Filsham Lodge

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury and has since died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of scalding. This inspection examined those risks.

This inspection followed up on previous breaches of regulations relating to safe care and treatment, and good governance. At this inspection we found insufficient improvements had been made and the provider remained in breach of these regulations.

People’s safety was not robustly managed. There was a lack of evidence of lessons learned when people experienced recurrent falls, choking or an incident that affected their well-being. Risk assessments relating to falls were not always completed in full and lacked follow up actions taken by staff. Some risk assessments for example, for people living with diabetes and swallowing issues were not in place. Not all PRN (as required) medicines had protocols in place to advise staff about administration and creams in peoples’ rooms were not prescribed for that person. The maintenance of the service had not ensured peoples continued safety and the cleanliness of the service placed people at risk of cross infection.

The governance and overview of processes had not been robust enough to highlight the shortfalls found at this inspection. Care plans and risk assessments had been reviewed but had not captured recent incidents or accidents. People’s weights had not been overseen resulting in gains and losses not being monitored and therefore putting people at risk. There were concerns about some aspects of maintenance of the service with parts of the service not being safe for people, which had not been identified through the audits. Cleaning audits were also not highlighting areas that required attention.

Since the incident the provider had taken steps to ensure that all risks relating to hot water and surfaces were managed. The registered manager checked temperatures daily and advised they would continue to so until the new maintenance team commence work.

People’s needs had been assessed prior to moving to the service. Staffing was seen to be sufficient to meet peoples’ needs, when there was a need, agency staff were used. People were treated with kindness and dignity.