Seton Care Home

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• 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

We reviewed 5 quality statements under this key question; Safeguarding, involving people to manage risk, Safe and effective staffing, Infection prevention and control and Medicines optimisation. At this assessment we found a positive culture of safety based on openness and transparency. Concerns about safety were listened to, investigated, and reported to the relevant authorities where required. Staff had been recruited safely and were suitably trained, and there were enough staff to meet people’s needs. People received their medicines by staff who were trained to do so. Minor concerns were found with the medicines management which the auditing process had not always picked up; however, the manager took immediate action following the assessment to respond and resolve these concerns. Care plans contained risk information relating to individual people’s needs. Effective infection prevention and control measures were in place.

This service scored 75 (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.

Overall people were positive about the care they received, people told us they felt safe and were involved in their care plans. One person told us, “The staff are very good. We are all treated as individuals, if we want to go anywhere, we are taken. I think it is very well run here.” People told us there were enough staff available to support them when they needed assistance. People told us they received their medicines on time. Although we did find some minor issues with some medicines not reconciling the manager responded proactively and implemented daily checks of the medicines trolley and the deputy manager will be reviewing all staff’s medicines competencies. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; however, the policies and systems in the service did not always support this practice. Following our assessment the manager told us they would review people’s mental capacity assessments. If any person was deemed to lack capacity a Deprivation of Liberty applications would be submitted to the relevant authorities. People were supported with their nutrition and hydration needs. Staff treated people with kindness, dignity and respect and spent time getting to know them and their specific needs and wishes. Care plans reflected people’s individual needs and preferences. The provider had systems in place to monitor the quality of the service although these were not always effective in identifying some of the concerns we found on the day of our site assessment, the manager responded promptly to take action to make the necessary improvements.

Staff had received training in how to safeguard people, knew how to raise any concerns with the management and how to report concerns externally if required. A member of staff told us, “If I had any safeguarding concerns I would go to the manager and whistle blow to CQC if I had to.” Another member of staff told us, “I would report abuse straight away. I would go to the sister servant or CQC.”

We observed people to be comfortable in the presence of staff members. It was evident staff knew people well. There was a calm, relaxed, friendly and homely atmosphere.

Safeguarding policies were in place. The provider had systems in place to ensure all safety concerns, where appropriate would be investigated and action taken to ensure people’s safety. Records showed the service had made appropriate safeguarding alerts to the local authority when necessary.

Care plans and risks assessments included information on how to support people safely. One person told us, “We are involved in everything, including any risks. They (staff) and the sister servant ask our views about everything.”

Staff appeared to know people's needs and told us, information regarding risks to people was recorded within their care plans. A member of staff told us, “People’s risk assessments are located in their care plan. A person returned from hospital recently so needed 2 carers for a couple of weeks. This was updated in their care plan and included in the handover as well.”

We observed new flooring being laid for 1 person in their bedroom, appropriate measures had been taken to ensure the area was secured and mitigated the risk of being a potential trip hazard for people.

During the assessment, we reviewed people’s care plans and risk assessments which provided information about potential risks to people. Systems and processes were in place to cascade information regarding changes to people’s care, and these were reviewed regularly by the senior carers.

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

People told us there were enough staff to provide the care and support they required. Comments included, “There are plenty of staff and they are very patient with us, “There are usually enough staff, 3 on every day also the senior staff, plenty to go round.” And “There are enough staff as someone always answers me quickly.”

The staff we spoke with were positive about working at the service. They told us there were enough staff to support people safely. Comments included,“There are quite a lot of staff, you have enough time to talk with people, it is calm, and we get time to sit and talk with people,” “There are enough staff here. I am getting to know people well and people are opening up to me.” And “Enough staff too many, I am amazed how may staff there are here.”

On the day of our assessment, we found there was enough staff present to support people safely. The communal lounges had a member of staff present to attend to people’s care and support needs, and the home’s atmosphere felt calm and relaxed. The sister servant was present throughout the day, checking on the well-being of people and ensuring they had everything they needed. Staff undertook their duties responsibly and professionally, showing care and respect for the people using the service. Time was spent ensuring people were engaged in their daily routines of prayers, reflection and activities.

Systems were in place to ensure there were suitably qualified, skilled and experienced staff and safe recruitment practices were followed. We checked the recruitment records for 4 members of staff and all the required pre-employment checks had been completed. This included disclosure and barring service (DBS) checks and obtaining up to date references. The service occasionally used agency members of staff. We found not all the agencies’ profiles had been updated. The manager took action following our assessment to request updated profiles for the agency members of staff working at the service.

People told us they felt the home was comfortable, homely and clean. A person told us, “It is very nice here, my room is lovely and bright and is always kept clean.”

Staff told us they had access to personal protective equipment (PPE). A member of staff said, “I make sure I wear my gloves and apron,” Another said, “I have had Infection prevention and control training.”

The home was clean and tidy throughout. People’s bedrooms, communal areas and bathrooms were free of malodours. Personal protective equipment was readily available for staff. On the day of our site assessment a person was having new flooring laid in their room. New furnishings for rooms had been sourced and all equipment was clean and in good working order.

The provider had an infection prevention and control policy in place. The manager carried out a daily walk round of the service and liaised with the housekeeping team and logged any issues with the maintenance staff member. The provider was in the process of implementing a new audit check. Staff had undertaken infection prevention and control training.

People told us they received their medicines when needed. Comments included, “The staff do understand my health concerns, they always respond to my requests for pain relief.” And “They notice things even before us and always good at referring. If we have any pain, they will offer us something straight away.”

The senior staff were responsible for administering people’s medicines and we observed people receiving their medicines when they needed them. The manager told us they had spoken to their line manager and were in the process of implementing the EMAR system for administering medication. (Electronic Medication Administration Records). This was with a view to improving efficiency, reducing errors and providing more accurate medication records.

The provider's medicine policies and procedures were in place and regular audits were carried out. However, we found a few medicines when counted did not reconcile with the number of signatures on the person’s medication administration chart (MAR). The medicines audits for May 2024 we reviewed had identified 2 incorrect counts however the action taken stated ‘adjusted and rectified’ with no explanation as to how the error may have occurred in the first instance. The manager told us they would implement daily trolley checks and counts of medicines with immediate effect to ensure any future discrepancies could be picked up instantly and appropriate action taken.