South Haven 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 assessment we rated this key question Inadequate and found 4 breaches of the legal regulations in relation to safe care and treatment, staffing, safeguarding and fit and proper persons employed.

At this assessment we found some improvements had been made and the service was no longer in breach of the legal regulations in relation to staffing, safeguarding and fit and proper persons employed. Some improvements had been made in relation to safe care and treatment however the provider remained in breach of this regulation. The improvements that have been made require time to be embedded into practice and sustained.

The rating at this assessment has changed to Requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety.

This service scored 59 (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.

At our previous assessment we saw evidence that people were not receiving safe and effective care, and their basic needs were not met. At this assessment we did not see any unsafe practice or conduct by staff and found peoples basic needs were being met.

People told us they felt safe living at South Haven Lodge Care Home. One person told us, “It’s very good here, yes I feel very safe, and the staff are always popping in (my room) to check I’m ok.” Another said, “I don’t have any concerns about my safety, they [staff] look after me well.” Relatives told us they felt their loved ones were safe. A relative said, “I think [person] is safer than she has been in years.”

Staff had received training in safeguarding and were able to describe types of abuse what action to take if they had any concerns. The management team ensured safeguarding concerns were shared with other appropriate agencies, as required.

Approximately 3 weeks prior to our first assessment visit completed on 13 February 2025 a new manager had been appointed to oversee the safe running of the service. Since the start of their appointment, they had implemented a number of new processes and systems to ensure staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. These processes and systems included the implementation of a monthly incident overview sheet, which included the completion of action plans and root cause analysis to establish potential causes, themes and trends and mitigation to prevent future incidents. This system was in its infancy and needed to be imbedded into practice.

Mental Capacity Act (MCA) assessments, best interest decisions and Deprivation of Liberties Safeguard (DoLS) applications had been completed where required which meant we were assured staff protected people's human rights in line with the MCA.

At our previous assessment we found concerns in relation to risk management and mitigation. At this assessment although we found some improvements had been made, we identified continued shortfalls in the area.

Although we found information within people care plans was clear and consistent on review of people’s daily records, we could not be assured this was always followed. For example, one person’s care plan described them as requiring a level 6 (diet) and Level 1 fluids. However, we found fluids at level 1 consistency was not always provided. This placed the person at risk of choking. We brought this concern to the attention of the manager who discussed these findings with the staff members involved and felt it was a documentation issue.

Although we found improvements in the prevention of pressure damage to people, we could not be fully assured people at risk of developing pressure damaged had been repositioned as highlighted within their care plan. For example, one person’s care plan stated, ‘Needs assistance to reposition four hourly when in bed.’ On review of this person’s daily records, we found this person had not always been repositioned as described. This placed people at risk of experiencing skin damage.

During our assessment visits we observed numerous people in their bedrooms did not always have access to drinks. This placed people at risk of dehydration. We also observed most people in their bedrooms did not have call bells accessible to them to allow them to request support in a timely way.

The concerns we found were discussed with the management team who agreed action would be taken to investigate and address these concerns to ensure people’s ongoing safety as a matter of urgency.

Since the last assessment the provider had implemented more robust procedures and systems to help ensure people were receiving appropriate and safe care. These new processes and systems require time to be embedded to ensure improvement is sustained.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Throughout our assessment we could not be assured routine monitoring of environmental risks had been undertaken appropriately as we observed a number of environmental risks which had not been addressed or always identified through the service’s internal audits. For example, keys to areas of risk such as electrical cupboards and the boiler cupboard were easily accessible to people. Additionally, some vacant rooms were being used as storage and contained items which could cause harm to people. These areas were not locked. We shared these concerns with the management team who immediately removed the accessible keys and locked the vacant rooms.

We identified fire safety concerns including but not limited to, doors not closing properly and fire doors with compromises such as lock barrels and handles being removed and therefore rendering them ineffective in the event of a fire. The manager told us that they were aware of these issues and plans were in place to address these as a matter of urgency.

