Archived: Schoen Clinic York, Wellen 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the management of medication, risk management and safe staffing.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty.

Whilst staff recorded accidents and incidents and knew how to escalate concerns, the provider had not always monitored or investigated all of these. There were missed opportunities to learn lessons and to support the service to continually identify, improve and embed best practice.

One staff member told us “There was no process or debrief following any incidents or accidents. There was a lesson meeting every month, which no longer happened so lessons were not learnt to improve the service.”

The provider took steps to maintain safe systems of care when people move between different services

Information was available if people needed to access another health care setting. For example, people had hospital passports in place to ensure important information about people’s healthcare needs could be shared should people be admitted to hospital from the service.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately with external stakeholders.

Systems and processes were not always followed. Safeguarding referrals were not always completed in a timely manner which could have delayed concerns being identified and acted on. Not all staff had received safeguarding adults training; however, the staff we spoke with understood their responsibilities to protect people from abuse and harm.

Relatives did not always feel the service was safe. One relative expressed concern about the falls their family member had experienced and had not always made aware of action taken by the staff and provider. Other relatives raised concerns about personal care. “Personal care is not great, no socks or slippers, toenails incredibly long. I had to clip them” and “[Name]is usually unkempt, unshaven written in [their] care plan, to have hair combed in a particular way. Not always clean and tidy.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people were identified; however, action to manage and reduce these risks were not always known or followed by staff. For example, we observed staff supporting one person with their meal. The staff member did not follow information provided by health professionals to reduce the risk of choking. We shared this information with the provider, they explained they would review this and ensure staff were following the correct procedure when supporting people with their meals.

The provider had not ensured information relating to risks associated with specific health conditions was consistently incorporated into care records. This meant staff did not always have access to the necessary guidance to support safe care delivery. For example, advice provided by healthcare professionals regarding the management of diabetes had not been reflected in one person’s care plan. We raised this with the provider, who acknowledged the concern and confirmed they would urgently review the care plan in consultation with the GP.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had policies in place to support systems and check to identify and manage risks within the environment. The provider had identified risks relating to emergency cords and the security of firefighting equipment and was taking action to address these. Equipment was available to staff to support people in emergency situations. For example, we observed staff using equipment to safely support one person to stand when sat on the floor.

The provider had appropriate arrangements in place for ensuring the security of the premises and carrying out regular health and safety checks such as, fire safety, water and gas.

The provider did not make sure staff were qualified, skilled and experienced to meet people’s needs.

Staff were not always suitably trained and supported to care for people in line with their assessed need. Whilst the provider ensured appropriate staffing levels and had developed a training programme that was been implemented, not all staff received dementia related training for the specialist care they were employed to provide. One staff member told us “I did not receive any dementia training initially and felt I was thrown in the deep end; however, I have now completed this.” This was discussed with the provider, who told us that “dementia training had been organised but then rearranged due to unforeseen circumstances.” However, we observed people were supported in a timely manner.

Staff were not always suitably trained and supported to care for people in line with their assessed need. Staff had not always received an appropriate induction and training when starting employment. A staff member told us “I’ve not had a proper induction, not really any shadowing opportunities, I was just straight into the staffing numbers.” There was no evidence in the providers training matrix to show induction training had taken place or how this was being organised.

Rotas were in place to inform staffing levels at the service. Where shortfalls occurred, the provider used agency staff. However, the provider did not always follow their own policies and procedure to ensure these staff were suitable to work within the service or consider the skill mix and abilities of staff in place for each shift.

Staff recruitment was safe, and appropriate pre-employment checks were in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had received training in infection, prevention and control and had access to Personal Protective Equipment [PPE], which included gloves and aprons. Staff were observed using PPE appropriately.

The provider had employed additional housekeeping staff to ensure the cleanliness of the environment.

The provider did not always make sure medicines management and treatments were safe.

Staff did not always administer people’s medicines as prescribed. Staff had administered one person’s medicines alongside other medicines, despite the prescribers’ instructions not to administer this medicine with any other medication.However, we observed that this did not impact the person.

Staff had not always recorded when people had refused medicines or action when this occurred. For example, consulting with a person’s GP.

Timely action was not always taken to ensure people had adequate supplies of their medicines. Because of this people did not always receive their medicines until further stock was made available.

Records relating to the administration of topical medicines, like creams and ointments, were not always completed. This meant there was a lack of assurances they were administered as prescribed. Information for these medicines was also not included in the persons care plans.