Prinsted Care 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 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 people’s safe care and treatment.

This service scored 62 (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. Staff did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Systems for reporting incidents and accidents were not robust. There was inconsistent practice regarding recording and investigating incidents. Some incidents of choking had not been recorded, and investigations were not always thorough to identify improvements in practice or prevent further occurrences. For example, incidents of choking had occurred, but incident reports had not always been completed. The registered manager was aware of these incidents because a complaint had been raised regarding the incident. Actions were taken to investigate the complaint, but this did not include a thorough and robust investigation about the two incidents of choking that were mentioned within the complaint. Another person who was assessed as needing a modified diet had an incident of choking. An incident report was completed and indicated the serious nature of the incident which required a staff member to perform abdominal thrusts to dislodge a blockage. There was a failure to complete a thorough investigation into the incident, and this meant the root cause of the incident was not established, and no further measures were identified to prevent a reoccurrence. We asked the registered manager to urgently review people who were identified to be at risk of choking. Following this assessment they have provided assurances that risks have been reviewed, and appropriate referrals have been made for Speech and Language Therapy (SaLT) assessments to be completed or reviewed.

Other incidents had been recorded, for example when people had fallen. Investigations had taken place and included analysis of possible causes and identified changes to reduce risks of a reoccurrence including additional equipment to support people’s mobility. Relatives told us they were kept informed about incidents that had occurred. One relative said, “I’m always informed if there is anything I need to know.”

Staff told us they knew how to report incidents and said they felt they would be supported if mistakes were made. One staff member said, “If you do anything wrong, they talk to you quietly and discuss what happens, it’s a most respectful place.”

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’s systems supported smooth transitions when people moved to the service. An initial assessment was completed before the person moved in to ensure the provider was able to meet their needs and to identify individual choices and preferences. People and their relatives described being involved in planning their care and support. One relative told us, “We chose this place very carefully, having looked at lots, this was the one that ticked all the boxes.” They described how the homely atmosphere had helped their family member to settle in well, including bringing familiar items from home to personalise their bedroom. Another relative said, “Communication (with staff) has been very good and that gives us reassurance.” Staff described working effectively with health and social care partners to ensure smooth transitions of care. One staff member told us, “The nurses mainly deal with the health care professionals and make sure everything is in place for people.”

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 told us they felt safe living at Prinsted Care Home. One person said, “The staff are all kind and it’s a wonderful place.” A relative told us, “I have no concerns at all, it’s very safe here.” Staff had received training in abuse and demonstrated a firm understanding of their responsibilities with regard to safeguarding people. One staff member told us, “If I saw anything untoward, I would report it to the manager. I can honestly say I have never seen anything worrying.” Records showed safeguarding concerns were reported in line with the provider’s policy and local safeguarding arrangements.

Some people were subject to Deprivations of Liberty Safeguards, (DoLS). The provider had appropriate systems in place to ensure applications for DoLS were made in a timely way and any conditions imposed for DoLS agreements are kept under review.

The provider did not 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 mitigated risks.

Systems for assessing and managing risks were not consistent and robust. Some people were assessed as being at risk of choking and needed food and /or drinks to be modified in line with the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. Staff had received training about the IDDSI framework but did not always demonstrate a clear understanding of what the difference levels meant. Risk assessments, care plans and handover information did not always provide clear, consistent information and guidance for staff. This meant there was an increased risk that people might not receive the support they needed, and the provider could not be assured of people’s safety.

The care plan for a person living with advanced dementia indicated they needed support to eat and drink. They required a level 4 modified diet, this meant food should be pureed. We observed a plate with buttered toast was left in front of them and no staff were sitting with the person. This put them at risk of choking.

At lunchtime we observed a person being supported with their meal. They required a level 5 modified meal, which means food should be minced and moist. Their meal included runner beans which are not recommended for a level 5 meal. The person was heard telling a staff member that there were lumps of meat in their meal. The staff member proceeded to cut up the meat, but this was not minced and did not comply with a level 5 meal. This meant there was an increased risk of choking because the meal was not correctly modified.

Another person’s care plan identified they needed fluids provided at IDDSI level 4, that is extremely thick, and fluids should be given on a spoon. The handover sheet provided to staff identified fluids should be level 2, mildly thick. We asked a staff member if they knew what level of thickness this person needed, they were confident in their response and said, “Yes, Level 2, that means 2 scoops of thickening powder.” A record for the previous evening showed fluids provided to this person were “slightly thick” consistency, which is level 1. These inconsistencies meant the provider could not be sure that the person was receiving fluids modified at the correct level for their needs.

We asked the registered manager to urgently review risks of choking for five people. Following this assessment they have provided assurances that risks have been reviewed, and appropriate referrals have been made for Speech and Language Therapy (SaLT) assessments to be completed or reviewed.

Other risks to people were identified, assessed and managed. Risk assessments were comprehensive and detailed and provided clear guidance for staff.

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

There were robust systems in place to ensure environmental risks were identified, assessed and managed. Staff undertook regular monitoring to ensure safe standards were maintained. For example, maintenance records showed equipment was regularly checked and serviced. Checks were in place to ensure the call bell system worked effectively.

There were safe systems in place to maintain and monitor fire safety. Records confirmed fire drills were held every 3 months and included night staff in line with the fire safety policy. Personal Emergency Evacuation Plans (PEEP) were kept updated and the service had a business continuity plan to ensure arrangements were in place in the event that an emergency evacuation was needed.

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 their relatives spoke highly of the staff and told us the staff were skilled and professional in their approach. One person said, “They all know what they’re doing alright, ever so competent.” A relative told us, “Staff of all levels, activities, nurses, cleaners, and carers are all very professional, caring and empathetic.”

Staff were receiving the training and support they needed for their roles. Nurses told us they received clinical supervision and support from the registered manager. Records showed, and staff told us, they were receiving regular supervision. Staff said they had opportunities for professional development. For example, staff received training through on- line courses, and some face to face training. One staff member explained how supervision meetings were helpful, they said, “It’s useful to discuss any problems and you can speak freely and sort things out.” Another staff member said, “I can express any concerns and seek support. It’s useful to identify training needs and to support my mental well -being.”

The provider had safe recruitment systems in place to ensure staff were suitable to work with people.

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.

Systems to support the prevention and control of infection were robust. There were cleaning schedules for all areas of the service. We observed the service was clean and tidy throughout. People and their relatives confirmed their rooms were regularly cleaned. One person said, “They are very good, the cleaners keep it beautifully.” A visitor told us, “It’s always clean, never any unpleasant smell at all.”

Staff had received training in Infection prevention and control (IPC) and told us supplies of Personal Protective Equipment (PPE) were always available. We observed there were PPE stations on each floor and staff were seen using PPE that was appropriate for the task they were undertaking.

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 were receiving their medicines safely from staff who were trained and had been assessed as safe to administer medicines. A relative told us they were confident in the staff administering medicines and people received them as prescribed and on time. They said, “Parkinson’s medicines are time critical, they are usually pretty good.”

We observed a member of staff administering medicines to people. They followed safe practice in line with NICE guidance and supported people in a personalised way. They were systematic and methodical in their approach and administered medicines to people in the way they preferred. For example, on person liked medicines to be placed in their hand, another person received them from a spoon. Medicines were stored safely, and Medicine Administration Record (MAR) charts were clear and accurate. Some people were receiving as required or PRN medicines. There were clear protocols in place to guide staff in when to administer these medicines. Protocols had been regularly reviewed, and outcomes were clearly recorded, for example when a medication was administered for pain this was recorded as effective or not effective.