April 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

Systems and processes were in place to keep people safe however, risks associated with people's care needs had not always been assessed. Information relating to people's individual risks was not always recorded, up-to-date or did not provide enough assurance that people were safe. There were sufficient staff to meet people's needs and recruitment processes and procedures were robust.

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.

There were systems in place to record incidents and accidents which were reported by staff. Where people needed medical attention, for example following a fall, this had been arranged as appropriate. Incidents were reviewed monthly to identify if there were any trends which needed to be addressed to reduce the risk of incidents re-occurring. No trends were identified. Lessons learned from incidents were shared and discussed at team meetings.

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.

Safeguarding systems were in place to safeguard people from abuse. The provider had safeguarding policies and procedures in place and had a procedure for ‘whistleblowing’. The registered manager and deputy manager were aware of the reporting procedures and raised appropriate safeguards when required. Records we looked at showed when safeguarding incidents had occurred, the registered manager had reported these to the relevant safeguarding authority for investigation and notified us as is required by law. This meant people were protected from the risk of harm or abuse. All staff had received training in abuse awareness.

Staff understood how to recognise the signs of abuse and could describe the actions they would take to safeguard people including informing other agencies if they were concerned about action being taken. A staff member told us, “I would report to my manager, and I would escalate to Local authority if I needed to”. Safeguarding incidents were discussed with staff in meetings for lessons learned and to prevent reoccurrences.

During the inspection, we observed staff responded to support people promptly. Staff supported people to move safely using assessed equipment where required.

People and their relatives told us they felt safe. One person told us, “My [relative] visits me every week. I feel very safe living here. The staff know exactly how to keep me safe here.” A relative said, “My [relative] is a lot safer here than they were living at home with me. I have no concerns. [Relative] is very well looked after. I was unable to look after my [relative] at home due to various different reasons and I am so happy to see how [relative] is settled here. I visit all the time and [relative] often comes home to see me too.”

People's care was not always delivered safely. Information relating to people's individual risks was not always recorded, up-to-date or did not provide enough assurance that people were safe. For example, whilst changes to people's care needs were identified by staff who knew people well, the information was not documented in the care plans placing people at potential risk of harm if they were being supported by an unfamiliar member of staff. This was breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Throughout the assessment, we observed people being supported to move using mobility equipment and this was done safely. A person was using a Zimmer frame to enter the dining room and staff supported them and were responsive to any potential risks.

Although there was limited impact for people using the service, not all risks to people's safety and wellbeing were assessed, recorded or provided enough detail as to how identified risks should be managed and mitigated. This placed people at potential risk of not having risks to their safety met in an appropriate and safe way. For example, a person who had been diagnosed with schizophrenia, there was no information available in their care plan for staff to support them. Another person who used a Zimmer frame did not have a risk assessment or care plan in place for his mobility needs. People's care plans and risk assessments were not always personalised, and support was not always in line with people's care plan guidance. Improvements were required to ensure completed care plans and risk assessments were person centred and included how risks to people were to be mitigated and reduced. Some information was generic and not personalised to the individual people using the service. Systems had not been established to ensure care and treatment was provided in a safe way for service users. This placed people at risk of harm. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During the inspection, the registered manager told us they had introduced new care plans and risk assessments, however, these had not been completed. On review of people's care records, there was little evidence people had been reassessed and their care records updated to reflect their current needs. Staff we spoke to knew people well and were able to tell us about people's care needs and how to safely support them. Staff had received appropriate training to meet the needs of the people they cared for.

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

There was enough staff to provide support to people. Staff had the skills and knowledge they needed to provide safe support to people. Staff had completed the training they needed to undertake the role. Staff received regular supervision and their competency to undertake tasks such as administering medicines was checked. There was an induction period for new staff. Staff would shadow an experienced member of staff until they were competent to work on their own. The induction covered their familiarisation with the service, the people who used it and the policies and procedures of the provider. Staff were recruited safely. For example, Disclosure and Barring service (DBS) checks were undertaken. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff we spoke with told us there were enough staff. A staff member told us, “I think there is enough staff. It is a nice place to work, we all get on really well with each other. We work well together.” The registered manager told us, “I have got a very good staff team, and they all work hard. We don’t use agency. We have enough staff to cover shifts. Everyone works well together and some of our staff have been here for many years.”

On the day of the assessment, we observed there to be sufficient staff on duty. Throughout the visit, we observed staff were attentive to people’s needs and responded quickly to requests for support. The service ensured communal areas were not left unattended and people had staff on hand when needed.

People and relatives told us there was enough staff. A person told us, “There is always someone here to take me out if I need to go out. There is enough staff here. I don’t have to wait around if I need something.” A relative told us, “There are plenty here. It is usually the same team, so we know who everyone is. I’m not worried about the staffing levels.”

Staff confirmed they received infection prevention and control (IPC) training and felt confident to support people with their personal care. We were informed by all staff we spoke with that there was sufficient personal protective equipment (PPE). The registered manager carried out regular audits to monitor the cleanliness of the service.

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