South Haven Lodge Care Home

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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

We assessed 5 quality statements within this key question. We found 4 breaches of the legal regulations in relation to safeguarding, safe care and treatment, staffing and fit and proper persons employed. South Haven Lodge Care Home has been rated required improvement or inadequate within the safe domain for the last 3 consecutive inspections completed by the Care Quality Commission (CQC). The breach relating to safe care and treatment was a continued breach of regulation for the last 3 inspections completed by CQC of the home and the breach relating to fit and proper persons employed had been identified during a previous inspection. Risks to people's health, safety and wellbeing had not always been identified and guidance for staff on how to mitigate risks was not always available, was inaccurate or was contradictory. People did not always receive their medicines as prescribed. People had not always been safeguarded from risks of avoidable harm and experienced neglect and organisational abuse. There was not enough staff, who were sufficiently trained available to meet people’s needs. There were delays in people accessing care and ongoing supervision and pressure relief management was not always provided as directed, placing people at significant risk of harm. The provider had not completed all necessary recruitment checks.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

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 had not always been safeguarded from risks of avoidable harm and there were safeguarding investigations which were ongoing at the time of assessment. Throughout the assessment it was evident people were not receiving safe and effective care and their basic needs were not met. We received mixed views from people and their relatives in relation to personal safety. A relative told us, “South Haven Lodge has transformed [persons] life and allowed us to relax in the knowledge that she is safe and well cared for.” However, another relative said, “I worry about [person] every day, I know the staff aren’t providing them with the care they need.”

The staff and management team failed to recognise and respond to people’s needs and to ensure care was provided in a safe way. The staff and management team failed to recognise the lack of person centred, safe and effective care provided to people could constitute neglect. Discussions with staff further supported our findings. A staff member said, “I don’t think we have ever used the bath. Certain staff members will occasionally shower people, but not all staff can be bothered. I have spoken to management about this but nothing changes.” Another staff member told us, “People will only have baths and showers when certain staff are on.” A third staff member said, “People are totally neglected, but nothing ever changes.” We could not be assured all staff understood their safeguarding responsibilities. Staff spoken with were unable to demonstrate they understood how to recognise abuse and the action to take if they had concerns.

Throughout all our assessment visits we observed some people appeared unkept. People were not provided with appropriate support to ensure their basic care needs were met, including baths/ showers and nail care. People were ignored by staff and support was not always provided to people during periods of anxiety and frustration. We noted in one person’s care records they posed a risk to female residents and staff, however guidance for staff on the management of this was lacking. The guidance provided to staff noted within the persons care plan was for them to ‘be vigilant to triggering behaviours; shouting, respond effectively.’ It was also noted ‘a member of staff will need to supervise this person when they are out of their room, due to the risk they pose to others.’ Throughout our assessment visits we saw this person unsupervised and staff failing to respond to them when shouting frequently. This placed other people, staff and the person at risk of harm. We raised safeguarding concerns to the local safeguarding team following our site visits.

The provider failed to ensure effective and robust processes and systems were in place to protected people from neglect and improper treatment. Observations throughout the assessment showed organizational abuse and neglect. We identified concerns of the services safeguarding systems, processes and practices. The processes were not robust as records did not demonstrate robust investigations had been completed where incidents, accidents and near misses had occurred to prevent and mitigate future risk. Mental Capacity Act (MCA) assessments, best interest decisions and Deprivation of Liberties Safeguard (DoLS) applications were not always completed where required which meant we could not be assured staff protected people's human rights in line with the MCA. At the time of our assessment no care staff had received training in MCA and DOLs. Many people living at the home had a diagnosis of dementia which could impact their ability to make informed decisions and understand risks. Care staff would be responsible with providing these people with support in accordance with the MCA. Not all staff had completed or had refresher training in safeguarding adults from abuse in a timely way. Where staff had received this training checks had not been completed to ensure staff understood the training received.

