Collingwood Court

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

We identified 1 breach of the legal regulations. Effective systems were not all in place to ensure people received safe and person-centred care. Improvements were required to ensure people’s safety including to medicines management. People’s care records and medicines records did not all provide guidance to ensure people received safe and person-centred care. Risk was not always well-managed as the service did not have effective systems in place to proactively manage risks before safety events happened. Incidents and accidents were reported and investigated but a more robust analysis and lessons learned needed to take place to reduce risk of re-occurrence. Systems were in place to ensure people were kept safe and protected from the risk of harm and abuse, however improvements were needed for the management of risk to ensure people’s safety. Improvements were needed to the collection of information before people started to use the service and consistent information needed to be available if they moved between services. There were enough competent staff to meet people’s needs safely, however, improvements to staff deployment were needed so people were engaged or occupied, if they wished. People and staff were positive about the open culture of the service, they all said they were listened to, had opportunities to give feedback and concerns were addressed. People’s mental capacity and ability to consent was taken into account, and people and their representatives were involved in planning their care and support. Staff received training that was relevant to their roles and responsibilities. They received support and regular supervision with opportunities for personal development. There was robust recruitment of new staff. Systems were in place to promote good infection prevention and control.

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.

Most people told us they felt safe and staff responded immediately if they needed support. A relative commented, “I am confident that [Name] is safe when they use their walking frame.” Another relative told us, “[Name] has had a couple of falls. The home staff took prompt action after each one”, and "[Name] has had several falls. They [staff] do try to keep an eye on [Name] and they call me every time they have a fall.” However, some relatives thought improvements could be made. Their comments included; "[Name] has had several falls,” and “[Name] could be encouraged to use their walking aid more. They tend to come out of their room and walk without it", and "People do have to wait a long time for assistance.”

Staff told us they were encouraged to report incidents. Any incidents about people's safety was discussed with staff, but actions taken to mitigate further risks was not always effective as the same incidents re-occurred. While learning was identified for individuals in response to an incident, not all staff felt wider learning was shared.

Improvements were needed to ensure people’s safety and safety concerns acted upon were effective. Staff filled out accident and incident forms which were reviewed by management. A more robust analysis of all accident and incident reports was needed to help mitigate risk to people’s safety. Lessons were not all learned from incidents, with learning widely shared with the staff team to prevent similar incidents occurring and to raise awareness of complying with standards and safe working practices.

Sufficient information was not always available about people if they moved between services or started to use the service to ensure their safety and continuity of care.

Staff were aware of when people had health or social care professional input. They said they felt confident working with other agencies. Recommendations from health professionals or other professionals had been implemented.

We received no feedback from partner agencies relevant to this quality statement.

Systems were not all in place for staff to work with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. Information such as a hospital ‘passport’ containing standardised information about people’s care and support needs was not available for all people to ensure they received a continuity of care when either visiting another service or discharged from the service. Before a person started to use the service, more detailed information needed to be collected to ensure their needs could be met by staff and that the service was right for the person, as well as the person being right for the service. A process for the smooth admission and discharge of people who stayed temporarily at the service needed to be implemented to ensure their safety and continuity of care.

People told us they felt safe being supported by staff. They knew how to raise any concerns they might have. A person commented, “I am not unsafe. Staff come straight away if I buzz for assistance.” People were asked for their consent before staff provided support, "The staff do ask [Name]'s consent before they give them care which I find impressive.”

Staff members told us they knew to raise any safeguarding concerns to management, they said they felt confident they would be dealt with appropriately.

People appeared to be happy and comfortable in their surroundings. They told us they felt safe, they would speak with staff if they were worried, and they felt listened to.

Processes were in place to protect people from abuse. Staff had received training on identifying and reporting abuse and knew what action to take if they identified abuse. Concerns were reported to the local authority as appropriate. Safeguarding incidents were investigated and showed evidence of action taken and effective lessons learned, where needed. Safe staff recruitment helped ensure people were protected from staff unsuitable to work in the care sector. The service was complying with the Mental Capacity Act 2005 (MCA). The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Records showed people's consent to care was sought. Where relatives, or others involved in people's care had the authority to make decisions on people's behalf, this was recorded in their care records. This included what decisions the person had authorised them to make.

People, and the majority of relatives felt included in decisions about their care, including how risks were managed to support them to continue with day-to-day tasks safely. A relative commented, “A care plan was discussed around two months ago. I am absolutely happy with the way they handle [Name]’s care.” Some recent concerns had been raised which were being investigated by the local safeguarding team.

Staff understood where people required support to reduce the risk of avoidable harm. Staff knew the risks to people and told us they were kept up to date if there had been any changes to people's care and support needs. Some improvements were being made to the management of risk to people, such as for the risk of falls, however changes needed to become sustained to help ensure people's safety. A staff member commented, “The matrix and analysis of falls indicate that the number of falls are down.”

Staff supported people safely and appropriate equipment was available if people needed assistance. People and relatives told us staff knew how to support them.

Robust systems were not all in place to ensure all risks to people's health, safety and well-being were mitigated. Some risks to people had been assessed and risk assessments had been put in place to help mitigate risks. There had been a high incidence of people falling, but recent monitoring records showed the number of falls each month was now decreasing. However, further improvements were needed to managing risk and ensuring identified need was transferred to a care plan that detailed how a person wanted and needed to be supported to ensure people’s safety and person-centred care. Care plans required more detail of the measures for staff to follow to keep people safe, including how to respond when people became distressed. This included guidance for staff about triggers and signs, how to de-escalate and reassure a person if they became upset, with guidance for the use of ‘when required’ medicines and their use as a last resort. Staff worked to mitigate any identified risks, however, risk assessments and care plans, that contained information on the actions staff needed to take to keep people safe, needed more regular review to monitor people’s well-being and identify any current risk and reflect people’s changing needs. Staff had the knowledge and skills to protect people's safety. Staff received health and safety training and training about safe working practices. They understood their responsibilities for reporting accidents, incidents, or concerns.

