers were dirty, and some were missing the plastic coating which meant they couldn’t be cleaned properly. Some commodes and furniture were worn which posed an infection control risk. We spoke with the manager and area manager who confirmed a rolling plan of renewal and repair for improvements. Staff were observed to not always be wearing appropriate personal protective equipment (PPE), for example, wearing facemasks but not aprons and gloves when barrier nursing. This was raised with the manager to address. We were assured that the provider was preventing visitors from catching and spreading infections. There were systems in place for visitors and agency staff to follow.

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