Pottles Court

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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

The provider organised managers’ away days to create an opportunity for case studies to be discussed and reflected upon based on the people they supported. Staff learnt from each other, embracing success and reflecting on where to improve. Lessons were learnt to continually identify and embed good practice

Staff listened to concerns about safety and investigated. Accidents and incidents, including episodes of distress, were recorded on the electronic system. Staff told us they valued debriefs after difficult incidents and space to reflect on the life of a person after their death.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when people moved between different services.

Staff had detailed care plans to assist them to support people in a person centred way. These brought together information about their physical and mental health, communication, and day‑to‑day support. Staff worked closely with the local GP and community nurses. Staff knew when to contact specialist community teams for additional guidance, such as speech and language therapy, and the older people’s mental health team to plan and review care.

People moving into the service were carefully planned and managed. A relative described the reassurance provided by the registered manager and staff and how they welcomed their mother to the home. They told us how much this approach had eased their concerns and how their confidence was restored in making the difficult decision to move their relative from another care home.

The provider worked with people and 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, abuse, discrimination, avoidable harm and neglect. However, staff outside of the care role had not completed safeguarding training despite their contact with people living at the home. The registered manager said this would be addressed to ensure they knew how to recognise abuse and report concerns.

Care staff completed safeguarding training and were clear about how to report concerns both within the service and to external agencies.

People looked at ease in their surroundings and felt safe to express their opinions. Visitors told us their relatives were safe. They based this view on the numbers of staff, and their kind and attentive approach which had a positive impact on their relative’s sense of safety and wellbeing.

Safeguarding policies included clear guidance on when to raise concerns with local authorities. Records showed appropriate referrals and follow‑up when safety concerns were identified.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care that was safe and supportive and enabled people to do the things that mattered to them.

Risk assessments were person‑centred, recognising people’s strengths, what they could do independently and where they required staff support, for example with moving. Care plans described early warning signs and strategies to support staff to provide personal care in a manner or time which was acceptable to the person. This included explaining clearly what support they wanted to offer, changing their approach and the timing of this intervention. Staff were skilled at recognising when people were in pain and how this might impact on their willingness to participate in an activity, such as personal care.

Staff used risk plans in day‑to‑day practice and gave examples of adapting support when people’s needs changed. For example, recognising when a situation was overstimulating them and they needed space to feel safe and in control again.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental safety checks covered areas such as fire safety, gas and electrical installations, water systems and equipment maintenance, however improvements were needed in the oversight of these checks. Improvements were also needed to ensure there was better communication between staff and the management team when issues needed addressing. For example, a delay was identified in rectifying an uncovered radiator in an occupied room, which potentially could cause a risk of burns.

All staff had completed fire safety and fire extinguisher training which was in date. However, formal fire drills were overdue for staff and records did not show how the registered manager was overseeing staff attendance in response to unplanned activations of the fire alarm. We raised this as an area that needed addressing.

Recent investments by the provider included replacing windows, flooring, laundry equipment, redecoration, profiling beds, boilers and investing in the lift to increase its reliability. However, a new specialist bath had been fitted which required additional work to make it useable. This meant people did not have the choice of a bath or shower. Some aspects of the home were looking tired, including the paintwork on people’s doors and 2 rusty radiators in communal toilets.

Relatives and staff told us they liked the homely appearance of the service but also said they would like to see more work on the home’s décor and investment in updating furnishings. A group of visitors had volunteered to brighten up a communal area of the home to benefit people living at the home, including their own relatives.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs.

The provider told us they chose to staff the home at a level above the dependency tool level. This was noticeable as there was always staff observing communal areas which meant people received attentive care and helped to reduce the risk of falls. For example, staff responded quickly to support people if they chose to get up and walk without equipment, which potentially placed them at risk of falls. People and relatives said there were enough staff who knew them well and responded when they needed support.

A training matrix showed high completion rates for mandatory and specialist training, including dysphagia, food and fluids and oral health care. Ongoing competency checks covered medicines and other key tasks. Recruitment practice ensured staff recruited were suitable for their role.

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.

People and their visitors commented on the cleanliness and said they were impressed with the lack of unpleasant odours in people’s rooms and communal areas. There were cleaning schedules, including a deep cleaning rota for bedrooms, and systems in the laundry. Staff had infection prevention and control training and used personal protective equipment appropriately.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Relatives and staff said medicines were well managed and health professionals were involved when changes were needed. Staff were gentle and reassuring in their approach when they brought people their medicines, including explaining the purpose of the medicine.

During our visit, the registered manager liaised with the GP to discuss covert medicines for a person becoming increasingly reluctant to accept their medicines. Their understanding of its purpose had deteriorated as their dementia progressed. Discussions took place around it being in their best interest.

Staff also involved relatives in discussions in recognition of them holding a lasting power of attorney for health and welfare. The service followed a clear approach to reducing unnecessary medicines, especially those used for supporting people who were agitated. Alternative strategies were used before giving “as required” medicines, in line with best practice.

The provider had invested in a new electronic medicines system, which staff praised. This enabled close monitoring of medicines administration and enabled a robust auditing of medicine management. Improvements were being made to medicine storage arrangements

Medicines administration records, protocols for medicines taken when required and individual care plans set out clearly how each person preferred to take their medicines and what support they needed.

Staff received face‑to‑face and online medicines training, with competency assessments and practical observations by senior staff.