Sandiacre Lodge

At the time of the assessment there were 2 people receiving regulated activity. This is the first inspection for this service.

This assessment found 2 breaches of legal regulation relating to safe care and governance. We found although Sandiacre Lodge delivered a caring and compassionate service, there were areas requiring improvement to ensure safety and governance were consistently maintained. We have asked the provider for an action plan in response to the concerns found at this assessment.

We found the provider had deployed staff in a way that placed people at risk of harm as some staff were scheduled to work consecutive 12‑hour shifts during both the day and night and scheduled to complete training immediately after working a waking night shift.

The provider did not have effective governance arrangements in place to ensure the service continually improved. Although a series of audits had been completed, these did not in identify the concerns we found during the assessment.

We found unsafe practice guidance was in place in relation to the preparation of medicines. We raised this concern during our assessment, and the provider has confirmed this guidance is now no longer in place.

We also found fire safety concerns in a person’s home, although CQC does not regulate these premises, as the responsibility for the building lies with the landlord. We found the systems in place to monitor the safety of the premises and to report and progress tenancy matters were not always effective which created risks to the provider maintaining a safe service. The provider has since told us the works required for the fire safety concerns have now been completed.

Staff had received training in equality and diversity; however, this was not always embedded into practice. We found one person had a specific cultural diet and there was not any clear protocol in place of how staff could consistently support this. We raised this with the provider who took action to address the issue.

Assessments of people's needs had been carried out prior to people using the service and involved the person and, where appropriate, their relatives and healthcare professionals, to ensure the service was able meet the person's needs and preferences.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent. People’s care plans detailed the outcomes they required to ensure their needs were safely met.

Staff knew people well and understood their individual needs. Relatives confirmed their family members were treated well. People’s care plans provided staff with guidance on responding to people’s immediate needs in a safe and person-centred way.

Staff advocated for people when accessing healthcare environments and ensured reasonable adjustments were made so people could do so comfortably. The provider took people’s known preferences into account when organising future events and activities. We saw evidence of effective collaboration with external partners, including appropriate information sharing and seeking specialist input to support improvements in people’s care.