Spencefield Grange

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.

The provider was previously in breach of the legal regulations in relation to
safe care and treatment, safeguarding and safe staffing. Improvements were found at this assessment and the provider was no longer in breach of these regulations.

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 reviewed regularly by the manager who analysed these for themes and trends. Actions were followed up by the management team. The service had procedures to ensure a positive learning culture. Staff were knowledgeable about what to do in the event of an accident or incident. The staff told us they felt well trained, and meetings and handovers were effective, allowing for good teamwork. One staff member told us, “If something happens in the day, the senior will be informed in the handover in the night. We attend the handover, so we hear what’s happened.” This meant staff could take steps to ensure people’s needs were met and learning was shared to prevent incidents from reoccurring in the future.

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 and their relatives told us they were supported when they used different services. One relative told us, “Any appointments and staff will take her.” During our inspection we observed a person being supported by a staff member to an appointment. The service collaborated with people and healthcare partners to establish and maintain safe systems of care, ensuring safety is effectively managed and monitored. People had initial assessment documents in place which covered all appropriate areas and helped to formulate their care plans. One staff member told us, “We do ask about personal info for care plans.” The manager said, “For admissions we do an assessment face to face of what their needs are, how they will integrate with the others in the home. We always ensure it is a safe admission.”

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. People told us they felt safe living at the service. Relatives felt their family member was kept safe and staff would act if they observed anything they thought was wrong. One person said, “I feel safe here because nothing awful ever happens.” The provider shared concerns quickly and appropriately. Staff had undertaken training on safeguarding, mental capacity and Deprivation of Liberty Safeguards (DoLS). Staff knew how to recognise signs of abuse and discrimination; they understood their role to report concerns. They were confident the manager would take the appropriate action. 

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. We observed staff supporting people to move safely around the service using the correct equipment. Staff told us they had enough information about people’s risks and used the electronic care planning system. Risk assessments addressed all aspects of people’s care and support needs. Where people were at risk of falls, assistive technology was used such as sensor mats to alert staff when people were moving independently. One relative told us, “[Relative] has had no falls or accidents, they have a crash mat and bed alarm which I have experienced in use and staff reacted very quickly.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. We observed people using different parts of the service including communal areas and were observed to move freely as they wished. When people were in communal areas staff were present to offer support if required. The manager understood their responsibilities to ensure a safe environment and told us how they ensured the environment was safe.  The management team completed daily walk arounds to check the environment was safe. The manager told us, “I do a daily walk around the service to check the environment, and my staff know to let me know of anything that occurs.” Records demonstrated where issues were identified they were rectified promptly. External specialists and contractors conducted essential checks, including gas and fire safety. Personal emergency evacuation plans were in place and accessible to staff and others, in the event people needed to be evacuated. The provider had a service improvement plan in place, and we observed ongoing redecoration during our inspection. One relative told us, “The Home is always clean and tidy, newly decorated, light and airy.”

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. Procedures were in place to ensure the required checks were carried out on staff before they commenced their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions. The provider used a dependency tool to assess people’s individual care and support needs and was used in determining staffing levels. We observed there were enough staff on duty to meet people’s needs, and feedback from most people confirmed that staff were available when needed. Comments included, “I’m sure there are enough staff. They work very hard,” and “If I need help, I just press the buzzer. They come.”

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. We observed the service to be clean and well-maintained. Personal Protective Equipment (PPE) was readily available throughout the service and staff used PPE when needed. Staff had received infection prevention and control training, and they had access to relevant policies. Staff had a good understanding of appropriate waste disposal and the need to dispose of infectious waste appropriately. They also spoke about measures to contain infection. 

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. Staff received medicines training, and their competency was assessed annually. Staff were able to explain about the different tablet formulations and appropriate management such as administration of critical medicines.

Systems and processes to safely administer, record and store medicines were in place. There were topical medication administration records (TMARs) and body maps for people. However, staff did not always use them to record the application of external products such as creams and ointments as this was done online under people’s personal care. Transdermal patch rotations were used to ensure appropriate application and site rotation of pain patches.

Where when required (PRN) medicines were prescribed and administered and there were records for rationale and outcomes. The majority of care plans and PRN protocols were person-centred and contained sufficient information for staff to support people with their complex needs. We saw good examples where staff carried out additional monitoring for medicines where necessary to ensure that they were safe and effective. These included regular blood glucose monitoring, as per insulin protocol, and regular oxygen saturation monitoring.

People’s medicines with a limited shelf-life like liquids and creams were dated appropriately.

Room temperatures were recorded daily and medicines that needed refrigeration were stored securely with records available of current temperatures monitored daily. However, the maximum and minimum temperatures were not recorded, and the fridge thermometer was not adjusted to ensure the medicines were stored safely, as per the provider’s policy.

Controlled drugs (medicines requiring more control due to their potential for abuse) were stored safely and securely with access restricted to authorised staff and recorded appropriately.

Medicines were disposed of safely and regularly when no longer required and records were kept up to date.