Hope 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 inspection the rating remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of the legal regulation related to safe care. People had not always received their medicines safely. Environmental safety and infection prevention and control risks had not always been safely managed.

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 did not always have a proactive culture of safety. We identified medicines prescribed to be used when required had been given to people without there always being a documented reason why. This increased the risk of people receiving medicines unnecessarily. We identified where people had experienced emotional distress, and this had not been documented on incident or behaviour monitoring forms. However, the service had systems to communicate lessons learnt from incidents and accidents to staff.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. When people had moved to the service, they had done this with transition plans which involved their relatives and relevant external professionals.

People were safeguarded from the risk of abuse and improper treatment. The service shared concerns quickly and appropriately. Staff had received safeguarding training and could tell us who they could report concerns to externally if needed.

People's care plans did not always include up-to-date information about when they should receive medicines to support them with emotional distress. Not all relevant risks relating to a person’s health condition had been assessed. This increased health and safety related risks to people. However, people’s care plans and risk assessments in other areas such as those relating to their daily routines and meal preparation, supported their independence and safety. Staff were knowledgeable about signs of people becoming distressed and knew how to support them when they felt anxious or upset.

The service did not always detect and control potential risks in the care environment. We identified some environmental risks such as excessive gaps in fire doors, upstairs windows not being appropriately restricted or risk assessed where they were not, and a shower that could get hot enough to scald. However, relatives we spoke with did not raise any concerns about the environment. The provider arranged for window restrictors to be fitted in response to our concerns. However, our concerns in relation to fire doors had not been resolved by the provider. As a result, we communicated this to Bedfordshire Fire and Rescue services.

Staff were not always deployed safely. During our second visit, we observed a staff member had lone worked without the training to support a person with their health condition and give them their emergency rescue medicine had this have been required. This put the person at increased risk. However, staffing numbers were safe. Staff were recruited safely. Staff told us they received regular supportive supervisions and team meetings. All staff we spoke with felt there were enough staff deployed. A staff member said, “There is enough staff on shift to take people out.”

The provider had not ensured they had an up-to-date legionella risk assessment and had not followed their risk assessment to test cold and hold water distribution temperatures to prevent the risk of water bourn illness. However, the service was clean and free from malodour.

The service did not make sure that medicines and treatments were safe. Where people were prescribed psychotropic medicines to be taken ‘as-required’ their care records did not provide justification for why these had been administered. Medicine with psychotropic effects can alter mood, awareness, thoughts, feelings and behaviour. Protocols in relation to these medicines were not specific to signs and indicators staff should observe before administering these. This meant there was an increased risk of people receiving medicines inappropriately. Although staff had received training, and competency checks the service had not independently identified this concern. However, medicines were stored safely.