Philip Cussins 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 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 provider was in breach of legal regulation in relation to good governance.
 

This service scored 56 (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 completed incident and accident records, and these were investigated. However, lessons were not always learnt to continually identify and embed good practice. Whilst the provider had developed a specific template to record the findings from analysing individual incidents and accidents, this lacked any meaningful information about trends or lessons learnt.

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 assessed before and after their admission to the home. This helped staff gain an understanding of people’s needs.

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 the home. A person said, “The staff check every 2 hours at night to check we are alright.” There had been no recent safeguarding concerns involving people living at the home. However, the provider and staff were aware of the correct procedures to follow. Deprivation of Liberty Safeguards (DoLS) authorisations were in place for all relevant people, and any conditions were added to people’s individual care plans.

The provider did not always 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 enabled people to do the things that mattered to them. Risk assessments lacked specific information about the measures needed to keep people safe, such as where a person had been assessed as a high falls risk.

The provider did not always effectively detect and control potential risks in the care environment. Environmental risk assessments and health and safety checks were completed. However, there had been a delay in carrying out the most recent fire risk assessment and an on-going minor defect on a fire extinguisher had not been addressed in a timely way. Equipment had been serviced to ensure it was in working order.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The provider did not maintain oversight of which staff had completed all their essential training and had received regular supervision. However, staff told us they had completed these. People told us there were enough staff to meet their needs in a timely way. A person said, “Oh yes, there are plenty of staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly. The home was clean and tidy throughout.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in developing their care plans. Medicines storage required improvement to ensure medicines were stored securely and safely. Records showed there were times when medicines were not stored at a safe temperature and lacked information about action taken to investigate and address this. For a person with time critical medicines, staff were not recording the time these were administered to provide assurance they were given on time. Guidance for staff was not available for some ‘when required’ medicines. Where guidance was available, this had not been reviewed since 2023. Recording of ‘when required’ medicines was inconsistent, with some staff using the agreed code and others not recording anything. Medicines competency checks, to ensure staff were skilled to give medicines safely, were not documented appropriately. There was also no evidence to show the staff signing off competency checks had received training from a competent person to do this.