We received mainly positive comments from people and relatives about safety. One person responded, “Yes, it’s nice, I’m not worried.” Another person told us, “I think I’m well looked after.” However, a third person said, “I stay in bed as I don’t like them [staff] using the machine (hoist), it hurts, and I don’t feel safe.” A relative said, “They [staff] are really looking after [person], I’m really pleased, and they always ring me to let me know if anything has changed.” Another relative said, “[Person’s] general risk factors are reasonably high, but they have never been as well managed as they are at South Haven Lodge.”

During our assessment we asked the registered manager and a representative of the provider what systems and processes were in place to ensure people were receiving appropriate and safe care to mitigate the risk of harm and the deterioration to the health and wellbeing for people. The registered manager and providers representative confirmed they did not review or audit daily records or care plans as this was the responsibility of the homes ‘clinical lead’ and nursing staff. The registered manager and providers representative was unable to confirm if or how these audits had been completed. Discussions with staff demonstrated not all staff understood peoples’ specific needs and how these should be managed to mitigate risk and ensure safety. Furthermore, we could not be assured that where staff knew specific risks to people, they acted to ensure people’s ongoing safety and wellbeing. For example, a staff member told us a person had an allergy to a type of food, this staff member them proceeded to support this person to eat this type of food.

During our assessment visits we observed poor care which placed people at risk of harm, injury and health deterioration. We saw numerous occasions when two staff supported a person to transfer from wheelchair to chair/chair to wheelchair. These transfers were unsafe and ‘a drag lift’ was used. The use of a drag lift can cause significant injury. One person’s care record stated, ‘due to increased confusion and being restless (person) needs 1:1 support when awake and when sat in the communal areas of the home.’ We visited this person in their room who awake in bed and attempting to get up over their bedrails. 1:1 support was not in place. We discussed this with the registered manager, and they told us, the person only needed 1:1 supervision when sat in a chair and that the care plan was incorrect. On reviewing this person’s daily records there was no guidance for staff to complete regular checks on this person when in bed and daily records demonstrated they were often not checked for up to 3 hours at a time. We saw some people were provided with meals whilst in bed. These people were not always appropriately positioned to allow safe swallowing. This placed these people at risk of choking, aspiration and scolding. We witnessed ongoing and regular supervision was not provided as required to keep people safe. For example, we observed long periods of time where people were left unattended within the lounge and dining area. Some of these people were at risk of falls or would have episodes of anxiety or frustration which could impact on themselves and other people’s safety and wellbeing.

We found inconsistent information in people’s care records and guidance provided was not always followed by staff. This placed people at risk of not always receiving safe care. There was an absence of risk assessments and care plans for some people known to have specific conditions. For example, there was no detail about how staff should support two people with their diagnosed specific mental health disorder. People at risk of developing pressure damaged had not been repositioned as highlighted within their care plan. A care plan for one person stated, ‘To be repositioned at least every 4 hours to maintain skin integrity.’ However, this person’s repositioning records demonstrated from 1 to 24 September 2024 repositioning had not been completed as described, on 68 occasions. For another person their care records stated they required, ‘Turning and Positioning 2 hourly.’ This person repositioning records demonstrated from 1 August to the 8 October 2024 repositioning had not been completed 2 hourly as per requirements on 272 occasions. This demonstrated staff were not providing appropriate care and treatment to support healing and prevent further deterioration. We reviewed people’s daily records and found people were not provided with food and fluids appropriately and at the correct consistency to ensure their health, safety and wellbeing. One person’s care plan described them as requiring a level 7 (diet) and Level 0 fluids. However, information from the care plan, kitchen records and staff knowledge was inconsistent as to the variation of modification and detailed four different levels of food consistency for this person. The registered manager and nursing staff were unable to tell us the correct consistency that was required. This placed the person at risk of asperation and choking. The concerns we found were discussed with the management team who agreed action would be taken to address these concerns and ensure people’s ongoing safety as a matter of urgency.

