Stanbrook Care Home

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. This is the first assessment for this newly registered service. At this assessment the rating has been rated Good. This is the first assessment for this newly registered service. 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. The providers system to review accidents and incidences was effective. The manager told us monthly analysis were carried out to monitor trends. For example, we saw analysis done for behaviour incidents. Partners told us when quality referrals for safeguarding or whistleblowing are raised, the manager has a proactive response and is open and transparent. The manager told us she will share learning from any accident or incident analysis with the staff. The manager told us she had also approached the quality in care team (QICT) for educational purposes to support with any learning required. Staff told us the training delivered by the provider was “really good”. Staff told us they worked collaboratively with the person and their representatives and external agencies. For example, a person at high risk of falls had not had any falls for 5 months since the implementation of assistive technology.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider had systems in place to assess people’s needs and develop care plans. We saw preadmission assessments in place, care planning tools and these included risk assessments and mental capacity assessments. Care plans showed people were supported to access services relevant to them, such as referrals tothe GP, chiropody, occupational therapist (OT) and district nurses (DN). Partners told us the manager completes assessments to support people into the service. Partners told us processes were in place to transition people between services. We saw the provider had relevant assessments in people’s care plans to ensure they received safe and appropriate care. These included weights, body maps, moving and handling, constipation, medication, choking, The Malnutrition Universal Screening Tool (MUST).

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. People told us they felt safe at the home. One person told us, “They keep me safe.” One relative told us “It’s very good here. I am well impressed. They are warm and welcoming. They communicate with me very well. Staff keep me up to date. I felt comfortable with it straight away. I knew it was the right place.” Staff understood how to recognise signs of abuse and knew how to report any concerns. Incidents are recognised, investigated and referred to the appropriate safeguarding teams. The manager told us safeguarding audits were completed by herself and reviewed. We reviewed people’s care plans and systems in place to manage and monitor any safeguarding concerns. We found the provider had taken appropriate actions to effectively manage known risks. Additionally, the provider shared learning with staff when things went wrong.Where people were being deprived of their liberty, applications had been sent to the local authority for authorisation, and these were evidenced in people’s care plans. We saw the manager had a DoLS tracker in place and this was linked to a 2 stage MCA test. The tracker detailed authorisation and expiry dates.There were systems in place to assess risk, and risk was reviewed monthly. For example, where people were having falls, the provider had a prevention plan in place and had professional guidance on how to support people.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs in a safe and supportive manner, enabling people to do the things that mattered to them. Risk assessments were in place and reviewed monthly. We saw that the care plans were person centred. Risks considered included nutrition, skin integrity, behaviour and health conditions. Staff told us they used people’s care plans to ensure they knew how to meet people’s needs. For example, where people were at risk of skin damage, the care plans outlined what actions staff should take to manage the associated risks. Staff we spoke with understood the risk of skin breakdown and gave examples of how to mitigate these risks. We saw care plans referenced this with additional information such as input from professionals, previous medical history and current treatment plans.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The providers systems ensured the environment was safe. Records showed safety checks were carried out around the home. Fire risk assessments were in place and records were up to date. The manager told us the actions from the last fire assessment had been completed. We saw window restrictors were in place and that audits had been completed for the environment and the equipment. People had personal emergency evacuation plans (PEEP) in place which included information about the person, physical considerations and general medical conditions which may affect their evacuation in the event of a fire and their awareness of evacuation and procedures.

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. Staff were recruited safely and there were sufficient staff to meet people’s needs. This included checking their identity, their eligibility to work in the UK, obtaining at least two references and Disclosure and Barring Service (DBS) checks. The DBS checks help employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Staff told us that they felt there was enough staff available throughout the day and night. People told us “It’s safe because I have to go out with someone and not by myself. I think there’s enough staff because of that.” People said staff were “kind” and “friendly”. We saw staff were available to support people when they needed it. There was a dependency tool in place that determined how many staff should be available. The provider had a recruitment policy in place. The recruitment process had some gaps in information on application forms however, the provider is taking actions to address these. The manager told us they have a training matrix in place which gave them oversight of the training staff had. We saw there were no gaps in mandatory training and staff had access to new courses.

The provider had a system in place for Infection prevention Control (IPC) with an up-to-date policy. A recent audit showed 96.1 % compliance and there was no action plan put in place. From our observations the home was clean. A relative told us, “The place is very very clean” and “The cleaning of all areas is always up to scratch.” Staff told us they had received training in Infection prevention control (IPC) and we saw staff used the Personal Protective Equipment (PPE).

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in decisions involving their medication including planning when changes were made. We observed staff administering medicines at lunchtime. The staff member spoke with the person about their medicines and gained their consent before administering. Topical medicines were safely stored in individual’s bedrooms in a lockable facility. The manager carried out appropriate checks such as medicine stock and temperature checks. We saw all medicines were stored safely and stock checks were accurate. Pro re nata (PRN – as and when required) protocols were in place. There were regular audits of people’s medicines carried out weekly. The manager and staff told us competency checks were done monthly. A medicines policy was in place which provided guidance to staff. People’s care plans contained medication risk assessments. Where people had a plan in place for covert medication we saw there was a 2-stage capacity assessment and best interest decision documented. There was covert medication guidance from the GP documented. We saw labels on medicine boxes instructing staff how to mix medicine safely.