Imperial 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 felt they were safely cared for. However, we identified some improvements were needed. The staff had not always ensured good cleanliness. This presented a risk of the spread of infection. We discussed this with the deputy manager who began to address the concerns. Medicines were generally well managed, although some improvements were needed to the way 'as required' medicines were being administered and recorded. We also discussed this so the staff understood what they needed to do to improve. There were enough suitable staff. The staff had training and support. They understood how to meet people's needs. There were systems to help everyone learn when things went wrong. People using the service and staff were able to reflect on adverse events and learn from these. Risks to people's safety were well managed. People were able to make informed decisions about risks.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People knew how to raise concerns and make a complaint. They felt staff listened to them and acted on their concerns. They were involved in discussions following incidents and were able to reflect on what had happened and take part in learning.

Staff told us they had regular meetings with the registered manager. They also had meetings following adverse events to discuss these. They felt information was appropriately shared. They described good learning opportunities including supervision and reflective practice sessions.

There were procedures for dealing with complaints, accidents, and incidents. The staff were familiar with these, and these procedures had been followed. We saw records showed when things had gone wrong and the action that had been taken. This included checking people using the service and staff were safe, asking everyone to reflect on the situation and root cause analysis investigations. When needed, changes had been made to the service to improve practice.

People using the service were supported with transitions. Some people had moved to the home following hospital admissions or as part of rehabilitation programmes. The staff worked closely with the person and external professionals to make sure they received the right support. They also worked with community teams to help people move to more independent settings if this was right for them.

Staff explained they worked closely with other professionals. No one had moved to the service since the last inspection.

We were unable to gather feedback directly from external partners. No concerns had been raised with CQC and we reviewed the provider's records which showed they had good communication with external professionals.

The provider has systems to ensure staff had the knowledge and skills to support people with their transitions. This included an understanding of different mental health conditions and substance misuse.

People told us they felt safe at the service. They had opportunities to speak with staff about any worries they had.

The staff explained they had undertaken safeguarding training and were able to describe what they would do if their suspected someone was being abused or at risk of abuse.

Staff supported people in a safe way during our visit.

The provider had systems for dealing with allegations of abuse. They worked closely with external agencies to investigate these and help protect people. There were also systems to help ensure people at risk of self-harm or neglect were properly supported.

People were involved in managing risks to their safety. Care plans and risk assessments were developed with people. They were supported to understand the risks they were exposed to and to make decisions about keeping themselves safe.

Staff told us they regularly met with people on an individual basis to discuss risks and care plans. They explained how people were empowered to understand risks and make decisions around these.

We observed staff supporting people in a safe way. They guided them when they identified risks and helped people to manage these.

People had regular meetings with external professionals, such as the substance misuse teams to discuss their plans and how they were keeping themselves safe. The staff had developed risk assessments relating to people's physical and mental wellbeing, as well as any addictions or risks of self-harm. Assessments included ways to keep people safe and outlined who was responsible for this. There were some house rules which people were asked to agree to in order to keep everyone safe, for example not bringing alcohol into the house and smoking outside. Staff regularly met with people to monitor risks and discuss these.

People liked the home and felt this was safe and suitable to meet their needs.

Staff were able to explain how they would keep people safe in the event of a fire. They also told us how they supported people to use the kitchen safely.

We identified some areas of the environment needed repair or attention. This included some broken garden furniture, a worn carpet and broken kitchen equipment. We discussed these with the deputy manager who showed us they recorded when repairs were needed, and this was monitored by the registered manager.

The repairs we identified had not been addressed through the provider's own processes. However, the registered person had ensured there were regular checks on safety of most of the environment including some equipment, fire safety, water supplies and electricity. Staff undertook regular health and safety checks.

People told us they had good relationships with staff. They said staff were available when they needed them.

Staff felt there were enough of them. They worked well together and had good systems for communication. They felt well supported and explained they undertook a range of training which they were able to describe to us.

Staff were attentive. They were available when people needed them and offered them good levels of support.

Since our last inspection, the provider had recruited more staff and had a full staff team. Rotas showed staffing levels were maintained and staff did not work excessively long shifts. There had been improvements to the recruitment procedures. We saw the provider had undertaken a range of checks on staff suitability when selecting them. They also assessed their knowledge, skills and competency during recruitment and as part of their induction. Staff were supported to understand the provider's systems and get to know people. They undertook a range of training, both in person and online. The registered manager supported them with group learning, reflective practice, and supervision.

People did not always live in a clean environment, and this increased the risk of the spread of infection.

Staff were not able to describe how some areas of the environment were not well cleaned. They had recorded they had checked areas which were not sufficiently cleaned. We discussed this with the deputy manager who agreed to address this issue.

Areas of the kitchen required cleaning. These included food storage areas. Some food was not correctly stored or labelled. Some communal areas needed cleaning, including handrails and bannisters. The dustbin area was not well maintained and presented a risk because bins were overflowing.

There were systems for helping prevent and control infection, but these were not always operated effectively. Audits of cleanliness had failed to identify where improvements were needed. We were assured the provider had started to take action to address this during our visit to the service. The staff acknowledged there were concerns and started to make improvements.

People were happy with the support they had with their medicines. One person administered their own medicines. Another person had medicines administered in a format? they had requested. We observed staff offering people choices about medicines and giving them information, time and support. People's health was well managed, and this had led to a reduction in 1 person's medicines.

Staff told us they had received training to understand medicines management. They were able to describe good systems. However, some people were receiving regular doses of 'as required' medicines. These are medicines which are not supposed to be given every day but only when needed. For 1 person, staff explained a social care professional had agreed the regular dose could be administered. However, they had not discussed this with the prescribing doctor. The deputy manager agreed to speak with the prescriber following our inspection visit to confirm they agreed with this arrangement.

Some people were prescribed 'as required' medicines. The staff did not always record the outcome when they administered these to make sure they were effective and had the desired effect. One person was prescribed a medicine to be administered in an emergency situation. Staff told us they had received training about this. However, there was not enough information available for staff. The provider had not recorded staff training or tested their knowledge relating to this specific medicine administration. Medicines were safely stored. Staff received training to understand about safe medicines management. The provider tested staff competency and knowledge. Staff kept clear records of medicines administration. There were regular audits of medicines records. There were regular reviews of people's medicines. During our visit, we witnessed staff contacting health professionals when they had a question about one person's medicines.