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

People consistently told us there were insufficient staff to meet their needs. Comments included, "Yes, [I can use my call bell] but they [staff] don't come quickly", “I must stay in bed, I get lonely. Staff never come and just sit and talk to me” and “I’m stuck here like a stuffed chicken, my call bell is usually out of reach, I will shout for staff, but no one comes.” We received mixed feedback from relatives. Relatives’ comments included, “No there is not enough staff, they are really pushed at times”, “There is not enough staff, they don’t always check [people] or get them up as there isn’t enough of them” and “I can only comment on weekends, and it feels that there is a shortage of staff then.”. However, some relatives were more positive, one said, “I am absolutely gobsmacked as to the availability of staff at the home, and this is at every level.”

The registered manager told us staffing levels were provided at a ratio of 1 staff member to 5 people, however, was unable to explain how they ensured this was sufficient to meet people’s needs. We received mixed feedback from staff in relation to the staffing levels at the home. Some staff attributed to lack of engagement with people down to the numbers of staff available while other staff members felt it was down to staff skills, competency and laziness of some staff members. A staff member told us, “We do have enough staff but there is always someone calling in sick. The staff don’t always want to engage with people and yesterday there were no staff in the lounge and a person was really distressed.” Another staff member told us, “There is not always enough staff, people are neglected.” We spoke to staff about specific training to enable them to carry out their role adequately. A staff member told us, “The training is online, its ok but some staff will come here who have never worked in care before and are chucked straight into the deep end, with minimal support and training.” Another staff member told us, “We don’t really get specific training for our role. I did safeguarding training which I didn’t feel was very helpful. I discuss this with the registered manager, but no additional training was offered or provided.”

We observed multiple examples of poor staff practice, including, lack of support provided to people, failure to respond to people’s requests for help, lack of staff availability within communal areas and the provision of unsafe care practices. On at least 3 occasions during our assessment visit on the 17 September 2024 we noted call bells ringing for over 20 minutes. When this was discussed with staff members, they would respond with comments such as “Well they are sat there (pointed to person in a chair in the lounge), the carers must have stood on the alert mat when they were bringing her down.” However, not all staff would have known the person was in the lounge, yet still no staff members checked to respond to the call bell. Our observations of staff practice meant we could not be assured staff had the skills to manage people’s anxiety and distress during escalation. Throughout our assessment visits we observed two people become agitated, frustrated and distressed. Staff failing to respond to this in a supportive way or attempt to de-escalate the episodes of increased frustration or anxiety. When these incidents occurred, we often observed staff to walk away. Staff members acknowledged some staff would ignore these situations and will often ‘find something else to do.’ A staff member said, “We don’t get enough training, when a person’s behaviours get a bit difficult some staff avoid them as they don’t know what to do, they don’t have the confidence in how to manage it.”

There were not robust systems and processes in place to ensure staffing levels were sufficient to meet the needs of the people. The registered manager told us the provider worked on a ratio of one staff member to five people. However, they were unable to evidence how they had ensured there was enough staff in place to meet people’s needs, how staffing levels had been assessed and decided and how it had been determined that a ratio of one to five was sufficient. There were no systems in place to demonstrate people’s changing and increasing needs had been assessed, reviewed or considered to help ensure staffing levels were sufficient to meet people’s needs. We could not be assured all staff had received training to equip them in their role and to ensure they could provide safe care to people. On review of a copy of the training matrix we found staff had not received appropriate training in a timely way to enable them to carry out the duties they are employed to perform. Concerns in relation to training were discussed with the manager who had started employment at the home on the 30 September 2024. This manager confirmed additional training would be provided to staff as a matter of urgency. Recruitment processes in place had failed to ensure safe recruitment processes were being followed. This resulted in staff being employed into the service without having all the required pre-employment checks in line with the statutory requirements.

People and relatives did not share any feedback in relation to the cleanliness of the home.

The registered manager told us they checked the cleanliness of the home and the kitchen cleaning records daily, however, they were unable to provide us with detailed records of these checks. We discussed general housekeeping with a member of the housekeeping staff who told us, “Over the last month, I think things have really improved with the housekeeping, we have been provided with additional staff and we are really getting there now. Things were a bit difficult for a while.”

