Conifer Lodge Residential 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

People told us they felt safe living at the service. People reported staff responded well to calls for assistance and felt staff understood their individual needs. People raised concerns that staff were not always in communal areas and due to staffing there were very limited activities available. Staff told us whilst they believed staffing levels were safe, though felt staffing could be improved upon and explained the impact of when people needed additional support. We saw people in a lounge at various times with no staff present for up to 10 minutes.

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.

A family member was positive about communication and how the registered manager kept them informed about their relative’s care and any actions taken. An example of this was the use of a sensor mat to alert staff, which reduced the risk of falls.

Staff told us the management team were open and honest and this was expected of staff. Staff were confident they could raise any issues concerns directly with the registered manager and provider and they would be listened to. Staff gave examples of how learning from incidents was shared with them and of the action taken to reduce further risks. A staff member said, “The management team and staff are all open and honest, we say how it is and don’t try and cover anything up. The manager and the provider are always around and encourage us to raise and share any concerns. They listen and are responsive.”

The management team were found to be open and honest throughout the assessment and showed a commitment in wanting to further improve the service. There were systems in place to learn from mistakes and this was shared with staff. For example, accidents and incidents were reviewed and audited, internal investigations took place when significant incidents occurred, and actions were taken to reduce risks. These actions were discussed with staff via handover meetings, staff meetings, a WhatsApp messaging service and staff supervisions.

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.

People told us they felt safe living at the service. People reported staff responded well to calls for assistance and felt staff understood their individual needs. People raised concerns that staff were not always in communal areas and due to staffing there were very limited activities available. A person said, “The staff are pretty good. I have a bell, the last few times I’ve used it they come quite quickly.” Another person said, “It’s all safe, I’ve never had a problem. There are codes on all the doors.” A relative said, “I think [relative] is safe and cared for. On the whole staff respond quickly, sometimes they say can you wait a few minutes.”

Staff had received safeguarding annual refresher training and had access to the provider’s safeguarding and whistleblowing policy and procedures. Staff demonstrated a good understanding of their roles and responsibilities to protect people from abuse and avoidable harm. The registered manager reported safeguarding concerns and incidents to external agencies and completed internal investigations and actions to mitigate further risks. A staff member said, “We’re here to protect residents as best we can, any concerns noticed, we record, report, we have a duty of care.” Another staff member said, “Confident people are safe and protected. Staff act on any concerns and changes to a person’s health is quickly followed up.” Ensuring consent to care and treatment in line with law and guidance The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. When people receive care and treatment in their own homes an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. Staff understood the principles of MCA and DoLS. A staff member said, “Deprivation of liberty has to be authorised, it’s to protect people from harm who lack capacity to consent to any restrictions such as the door locked.”

Staff were observed to complete moving and handling following best practice guidance. Staff provided people with explanation and assurance and were unrushed.

Accidents / incidents procedures were in place. A sample of accident and incident records were reviewed, and these were well detailed by staff. The registered manager reviewed and signed incidents and accidents records and completed a monthly audit. The January to April 2024 audits were reviewed. Actions were taken to mitigate risks recorded and referrals had been made to all relevant agencies and relatives informed. Whilst the registered manager reviewed this information, there was no clear analysis of themes and patterns. It was discussed with the registered manager and provider of having a second sheet for this information. This was implemented immediately. The registered manager demonstrated a good awareness of risks and actions taken to prevent these. Staff had access to the safeguarding and whistleblowing policy. There was no safeguarding information on display or available information for people or visitors and safeguarding was not discussed in resident meetings. This was raised with the registered manager who agreed to follow up. Safeguarding statutory notifications have been submitted as expected. Mental capacity assessments were completed in line with best practice. Accident and incident reporting, falls management, serious incident policy and procedure policies and procedures were reviewed and all reflected best practice guidance.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

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

Whilst people said staff were kind, caring and competent they were frequently too busy to spend time with them. People raised concerns that staff were not always in communal areas and due to staffing levels, there were very limited activities available. Whilst some people told us staff responded in a timely manner to calls for assistance, others said there was a delay. A person said, “There’s not enough staff, if there was, they could take me out. When I use my call bell I have to wait a long time. There’s never enough time to chat.” Another person said, “Sometimes there’s no one [staff] in the lounge with us, it happens a lot, all the time.” People raised concerns about what time they got up. For example, some people told us they could not have a lie in, but others said they could not and a person raised concerns that they could not go to bed until after 7pm. We discussed these issues with the registered manager and provider. They provided evidence they had followed up these concerns. Extra staff were put in place for the late shift and activities organised. People were asked about their preferred times to go to bed and get up.

The registered manager confirmed whilst they had a staff dependency tool, though this had not been used since 2023. Staff confirmed in addition to their caring roles, they were required to provide activities and complete the laundry. Staff told us whilst they believed staffing levels were safe, though felt staffing could be improved upon and explained the impact of when people needed additional support. A staff member said, “Sometimes would be nice to have extra staff when [name of person] who walks a lot and can get tired / frustrated, behaviours occur. [It is] not unsafe though.” Another staff member said, “If the kitchen staff are sick care staff have to cover and this makes us short - not good. 2 people can need a lot of staff attention.” Staff confirmed they had completed recruitment checks before they commenced. Staff also said they had opportunities to discuss their work, training and development needs. They confirmed competency assessments were completed for medicine and moving and handling. Following the on site assessment, the provider and registered manager confirmed action had been taken to address the issues raised. The dependency tool had been completed and showed current staffing was slightly above the recommended number. However, the provider agreed to rota an additional staff member on the late shift to meet peoples’ needs.

We saw people in a lounge at various times with no staff present for up to 10 minutes. In the dining room after lunch for 2 people in wheelchairs, 2 staff wheeled them into the lounge at the same time, leaving the other 2 people alone in the dining room. This showed a lack of organisation, which was also seen by the registered manager, who agreed this was poor practice. Activities had been provided in 1 lounge with 3 people playing dominoes. The TV was on in the other lounge but no activities had been offered to people and no staff were sitting spending time with people.

The registered manager stated staff received 6 supervisions a year and an annual appraisal. Staff files showed staff were receiving supervision but not at this frequency. From the 3 staff files reviewed, this showed staff were receiving supervision but not at this frequency. However, there was no evidence of negative impact for peoples’ care. Staff confirmed the registered manager and provider were always available and very supportive. Staff had a good awareness of people’s individual needs. 3 staff files were reviewed to check staff recruitment. There was no photo on staff files and interview information was missing for 2 staff. 2 staff commenced working before all checks had been completed. This was discussed with the with the registered manager, who took immediate actions to make improvements. They have reviewed and re-implemented a recruitment check list, added to the schedule of audits and an immediate review of staff files.

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.

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