Shore Lodge - Care Home Learning Disabilities

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• 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

At this assessment we found the standard of care had deteriorated and breaches of regulation were identified. People were not supported following ‘Right support, right care, right culture’ guidance. Potential risks to people’s health and welfare were not managed to keep people as safe as possible. People had been placed at risk as staff had not followed guidance from healthcare professionals. Staff had not used the correct equipment to move people. Staff had not maintained a safe environment by not locking away hazardous substances or ensuring the service was clean. People’s medicines had not always been managed safely. Accidents and incidents had not always been recorded or reported to safeguarding when required placing people at risk. Staffing levels were not appropriate to support the complex needs of people. The skills of staff to support people in the way they wanted varied considerably and people did not always receive support in the way they preferred.

This service scored 50 (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.

Some relatives told us their care was well-assessed and coordinated so they could access timely support from staff in the home and other services when needed. However, one relative told us the “GP has never come to visit [people] here” and “everything is done over the phone”. People were not always supported by staff when they moved between services. When people had gone into hospital, staff had not stayed to support them to help reduce their anxiety. Staff did not visit people in hospital regularly to make sure hospital staff understood the person’s needs and were able to communicate successfully. People were at risk of isolation and feeling abandoned.

Staff told us they were not able to stay with people when they were in hospital, or visit them regularly, due to staff and funding pressures.

Healthcare professionals expressed serious concerns about the service, even following their own interventions. The service had significant support from health and social care professionals over the 6 months before our assessment, to support improvement. Although some healthcare professionals had noticed some improvement, they all felt this was down to their intervention rather than at the instigation of staff. Healthcare professionals had found staff did not always follow their advice and appeared to not take on board their advice, leading to poor and at times unsafe care.

There were no processes in place to consider options to enable staff who knew people well to support them when they were a hospital in-patient, to enable a safe and more positive experience when people were receiving medical treatment. The provider had not considered people's experience and how they could reduce people's anxiety and stress and to support hospital teams to provide good care. There were no systems in place to provide guidance for staff to meet people’s changing needs based on healthcare advice. People were at risk of poor care as the provider did not take the opportunity to learn from healthcare professionals in order to drive improvement and increase the opportunity for positive outcomes.

Some relatives told us they felt their loved ones were safe at the service and they did not worry about them. One relative said “I think [the person] is cared for quite well in the home” and another said “[the person] feels safe and likes it there”. However, one relative was concerned whether their loved one was “getting what [the person] is supposed to” and another relative who had raised concerns with the service previously added they had “seen such an improvement”.

Staff understood the main principles of safeguarding and the action they should take if they had concerns about people’s care or safety. Although the management team understood their responsibilities to safeguard people, this was not supported by systems to ensure the process of investigation, recording, monitoring and learning lessons was consistent.

Staff had not acted to safeguard people's environment, they had not locked away hazardous substances. We observed cleaning equipment unlocked where people could access them. There was thickening powder, which is a choking risk if not added to water, in easy reach of people. We observed people isolated in rooms, staff did not go into the room for long periods, other people were observed distressed and causing themselves harm. They had been assessed as requiring 1:1 support but there were no staff with them and we had to intervene and alert staff.

The records we reviewed showed a lack of understanding of what would constitute an appropriate referral to local authority safeguarding to protect people from the risk of abuse. Safeguarding referrals made by external bodies/people contained documented actions the provider needed to take which had not been completed. Records were not organised and there was no process to check action had been taken. A record called a notification tracker contained an incident about an over administration of a person’s medicine. This was not recorded on the safeguarding tracker, although it was a safety incident. No information was available in the safeguarding file and there was no evidence of the incident being investigated or referred to local authority safeguarding. The systems in place had not been followed consistently to make sure all safeguarding alerts were recorded, investigated and lessons were learnt. We could not be assured there was sufficient oversight or investigation to safeguard people. Some people had conditions on their Deprivation of Liberty Safeguards (DOLS). We were not assured these were being adhered to. One person had a condition that they were to be seen by a dentist and then annual checks thereafter. We could not find any record that the person had visited a dentist. Another person had a condition of their DoLS that their family should be included and involved in all best interest decisions. Staff told us the person’s family are involved, however, there was no record of any involvement.

There was some evidence people were supported to understand and manage risks. One person was supported to regularly go for visits to their family home. However, one relative told us “there are no activities here” and added “they are isolated in their wheelchairs”.

Staff told us about people’s individual risks, such as choking, seizures and increased agitation and distress. However, we found people were not always supported safely and risk mitigation plans was not always followed. The manager told us they did not have the information they needed to be assured staff had sufficient training to keep people safe. The manager told us they could not be assured that staff on shift were sufficiently trained to keep people safe from choking.

