Sotwell Hill 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 63 (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 demonstrated a proactive and positive culture of safety that was underpinned by openness and honesty. Staff listened to concerns about safety and took appropriate action to investigate safety related events. Learning from incidents was used to identify areas for improvement and to embed good practice.

People felt confident raising concerns and knew who to raise concerns with. One person said, “If I say something to them, they do listen and deal with things. If I need something they will get it for me.” Another person told us, “I have been treated well. I know I could talk to [named senior carers, owners and key worker].”

Lessons learned following incidents and accidents were now in place. Incidents documented and included root cause analysis. These lessons were shared with the staff team, including through daily handovers, which supported learning and improvement.

The provider worked effectively with people and healthcare partners to establish and maintain safe systems of care. Systems were in place to monitor safety and support continuity of care, including when people moved between different services.

People spoke positively about the support they received to attend appointments and access healthcare services when required. Comments included, “[Staff and relative] sees to all of the appointments I need, mostly people come to see me here. I know the GP comes to see me sometimes if I’m not well,” “It’s good because the GP comes in,” and “They [staff] have spent a lot of time sorting out hospital appointments, transport etcetera.”

Referrals to healthcare professionals were made in a timely manner, staff demonstrated an awareness of risks across people’s care journeys.

Staff understood people’s needs and took a proactive approach to identifying and managing risks.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately.

The provider did not always consistently follow safeguarding procedures. Although concerns had been identified as safeguarding issues, these were not always referred to the appropriate safeguarding authority. In addition, where safeguarding concerns had been raised, the Care Quality Commission (CQC) had not always been notified in line with regulatory requirements. This reduced external oversight and assurance safeguarding concerns were being managed appropriately.

People were supported to understand what being safe meant to them and how to raise concerns if they felt unsafe. People consistently told us they felt safe using the service. One person said, “The main thing is that I feel safe here and the care is good.”

Staff we spoke with were able to describe how they would recognise and raise safeguarding concerns, demonstrating an understanding of their responsibilities to protect people from abuse and neglect.

The service showed a commitment to taking action to keep people safe. Where incidents occurred, investigations were undertaken and referrals made for additional support or equipment where required. Learning from incidents was identified and shared to support improvements in practice. However, documentation of actions taken was not always detailed, which reduced assurance processes were consistently followed and embedded.

The provider worked with people to understand and manage risks in a holistic way. Staff supported people safely and in a manner that enabled them to maintain independence and engage in activities that were important to them. However, assessments did not always reflect people’s current needs and risks.

People spoke positively about the support they received to remain safe. Comments included, “[Staff are] very good they go out of their way to be helpful,” “The staff need to do most things for me because their main concern is that I don’t fall over. I’ve not fallen here but I have done at home,” and “Safe, definitely. They did a fire check, and they know I am claustrophobic. They came and told me there was a practice so I wouldn’t panic and get anxious when the door closed.” This demonstrated staff understood people’s individual needs and took proactive steps to reduce risks.

Risk assessments were not always fully documented. For example, one person identified as being at risk of urinary tract infections did not have a corresponding risk assessment outlining the signs, symptoms and required actions. However, staff showed a good understanding of people’s risks and were able to describe how they monitored changes in people’s health and wellbeing. For example, staff were able to explain the signs and symptoms of conditions such as urinary tract infections and how they would escalate concerns appropriately.

Although staff demonstrated good knowledge in practice, the absence of clear and consistent documentation reduced assurance that all staff would have access to up‑to‑date guidance.

We discussed this with the provider, who acknowledged the shortfall and told us they would take action to ensure appropriate risk assessments were implemented. This will help to strengthen consistency and ensure risk management is fully supported through care planning records.

The provider did not consistently identify, assess or control risks within the care environment. They did not always ensure that equipment, facilities and systems supported the safe delivery of care.

People told us they felt safe within their home environment. Equipment used to support people was within service date and included the future inspection date. The laundry and chemical storage areas were secure, with appropriate locking and clear labelling in place. However, we identified a number of environmental risks which required improvement.

Fire safety arrangements were in place, Records of fire safety checks and drills were maintained. However, Personal Emergency Evacuation Plans (PEEPs) were not consistently available. The provider subsequently confirmed this had been rectified.

A fire exit was partially obstructed. This had previously been identified as a risk in a fire risk assessment completed in 2024. We raised this with the provider, who took immediate action to remove the obstructions and confirmed steps were taken to address the locking mechanisms.

Where fire safety checks had been completed, further documentation around actions and learning were required. The provider told us they would strengthen this further to ensure all required actions and learning were consistently recorded and followed up.

