People in Action - Old Hinckley Road

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 inspection we rated this key question good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

Accidents and incidents were recorded and analysed to identity any trends or patterns so actions could be taken to mitigate emerging risks. Processes ensured any learning was shared with staff through handovers and staff meetings, to ensure they had up to date information to support people safely.

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.

People’s needs were fully assessed before they moved into the home. This information was used to develop care plans and risk assessments to ensure staff had the information needed to provide safe, personalised care.

Staff knew people well and demonstrated a good understanding of their needs. During our visit, we saw staff quickly understand and respond to changes in people’s behaviour who were unable to express their needs verbally. For example, one person became slightly distressed rocking back and forth. Staff intervened and found they needed help to blow their nose, staff quickly sorted this out and the person calmed.

Staff worked closely with health and social care professionals to ensure people achieved good outcomes. One staff member said, “We all (staff) know people very well and pick up on any changes in their health quickly, it’s important to take notice of all the subtle, little changes which may indicate a health concern."

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 shared concerns quickly and appropriately.

People felt safe with staff. One person told us, “Yes, I am.” A relative said, “[Person] is safe and well looked after.” Another relative, told us, “My loved one is very safe at the home.” During our visit we saw people were relaxed and enjoyed the company of staff. Staff had received safeguarding training and understood their responsibilities to keep people safe. One staff member told us, “I would reassure the person and report any concerns to my manager straight away. I need to make sure they are safe.”

Records showed the management team had referred safeguarding incidents to the Local Authority (LA) and CQC appropriately.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the service was meeting these principles for example, care records contained capacity assessments and where needed, for people assessed as not having capacity, decisions relating to aspects of their care were made in people’s best interests.

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

Relatives felt staff supported them well to manage any risks of potential harm or injury. One relative told us, “[Person] has special dietary requirements, all staff are aware of this and are totally on top of the food situation required by them.”

Risk assessments were in place to guide staff on how to support people safely, to mitigate risks associated with for example, falls, choking and people’s mental wellbeing. Records confirmed staff had followed these instructions.

Care records and risk management plans had been regularly reviewed and updated where needed.

People were involved in regular fire evacuation drills, so they were familiar with the sound of the fire alarm and the importance of quickly moving to safety. People also had personal emergency evacuation plans (PEEPs) and staff knew what support each person required in the event of an emergency.

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

Processes were in place to ensure the home and equipment were regularly checked and maintained in a good working order.

The provider ensured staff were trained to use any required equipment. Discussions with staff demonstrated they understood the importance of checking any equipment prior to its use, to ensure it was safe and in good working order. A staff member told us, “If I found the (pressure) mattress deflated, I would check all the settings and that it hadn’t been unplugged. If this didn’t sort out the problem, I would call the company out as a priority and let staff know.”

During our visit, it was a very hot day, and staff had ensured curtains were drawn and portable fans were used to ensure people remained as comfortable as possible.

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.

People and relatives were happy with the support they received from staff. One person said, “I do like the staff and have got to know them well.” A relative told us, “Staff seem to be trained to the highest level, and I cannot compliment them enough.” Another relative said, “Staff know [Person] very well and can easily adapt to any situation that may arise.”

Rotas demonstrated staffing levels were maintained and people were supported by a consistent staff team. During our visit staff were available when people needed them and people's requests for assistance were responded to promptly.

Staff had been recruited safely in line with the provider’s safe recruitment processes to ensure their suitability before they started working at the service. New staff received an induction which included training and working alongside more experienced staff to learn about their role and people’s individual needs. One staff member said, “I get all the training I need to do my job well."

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

The kitchen had not been well-maintained, for example worn and damaged cupboards made it difficult to ensure effective cleaning and good hygiene standards were in place. The executive director told us, “The infection control risks raised will be treated as a priority, I will expedite work to ensure they are addressed, while we wait for the kitchen refurbishment scheduled towards the end of the financial year.” In contrast other areas of the home were welcoming, personalised and in a good state of repair.

Staff had received training in infection prevention and control. During our visit we observed staff washing their hands regularly and using personal protective equipment (PPE) appropriately.

The registered manager regularly completed infection prevention and control audits which highlighted any shortfalls and the actions needed to address these.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. Staff responsible for medicines management had completed training and their competency to administer medicines safely was assessed.

Robust systems and processes were in place to ensure medicines were stored and managed safely.

Protocols for medicines prescribed ‘as and when required’ (PRN) included guidance in terms of medicine to be administered, reason for administration, and the maximum dose to be taken in 24 hours.

Clear guidance and body maps were in place to inform staff where to apply prescribed creams on the person’s skin. Risk assessments were also in place for those creams which contained flammable ingredients to inform staff of the measures they should take to reduce the risk.