St Helens Hall and Lodge

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

We assessed all 8 quality statements from this key question. Our rating for this key question remains good. We were assured that safety in the home was prioritised and people were protected from the risk of harm. Effective processes and systems were in place to ensure that safeguarding concerns were reported, responded to, and investigated appropriately and lessons learned were shared amongst the team and wider management. Staff were recruited safely, provided with a comprehensive induction, and offered supervision in line with their policies. Staff received relevant training and dates for any outstanding training were being arranged urgently by the registered manager. People felt safe in the home and were happy with the care they received. Partners provided positive feedback, and a recent assessment carried out by the local authority identified no concerns. The environment was safe and suitable for the needs of people. Risk assessments were in place and care records contained information on how to support people in line with best practice guidance. Concerns were identified around the storage and administration of some medicines, however when raised with the registered manager, urgent steps were taken to resolve these issues.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most people and their family members told us they had not raised any complaints but told us they would speak to the manager if they needed to. Some comments included “it’s very good", "got no complaints.” One person told us she had “once raised a complaint against a member of staff, and it was not resolved to her satisfaction.” Family members told us communication was good and they had been kept up to date with any change to their relative’s needs.

Following an accident or incident staff told us they follow internal processes and “report to the senior or unit lead and completed an accident pack.” Staff described the processes and actions to take after a fall, one staff member told us “Handover informs us” and another staff member said, “the senior tells us when she sees us, we do have handovers and staff meetings.” Staff accessed risk assessments via their held hand devices. The registered manager was knowledgeable about the organisations policies and processes in relation to complaints and the management of falls and discussed how learning from incidents is shared throughout the company at all levels.

The managers had good oversight of accidents, incidents, and risks. There was a strong process in place to review accidents and incidents, that was completed following each incident. This process involved risk analysis and rating, investigation details and involvement with residents and relatives. Trends were recognised following the reporting of incidents and analysed more thoroughly for example – in depth analysis of falls was carried out each month – which included documenting the number of falls overall and by person, times of day and actions taken. Team meetings minutes evidence that lessons learned were shared amongst the team. A falls management policy, complaints policy and whistleblowing policy were all in place.

People and their family members told us that staff act promptly and would call a doctor if a person was unwell. A person who had only been at the home for 6 weeks told us that he found it easy to move into the home. We spoke to a family member whose mum had only been in the home for 2 weeks and he was pleased with the home and actions taken to ensure she was appropriately accommodated there.

Staff knew people well and could identify their individual needs such as those people who were on insulin, thickeners, and soft diets. Staff knew what to look out for when monitoring people’s conditions and when to make a referral to the appropriate agencies. They said they had received training on diabetes and epilepsy. One staff member told us “OTs [occupational therapists] come in if someone needs equipment” another staff member told us “We have a good relationship with district nurses, falls team, dieticians, frailty, OT, and GPs.” The registered manager discussed the pre-admission/assessment which involved other professionals and family. The registered manager also explained how they had improved the experience for people who needed to go to hospital following lessons learned from a previous incident.

External audits completed by partner agencies, informed the positive feedback we received. A quality assessment completed by the local authority stated ‘records viewed during the visit demonstrated multi-agency working between the home and other relevant professionals such as GP practices, Pharmacies, district nurses and the hospital for example.

Referrals to the appropriate professionals were submitted in a timely manner. The service worked closely with other health professionals to ensure people received the appropriate care and treatment.

People told us that they felt safe in the home, as did their families. People told us they were happy with the care they received, and staff treated people well. Family members told us they would speak to the manager if they had any concerns or felt their relative was not safe.

Staff told us they had received training in safeguarding, knew where to access the safeguarding policy, and said they understood when and how to report any safeguarding concerns. One staff member told us, “I would report straight away to my manager.” One staff member described how concerns could escalate if not acted upon. Staff understood MCA (the Mental Capacity Act) and DoLS (Deprivation of Liberty Safeguards) and gave examples to explain this. The registered manager used a recent incident involving a staff member and a resident to explain the safeguarding process and how safeguarding incidents are managed appropriately.

We observed people receiving safe care and treatment. People were supported safely.

The safeguarding policy in place was adhered too. Processes were followed and any concerns identified were referred to the appropriate professionals. Most staff had completed their safeguarding training. The manager was aware that training was outstanding for some staff, and this was being managed. The whistle blowing policy that was in place was visible in the home.

People told us that equipment needed to help them was always available. One person told us that she had never had any accidents or falls and felt supported to manage her risks. She said of the care she had received, “it’s very good,” “they all do their best.” Staff help her shower and dress and that makes her feel safe. Although most people and their families told us they had not seen their care plan, family members told us they were updated with any changes in their relative's care needs.

Staff told us they had received training on equipment, hoists, and manual handling. Staff would accompany residents if they were a falls risk, one staff member said, “I would stay with them and ensure they had on correct footwear.” The registered manager understood the importance of identifying and managing risks posed to people. They described how people and other services are involved in the management of risks such as mobility and falls, the different types of risk assessments, when these might be used and how non-verbal ways to communicate with people are documented.

We observed people being supported safely. For people that required support or encouragement with eating and drinking this was provided.

