Seahorses

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

In this key question we looked at 5 quality statements. We found breaches of regulation relating to health and safety, fire safety, infection control, managing risks and safeguarding people from abuse.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

There was not a clear system or process in place to manage incidents relating to safeguarding. This meant trends, themes and learning could not clearly take place following incidents and accidents and meant there was an increased risk that safeguarding incidents re-occurred. When reviewing monitoring sheets and risk assessments, people were not always receiving adequate pressure care. We made a safeguarding referral as we felt people were at risk of significant harm from pressure damage.

Staff did not always have a good understanding of safeguarding. One longstanding staff member told us they had started safeguarding training but had not finished it. When asked about safeguarding, the staff member told us: “I don't know what to answer. I will go and speak with duty manager or [acting manager]. Or even to the owner, he will support us always.” Other staff we spoke with told us they had received training in safeguarding and were able to tell us about the different types of abuse.

People told us they felt safe. Comments included: “I feel so safe, I look after myself. If I need help people [staff] come along”, and “I always feel safe, there is someone to help if you need it, carers are nice to you. The doors are locked at the front.” Relatives echoed this, telling us: “[Their relative is] definitely safe, I have not seen anything that has worried me. They are the kind of people you could approach and not be worried.”

We did not observe any safeguarding concerns regarding the way staff spoke and interacted with people living at the service.

Staff and leaders did not have a good understanding of people’s risks. For example, one person’s care plan stated they ‘prefers moist, easy swallowed food with meat cut up into small pieces, as [person] can choke easily.’ However, all staff and management informed us there was no one at risk of choking.

We saw that various health and safety checks had been completed, such as electrical equipment testing, and saw other equipment was regularly serviced. However, the service did not adequately protect people from the risk of fire. We found people had personal evacuation plans (PEEPs) in place, however, these did not contain key information such as where people’s bedrooms were located and pictures of people, so that people could be easily identifiable in case of a fire. We requested a copy of the service’s fire risk assessment; however this was not provided. There was no evidence this document was in place.

People did not always have adequate risk management in place. We observed one person who had not been assessed for risk of pressure damage, and we observed this person was not repositioned for significant lengths of time during our inspection.

People and their relatives felt people’s risks were managed well. One relative told us: “[Family member] is safe because of the constant attention they give to [person] and all the other residents. [Person] has a bed that can be lowered and a pressure mat to alert staff if there is a problem.”

One relative told us they felt the environment and equipment supported their relative to stay safe. They told us: “[Relative] has a bed that can be lowered and a pressure mat to alert staff if there is a problem.”

The provider told us they were assured the environment was safe. They explained: “We do daily room checks and a walk-around. We have a very good team of support people; a plumber and electrician and maintenance people will come in at a moment's notice. Because of the nature of how we work, we have our maintenance book, it's part of handover.”

We saw that various health and safety checks had been completed, such as electrical equipment testing, and saw other equipment was regularly serviced. However, the service did not adequately protect people from the risk of fire. We found people had personal evacuation plans (PEEPs) in place, however, these did not contain key information such as where people’s bedrooms were located and pictures of people, so that people could be easily identifiable in case of a fire. We asked the provider for a copy of the service’s fire risk assessment; however this was not provided at the time this was requested. The provider sent us a copy of a completed fire risk assessment at a later date, which identified some hazards, however actions were not always taken to reduce the risks from these identified hazards.

The environment was not always managed safely. We found windows at the front of the building had restrictors that could be easily removed by unhooking a part of the fitting. These were on the ground and first floor. This meant there was a significant risk of people falling from height. Guidance from the Health and Safety Executive (HSE) states window restrictors must be ‘be suitably robust to withstand foreseeable forces’ and ‘be robustly secured using tamper-proof fittings so they cannot be removed or disengaged using readily accessible implements (such as cutlery)’. This was raised to the provider at the time of our on-site visit and the provider has now installed safe window restrictors.

Staff were not always recruited safely. We found one staff member had a Disclosure and Barring Service Check ten years ago. There was no evidence this had been re-applied for as per best practice, or any evidence the risk of the staff member not having a recent DBS check had been considered. Staff had received some training however there was no effective system to show when training was completed and if staff required any refresher training.

We observed there were enough staff to support people. The call bell system was broken during our inspection, the provider had put additional measures in place to manage this, these included half hourly checks to people who were in bed and unable to call for help. However, we observed that these were not always being completed.

Most staff we spoke with told us there were enough staff, or that management can support if needed. Staff told us: "I think at the moment we are fine, when we have too much work we can speak with manager or deputy manager, they are always coming downstairs to help. Every day is different, if there are more visitors, doctors, nurses then you are more busy. If we ask them for help they are always coming to help." However, another staff we spoke to felt there were not enough staff. The staff member told us: "No [there are] not enough staff... There is too much to do, I don't know what it was like when you were there. There are normally 2 carers on the floor, a cook who helps people to the toilet and then goes back to the kitchen. There is one member of staff doing the cleaning."

People told us they felt that there was enough staff to support them when required, comments included: “Always feel safe, there is someone to help if you need it, carers are nice to you. The doors are locked at the front”, and: “I feel so safe, I look after myself. If I need help people [staff] come along”, and: “There are always staff around. I can get somebody to help me if I need them." Relatives told us they felt there were enough staff in the service to support people safely. Comments included: “I would think that there are enough staff. If anyone calls out a carer comes to see them.”

People and relatives did not raise any concerns about the cleanliness of the service.

We asked the owner how they ensure the service follows safe infection control practices. They told us: “We have our infection control manuals. The cleaner has to fill this in every day. We also monitor PPE, to ensure a correct amount is being used. The room checks are done on a walk around. We make sure it's clean. We also have a process that we all check each other's work. One staff raised a concern about the cleaning over weekends. They told us: “I have concerns about the weekend staff cleaning. They don't do it properly.”

We observed various concerns relating to infection prevention and control practices during our site visit. We found a large pile of dirty laundry by the entrance of the laundry room and found dirty laundry was not in a water-soluble bag. This increased the risk of cross contamination between clean and dirty laundry. Areas of the care home were damaged and in need of repair. We saw wooden fittings, doors, skirting boards and radiator covers had numerous chips in the paintwork and some fittings had chipboard exposed. This meant that these fittings could not be cleaned appropriately and presented an infection risk, especially in the event of infectious diseases such as coronavirus and norovirus. Some light switches were not able to be cleaned effectively; we saw 2 bathroom light fittings that were a pull cord with no end piece, and these appeared visibly dirty. Some areas of the home had a strong smell of urine. The medicines room was also being used as a staff storage area and a staff toilet. We observed a box of lancets that were slightly open, stored right next to the open door of a staff toilet. This was an infection control risk due to a risk of cross-contamination when staff used the toilet.

Infection prevention and control audits took place monthly, however these did not identify the concerns found during our assessment. For example, the audits checked that windows, doors, storage items, chairs and bedframes were clean and that appropriate hand washing facilities were in place. However, the audit did not identify the concerns identified by CQC such as risks around cross contamination, storage of dirty laundry, chips in paintwork and equipment which was visibly dirty.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.