Freshfields Residential Home

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 requires improvement. At this assessment, the rating has changed to good. This meant people were safe and protected from avoidable harm.

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.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had systems in place to record accidents and incidents. Staff documented any events, and the management team carried out investigations to identify the root causes. This process helped reduce the risk of similar incidents occurring again, supporting people to remain as safe as possible while using the service.

Staff were informed of the outcomes of these investigations and were encouraged to report any concerns they identified while providing care and support. This promoted transparency and continuous learning within the service.

The provider had an on-call system in place where a member of the management team was available to advise staff in the event of an emergency. Procedures were in place for staff to follow in an emergency, for example, if a person become unwell or had a fall.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked collaboratively with people and healthcare partners to establish and maintain safe systems of care. These systems ensured that risks were appropriately managed and monitored. The provider also made sure there was effective continuity of care, including when people moved between different services.

Pre-admission assessments were thorough and included relevant information. This ensured staff had sufficient detail to understand people’s needs and to determine whether the service could meet them effectively.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider had effective procedures to guide staff on protecting people from abuse and avoidable harm. People using the service told us they felt safe, with a person saying, “I do feel safe here.” Records showed, and staff confirmed, that they had completed training to support their knowledge and understanding of how to keep people safe.

Staff were confident about the procedures to follow if they identified any concerns or if someone disclosed information of concern, and they understood their responsibilities to protect people from harm. A staff member told us, “I will report any concern to the manager.”

Relatives knew who to contact if they had concerns about the safety of their family member. A relative commented, “My [family member] is safe in the home, I have no concerns.” The registered manager and the deputy manager demonstrated a clear understanding of their responsibilities in safeguarding people. Through our discussion on safeguarding, it was evident they and the staff working in the service knew how to escalate any concerns appropriately.

The provider worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our last inspection, we found that risk assessments did not always consider factors that could increase or decrease risk. For example, we looked at a person’s falls risk assessment, and we saw that it did not consider the person’s medical conditions. The person’s medical conditions affected their mobility and stability and therefore should have been taken into account.

During this assessment, we found the service completed individualised risk assessments to monitor potential risks and help keep people safe from harm. These assessments were personalised and covered different aspects of people’s lives, including health conditions, and the risk of falls. Guidance was in place for staff to follow on what actions to take in relation to manage risks to make sure people remained as safe as possible.

Additional supporting documentation was in place to help manage identified risks, such as weight-monitoring records and fluid charts.

Risk assessments were reviewed regularly and updated as required, for example, when a person had been discharged from hospital and their needs had changed.

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 management team conducted an environmental assessment to identify potential hazards and implemented appropriate risk mitigation measures. Staff ensured that all areas were free from trip hazards, and equipment, such as hoists, were routinely inspected to confirm safe and effective operation. These actions supported the delivery of care in a safe and controlled environment.

We saw fire safety checks were undertaken and the hot water temperatures were monitored to ensure people were not at risk of scalding.

At the last assessment, we felt the service could be made more dementia friendly, such as personalisation of peoples' room doors and different flooring. We discussed this with the provider, and they told us they would discuss this further with people using the service and investigate how to improve based on people’s preferences.

During this visit, we found the provider had acted on our recommendation and they had made improvements to the areas making the service more dementia friendly. The provider ensured the environments were familiar and homely for people who used the service. People were also able to personalise their bedroom. Some flooring had been replaced as well.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff working for the service to meet people’s needs and to provide personalised care and support. We reviewed the staff rota, and this showed there were enough staff on duty. The registered manager made sure that people were looked after by the same group of staff members who were familiar with their care and support need. This helped with consistency and continuity of care.

At our last inspection, we found recruitment practices at the service were not always robust. The service had no record explaining gaps in staff’s employment histories. During this assessment, we found the provider had effective recruitment procedures to make safe recruitment decisions when employing new staff. Checks had been undertaken before new staff started working for the service. We saw evidence of identity checks, employment histories, references being taken and criminal records checks had been carried out for each staff member.

People were supported by staff that had the necessary skills and knowledge to effectively meet their assessed needs. At our last inspection, records showed that some staff had not completed training that the provider considered mandatory. For example, 8 care staff had not had infection control training.

During this assessment, we found the provider had a training programme for all staff to complete to ensure they had the skills to meet people's needs. Staff completed training in a number of key areas such as moving and handling, medicine management, first aid, food hygiene and infection control to ensure they were competent in their role.

Relatives told us that staff knew how to care and support their loved ones. A relative said, “The staff do a good job, and they know what they are doing.” A staff member said, “The training is good.”

New staff received an induction, which covered their familiarisation with the service, the people who used it and the policies and procedures of the provider. Before staff worked on their own, they were given opportunities to shadow experienced staff. We met a new member of staff who was doing their induction on the day of our first visit. They commented positively about the provider’s induction process.

Staff were given appropriate support, which helped to ensure they were able to provide effective care. Staff had regular 1 to 1 meetings with their line managers, where a number of areas were discussed, such as their training needs and people’s care needs. Staff felt well supported by the management team. Staff who had worked for the service for more than 12 months, received an annual appraisal to check their competencies and the skills to do their work.

The provider had an effective approach to assessing and managing the risk of infection, which is in line with current relevant national guidance.

The provider had policies and procedures on the prevention and control of infection. Staff were aware of their responsibilities regarding infection control and prevention.

Staff were provided with personal protective equipment (PPE) such as gloves and aprons to protect the spread of infection.

We observed that the home was clean and tidy and a cleaning schedule was in place to minimise the spread of infections.

Staff had received infection-control training and understood their responsibilities in this area. For example, they were aware of the steps required to prevent the spread of infectious diseases, such as proper hand hygiene and ensured PPEs were disposed of appropriately.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People told us they got the help they needed to take their medicines, and they were happy with how everything was organised. A person said, “The staff give me my medicines on time.”

Each person’s care records clearly showed what medicines they were prescribed. Staff who supported people with their medicines had their competency checked, so they understood how to give medicines safely. Staff had received training in the management of medicine.

The medicines administration records (MAR) we looked at were completed properly, with no missing signatures. A senior staff also regularly audited these records to make sure people had received their medicines as prescribed.

Any medicines prescribed to be given ‘as necessary’ were monitored and protocols were in place to explain when these medicines should be given.

Controlled Drugs (CDs) were stored correctly, and a running balance was kept and checked at every entry.