Delamere Lodge

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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

During our assessment of this key question, we found concerns around the safety and cleanliness of the service and in relation to medicines management. This resulted in a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities). You can find more details of our concerns in the evidence category findings below. Staffing arrangements needed to improve to ensure people had consistently person-centred care and the home was adequately cleaned. Some staffing and recruitment records were incomplete. Some staff had not had regular formal supervision. There were processes to respond to risk and learn from incidents, however we received feedback, and observed, that these were not always effective. Staff had safeguarding training and knew how to recognise abuse but had not always followed the requirements of the Mental Capacity Act 2005 (MCA). Concerns and areas for improvement were fed back to the management team. They told us that they were updating records and had already made improvements to the safety and cleanliness of the home. People and relatives told us that people felt safe at the service, they were happy and that they knew who to speak to if they had concerns.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives felt that care packages met people’s needs. They told us they were involved in planning care and how care was delivered. Relatives told us when there had been accidents and incidents, they were informed and knew the actions being taken to learn from these and reduce future risks.

Staff told us they knew how to report incidents. Concerns about people were escalated from care staff to nurses. Nurses told us they felt staff knew people they supported well. We received feedback from one staff member that their concerns and suggestions about people’s care were not listened to and acted on by management.

There were processes to support a learning culture, but these were not always effective. Processes were in place to learn from accidents and incidents. However, we found one example where learning from an incident was not being followed, placing that person at risk of the incident reoccurring. We raised this with the manager so the risk could be addressed. The provider had completed surveys, held meetings to gather staff and people’s views and acted on any suggestions made through these processes. Audits and action plans were in place, but these were not effective and therefore did not support continuous learning and improvement.

People and their relatives told us they felt care was safe and staff worked with other agencies, such as: GPs and specialist health services. Where people had recently moved to the home relatives told us this had been managed well and they had been involved in needs assessments. However, processes did not always ensure consistent care. For example. some people had not seen a dentist in line with their planned care.

The management team and staff told us they had good working relationships with other agencies which supported smooth transition and care pathways. The management team told us they were in the process of improving and developing systems to support safe care. They had introduced new electronic systems and felt some of the recording issues noted at this assessment were due to the transfer of information between systems.

We received mixed feedback from partners. Partners told us that staff and the manager were approachable and showed a willingness to work in partnership. A professional we spoke with told us there had been a planned transition (someone moving into the home) which had gone, “really well” and involved staff the person felt comfortable with. However, some partners also identified shortfalls in the home. These included issues with infection prevention and control and incomplete nutritional records. In both areas professionals made recommendations about how the home could improve.

Processes were in place to support safe systems and transitions, but they were not always effective. Information documented within people’s care plans and risk assessments was not always accurate or detailed enough to ensure safe and effective care. Important information relating to people’s nonverbal communication was incomplete. Food and fluid records were not accurate or fully completed. Some people had not seen a dentist recently or in-line with their plan of care. We observed some people not receiving care in accordance with their plans. Quality assurance systems to ensure safe care and smooth transition had not identified all the issues found at this assessment.

People and relatives told us they felt people were safe, and they knew who to speak to if they had concerns. A relative told us, ‘If I had a problem, I would speak to the staff but if it was anything major, I would go to the manager.’ People and relatives told us people were asked for their consent before care was given.

Staff told us they supported people with decision making. The management team told us processes were in place to support people to make decisions in-line with MCA. However, we could not be assured that staff were supporting people consisently around MCA as guidance was not always in place to support this. We observed staff support a person in potentially restirctive ways without clear guidance being available. Staff understood how to identify abuse and how to report safeguarding concerns. Staff told us they valued having regular training to refresh their skills. One said, “I've had lots of safeguarding training over the years. Just done an online refresher. It's important to be able to keep on top of it and refresher training does jog your memory.” Staff had received training around the Mental Capacity Act 2005 and associated Code of Practice.

One person had specific needs around personal care; we observed staff practice did not match guidelines set out in the person’s care plan. Practice was more restrictive than was planned.

Safeguarding processes were in place and concerns about people’s safety were reported. Staff had training on safeguarding. Where people lack capacity to make decisions for themselves these need to be made in-line with the Mental Capacity Act 2005 and in their best interests. Documentation relating to MCA was not always up to date. Some people who received medicines covertly (without their knowledge) did not have best interest decisions in place around this. The management team told these were in place but could not be located when we visited due to moving information on to a new electronic system. We could not be assured that staff always had access to the correct information to support people in-line with MCA requirements. CCTV was in use in communal areas of the home, but we did not see documentation about how people had consented to its use. Some relatives told us they had not been asked about this, but they did not object to it being used for people’s safety.

People and relative were involved in the design of the care package, how it was delivered and felt their suggestions were acted upon. Relatives told us they were involved in discussion about how risks were managed. However, we found that people were place at potential risk because staff were not following processes to manage risk, or there was a lack of clear guidance about risks.

Staff and the manager told us there were processes and training in place to help them manage risks. We had mixed feedback from staff about how well risks were managed. One staff member told us, “In terms of residents' needs we are able to meet everyone's needs at the moment. If there are people with difficult or challenging behaviour, we refer to [mental health support services]. Most of our nurses are mental health nurses so are used to this type of challenge.” Another staff member told us, “We have had residents that hit each other, push each other over. We do our best to keep an eye on things, try to encourage those people to stay in the lounge.”

Staff were not consistent in their approach to managing risk. We observed that people were not always being involved to manage risks effectively. Some staff were proactive in their approach and other staff did not respond to people on an individual basis. We observed one person seated in an inappropriate chair, even though this had been identified as increasing their risk of falls. Some people with distressed behaviours were not offered distraction or alternative activities to reduce their anxiety. Cleaning products and prescribed drinks thickener were not always locked away. This posed a risk, especially to people living with a dementia, who may mistake these items for food or drink.