During our visit we saw that some people were left unsupervised for long periods of time. Although staff were available, people did not have the right support when they became distressed. We observed some people becoming agitated. Staff intervened but there were no proactive strategies to mitigate the risk of this happening again, placing people at increased risk of harm and their needs not being met. We observed staff supporting people to eat meals which did not follow the guidance from the Speech and Language Therapist (SaLT). Although some of the meals were mashed, the carrots were cut into sliced rounds, this placed people at risk of choking. We were not assured that all staff had the skills to cook and present meals that were safe for each individual and as specified by healthcare professionals. Following our observations we asked the provider to take immediate action to make sure staff had the appropriate training to prepare, cook and support people with modified diets to keep people safe. This was completed in the timescale set by the provider.

There were no effective systems in place to make sure potential risks to people's health and welfare were mitigated. There was little oversight of staff to ensure they were following guidance from professionals to keep them safe. One person could become agitated and was at risk of regular self-harm. The person did not have a care plan or risk assessment in relation to incidents caused by anxiety and distress. Staff did not have the guidance to provide positive support to the person and ensuring consistency in practice. Staff had completed 28 ABC charts for the person. These had not been analysed to learn lessons or to inform a specific care plan to improve quality of life and outcomes. One person had epileptic seizures and had a seizure alarm in place when they were in bed. Staff were required to record daily checks of the seizure alarm in place, to make sure it was working correctly. The record was not completed daily. For example, checks had not taken place on 10 out of 16 days from 21 February to 5 March 2024. Although epilepsy care plans and risk assessments were in place to provide guidance, these did not include ensuring the safety of people in relation to bathing, or the procedure to follow if they had a seizure while sitting in their wheelchair. Guidance and explanation around the risks of sudden unexpected death in epilepsy (SUDEP) were not included.

Relatives told us there were areas where the interior decoration needed replacement, renovation or improvements, “it needs a bit of TLC” and another said “I was more concerned with the decoration when they first arrived."

The deputy manager was unsure if people were using vital equipment they had been assessed for by a healthcare professional, to ensure their safety. They told us a shower chair belonged to a person and they had been assessed appropriately. We checked with the healthcare professional who confirmed the equipment for the person had not been delivered to the service. Staff had continued to use equipment which was not appropriate for the person placing them at risk. We asked the deputy manager about concerns we had about the environment. This included a lock on a cupboard used to store a hazardous substance, they confirmed the lock had been broken for at least 2 weeks, placing people at risk.

During our on site assessment we were concerned about aspects of the building and how this affected people's quality of care. People’s living environment was poor and institutional. No part of the building had a homely appearance and did not reflect the people living there. People’s bedrooms, apart from one, were bare and gave minimal hint of the person whose room it was. Furniture was old and stained and added to the appearance of not being well cared for. One person had a chest of drawers with ring style handles on the drawers, all handles were missing apart from one. People had been using equipment such as wheelchairs and shower chairs that had not been assessed as being safe for the individuals using them. There were 2 bathrooms with baths out of use. These were used as storage areas, cluttered with equipment and empty boxes, leaving 2 shower rooms in use. People did not have use of all the facilities and did not have access to a bath if this was their choice. Some people’s bedrooms were very hot. A daily record sheet for staff to check temperature in every room twice daily was in place and the guidance recorded temperatures should be between 18 and 24 degrees. One person’s room was stiflingly warm, we checked their daily record. Temperatures recorded were consistently above 24 degrees, and as high as 29 degrees. The person had been spending time in their room for at least the previous 2 weeks, so had suffered these high temperatures. The manager told us there were ongoing issues with temperature controls. Food was not always stored safely. Some food was stored in fridges and freezers without use by dates or opened by dates. A mixture of raw meat and ready meals, used for people’s meals were stored together.

There were no effective systems in place to make sure the environment was safe and personalised. Staff had not taken action to ensure the environment was safe. There was no oversight by the management to make sure equipment was fixed or replaced quickly to keep people comfortable and safe. There was no oversight to make sure people had access to the appropriate equipment to make sure they had choices about how they were supported.

Some relatives told us there were enough staff to meet people’s needs. One relative said “All the staff are very good” another added they were “quite pleased with the home really”. However, another relative told us “they have good staff, but I have noticed the staff are leaving, I don’t understand why”. Another relative told us “there are areas for improvement” but added “at the moment we are quite content”.

