Susan Hampshire 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 75 (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.

Systems were in place to learn lessons and make improvements to people’s care. Daily handovers and team meetings were used to share learning.

The registered manager ensured accidents, incidents and complaints were investigated appropriately, with outcomes and lessons shared with staff to reduce the risk of recurrence. The registered manager had implemented a new lessons learnt form to capture more detail to help with an analysis to ensure any learning was considered and embedded. This was in response to a recent falls audit that was completed. This was because the log of incidents did not fully capture the learning that had taking place.

There was evidence of openness and transparency, in line with duty of candour requirements. Relatives confirmed they were kept informed of any incidents, accidents or safeguarding concerns. A relative told us they had some concerns, but this had already been flagged by staff, and there was a plan in place to support (name of person).

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.

Two people had recently moved to Susan Hampshire House. A comprehensive assessment had been completed seeking the views of the person, their relative and health and social care professionals. A relative spoke positively about the move, with opportunities to visit home to meet staff and the other people living in the home. This helped their relative to make the decision to move on a permanent basis. The registered manager and deputy manager had met both people in their previous home enabling them to get to know them before they moved to the service. This enabled them to complete a comprehensive assessment, which then informed the person’s plan of care. The registered manager told us the care plan was evolving as they were getting to know the individuals.

Healthcare passports were in place to support people when they were admitted to hospital or moved from one service to another to ensure continuity of care. A relative raised a concern that their loved one had been admitted to hospital recently and was not accompanied by staff. The registered manager told us this was Freeways Trust Policy. However, where possible staff would support where this did not compromise the care at Susan Hampshire House. The registered manager recognised that the ward environment could trigger a number of emotions for people, especially where people were unable to communicate their support needs.

People told us they were supported to attend healthcare appointments, and other professionals were involved in their care as necessary. Specialists such as the local Community Learning Disability Team, neurology and speech and language professionals supported people who lived at Susan Hampshire House. Clear records were completed of any appointments including any follow up appointments or actions.

The registered manager confirmed that everyone living at Susan Hampshire House was now registered with a dentist. Oral health care plans were in place to guide staff on the support each person needed.

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.

The registered manager had made improvements since the last assessment to ensure staff were fully aware of the importance of reporting concerns promptly. This had been discussed during supervisions and team meetings. Staff confirmed they knew what to do in the event of an allegation of abuse being made. All staff had completed safeguarding training. Staff were aware of the reporting process for allegations of abuse. There were policies and procedures to guide the staff on what to do if an allegation of abuse was made, and how staff could raise concerns using the whistle blowing policy.

The provider had appropriately raised safeguarding concerns. This included sharing information with the local authority and the Care Quality Commission (CQC). The level of information shared with other agencies had been appropriate and sufficient to keep people safe. As a result of the safeguarding concerns and subsequent investigations, changes were made to people's care arrangements when required to keep them safe and help prevent recurrence.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA. Deprivations of Liberty Safeguards were in place or with the Local Authority waiting for authorisation for people who lacked capacity.

People’s care plans included information about any Lasting Powers of Attorney (LPA). A Lasting Power of Attorney (LPA) isa legal document that allows you to appoint trusted people, called attorneys, to make decisions on your behalf if you lose mental capacity in the future.However, it was not clear who had this and whether it was for health and welfare or finances. The registered manager provided assurances that this would be addressed along with seeking copies of the LPA for the new person who had recently moved to the home.

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.

Since the last assessment, the registered manager had made improvements to ensure people’s safety was assessed, monitored and managed effectively. Where people were at risk of malnutrition and weight loss, systems had been put in place to monitor these areas including skin integrity. Staff were now completing food and fluid charts electronically. The registered manager and the provider could monitor these remotely enabling them to analyse the data to ensure people’s needs were being met and risks minimised.

Risk assessments were in place to help keep people safe whilst they were in their home and the community. This included planning for holidays for people ensuring staff had guidance available to minimise risks whilst away from the home. Staff described how they kept people safe without restricting them and supported them to have control over their life. Environmental risk assessments had been completed to help keep people and staff safe.

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 was a programme of ongoing maintenance, refurbishment and decoration. The kitchen had been replaced since our last visit to the service, and the access arrangements to the home had been reviewed. Visitors now only entered the building via the front door. Clear signage had been placed in the home’s car park and a signing in book was by the front door.

