St. Michaels Lodge

What inspectors found

From the Care Quality Commission's assessment published 13 September 2024 (assessment visit 14 March 2024). Quoted under the Open Government Licence.

1. Safe

   –No rating No rating

   Risk assessments did not provide clear guidance and support to staff to help reduce and mitigate risk. Specific details known by staff were not documented for reference and accessibility to risk assessments was limited.

   Staff had a training programme in place, but we were not assured this was effective as some training modules were rushed. We did not see how competency was checked by the registered manager after training had been completed.

   The above was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

   The home was clean and staff were responsible for cleaning. However, observation of staffing levels showed that this could be challenging in addition to supporting people with their health needs during each shift, in addition to managing people who had a health condition requiring extra cleaning throughout the home.

   Staff told us they felt supported and could speak with experienced staff or the registered manager if they required extra guidance. Staff had an understanding of safeguarding and told us they would report concerns to the registered manager. Information on who to whistleblow to had to be prompted. The safeguarding policy in place did not have information on who to contact outside of the home if a concern needed to be raised. We recommend the provider seeks safeguarding guidance.

   Accidents and incidents were recorded with actions taken post the event, information on learning from these incidents had not been evidenced. The registered manager told us they discussed this with staff.

2. Caring

   GGood Good

   Overall were happy while living at the home and had built good relationships with long standing . At times people were seen asking for support from staff and people did comment on the number of staff present at the service. People were supported to enjoy activities of their choice in the community. Relatives were generally positive and provided comments on how extra staff would benefit outcomes for their family member and provide more personalised support.

3. Responsive

   GGood Good

   People had goals and targets set to promote independence within their care plans, however, records did not demonstrate whether people had met these goals or their progress towards them.

   Relatives found the care to be generalised and not always personalised. A relative gave an example of having staff who could speak their family members language to increase engagement and provide better outcomes for them. Staff understood the importance of treating people with respect and not to discriminate. Staff told us they included people by asking them what they wanted to eat and trips they wanted to go on.

   People were supported to receive healthcare support to maintain people’s health needs.

4. Well-led

   –No rating No rating

   Systems to monitor the quality of the service were ineffective. Audits were not being completed which would have give the registered manager to identify the issues found during our site visit. There were concerns with recruitment records, training, risk assessments and daily logs. This was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

   The registered manager told us they were trying to recruit extra staff and a deputy to support them in their role and quality assurance. Staff told us they were well supported by the registered manager and they could raise concerns freely.

   Feedback from a health professional was positive when discussing their interactions with the registered manager and staff within the home.