Staff told us they worked as part of a good team, they were well supported by management and received a good level of training and induction. One staff member told us, “My colleagues are always so helpful, the management, I can tell them my issues and I feel comfortable working with them all”. The manager told us they thought there was sufficient staff as they had recently recruited new staff. They said they had a dependency tool to check the levels of staff needed and this showed they had sufficient staff. Staff did not know if they would be able to take anyone out on the day of our site visit as it was dependant on when they returned from a person’s appointment. Staff did return in time for 2 people to go out in the minibus.

People's needs were not always being met because some people were left unsupervised for long periods of time, including those requiring 1:1 care. For example, one person who could experience behavioural or mood changes had been assessed as low risk even though they and others could be placed at harm. There were 8 people who needed either support or supervision at mealtimes. People were having to wait for their meals. At lunchtime staff were supporting 2 people while another 2 sat at the table waiting until they had finished before they were able to have their meal. Another mealtime observed was chaotic with 3 separate staff supporting a person to eat their meal at different times. During a site visit, there were not enough staff for people to receive their 1:1 support. There were 6 members of staff on duty, 2 staff were out most of the morning supporting a person at hospital which left 4 staff in the service. There had been no consideration to how people would continue to be supported while staff were away from the service. The skills of staff varied considerably. At times, people were shouting out, we observed some staff successfully engaging with people which clearly enabled their contentment and happiness, and at other times, staff clearly struggling with the ability to do this. We observed staff not being able to effectively communicate with people as they had not been received training in the person's communication method.

Staffing levels were not sufficient to support people’s complex needs. The manager told us they had a dependency tool which showed there were sufficient staff. However, our observations showed, people were not receiving care in a timely way that met their needs. People were not able to go out regularly. This was dependant on staffing levels and availability of the minibus. Only 2 people can go on the minibus with wheelchairs, so although a car/minibus ride was on activity planners for Thursday afternoons for everyone, only 2 people could go. Two people were funded for 1:1 hours, there were no records to evidence the hours used and what they were used for. We did not see any evidence of either of these 2 people being given specific 1:1 support by staff during our site visits. Staff had not always received the training they needed to support people with their assessed needs. Some staff had not received dysphagia training, to support people at risk of choking, sufficient to meet the needs of people living at the service. Care staff prepared and cooked people’s meals. Staff did not have sufficient skills and knowledge to ensure the safety of people requiring modified diets to prevent the risk of choking. Training records reviewed showed not all staff had received other essential training, including moving and handling training to provide safe support to people. Staff were taking people’s blood pressure but had not received training to ensure they had the skill and competence to understand accurate readings and when they needed to escalate and report to a GP.

People’s relatives did not express concerns about the cleanliness of the environment, one relative told us that their loved one “is clean and [their] clothes are always tidy”.

Staff told us they had plenty of personal protective equipment to support infection control procedures. Staff told us they had access to the equipment and products they needed. We were told by a member of staff a stained chair seen in a person's room, had been purchased second-hand from a charity shop.

Some people had upholstered chairs in their bedrooms which were stained and appeared dirty. A healthcare professional had not been involved in assessing the suitability of the chair bought from the charity shop. Shower chairs used by people were dirty and badly stained and we were not assured regular cleaning of these pieces of equipment had been completed. The premises were clean.

Not all staff had completed their Infection, Prevention and Control (IPC) training according to the audits we reviewed. There were outstanding actions from these audits that had not been completed such as to ensure staff complete the services audits and complete IPC and handwashing training.

People’s relatives did not raise any concerns around support people received with their medicines. They were complimentary around overall standard of care and treatment provided to their loved ones in the home. One relative told us “In the home I think [the person] is well cared for, they are always giving [their] medication when I go up there”.

Staff told us they were trained in medicines administration. Staff told us the electronic medicines administration system worked well and made the process safer.

People’s medicines were not always managed safely. We counted a random selection of medicines in stock. Some of the medicines left in stock did not tally with the amount recorded on the medicines record. There was a risk people had not received their medicines or had received too many. Some people were given their medicines with a spoonful of yoghurt, staff did not think this process was giving people medicine covertly. Covert administration is when the medicine is being disguised in food or drink without the knowledge of the person taking it. Staff had not followed the principles of the Mental Capacity Act 2005 to assess if people had capacity to make the decision. There was no record about how the decision to give medicines this way had been made. Staff told us, the GP had agreed to this, but there was no evidence any health professionals including a pharmacist, had been consulted. Some people were prescribed rescue medication to be taken in the event of a seizure/seizures lasting longer than a specified period of time, such as 5 minutes. There was no guidance included in care plans or risk assessments to ensure all staff were aware people needed to take the medicine with them at all times whenever they went out.