South Haven Lodge Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s needs were not always effectively assessed, reviewed and managed. Feedback from people and their families about their involvement in reviews and assessments and how the service assessed and met people’s needs was mixed. We observed care being provided to people that did not met their needs.

All but one of the staff members we spoke with told us they were not provided with clear and detailed information about people’s needs and how to manage these effectively. This was also evident through our observations, particularly in relation to when people expressed anxiety and periods of distress. From discussions with staff, we could not be assured they fully understood people’s needs or how to best support them.

People’s needs were assessed prior to moving to the home. We reviewed 3 assessment records and found these contained minimal information about people’s needs and abilities including the levels of support they required. There was no evidence that consideration had been given to whether sufficient staff would be available, who had the appropriate skills to manage the persons specific needs in a person-centred way. Systems and processes were not being used effectively to ensure people’s needs were reviewed regularly or when things changed. Although we identfied reviews of people’s care plans were regularly completed, these were ineffective and failed to identify they lacked detail, and information was incorrect and contradictory. The lack of clear guidance put people at risk of receiving inappropriate or inconsistent care.

People had mixed views of the support given. Some people and relatives were generally happy with the support provided but we observed and were told by some people, relatives and professionals the standard of care provided was often poor. People were not consistently getting good levels of personal care, including oral and nail care and were not being repositioned or provided with appropriate food and fluid at the correct consistency in line with their assessed needs. People and relatives gave mixed feedback about the food, and we could not be assured people’s preferences or specific dietary requirements were adhered to. For example, one person was provided with potato, yet records suggested they had an allergy to potato and another person was served chilli when it was documented within the kitchen, they were not to eat chilli. A relative told us, “When [person] arrived the staff just blended all their food together, there was no need. I still don’t know why they were doing it. I had to tell them, so they don’t do it now.” This demonstrated people’s specific needs and wishes were not always considered and acted on. Throughout the assessment people’s requests for drinks were ignored and drinks were not always made available to people. This placed people at risk of dehydration. During our first 3 assessment visits to the home, we found the mealtime experience to be disorganised, uninviting and chaotic and did not promote a comfortable dining experience for people. This was discussed with the manager on our third assessment visit, who implemented new processes around mealtimes to help improve people’s experiences.

Staff were not able to demonstrate people received care, treatment and support that was evidence-based and in line with good practice standards. Most staff spoken to felt they hadn’t had enough training in relation to certain aspects of care provision. A staff member told us, “We [staff] haven’t had training to pressure area care, repositioning, catheter care, oral health, constipation, but we are expected to know what we are doing and to do a good job. We definitely need more training.”

Assessment tools were not used effectively to minimise risk to people. For example, where swallowing assessments and Waterlow checklists were completed the outcome of these were not always followed or shared appropriately to ensure safe, effective and consistent care was provided. There were not a robust auditing process in place to ensure people had care and treatment which was in line with best practice and met their needs.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

People who were able to make informed decisions and choices about their care did not raised concerns about their opportunity to consent to care and treatment. Their comments included, “I like to do my own thing, I prefer to stay in bed, and they [staff] don’t have a problem with that” and “I can get up and go to bed when I want, they [staff] let me choose.” However, due to the shortfalls found at this assessment we could not be assured that where people had an impairment to the mind or brain full consideration had been given to their abilities to consent to care and treatment or they were given the opportunity to make informed choices especially in relation to restrictive measure in place including the use of bedrails, mobility sensors and welfare checks. We observed staff did not always provide people with choices around their care, including what they ate. People’s consent was not always obtained by staff before providing them with care or treatment.

The management team and staff were unable to demonstrate they had a good understanding of the Mental Capacity Act (MCA) or Deprivation of Liberties Safeguards (DoLS). At the time of our assessment although all trained nurses had received training in MCA and DOLS only 24% of care staff had received this training. Many people living at the home had an impairment of the brain which could impact on their ability to make informed decisions, understand risks or provide informed consent to care. Care staff would be responsible with providing these people with support in accordance with the MCA and in their best interests. Therefore, we could not be assured people would be provided with care which they had consented to, or which was in their best interests.

There were not robust processes in place to ensure people were provided with care which followed the principles outline in the Mental Capacity Act. This meant we could not be assured the provider was acting within the law. There was no evidence made available which demonstrated people were provided with information to support them to make informed decisions to consent to their care. From the records we reviewed we could not be assured people had been given the opportunity to consent to specific decisions and there was a lack of evidence available that capacity assessments had been completed, where required. Some people living at the home had a diagnosed impairment to the mind or brain which meant they would not always be able to make decisions about specific care and treatment and decisions in relation to some aspects of care would need to be made in their “best interest.” Capacity assessments had not always been completed for people in relation many aspects of care including but not limited accommodation, locked doors, consent to care and treatment, the use of bedrails and the taking of photographs. The concerns we found in relation to consent and capacity had not been identified though the registered manager or providers processes.