South Collingham Hall

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 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.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed, the environment, infection control and obligations under the Mental Capacity Act (2005).

This service scored 47 (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 not established a proactive and positive safety culture rooted in openness and honesty. Staff did not consistently respond to or act on safety concerns, and incidents were not always fully investigated or reported. As a result, opportunities to learn and embed improvements in practice were missed.

Although staff did report incidents, there was no structured process in place to review and analyse these at a managerial level. This meant lessons were not effectively identified or learnt, and outcomes for people did not consistently improve.

The provider did not consistently work effectively with people or healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety appropriately, nor did they ensure continuity of care, including during transitions between services. Care records were not maintained in an organised, accessible, or consistent manner, staff were not always able to locate information. Information from weekly GP visits and handovers was not routinely incorporated into care plans, meaning safe systems of care were not reliably embedded.

A healthcare professional told us that although communication was generally good, “Sometimes staff will say they haven’t been at work so don’t know, so information may not be passed on or recorded in an easily accessible format,” highlighting gaps in information sharing and record-keeping.

The provider did not consistently work in partnership with people, or with healthcare partners, to understand what safety meant to them or how best to achieve it. They did not always focus on improving people’s lives or protecting their right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. Concerns were not always shared promptly or appropriately.

There was inconsistent reporting and escalation of potential safeguarding concerns. For example, incidents such as unexplained bruising, swelling, and peer-related events had not always been escalated to the relevant external agencies. There was a lack of effective oversight and risk mitigation, alongside a failure to meet obligations to notify relevant external agencies. Managerial reviews of safeguarding incidents sometimes took place, however, there was little evidence of thorough internal investigation or learning being identified and implemented.

Some people had been assessed as lacking the mental capacity to make certain decisions. While mental capacity assessments (MCAs) were in place for areas such as accommodation, personal care, and medicines, there was an absence of decision-specific best interest decisions relating to restrictions, including the use of room sensors and bed rails. In addition, some people were subject to Deprivation of Liberty Safeguards (DoLS), which contained conditions the service was required to meet. Due to poor record-keeping, the provider was not able to demonstrate whether these conditions were being met.

The provider did not consistently work with people to understand and manage risks effectively. Staff did not always deliver care that was safe, supportive, and responsive to people’s individual needs, or that enabled them to engage in activities that were important to them.

Although risk assessments were in place, these were not always updated to reflect changes in people’s needs or presentation. There was insufficient guidance for staff on how to support people safely. For example, where risks associated with behaviours had been identified, there was limited information available to guide staff on appropriate de-escalation techniques. In addition, although people had Personal Emergency Evacuation Plans (PEEPs) in place, these did not clearly outline their specific needs. As a result, evacuation risks were not fully assessed or mitigated, potentially placing people at risk of harm, including difficulties evacuating safely or sustaining injury during an emergency such as a fire.

A lack of effective oversight of people’s needs and associated risks, combined with inconsistencies in record-keeping, care planning, and risk assessments, placed people at increased risk of harm or injury. These concerns were fed back to the provider, who took prompt action to address them.

The provider did not consistently identify or manage risks within the care environment, nor ensured that equipment, facilities, and technology supported safe care delivery.

We identified a number of environmental hazards, including loose cables in bedrooms which posed a risk of falls and strangulation, hazardous materials in communal areas, and general trip hazards. There was a lack of effective, regular, and consistent checks of the environment and equipment, which resulted in unmanaged risks that placed people at significant risk of harm. We fed this back to the provider who took prompt action to address these concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff available to provide care and support to people when they needed it. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

A relative told us, and our observations confirmed, “Low staffing levels is a regular thing. When visiting sometimes there are no staff in the lounge at all. I know they are busy elsewhere, it's not that they aren't doing work, [there’s] just not enough of them.” This placed people at risk of increased falls and delays to receiving timely support when required.

There were inadequate staffing levels at night to ensure people were looked after safely and their needs met in a timely manner. We fed this back to the provider who took immediate action to increase the number of staff.

Staff had not all been suitably trained to ensure they had the right skills to carry out their role safely. We fed this back to the provider who took immediate action to arrange suitable training.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found crash mats and sensor mats, which were soiled, surfaces and bannisters that were sticky and areas around the home that were damage and therefore not conducive to effective cleaning to prevent the spread of infection.

We observed, and relatives confirmed, staff wore personal protective equipment (PPE) when supporting people.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not being stored within the recommended temperature ranges, in line with best practice guidance. The provider had not ensured effective arrangements were in place to maintain appropriate storage temperatures, which could have compromised the quality, safety, and effectiveness of the medicines. In addition, we found prescribed creams were not always stored or managed safely.

There was no system in place to know when medicines had been administered to ensure the correct spacing between time critical medicines.

People who were prescribed medicines to be administered on an ‘as required’ (PRN) basis, such as pain relief or medicines used to manage anxiety or agitation, did not have clear, person-centred protocols in place to guide staff on when these medicines should be administered.

We raised these concerns and the provider took immediate action to address the issues.