Staff supported people safely and appropriate equipment was available if people needed assistance to mobilise or to assist with other support needs.

Staff told us they had received training in safe working practices. They said they had appropriate equipment to move people safely and had received training on how to use it. They felt supported when management were not on duty as an on-call system was available to provide support and guidance, in an emergency.

The service demonstrated people were cared for in a safe environment that was designed to meet their needs. The premises and equipment were well-maintained which helped support staff to deliver safe and effective care.

Environmental risks were assessed, with measures put in place to remove or reduce the risks. Regular health and safety checks were completed, this included of equipment such as, hoists and stand-aids. The provider employed a member of staff to carry out maintenance, there were effective arrangements to safely maintain the building.

We received mixed feedback about staffing levels. People told us they felt safe with staff support but not all people and staff thought there were sufficient staff. Their comments included, “They [staff] keep [Name] safe enough, but they could do with some extra staff”, “Sometimes they could do with some more staff. They really do their best”, “They are too busy, and I think there are not enough staff” and “You do sometime have to wait a long time for assistance.”

The manager told us a dependency tool was used to calculate the number of staff required. However, not all staff verified there were sufficient staff on duty to support people. Their comments included, “It is adequate to meet needs, depends if someone is on annual leave, can be short”, We don’t always get help from the team leaders, some are better than others. Some will step in and give hands on care but others not”, and “Sometimes enough staff, sometimes short but it has been improving.” Staff told us about the training they received as part of their job roles and were knowledgeable about the training they received. A staff member commented, “I find the standard of training to be of good quality, it has given me the knowledge needed to do job. Some training is e Learning, and some is face to face.”

Staff were available to supervise people, but care was not always person-centred. On the middle floor people sat unoccupied or walked around the unit during the morning. In the afternoon outside entertainment was taking place in the garden and some people were taken down after it had started. Due to the weather it had to end, and people were brought back, and they congregated on the landing by the lift as staff were busy elsewhere and not available to support them to take off their coats or to show them where to sit down. Therefore, not all people were attended to in a safe and timely way as staff were busy attending to other people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, improvements were needed to staff deployment, so people received safe, timely and person-centred care. Systems and processes were in place to ensure staff were recruited in a safe way. Staff files demonstrated that safe recruitment practices were in place to make sure that all staff were suitably experienced, competent and able to carry out their role. New staff had appropriate pre-employment checks in place which included photo identification, work history, references and a Disclosure and Barring Service (DBS) check in place. DBS checks provide information including details about convictions and cautions held. Staff received training to give them insight into people’s care and support needs. A system of supervision and appraisal was in place to help support staff members. The staff training matrix and staff records showed staff received a variety of training courses supervision, observations and checks of competency to carry out their role safely and effectively.

There were effective infection prevention and control systems in place. These included regular cleaning and systems to prevent people and visitors from catching and spreading infections. People told us they thought their home was kept clean. They were very positive about the refurbishment and improvements to the décor. A relative commented, “Residents including [Name] were involved in decisions around décor for the refurbishment”, and “They [housekeeping staff] are constantly cleaning.”

Staff told us personal protective equipment [PPE] and all cleaning materials needed were available. A staff member told us, “We always have enough supplies for PPE for providing care.” Staff confirmed they had received infection control training.

The building was clean, bright, well-decorated and well-maintained. People's rooms were personalised, appropriately furnished, warm and comfortable. The refurbishment programme included appropriate environmental design for people who lived with dementia or a dementia related condition to keep them orientated and maintain their independence. There were several communal areas and areas of interest such as the bird watching corner and a social club with bar were being created to keep people engaged.

Regular checks of the premises were carried out to ensure the environment and equipment was kept clean and free from malodours. Staff received training in infection control practices and used personal protective equipment [PPE] effectively and safely. The management team accessed support and advice on infection control and training and maintaining a safe environment.

Improvements were needed to medicines management and record keeping. There was no robust process for creams applied by care staff as part of personal care. There was no clear guidance and records were not accurately completed. Patch application records were not available for one person to demonstrate rotation in line with manufacturers guidance to prevent side effects. Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Guidance for how these medicines should be administered was not person-centred. There was no information when a variable dose was prescribed. Some guidance did not match the dose prescribed. People’s preferences about how they wanted their medicines were not always up to date or clear.

Staff told us they had completed medicines training and had been recently assessed. Management told us about the variety of medicines audits, however these had not all been effective, as they had not identified some of the issues found at our inspection.

Records of regular medicines followed national guidance including recording people’s allergies. However, we checked medicine stock against medicine administration records (eMAR) and found that some stock didn’t balance with theoretical stock showing that the records were not correct. Some medicines were out of stock and could not be given. Two medicines supplied on discharge from hospital for one person had not been used as prescribed. This was addressed and checked by the manager immediately. Care plans for medicines were available however these were not up to date or had conflicting information. Comprehensive policies and procedures were in place to support the administration of medicines. Medicines were stored securely and safely including controlled drugs, however the maximum temperature for one fridge had been incorrectly recorded. Although people were not harmed there was a breach of regulation for good governance and records.