Bumblebee 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

Although people at the service told us they felt safe living at Bumblebee Lodge and the staff supporting them worked to ensure their daily lives were meaningful, we found concerns in a number of areas that could affect people’s safety. Safeguarding concerns were not always managed robustly. Where people had been deprived of their liberty the provider had not always followed processes to ensure this was maintained in line with the Mental Capacity Act, 2005. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Risks to people’s safety were not always well managed. There was a lack of clarity over how staffing levels were managed and there were concerns around how medicines were managed. There was a lack of clear processes in place to learn from events.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there were processes in place for them to report any incidents or accidents. However, we did not find any clear processes in place to support staff learning from events at the service.

There was a lack of processes in place to show learning from events. Although incident forms or behavioural charts were completed there was no evidence to show discussions had taken place with staff to reduce risks to people’s safety.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives told us they felt their family members were safe at the service. One relative said, “Definitely, we can talk to staff. [Name] is nonverbal but can understand what is said and can make their wishes known.” However, while people’s relatives we spoke to expressed they were happy with their care, our assessment found elements of safeguarding people at the service did not meet the expected standards.

Staff told us they had received training in safeguarding adults and knew where the safeguarding policy was. One member of staff said, “I would report anything I considered to be wrong or abusive.” The present manager of the service understood their responsibilities in dealing with safeguarding issues. However, as shown below there were concerns that previous managers and staff had not always followed correct processes when managing safeguarding concerns.

The provider had a safeguarding folder in place, however there were no safeguarding incidents recorded. We were told of one historical incident which staff had put measures in place to prevent recurrence. However, the incident had not been recorded or reported in line with the provider’s safeguarding policy and there was no evidence of any investigation or input from the local safeguarding team. This meant there had been no oversight of whether the actions were the least restrictive and in people’s best interests.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS) The provider was not always following the principles of the MCA. People who were under a DoLS were living in a service with an unlocked door policy in place. The service is situated next to a busy road, there was no risk assessments in place to show the individual risks to people’s safety had been considered. One person living at the service suffered with deafness, their care plan showed they had no road safety awareness and all the people living at the service required one to one support when out in the community. A further person who had been placed under a DoLS order had not had this reassessed on the required date. Their DoLS order expired in October 2023. This meant the person was being deprived of their liberty without lawful authority. We also noted there were no records of best interest meetings to show any decisions made for people who lack mental capacity had been taken using the principles of the Mental Capacity Act 2005. This meant there was no evidence to show families and appropriate health professionals, had been involved in any decision making for people and the decisions were of the least restrictive option. This is a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s relatives told us they were involved in managing risk to support people to enhance their skills. One relative gave us an example of how they had worked with the staff at the service to support a person learn a new skill in a safe way. This had resulted in the person undertaking an activity they had wanted to achieve.

Staff told us they used the information in people’s risk assessments to support them. Staff knew people well and worked with people in a positive way to support them and reduce risks to their safety. However, although staff worked well there were aspects of assessing risk which did not always support good practices.

While we saw staff worked with people in a positive way, we also saw some measures in place to reduce risks to people were not always followed. Staff had worked over a period of time with one person to reduce their weight and improve their mobility. On viewing their records over the last 6 month we found the person had weight gains which if continued could be detrimental to their health. There was no evidence to show staff had acted upon the changes to the persons weight gain or how they would maintain a healthy weight. There was also a lack of information to show what type of diet or foods staff should be offering the person to help them sustain their weight loss.

Risk assessments did not always give staff strategies to guide them to reduce risks to people. This was evident when a risk assessment detailed a person’s behaviours but gave no further information on how staff should respond to the person's behaviours. There was also a lack of understanding of how to effectively score risks in a personalised way as some aspects of scoring was undertaken in a generic way. The majority of the risk assessments we viewed had a risk likelihood score showing the level of risk without staff support. This could be either a high or medium risk, but the score always showed a low likelihood score with staff support. While it was clear risks to people could be reduced with staff support, this did not always mean the score would be low as it didn’t take into account the varying levels of ability and understanding of each person. For example, people’s awareness of hazards in the kitchen varied and, although could be reduced with staff support, for some people the risk could not be mitigated to be considered a low risk. This meant the risks were not always safely mitigated and effectively scored to maintain people’s safety.

Staff told us they felt the environment was well maintained and well laid out for the people living at the service.

Our observations of the service supported what we were told. Throughout our visits we saw different people enjoying activities in both the communal areas and in their own rooms.

There were processes in place to ensure equipment used at the service was well maintained and regularly serviced. However, records showed an issue had been highlighted on an audit and it had not been addressed for a number of months. This showed a lack of oversight from the provider.

Relatives we spoke with told us there was enough staff to support their family members. One relative said, “Yes plenty of staff to support [Name]. There is consistent staff which is good as this really helps [Name].”

The feedback from staff around staffing levels were mixed. One member of staff felt they didn’t know whether there was meant to be 2 or 3 members of staff on duty each day as the levels varied. Another member of staff told us the levels varied, but managers were looking to have 3 members of staff on duty each day to effectively support the 1 to 1 care 2 people required.

On the days of our visits the staff levels varied. On the first day we arrived there were 2 staff on duty and a member of staff from head office came to support a person on a community activity. On the second day there were 3 staff on duty.

Our review of the staff roster showed it was not always being used to document clearly what staff were meant to be on duty. We saw there were 4 members of staff whose roster clearly showed when they would be on duty. However, there were two shifts per day which simply stated, ‘cover needed’. The manager was unable to show if these shifts had been covered by staff and told us the duty roster was not always used to record when these shifts had been covered. This meant we could not be assured people were always receiving the correct level of support they needed. For example 2 people required 1 to 1 support each day to maintain their safety. A further person could sometimes display anxious behaviours which on occasion required 2 members of staff to support them.

All the staff we spoke with were able to show their understanding of how to reduce the risks of infection for people in their care.

The service was clean and overall well maintained. However, there was some exposed woodwork which had not been sealed and made cleaning these areas difficult. We discussed this with the manager who told us they would address this issue with the maintenance team.

There were processes in place to support staff to maintain safe infection prevention practices.

Relatives told us they felt their family member’s medicines were managed well. One relative told us how the team had worked with their family member, themselves and doctors to support the person following a review of their medicines in relation to the Stop overmedicating people with learning difficulties and autism (STOMP) initiative. They told us the staff kept them informed and worked to ensure the person’s medicines were managed in a way that supported the person safely.

Staff who administered medicines told us they had received training for their role and were supported by their manager to undertake competencies when administering medicines.

Our review of medicines showed the practices in the administration of medicines were not always safe. Full counts of medicines were not undertaken robustly, this meant if medicines went missing, staff at the service would not always know when they went missing. We highlighted this to the manager who told us they would review practices to ensure safe management of medicines were improved.