Mrs P M Eales t/a Just Homes - 3 New Hill

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.

The service was in breach of legal regulation in relation to good governance as records were not always completed comprehensively to ensure people received their medicines as planned.
 

This service scored 66 (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. Staff completed incident forms which included details of the type of incident. Staff told us they recorded accidents and incidents, including body maps if there had been any injuries. Meetings took place for staff to review incidents to minimise risks and recurrence. However, the provider had not reviewed all incident and accident records to check any required actions had been completed and if staff had followed relevant guidance for example when people had injuries. An analysis of incidents to identify trends and any improvements required had not been completed so that this could also be shared with staff.

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. For example, the provider planned people's moves to the service with a transition plan which included the involvement of professionals and how to support people with their 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. Staff told us they completed safeguarding training and felt confident to raise safeguarding concerns. Relatives told us their loved ones felt safe. Comments included, “[Person] was very well cared for” and “yes, [person] was always quite relaxed.”

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. People had risk assessments in place, such as accessing the community, mobility, personal care and health and well-being. Staff told us care plans and risk assessments provided guidance on how to keep people safe. Staff understood people’s risks and they could describe for example, how they would always stay with people when supporting them during mealtimes, to reduce the risk of choking.
People were supported when they became anxious and agitated and guidance informed staff how to support people to remain safe when distressed. Staff told us, “Each resident has a full list of all their risk assessments in their current care file” and the care records “…give signs to watch for when the service user is uncomfortable or getting agitated, they give the triggers and measures to take to avoid escalation.”
 

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. We found the equipment, such as a hoist, used in supporting people had not been serviced. It was unclear from the provider’s records if follow up actions had been completed on the electrical condition report. We acknowledge the provider started to take action to rectify some of the issues identified. Relatives told us the environment and layout of the home was suited to people’s needs.

Staff were not assessed as competent to administer medicines and moving and handling. Recruitment records did not always provide comprehensive information to support the provider’s recruitment decisions.

The provider could not be assured there were robust recruitment processes in place. For example, we found gaps in application forms and interview questions were not fully answered. However, the provider actioned staff inductions and had records of proof of identity for staff. The provider actioned Disclosure and Barring Service (DBS) checks which cross reference against police records. A DBS check is a criminal record check used by employers to help them make safer staffing decisions.

We found staff had not been assessed as competent to deliver medicines and moving and handling by qualified professionals. The provider started addressing this shortfall during our assessment. Staff completed training such as safeguarding, first aid and basic life support. However, the records did not show if staff had received specialist training in all people’s health conditions, such as epilepsy.

Staff told us they received an induction, staff supervisions and shadowed experienced members of staff. Relatives told us the home was adequately staffed.
 

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. The provider had a list of cleaning tasks to be completed by staff for the day and night. Relatives told us they had no concerns regarding the cleanliness of the home and staff wearing Personal Protective Equipment (PPE). We observed staff cleaning the home to ensure a clean environment and there was no malodour. Relatives told us the home was “clean” and they had “no concerns.” We observed staff wearing gloves when medicines were administered.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We reviewed people’s Medicines Administration Records (MARs) and found, in most cases, people received their medicines as prescribed. However, where people were prescribed topical medicines, such as creams and eye drops, records did not always demonstrate whether these had been administered in line with the prescriber’s instructions.

Some people were prescribed medicines to be administered on a ‘when required’ (PRN) basis. Guidance was in place to support staff in administering these medicines. However, where people displayed behaviours that may challenge others, records did not always show if alternative support had been offered before PRN medicine was administered in line with people’s care records. For people with diabetes, when there was low blood glucose reading, care records did not show why a drink was offered instead of medicine in line with the risk assessment. Incomplete records increased the risk of medicine errors occurring and the provider could not be assured people had always received their medicine as prescribed.

Staff received medicines training. Staff told us they followed medicines procedures and two staff had to be present when administering medicines. Staff told us they managed the stock of medicines and when medicines arrived this was checked by two members of staff and signed for.