Cinnamon 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection for this newly registered service. This key question has been rated Good: This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. This meant lessons were learnt to continually identify and embed good practice. The service benefited from the support of a positive behaviour support lead and a safeguarding lead, who collaborated to identify trends and themes. The findings were shared to enhance learning and improve outcomes for individuals both within the service and across the organisation. Actions were taken to understand the reasons behind a person’s distress or incidents, aiming to prevent future occurrences. Relatives were consulted for their views and suggestions to inform the lessons learned.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service created quick reference care plans that summarised critical information about individuals, including triggers for distress and strategies to avoid or mitigate these periods. These plans were shared with healthcare professionals to maintain continuity of support. Relatives reported that transitions between services were well-planned, and communication was excellent. One relative told us, “The transition for [Person] was slow and carefully managed. Staff took a gentle approach to help them meet and get to know other [People].”

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. The service had clear safeguarding processes in place, they raised any concerns to the relevant agencies as required. Staff understood their responsibilities in relation to safeguarding people for the risk of harm and abuse.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Care plans contained robust Positive Behaviour Support (PBS) plans that outlined stages of escalation and supportive methods to prevent distress, as well as strategies to reduce the risk of further escalation. Relatives expressed confidence in the safety of the service. One relative said, “It’s absolutely 100% a safe place, we know that from time to time [Person] can have some sort of incident, but Cinnamon Lodge staff are managing all their needs, so they are safe.” Another relative said, “Cinnamon Lodge risk assess everything… with this kind of work in place [Person’s] quality of life improved multiple times since they moved into the service, they go everywhere every day. They go places we never dreamt to take them”

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. We found some fire doors were ill fitting or propped open and some radiators were exposed. This presented a risk to people living in the service. We raised this with the provider who was responsive to our concerns and took immediate action to address them.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. Staff had undertaken training in how to support autistic people and people living with a learning disability. Staff’s competency had been assessed to ensure they understood the individual needs and care plans of people they supported and were able to meet them. Staff told us they were given time to get to know people and were able to access training and support as required.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We found some areas of the environment could not be cleaned properly, for example, some flooring was damaged. We raised this with the provider who was responsive to our concerns and all areas had been actioned by the end of our assessment.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning. During our assessment we identified medicines that had expired were in use. This meant medicines may not have been effective placing people at risk. We raised this with the provider who was responsive to our concerns and acted immediately to replace the medicines. Additionally, prior to the completion of the assessment the provider retrained all staff around medicines administration and held workshops to further improve knowledge and competency.