Access arrangements within the building were not fully controlled. Staircases were unlocked, which presented a potential risk of injury. This was raised at the time of inspection, and the provider confirmed action was taken following the onsite visit to secure access and reduce the risk.

Staff knowledge and confidence in using equipment was inconsistent. Training relating to evacuation equipment was not consistently recorded on the training matrix, we were assured this was a documentation oversight. A member of staff was asked to demonstrate how to operate an emergency evacuation chair, they were unable to do so. The provider clarified there has been difficulty operating the key, however this indicated staff were not consistently confident in the use of equipment which may be required in an emergency. Staff we spoke with following the onsite inspection, provided adequate knowledge and confirmed they had received training. The provider advised this would be addressed, ensuring staff received further guidance and clarity.

Following the site visit, the provider demonstrated actions had been taken to address the concerns identified and further improvements were planned.

The provider ensured there were sufficient numbers of suitably qualified, skilled and experienced staff to meet people’s needs. Staff worked well together to provide care that was safe, effective and responsive to people’s individual needs.

People received timely support and felt confident in the care provided. People we spoke with told us they felt safe and well supported by staff. Comments included, “I feel safe living here because the staff are kind and lovely to me,” and “I receive care at night, I am assisted to the loo. They like to see me back in my chair. They have organised the extra care for me.”

Staff told us there were enough staff on duty to meet people’s needs safely and effectively. They felt supported in their roles and felt they had access to training relevant to their responsibilities. Staff told us they were able to ask questions, request additional training and were supported in their professional development.

The service was supported by a stable staff team, with many staff having worked at the service for a number of years. This promoted continuity of care and enabled staff to develop positive relationships with people. The service did not rely on agency staff. People told us, “I do see the same carers and managers and that’s nice because they know me and I know who I can talk to.”

Recruitment checks were in place, such as disclosing barring services [DBS] to ensure staff were safely recruited. There were some areas for improvement. Staff interview records were in place, however, they did not consistently include documented questions asked at interview. The provider assured us a structured process was followed and would ensure records were more detailed in future.

In addition, not all staff had completed specialist training relevant to the specific needs of people using the service. The provider told us they had experienced difficulties sourcing some training but had taken steps to address this and discussed key aspects with staff in the interim.

The provider assessed and managed the risk of infection effectively. They had systems in place to identify, control and reduce the risk of infection spread and shared concerns with appropriate agencies when required.

People spoke positively about the cleanliness of the service. Comments included, “They [staff] are very good on cleaning. I see them always wiping tables and surfaces. My room is well cleaned along with the rest of the place,” and “The whole place is quite tidy and clean inside and out.”

The home environment was clean and well maintained. Staff had access to appropriate personal protective equipment (PPE), including hand sanitiser, gloves, masks and aprons.

Staff we spoke with demonstrated a good understanding of infection prevention and control practices, including the correct use of PPE and maintaining hygiene standards. They also confirmed that adequate handwashing facilities were available to support safe practice.

The provider did not always make sure that medicine documentation was accurate and up to date. Staff involved people in planning, including when changes happened.

Medicine records did not always provide full assurance people received their medicines safely.

Stock balances and ordering processes were sometimes difficult to follow, therefore it was not always clear whether medicines had been missed. This reduced assurance medicines were administered as prescribed and monitored effectively.

One person was supported to administer their own medicines, however, there was no documented risk assessment or information outlining the medicines involved or how this should be managed safely.

Medicines were mostly stored appropriately. However, some medicines due to be returned had not been promptly recorded, and documentation for returned medicines was not always updated. Following the onsite inspection, the provider evidenced medicines had been returned and assured us this was a recording issue.

Care plans contained guidance on how people preferred to take their medicines and how their physical needs impacted on this. However, for 1 person, the medicines recorded in their care plan did not align with their Medicines Administration Record (MAR) chart.

People felt supported and reassured in relation to their medicines, people were happy with the way their medicines were managed. Comments included, “They [staff] bring them along on time [medicines] and watch while I take my tablets,” and “I do have some tablets. I get what I need, given to me at night. They will bring me [pain relief medicine] and give them to me [staff are] thoughtful and caring.”

The provider had systems in place to manage medicines safely, however these had not identified the issues we found during inspection. Weekly medicines audits were completed, which included checks of stock levels and identified discrepancies. Where issues were identified, these were reviewed and addressed. Protocols for ‘when required’ (PRN) medicines were in place, and staff medicines competencies were checked regularly to support safe practice.