Risk assessments were in place and up to date for those who required them to ensure risks could be mitigated. Daily handovers were carried out, so information was shared between staff members. This was also recorded on the electronic system. People’s dietary intakes were monitored to make sure people were receiving adequate fluid and nutrition, particularly for those people who were at risk of malnutrition. Care records contained relevant information on how best to support people and staff had access to the care plans on their electronic devices.

People and their families felt the home was safe and suitable for their needs.

Staff felt the environment was safe for people. Staff knew how often fire alarm tests took place, telling us “The fire test is every Tuesday” and how to evacuate the building. However, one staff member did not know how to raise the alarm if there was a fire.

The home was clean and well maintained. Window restrictors were in place in all upstairs rooms and furniture that could cause injury was appropriately secured. During our assessment we found one fire door that did not close properly. This was raised with the manager who took immediate steps to resolve and has confirmed that the door has been trimmed following a full external fire door survey.

Health and safety matters was managed well. All relevant maintenance certificates were up to date including gas safety, PAT testing and electrical testing. We viewed evidence that weekly fire alarm tests had been undertaken alongside monthly fire drills for all staff and all slings and hoists had been appropriately serviced in October 2023. One of the hoists had failed its safety check and therefore the assisted bath had been taken out of use pending a replacement hoist. Fire safety risk assessments were all complete and the last visit from the fire authority outlined no concerns. Business continuity plans were in place which included response to severe adverse weather, utility failure, building and equipment problems. Mitigating actions are documented. Training matrix evidenced that all staff have had COSHH (Control of Substances Hazardous to Health) fire safety, food safety and health and safety training.

Some people told us they do not feel there is always enough staff on duty however “they all do their best” and generally respond quickly. People told us that “staff are marvellous” and felt that they were well trained.

Staff reported they had received induction training and regular supervisions. Staff commented they felt supported by the manager saying, “I feel supported” and “absolutely supported by the manager.” Staff felt occasionally short-staffed, one staff member told us “Some days are well staffed, and some days are really low.” The registered manager had a good oversight of the recruitment process and induction programme, and clarified that staff receive supervision every 3 months. She highlighted that 4 staff were currently going through the onboarding process and told us the use of agency staff had decreased.

No concerns were noted over the staffing numbers. People were receiving support in a timely manner. Encouragement and support were provided at mealtimes to ensure people received an appropriate meal.

We reviewed 7 recruitment files. The files we viewed were mostly complete and evidenced a good recruitment process, however there were gaps in the information we would expect to see such as employment and photo ID. We saw evidence that this had already been picked up by the providers internal audit and actions in place and collated some information retrospectively. There was a comprehensive induction process in place for new starters, including agency staff, which outlined objectives for the induction and a timeline of expectations for example shadow shifts – a minimum of 3 during the first week. Scheduled one to ones and competency assessments were also built into this. In line with their supervision policy and procedure, the supervision matrix evidenced that staff were receiving regular supervisions and appraisals.

People told us that staff wear appropriate PPE when providing care. People and their families felt that the home was clean and well maintained. Family members told us that the home always keep them updated of any outbreaks, stating they are “very quick on that.”

Staff told us they had completed on-line training in IPC (Infection Prevention Control). Staff reported they had enough PPE and knew when to use it. If there was an outbreak staff described the procedures they would take to prevent the spread of infection, including “residents are encouraged to stay in their room, a designated member of staff will escort and keep that resident company”.

The environment was clean and free from damage. There was plenty of PPE around the home for staff to access. Staff were observed following personal good practice guidance such as wearing no jewellery/watches or nail varnish. Wall mounted soap dispensers were available to use around the home and hand washing instructions were displayed clearly. The laundry room was well organised and managed to avoid any cross contamination. We observed the bins in bathrooms had no foot access meaning staff and residents would need to use their hands to open bins. This was highlighted with the registered manager who informed us that she would look at changing these.

Daily cleaning records were complete and there was also a nightly cleaning schedule in place. Cleaning records included a housekeeping policy and procedure for staff to follow. All staff had received training in infection and prevention control. There was a comprehensive IPC (Infection Prevention Control) policy in place which outlined for example, handwashing techniques, spread of infection, PPE, and safe management of care equipment. Internal IPC audits completed by the provider evidenced that actions were being followed through for example an audit in January 2024 highlighted there were no wall mounted soap dispensers in place – we observed this had been actioned on our visit. Audits and observations that were in place for hand hygiene and the use of PPE evidenced good practice by staff.

People were not always sure what medication they had been prescribed but told us that staff do discuss with them and provide medication regularly. One family member told us that he gets informed of any changes to his mum’s medication and is not aware of any medication errors.

Staff who administered medication told us they had been given appropriate training and their competencies had been checked. Staff were able to describe when they would offer different types of medication and provided examples of this. The registered manager explained the process for checking the competency of staff yearly however this is increased if errors are being made and for new starters. She also told us the process for managing medicine errors.

Medication was not always safely stored. Topical creams were stored in people’s wardrobes. We found some creams that required storing in a fridge were left in the cupboard. We found eye drops that had expired were still being administered. These concerns were raised with the registered manager and urgent steps were implemented to ensure these concerns were rectified. There was a medication policy in place, all staff that administered medication had, had their competencies assessed to ensure they were suitable skilled to administer medication safely.