Nutley Lodge Care Home

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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe.

The provider was in breach of legal regulations in relation to safe environments, safe care and treatment, staffing, and fit and proper persons (recruitment).

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a positive culture of learning from incidents and accidents. For example, the registered manager analysed incidents and accidents monthly to identify themes or trends. The registered manager told us most incidents were related to falls. For example, following the analysis of a person's falls there was medical intervention resulting in the person having a pacemaker fitted and a decrease in falls.

The service worked with people and healthcare partners to establish and maintain safe systems of care. The service was enrolled in a Devon and Cornwall Care Records (DCCR) programme. The DCCR programme supported people living at the service to have continuity of care when moving between services. For example, when a person returned to Nutley Lodge from hospital the service could see if the person had any follow-up appointments, receive an electronic up-to-date TEP (treatment escalation plan) or any other relevant information. This information was also accessible to other medical professionals, such as the GP and ambulance service.

The service worked with healthcare partners to understand what being safe meant to people and the best way to achieve that. The service shared concerns with the local authority when required. Staff said they were aware of their responsibilities to raise and escalate concerns, where needed, to protect people’s rights to live in a service free from bullying, harassment, abuse and discrimination. Relatives said their loved ones were safe at the service, 1 relative told us, “I, as a relative, feel so lucky to know that my mum is in such a caring, stimulating and most of all safe environment.”

The service did not always work well with people to understand and manage risks. Risk assessments relating to people’s health, safety and welfare were completed. However, risks were not always mitigated. For example, where a person had been identified as high risk of skin breakdown and required support with regular movement, records showed gaps of between 5 to 12 hours. Where air mattresses were needed, we found the service was not always monitoring mattress settings. These shortfalls put people at increased risk of skin damage.

Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of the regulation linked to safe care and treatment.

The service did not always detect and control potential risks in the care environment. The provider had not prioritised identified environmental risks such as obstructed fire doors and potential electrical risks. We raised these concerns with the provider on the first day of the assessment, and immediate action was taken to address them. Weekly fire tests and monthly fire checks, such as emergency lighting were completed. However, the fire service had advised the provider to carry out fire drills so staff could practice the procedures to follow in the event of a fire, including simulating a full evacuation. The provider was unable to evidence all staff had attended a full evacuation. These shortfalls placed people at risk if there was a fire.

Whist we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to safe environment.

The registered manager used a tool to help identify appropriate staffing levels. However, we received mixed feedback from staff about staffing levels. Some staff told us they felt there was enough staff, and others said it could be busy and there was a need for more staff. A staff member told us, “The staff become frustrated when they can’t spend more time with the residents, and staff are trying to cover shortness of staff but that dips with staff morale.” The registered manager had completed supervision for some staff. However, some staff told us they had not received supervision, and the registered manager told us appraisals had not been completed for several years. Recruitment processes were not robust. For example, there was not evidence of full employment histories, or a satisfactory written explanation of any gaps in employment. This placed people at increased risk of potential harm as the provider had not adopted safe recruitment practices. Whilst we did not identify anyone who had come to harm, poor recruitment contributed to the continued breach of regulation in relation to staffing, fit and proper persons (recruitment). Relatives were positive about staff and felt they knew their loved ones.

The service did not always assess or manage the risk of infection. We identified cleaning records were poorly kept. The registered manager could not be assured all areas identified as needing to be carpet cleaned on a monthly basis, had been completed. We saw stained carpets within areas of the home, such as the lift, which looked like bodily fluids. The registered manager and staff confirmed continence aids were being disposed of in black bins within general waste. The service was not following their policy and best practice in relation to staff disposing of clinical waste in yellow colour-coded bags or containers, prior to collection and disposal. Whist we did not identify anyone who had come to harm, poor infection control contributed to the continued breach of regulation in relation to a safe environment. Personal protective equipment was readily available to staff, and we observed staff using this equipment where needed. Feedback from people and relatives did not highlight any concern with the cleanliness of the service.

The service did not always ensure medicines administration met people’s preferences and needs. The service did not always follow nationally recognised good practice guidance such as recommended by the National Institute of Clinical Excellence (NICE). When people had been assessed to have their medication administered covertly, the registered manager had not ensured there was a plan in place for staff to follow. Whilst we did not identify anyone who had come to harm, poor management of covert medication contributed to the continued breach of regulation in relation to safe care and treatment. Improvements had been made the storage of medicines including recording temperatures, and ‘as and when’ required medicines (PRN) guidance was in place. This meant staff were better informed on how to support people with these medicines.