Sowerby House

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 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. The registered manager reviewed all accident and incident records to identify any responsive action required. Any lessons learned from incidents, audits or safeguarding issues were discussed with the team in staff meetings.

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 or accessed different services. For instance, some people received elements of their clinical support from the community nursing team who regularly visited the home. A visiting professional told us there was good communication with the staff and a system to record any professional advice or instructions given.

The provider worked with people 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.

Staff were aware of signs of potential abuse, and how to report any concerns. They were confident the registered manager would deal with any issues appropriately, including reporting to the local authority safeguarding team. The provider took responsive action where required. There was an on-going safeguarding case at the time of our assessment, and the provider took prompt action in response to some shortfalls identified during the investigations.

Where required, applications had been submitted to lawfully deprive people of their liberty and staff received training in relation to the Mental Capacity Act.

The provider had made improvements in the management of risk and was no longer in breach of regulation 12. Staff demonstrated good understanding of potential risks relating to each person, such as mobility, health and wellbeing risks. They understood the need to respect people’s choices whilst encouraging them to accept care interventions aimed at reducing risk. For instance, regular repositioning to prevent pressure wounds. We saw staff intervened appropriately to support people and monitor their safety.

Relevant support and equipment were provided, where required, to help minimise potential risks. Care plans contained information about people’s preferences and views in relation to decisions about risk. Risk assessments were regularly reviewed and generally well completed. We noted some examples where elements of people’s care plans were not consistently updated or had contradictory information. The provider addressed this straightaway and told us they would continue to monitor the quality of care plans.

People told us they felt safe, and one person commented, “The people around me make me safe, nobody makes me feel unsafe.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Since our last inspection, the provider had made improvements to the environment. This had included redecorating various communal areas and replacing the lounge area carpet. The provider advised us people using the service had been involved in choosing the colours and décor, including new furniture and curtains which were on order for the main lounge. Some bedrooms had also been decorated and there was a plan to continue working through and redecorating the remaining bedrooms. Areas of the home that had been redecorated since our last inspection were already starting to show signs of wear in some areas. The provider was aware of this and advised they had an on-going program of maintenance and redecoration for the home.

The home had a maintenance person, who staff told us would promptly rectify any issues they reported. Regular health and safety checks were completed in relation to the environment and equipment. On our first visit to the home there were two free-standing heaters in use in a corridor. These had radiator covers over them which were not secured to the wall, so could potentially be knocked over or moved. The provider addressed this straightaway and secured the covers.

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.

Visiting professionals, people using the service and relatives felt there were usually enough staff available. Although one person indicated they had to wait for assistance sometimes. A relative told us there were, “Always enough staff when I visit. All friendly, very calm. All seem to know what they are doing”. Another commented, “Now they have regular staff it’s much better”.

The provider used a dependency tool to assess how many staff were required, and rotas reflected this number of staff. Agency staff were used to cover any shortfalls in planned staffing levels. Staff we spoke with told us there were generally enough staff to meet people’s needs. The provider told us recruitment was ongoing for some staff vacancies at the time of our assessment.

Safe recruitment procedures were followed by the provider and appropriate checks conducted. Staff were satisfied with the induction and training they received. Since our last inspection staff were now receiving more regular supervision.

The provider had made improvements since our last inspection and now assessed and managed the risk of infection appropriately. They detected and controlled the risk of infections spreading and had systems in place to share concerns with appropriate agencies promptly.

The environment was clean, the laundry was more organised and cleaning schedules were in place. There were still occasional gaps in cleaning records, but the provider was aware of this and was advertising for a head of housekeeping role to help address this. Findings of an externally conducted infection prevention and control (IPC) audit had been positive.

Relevant IPC policies and procedures were in place and staff completed training in this area. Staff had access to personal protective equipment (PPE) and knew when and how to use this.

Sufficient improvements had been made in medicine management that the service was no longer in breach of Regulation 12, however further improvements were needed in medicine records. Systems were in place to make sure people’s medicines were administered safely. Stock mainly balanced with records; however, a running balance was in place for assurance and some discrepancies had not been escalated for investigation.

People’s medicines allergies were recorded accurately. Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Information for how these medicines should be administered needed further person-centred detail. Since our last inspection a system was in place to record variable dose medicines, however, when medicines were not given there was a gap in the record where a non-administration reason was not recorded. Guidance was available for creams applied by care staff as part of personal care, however, records were not fully completed. Patch application records were in place but did not always demonstrate rotation in line with manufacturers guidance to prevent side effects.

Medicines were stored securely including controlled drugs. Temperatures were recorded for the medicine rooms and fridges to ensure medicines were safe to use. Comprehensive policies and procedures were in place to support the administration of medicines. Audits had picked up some of the issues we found. After our assessment the provider showed us improvements made in records. These need to be embedded in practice.