Some records in relation to environmental safety were not always clear as to what had been looked at, and any findings and actions taken. For example, the ‘fire door check’ record stated, ‘Visual inspection of fire doors, including closer mechanisms.’ We found that although this had been completed regularly, there was nothing to demonstrate that the issues we identified had been identified by the provider. Additionally, we found some bedrails and unsecure wardrobe's in place may compromise people’s safety. There were no effective records to demonstrate these risks had been considered.

The above concerns were discussed with the manager who told us these issues would be reviewed and addressed immediately.

At our previous assessment we found concerns in relation to safe and effective staff. At this assessment we found improvements had been made, however, changes made needed to be sustained and embedded into ongoing practice.

Systems and processes had been implemented to ensure staffing levels were sufficient to meet people’s needs. This included the use of a dependency assessment tool, to carry out continuous assessment of the needs of people. The outcomes of the continuous assessment were used to identify the required number and skills, of staff needed to support people. Staff deployment had been considered to help ensure timely and ongoing support was available throughout the home and we observed staff were always present in communal areas to check on people’s wellbeing in a timely manner.

People and their relatives told us staffing at South Haven Lodge had improved since the last assessment. They also commented on the qualities of the staff. One person said, “Yes, they [staff] seem more on the ball.” A relative said, “There is a mixture of staff and plenty of them. The general atmosphere is smiley and happy, and staff don’t appear stressed and are comfortable. The nurses are very impressive and professional.”

During this assessment staff confirmed they felt better equipped to meet people’s needs safely and effectively. Staff comments included, “We have done lots more training (since the last assessment) including, falls prevention, diversity and in the mental capacity act, I think this has really helped” and “We have more time to spend with people.”

We reviewed a copy of the training matrix and found there had been some improvement in appropriate training being provided in a timelier way to staff. However, this was an ongoing process, and further work was required in this area to ensure all staff had received the training required. Additional training and regular competency checks of staff practice had also been incorporated into the providers processes.

At our last assessment we found processes and systems in place to ensure the safe and effective management of infection, prevention and control were not robust. At this assessment we found improvements had been made in this area and action had been taken to address the previous concerns we identified.

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

During our assessment visits we noted the service was undergoing redecoration. This had impacted on the tidiness of some areas of the environment due to decorating equipment such as dust sheets and painting utensils within these areas. Despite the minor impact of the redecoration, we found the communal areas of the home and people’s bedrooms to be clean, and clinical waste, laundry and cleaning equipment were all managed safely. A member of the housekeeping team told us since the last assessment, “more housekeeping staff have been employed, and we get all the cleaning products we need.”

We reviewed the 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 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 being adhered to. Staff had access to both Covid 19 and infection control training, from the records provided we were assured this had been completed in a timely way by staff.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Care plans and ‘when required medicine’ (PRN) protocols were not always completed as required. Where these were in place with found they were not always person centred or detailed enough to support staff to know when and how to administer medicines. For instance, they lacked detail of when to give one tablet or two, or how to assess if someone was in pain or constipated when they were unable to communicate this themselves.

Medicines information was not always consistently recorded, for example in care plans, prescribed medicines were not the same as the medicines administration record (MAR). Risk assessments were not in place where necessary for creams containing paraffin, that may pose a fire risk or medicines that increase the risk of bleeding.

Records did not provide assurance medicines were administered as the prescriber intended or that people requiring specialist diets received these. For people that required their physical health monitored such as blood glucose, this was not always undertaken in line with care planning.

Some people required their drinks thickened to limit the risk of chocking, these were not always securely stored to prevent inadvertent or incorrect administration by untrained staff or visitors. Not all staff were up to date with medicines training and / or had not had their competency assessed to administer medicines.

Medicines related audits had been undertaken, which had identified some of the issues noted on assessment with actions assigned to individuals. However, these has failed to identify other issues we found during the assessment.

The concerns we identified were discussed with the manager who agreed action would be taken to address the issues highlighted.