Processes did not consistently support people and staff to manage risk. Some care plans and risk assessments lacked details about risks. For example, how to manage people’s distressed behaviours. Audits, and checks made by the management team, did not consistently ensure risks were safely managed.

Although people and relatives did not express concern about the environment, we observed safety issues and found processes to check the environment were not robust. A relative expressed a concern that there were no curtains up in one of the lounges, they told us, “It was sunny and there’s no curtains up so you can close them.”

Most staff did not express concern about the environment. However, one staff member told us, “Have you seen all the stuff in the shower room? It's a disgrace, people can't use it so if they want a shower they'd have to go downstairs.” The management team told us they were working on improvements to the environment. There was an action plan looking at redecoration, but it did not address some of the safety issues we observed in the home.

We observed safety issues with the environment. For example, stairwells and a shower room were cluttered, causing obstruction and possible fire hazard. We observed one lounge was very hot, with some glare from the sun, and were advised that curtains had been taken down to be altered. Some people in this room appeared overdressed for the temperature and looked uncomfortable. The management team told us the curtains had been put back up after our visit. Staff had been using fans and an air conditioning unit to try to maintain a comfortable temperature.

Processes were in place to check the safety of the environment, but these had not been effective at identifying the risks seen during this assessment.

Most people and relatives spoke positively about staffing. However, we also received some mixed feedback. One relative said, “In an ideal world, yes it could probably do with more staff – however, I do realise it’s not always that simple. The staff here are good, and they do seem to have a diligent attitude.” Another told us that although there appeared to be enough staff they did not always engage and direct their family member who was living with a dementia. They told us, “I feel as if [family member] does her own thing… they leave her to it, rather than trying to guide her.”

We received mixed feedback about staffing. Most staff told us they felt there were enough staff to deliver safe care. However, 2 staff commented that there were not enough domestic staff. A staff member said, “Care staff do try to cover [for cleaning staff] but they already have enough to do.” Another staff member told us there were some incidents of distressed behaviour that had resulted in incident and said, “there are not always enough staff to avoid these situations.”

We observed there were enough trained care staff. However, we observed that there were no activities taking place when we visited because the activities co-ordinator was not at work. Staff were expected to undertake this role but there was limited evidence of social engagement with people during our visit. The provider demonstrated that there were usually dedicated staff to assist with activities. Feedback from people and relatives reflected this.

The home was almost fully staffed with low use of agency. However, there was a vacancy for cleaning staff, which impacted on the cleanliness of the home. This issue had been fed back to the manager and another member of domestic staff was being recruited. Processes were in place around safe staffing and recruitment, but these were not always being followed. Some recruitment records were incomplete and checks on the identity of agency staff were not recorded. We found one example where referral should have been made to the Disclosure and Barring Service (DBS) but this had not happened. Employers have a duty to refer to the DBS when there is clear evidence of a person causing harm or putting someone at risk of harm. We advised the manager to make this referral retrospectively.

People and relatives did not raise concerns about the cleanliness of the home. Some people told us they felt the home was clean and well-kept. However, we observed that areas of the home were not sufficiently cleaned.

Staff gave mixed feedback about the cleanliness and tidiness of the home. Some staff told us they had concerns about cleanliness and felt the home needed more cleaning staff. One staff member said, “I am a stickler for cleanliness and it's bad in here.” Another staff member said, “The home isn't always as clean as it could be. At times we have an issue as there are not enough cleaning staff. That is definitely something that needs looking at.”

Some areas of the home were not clean or tidy, and this increased the risk of the spread of infections. Some carpets were very dirty and stained, handrails had damaged paintwork in several areas and armchairs were worn with damage to the upholstery, making effective cleaning difficult. Some bathrooms had not been adequately cleaned and were being used for storage. Food in a fridge was not labelled or covered, this increased the risk of people eating out of date or contaminated food.

Audits completed by staff and management had not addressed issues found at this assessment. Infection prevention and control nurses had visited the home in February and found similar issues. There were no plans in place to demonstrate how these issues would be acted on. Staff had raised the need for increased cleaning in staff surveys. The management team were recruiting for another member of domestic staff in response to this. Following our visit the management team sent photographs to demonstrate some areas of the home had been improved.

People and relatives told us they felt people received their medicines safely. We observed one person being given their medicines in a way that did not follow their care plan. We could not be assured people recieved their medicines as prescribed because we found ommissions and errors in medicines processes.

Staff told us they had completed medicines training and had been recently assessed to ensure they remained competent. The manager told us about the variety of medicines audits however these had not identified all the issues we found. After we raised issues with the management team they told us they were working to rectify these and improve systems.

Medicines were not always managed safely. Improvements were needed in the records of how people took their medicines and care plans for medicines, including for people with covert medication plans. Also, in the guidance and records for topical creams and when required medicines including those with a variable dose. There was no robust process for topical creams applied by care staff as part of personal care. There was no clear guidance and records were not accurately completed. For some people information to support staff to safely give ‘when required’ medicines were in place. However, we found for several people these were not person centred and for some people plans were missing. Where a variable dose was prescribed there was no information documented in relation to this. Records of regular medicines followed national guidance including recording people’s allergies. However, we checked medicine stock against medicine administration records (MAR) and found that stock did not balance showing that the records were not correct. Comprehensive policies and procedures were in place to support the administration of medicines. However, these were not always followed by staff. Medicines were stored securely and safely including controlled drugs, however there was a large overstock of some medicines that they were getting help to address from the pharmacy.