Field View

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 as 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.

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 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.

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 had been supported well to move from another of the provider’s services to Field View. A relative commented, ‘[My family member] is settled. The room is safe and suitable. They have ordered a bed [which is more suitable] …. The new staff are amazing and they know [my family member] already’. We saw information had followed people from their previous care home and the registered manager was observed reviewing and updating records to ensure information was accurate in the new setting.

Although the provider was clear about the need to protect people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, they did not always share concerns quickly and appropriately. For example, we identified two incidents which should have been reported to both CQC and the local authority. On each occasion no harm had been sustained, and the provider had not considered the incidents warranted reporting. However, reporting and sharing information about incidents at an early stage would have ensured better oversight of potential safeguarding issues.

Staff received safeguarding training and demonstrated a good understanding of the signs and symptoms of abuse and knew how to raise significant concerns and report them appropriately.

The provider did not always work well with people to understand and manage risks.

The majority of risks were assessed and regularly reviewed. However, we identified some care plans did not always contain sufficient detail to make the nature of risk fully clear to staff. For example, one person had a health condition which could make the impact of any fall more significant, but this was not documented within their falls risk assessment. Similarly, a pain assessment did not document another significant health condition which might cause the person to present with pain even though they appeared to be currently pain free. Risks relating to people taking blood thinning medicines, which make the impact of a fall or injury potentially more serious, were documented but not fully understood by all staff. The provider acknowledged this and assured us they would carry out a refresher session for staff, especially those new to the service having transferred from the provider’s other service.

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.

The provider carried out a series of regular tests and checks relating to maintaining a safe environment. However, we identified two areas of concern. We observed an upper corridor where a large amount of equipment, including wheelchairs and a wheeled trolley, was being stored. These items could impede a safe evacuation of the building in the event of an emergency. The provider addressed this issue whilst we were onsite, and we saw an additional storage shed was in the process of being built in the garden to help with this issue. We also identified that, although the provider carried out routine checks of the water temperatures which aimed to ensure the risks of legionella bacteria were reduced as much as possible, samples of the water in the system had not been sent off to an external agency for testing for several years. Whilst such testing is not a legal requirement, we questioned how the provider could be certain the measures they undertook with their routine testing were effective in reducing risk. They acknowledged this and gave us assurances they would review their practice.

Although the provider had enough staff and people gave us very positive feedback about this, some new staff had not received a local induction to the service which meant they were not fully aware of people’s needs. Some staff had transferred, or were in the process of transferring, from another of the provider’s services which was closing. Not all of these staff had received local inductions and had time to become familiar with the different ways of working and get to know the people who used the service. It was of great benefit to the people who had come to live at Field View from the other service, to see familiar faces amongst the staff team and this helped people settle. However, 3 staff, including Field View staff, had gaps in their knowledge relating to fire procedures, protocols for service users going missing and risks relating to blood thinning medicines.

Staff were safely recruited and received a variety of training to support their knowledge and practice.

lthough the provider mostly assessed and managed the risk of infection well we identified an issue relating to the management of legionella bacteria given that water was not routinely sampled and tested to ensure the effectiveness of the monitoring systems. We also noted two carpeted bathrooms, one of which was a communal bathroom which also contained a non-wipeable velour chair. The provider acknowledged the fact that ensuring carpeted and velour surfaces remained hygienically clean was almost impossible. The bathroom in question also included a bin which was not foot operated and areas of paintwork which were damaged. The provider gave us assurances the bathrooms were due for refurbishment and this would be completed as a matter of priority.

The service was clean and free from malodour. People’s rooms were regularly cleaned and communal areas were well kept. The provider had already identified some communal carpets were in need of cleaning and came over to the service on the day we were onsite to begin cleaning them.

The provider did not always make sure that medicines and treatments were safe and met people’s needs. Although mostly well managed, we identified two areas of concern relating to the safe administration of medicines. One person had a medicine which was required to be given to them 30 minutes before food, but it was being given with breakfast, potentially reducing its effectiveness. We also noted staff were not all clear about who was prescribed blood thinning medicine which makes people more susceptible to bleeding, including internal bleeding, should they experience a fall for example. One staff member told us nobody had this medicine which was incorrect. There was a protocol in place relating to blood thinning medicines, however it was over complicated and potentially confusing for staff. The provider acknowledged this and assured us they would review and simplify it. They also undertook to rewrite the existing risk assessments relating to blood thinning medicines and send them to us following our onsite visit.

Staff received training in the administration of medicines and had their competency to administer them checked annually. People told us they received their medicines, including any to manage pain, on time.