Systems were in place to ensure the home was safe. This included checks on equipment, fire and gas appliances. Emergency plans were in place to ensure people could be kept safe in the event they had to evacuate the home. Adaptations such as key codes on doors, restrictors on windows and covers on radiators all helped to keep people safe.

New equipment had been purchased to monitor people’s health such as blood pressure monitoring equipment as staff had said this was unreliable at our last visit. Lifting equipment had been replaced and was now working. New sit on scales had been purchased enabling people’s weight to be monitored safely for those people with mobility issues.

The service had been awarded a 4-star rating for food hygiene. Since the last assessment improvements had been made and fridge, freezer and food temperatures were consistently being recorded.

The registered manager told us they were doing some work in the garden to make it more accessible to the people that lived in Susan Hampshire House. New raised planters had been purchased. It was noted the Summer House was in a poor state of repair and assurances were provided that this was being removed.

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.

The provider had made improvements and were no longer in breach of regulations. They had increased staffing to ensure people’s needs could be met safely and responsively. Staff confirmed there were enough staff working during the day and night to support people safely. Since the last assessment two new posts had been introduced, and an activity co-ordinator and a laundry assistant had been employed. This enabled the care staff more time to support people.

The registered manager told us they had employed a cook, but they had recently left, and this post was presently being advertised. From talking with staff and the management team there had been a significant reduction in the use of agency due to the ongoing recruitment to the service. Where agency staff were used these were staff that had worked in the service before ensuring continuity of care for people.

People were supported by staff who had an induction that included shadowing more experienced staff, ongoing training and formal competency checks. Comments from staff included, “I did have a comprehensive induction and completed training relevant to me,” and “Yes the management team provided support when I first started working for the service and I attended an induction at the head office.”

Staff received regular supervision and yearly appraisals.There was a training programme in place, which was monitored by the registered manager and the provider’s representative. All staff had to complete refresher training at regular intervals. Examples included health and safety, first aid, safeguarding, equality and diversity, safe medicines administration, food hygiene and moving and handling, deprivation of liberty safeguards and mental capacity.

Staff had completed specific training to support people such as epilepsy and support with their rescue medication and supporting a person with their percutaneous endoscopic gastrostomy (PEG). A PEG feed refers tonutrition and fluids delivered via a Percutaneous Endoscopic Gastrostomy (PEG) tube. A member of staff told us, “We have had lots of on-site training as well, including lifesaving, fire safety, sepsis, moving and handling and PEG feed training.”

The registered manager demonstrated at the last inspection they followed safe recruitment practices. All members of staff had at least two satisfactory references and had received a Disclosure and Barring (DBS) check. The DBS helps employers make safer recruitment decisions and prevents unsuitable people from working with people who use care and support services. The registered manager said they now follow up all references with a telephone call to confirm the applicant’s suitability to work at Susan Hampshire House.

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 found the service to be clean and free from odours. People and their relatives felt the home was clean and tidy and no concerns were raised.

Staff had completed infection prevention and control training. Staff said they had enough personal protective equipment (PPE) such as gloves and aprons. Spot checks were completed to ensure staff were following the policies and procedures and not putting people at risk. Infection prevention and control policies were in place.

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.

Since our last assessment improvements had been made to the management of medicines.

People were given medicines in line with their wishes. Each person had individualised medicine support plan and risk assessments. Medicine administration records were clear and showed people were receiving their medicines as prescribed by the GP. The GP had been consulted on homely remedies to ensure they were appropriate to take alongside people’s regular medicines if required.

People's individual medicines were stored in a secure cabinet in their rooms. This helped staff to provide a more person-centred approach to the administration of people’s medicines. The registered manager told us this had also reduced medicine errors. Two staff were responsible for administering medicines on each shift, which meant additional checks had been put in place to ensure medicines were administered safely.

Some improvements were still needed to ensure medicine protocols for homely remedies were consistent. For example, one person’s medicines for constipation did not include the guidance recorded in the rehydration protocol. The registered manager said they would review all homely protocols which would include making them more person centred in respect of bowel management care plans (medicines for constipation) to include information to help staff make decisions when these should be administered.

Staff received training in medicines management, and their competency was checked before they were authorised to administer medicines. Staff carried out daily medicines checks and medicines were audited weekly as part of the provider's quality monitoring processes.

The service ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines. Staff understood and implemented the principles of STOMP (stopping over-medication of people with a learning disability, autism or both) and ensured that people’s medicines were reviewed by prescribers in line with these principles.