Overall, the service generally appeared clean and tidy and clinical waste, laundry and cleaning equipment were all managed safely. However, although the home appeared visibly clean some area’s had a marked malodour, deep cleaning was required in some areas, and consideration was needed for equipment which could not be effectively cleaned. For example, we observed stained flooring and shower curtains, a toilet handrail was rusty which would make effectively cleaning difficult, and there was a dirty/stained bed pan stored next to clean ones in the sluice. Staff were observed to be wearing appropriate PPE; however staff and management had failed to identify some of the face masks in use were past their expiry date. This meant they may not be effective in preventing the spread of infection.

Processes and systems in place to ensure the safe and effective management of infection, prevention and control were not robust. We reviewed the number of cleaning records in relation to kitchen cleaning tasks, clinical room cleaning and additional cleaning records in relation to all aspects of the environment and noted these had not always been marked as being completed. This meant we could not be assured cleaning tasks had been completed as required. We reviewed the providers ‘personal protective equipment (PPE) policy’ and ‘Acute Respiratory Infections (ARI COVID-19) policy’ and found these were not being adhered to. For example, the PPE policy highlighted PPE should be readily available for staff and within its expiry dates. However, we found boxes of out-of-date face masks throughout the building. We discussed this with the registered manager who said that she was not aware that PPE had expiry dates. This meant staff had been using out of date PPE that may not have offered adequate protection against the spread of infection. Additionally, testing equipment to test for Covid-19 was not available for immediate use as stipulated within the ARI COVID-19 policy. Staff had access to both Covid 19 and infection control training, however from the records provided we could not be assured this had been completed in a timely way. This placed people and staff at risk of cross infection and potential ill health.

We could not be assured there was safe management of medicines. This placed people at risk of harm. We found some medicine administration records (MAR) demonstrated some people’s medicines were not being administered in line with the prescribers’ instructions. Although we found people’s medicines were ordered monthly during our assessment we identified, people did not always have their prescribe medicine available to them. This included medicines to manage pain. This placed people at risk of experiencing unnecessary pain and discomfort. Were people were prescribed ‘as required’ medicines (PRN) there was not always person-centred and detailed PRN protocols in place. This meant staff were not provided with detailed information to ensure PRN medicines were offered consistently and only after other strategies have been exhausted. This placed people at risk of not receiving medicines in a timely way or being given medicines inappropriately.

We discussed medicines management with the registered manager who told us they had no involvement with the medicines management. The registered manager explained that because they were not clinically training, they were not allowed to complete medicine audits, and this were the responsibility of the clinical lead, and the registered nurses employed by the service. Staff who administered medicines told us they had received medicines training and had their medicines competency checked.

There were a lack of robust systems and processes to ensure there was safe management of medicine though the completion of effective and appropriate audits. We reviewed the completed medicine audits and found these were not effective and did not show that where concerns and issues were identified, action was taken in a timely way to address these. We were told by the registered manager the nurses were required to complete daily medicine audits. However, we found these were not always completed. For example, no daily audits had been completed during May 2024, in June 2024 only one audit had been completed and in July 2024 daily audits had not been completed on 8 occasions. This had not been identified by the management team. The providers ‘Medicine errors and near misses’ policy was not followed. This policy refers to completing a medication incident report form and conducting a medication error root cause analysis. An example of a medicines error within this policy was, 'Omission for any reason, including no stock'. We found people had run out of certain medicines however, there was no evidence of these forms having been completed when medicine errors or near misses had occurred. For example, one person was prescribed pain relief. This medicine was recorded as out of stock from the morning of 15 September 2024 and remained out of stock during our assessment visit on the 17 September 2024 resulted in 8 missed doses. On review of the medicine audits, we found the compliance from the providers audit shows ranges between 83% and 98% however, we identified concerns with stock management and out of stock medicines (raised on 4 out of the 6 audits reviewed), PRN protocols (raised on 5 out of the 6 audits reviewed), MCAs in relation to medicines and covert medicines (raised on 3 out of the 6 audits). This demonstrates action had not been taken in a timely way to address concerns.